Dissertations / Theses on the topic 'Tuberculosis Hospitals Tuberculosis Personnel'

Knowledge and safer practices regarding occupational exposure are crucial to all employees working in healthcare facilities, especially Tuberculosis (TB) hospitals. This study aimed to explore and describe the knowledge and practices of employees working in three specialised TB hospitals regarding occupational exposure to TB. The results of the study will be used to make recommendations to the Eastern Cape Department of Health (ECDOH) and hospital managers that could assist in reducing the prevalence of occupational TB. This quantitative, descriptive and contextual study was conducted in three specialised TB hospitals in the Nelson Mandela Bay Health District (NMBHD). Convenience sampling was used to select the research participants. The knowledge and practices of 181 employees towards occupational exposure to TB and infection control was measured through a self-administered questionnaire. The questionnaire covered areas such as the knowledge of TB and infection control, the infection control policy, infrastructure as well as patient transportation. The whole population was targeted and out of a potential 253 employees, 181 were on duty during the stage of data collection and agreed to willingly participate in the study. The data was analysed descriptively using MS excel and MS word. This study revealed that 69% (n=124/181) of employees in the three specialised TB hospitals in the NMBHD have adequate knowledge of infection control. However, only 10% (n=18/181) of employees reported appropriate infection control practices, while almost half of the participants 42% (n=76) apparently practice infection control poorly. The majority (78%, n=141) of the employees in the three specialised TB hospitals in the NMBHD reported knowing about the availability of an infection control policy in their respective hospitals, however only 42 % (n=76) have reportedly read the policy. In conclusion, knowledge and practices regarding occupational exposure in specialised TB hospitals in the NMBHD is not optimal. It is however, important to note that the majority of employees have knowledge about the TB disease itself and its symptoms. Recommendations were made in order to improve infection control knowledge and practices. These include the development of a plan for purchasing of equipment to address infection control, development of a curriculum specific for non-nursing personnel and the establishment of a plan to ensure the availability of patient consultation rooms and dining halls. A further recommendation deemed important by the researcher was isolation glass as a compulsory specification when purchasing patient transportation vehicles, in order to provide protection for the drivers transporting patients to and from the hospital.

Thesis (MMed)--Stellenbosch University, 2013.
ENGLISH ABSTRACT: Introduction: The morbidity and mortality associated with tuberculosis (TB) disease is of grave consequences for the health and employment of afflicted individuals. Healthcare workers are identified amongst high risk groups in communities. The prevalence/incidence of TB is dependent on the presence of associated risk factors which varies in diversity and intensity in different communities and workplaces. Understanding the risk factors operating in any given environment is indispensable to any tuberculosis control programme. Objective: The objective of this study was to describe the occurrence and trends of TB disease as well as to determine the risk factors associated with the disease among Tygerberg hospital employees. Method: A cross-sectional descriptive study design with a nested case-control component was used to determine the occurrence (and trends) and risk factors of TB disease respectively. Occurrence and trends of tuberculosis: The frequencies, distribution and trends of TB disease from 2008 to 2011 were obtained by calculating and comparing the annual incidence rates for each variable. Cases were identified from the occupational health clinic TB register, while the various denominator data were obtained from the Human Resource database. Determination of risk factors: Cases were recruited from the occupational health clinic TB register and controls were randomly selected from unaffected workers during the study period. Self-administered risk factor questionnaires were completed by both cases and controls. Multivariate logistic regression analysis was used to determine the association between known and suspected risk factors and the occurrence of TB disease amongst employees. Results: Sixty six cases of TB disease occurred in the workforce during the study period resulting in an annual average incidence rate of 397/100,000 population (95% CI: 307/100,000-505/100,000). Twenty three (34.8%) of the 66 cases occurred in Housekeeping staff, making them the most affected sub-group [1181/100,000 population (95% CI: 747/100,000-1768/100,000)]. The rate of TB disease in nurses was 1.7 times (95%CI: 1.4-2.0) that of doctors. Workers in the 40-49 years age-group experienced the highest incidence [490/100,000 population (95%CI: 329.6/100,000-706.8/100,000)] of TB disease compared to the other age-groups. There was no obvious difference in gender occurrences. Disease rates varied among different racial groups, with the highest rate in black employees [1473/100,000 population, (95%CI: 924/100,000-1981/100,000)]. Distribution of TB disease in the institution was widespread, with security department being the most affected [2500/100,000 population (95%CI: 311/100,000- 9262/100,000)]. There was a downward but statistically insignificant (annual range 9-23; p=0.28) trend in the rate of disease occurrence over the study period. No previous training on TB prevention (OR: 2.97, 95% CI: 1.15 - 7.71), HIV (OR: 67.08, 95% CI: 7.54 – 596.64) and working without knowledge of TB risk profile of the workplace (OR: 8.66, 95% CI: 1.10 – 67.96) were associated with TB disease occurrence. Conclusion: Occurrence of TB disease among Tygerberg hospital employees was low compared to that of the general population of its drainage areas. Disease occurrence in the facility was wide and varied with respect to occupational groups, workplaces and time. Well-established risk factors for TB infection (and disease) were found to be determinants of disease occurrence in the facility.

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Mestrado Profissional em Enfermagem Assistencial
Problema: O aparecimento de casos de adoecimentos por tuberculose entre os funcionários do HUAP. Objetivos: Analisar os fatores de risco para tuberculose e o perfil epidemiológico dos funcionários do HUAP/UFF com resultado da prova tuberculínica ≥ 10 mm no período de 2007 a junho de 2011; - Investigar os casos de adoecimento por tuberculose em funcionários do HUAP/UFF no período de janeiro de 2004 a julho de 2011; - Identificar a possível associação entre o perfil epidemiológico dos funcionários que apresentaram positividade na prova tuberculínica e os fatores de riscos para tuberculose. Métodos: trata-se de um survey interseccional, tendo como análise estatística a razão de chances (OR) e análise multivariada dos profissionais que apresentaram conversão na prova tuberculínica. Resultados: foram identificados 10 casos notificados de adoecimentos por tuberculose nos funcionários do HUAP/UFF no período de janeiro de 2004 a julho de 2011, sendo a predominância no sexo masculino com 80%, na qual o perfil de adoecimentos foi de funcionários que não realizavam suas atividades diretamente ao paciente com TB. Os funcionários que apresentaram positividade na prova tuberculínica no período junho de 2007 a março de 2011 teve como variável idade ≥ 50 anos maior risco de conversão na PT com p- valor (0,003), funcionários com tempo de serviço ≥ 30 anos tiveram (OR) 92,3% mais chances de conversão . Funcionários que tinha como ocupação atividades exercidas na categoria laboratório apresentou um risco de conversão 2,2 ( OR) vezes maior quando comparado as demais categorias. Conclusão: foi possível neste estudo estabelecer a relação entre a atividade profissional e a exposição ao risco de contágio em tuberculose. Portanto cabe as chefias de cada setor que as atividades educativas sejam realizadas de forma descentralizada com o objetivo de focar a individualidade de cada setor
Problem: the appearance of cases of illnesses due to tuberculosis among workers of the HUAP. Objectives: analyze risk factors for tuberculosis and epidemiological profile of workers HUAP / UFF results with the tuberculin skin test ≥ 10 mm in the period 2007 to June 2011 - Investigate cases for tuberculosis in workers of HUAP / UFF in From January 2004 to July 2011 - Identify the possible association between the epidemiological profile of workers who were positive in the tuberculin test and the risk factors for tuberculosis. Methods: this is an intersectional survey, with the statistical analysis the odds ratio (OR) and multivariate analysis showed that conversion of the workers in the tuberculin test. Results: were identificad 10 reported case of TB illnesses in workers of HUAP / UFF from january 2004 to july 2011, the predominance in males, with 80%, in which the profile of workers sickness was not performed activities directly to the patient with TB. Workers who tested positive in the tuberculin test in the period june 2007 to march 2011 was variable age ≥ 50 years old increased risk of conversion in PT with p-value (0.003), length of service workers with ≥ 30 years were 92.3% ( OR) conversion as likely . Workers who had occupation activities performed in the category laboratory presented a risk of conversion 2.2 (OR) times higher compared to other categories. Conclusion: this study it was possible to establish the relationship between professional activity and exposure to the risk of contagion in tuberculosis. Therefore it is the heads of each sector that educational activities are conducted in a decentralized manner in order to focus on the individuality of each sector

Thesis (M Med(Chemical Pathology))--University of Limpopo (Medunsa Campus), 2010.
Objectives: Tuberculosis (TB) is a major health problem in South Africa with disease rates more than double those observed in other developing countries and up to 60 times higher than those currently seen in the USA or Western Europe. Seventy years ago, it was demonstrated that approximately 70% of patients with primary adrenal insufficiency (PAI) was due to TB and this remains a major cause of PAI in developing countries. With these figures in mind it is of great concern that patients with TB are not screened for adrenal insufficiency more often. The aim of the study was to investigate the prevalence of adrenal insufficiency in patients diagnosed with TB. Study population: Seventy three patients at the Dr George Mukhari- and Kalafong hospitals in Gauteng, South Africa, aged 20-91 years, were included. 49 Females and 24 males were recruited. All patients had positive TB microscopy. Metods: High dose adrenocorticotropic hormone (ACTH) stimulation tests were done on all patients, a post stimulation cortisol concentration of > 500nmol/L was considered a normal response. Baseline ACTH determination was also done on all patients. ACTH determination was performed using the Siemens Immulite 2000 ACTH assay, whilst cortisol determination was done on a Beckman Coulter UniCel DxI 800 immunoassay system. Results: 68 patients had a normal response. 5 patients had a post ACTH stimulation cortisol of less than 500nmol/L. Conclusion: Five patients (6.85%) had a blunted response to the ACTH stimulation test which identifies some form of adrenal insufficiency. None of the patients had an increased ACTH concentration. This finding excludes PAI and the normal ACTH concentrations in these 5 patients are highly suggestive of secondary-or tertiary adrenal insufficiency.

Tuberculosis (TB) is a major public health problem in many low- and middle-income countries, including Indonesia. To accelerate TB case detection, and to improve the quality of diagnosis and treatment provided by all providers, the Public-Private Mix for implementing Directly Observed Treatment Short-course (PPM DOTS) was introduced in 2000. However, previous studies on PPM DOTS have focused on private practitioners and there has been a scarcity of research on PPM DOTS in the hospital setting. This dissertation aims to capture the potential of the PPM DOTS strategy, and identify the barriers to its implementation in hospitals in Indonesia. This dissertation is based on four separate but interrelated studies: 1. A costeffectiveness analysis, comparing incremental cost per additional number of TB cases successfully treated under three strategies of PPM DOTS in four provinces. 2. An evaluation of the access to TB services by a cross-sectional study among 62 hospitals, by estimating the proportion of TB cases receiving standardised diagnosis and treatment according to the DOTS strategy. The data were analysed using poststratification analysis. 3. The quality aspect was explored in a multiple-case study, including eight selected hospitals. The data were analysed using cross-case analysis. 4. The process of partnership was explored through a qualitative study. In-depth interviews were conducted with 33 informants, who were actors involved in PPM DOTS in hospitals in Yogyakarta province. Content analysis was applied to the qualitative data. PPM DOTS in hospitals was shown to be a cost-effective intervention in this particular context. However, the quality of the implementation was commonly suboptimal. In addition, a substantial number of TB cases did not get standardised diagnosis and treatment as per the DOTS strategy. The process of creating partnership among hospitals and National TB Programme was shown to be complex and dynamic. Process factors, such as commitment to collaboration and interaction and trust among the actors, were shown to be important. The rapid scaling-up of PPM DOTS in hospitals at the national level in Indonesia should be revisited. Indeed, considering the importance of hospitals in TB control, the implementation should be continued and expanded. However, more attention needs to be given to process, context and governance.

Thesis (MCur)--University of Stellenbosch, 2011.
ENGLISH ABSTRACT: Background: In her clinical practice as nursing manager the researcher was concerned about incomplete and inaccurate documentation of patients diagnosed with tuberculosis (TB) which were compromising the management of these patients. The primary care nurses endorsed these concerns. Goals and Objective: The goal of this study was to audit nursing documentation according to the phases of the nursing process and the discharge planning of patients diagnosed with TB discharged from TB hospitals in the Western Cape. The objectives for the study were to determine whether the patients were adequately assessed and diagnosed, whether nursing care plans were formulated based on the assessment and whether they were implemented and evaluated according to the nursing process - including the discharged planning. Ethics approval was obtained from the Committee of Human Research Science at Stellenbosch University and permission was also obtained from the respective institutions. Methodology: A descriptive design with a quantitative approach was applied for the purpose of this study. The total population for the study was N=1768. A systematic random sample of 12% from each hospital was drawn: n=214, hospital A (n=142) and hospital B (n=72). Criteria included:  all adult patients older than 18 years  patients who were discharged between 01 January 2007 and 31st December 2007  all discharged patients from the two hospitals specializing in patients diagnosed with TB. Instrumentation: An audit instrument based on the objectives of the study was approved as the data collection tool. Guided by the proposed study a 10% (n=21) of the number of discharged patient files were drawn for the purpose of a pilot study. Reliability and validity was ensured through the use of experts in the field of nursing, research methodology and statistics. A pilot study was also conducted to support the reliability and validity of the study. Data collection: The researcher collected the data personally with the support of five trained field workers who only assisted at hospital B and was reluctant to assist at the second hospital. Data analysis: Data was analysed with the support of a statistician and expressed in frequencies and tables. Results: All phases of the nursing process showed a low compliance. Results showed that only n=90(42%) of the registered professional nurses checked and signed the initial assessment, furthermore only n=53(34%) showed that a recording was made of all referral documentation to the patient’s follow-up clinic. Recommendations: Recommendations based on the scientific evidence obtained from the study include the implementation of a quality assurance programme namely standardisation, auditing, case management of patients, education and training, rewarding of staff and further research. Conclusion: In conclusion guided by the research question “Are the audited discharged patient files at hospitals specialising in the management of patients with TB in the WCDoH compliant?” The researcher concludes that the discharged patient files are not compliant.
AFRIKAANSE OPSOMMING: Agtergrond: In haar kliniese praktyk as verpleegbestuurder is die navorser besorgd oor die onvolledige en onakkurate dokumentasie van pasiënte wat met tuberkulose (TB) gediagnoseer is en wat dus die versorging van hierdie pasiënte in gevaar stel. Hierdie besorgdhede is deur die primêre sorg verpleegsters bevestig. Doel en Doelwitte: Die doel van die studie is om die verpleegdokumente te ouditeer volgens die fases van die vepleegproses, asook die ontslagbeplanning van die pasiënte gediagnoseer met TB van die hospitale in die Wes-Kaap. Die doelwitte is om te bepaal of die pasiënte korrek geassesseer en gediagnoseer is en of verpleegsorgplanne opgestel is, wat gebaseer is op die assessering en versorgingsplanne wat geïmplementeer en geëvalueer is volgens die verpleegproses, insluitende die ontslagbeplanning. Etiese goedgekeuring is toegestaan deur die Komitee vir Menslike Navorsingswetenskap van die Universiteit van Stellenbosch en toestemming is ook ontvang van die onderskeie instansies. Metodologie: ’n Beskrywende ontwerp met ’n kwantitatiewe benadering is toegepas vir die doel van die studie. Die totale bevolking vir die studie is N=1786. ’n Sistematiese ewekansige geselekteerde steekproef van 12% van elke hospitaal is geneem: n=214, hospitaal A (n=142) en hospitaal B (n=72). Die kriteria sluit in:  alle volwasse pasiënte ouer as 18 jaar  pasiënte wat gedurende die periode 01 Januarie 2007 tot 31 Desember 2007 ontslaan is  alle ontslag pasiënte van die twee hospitale wat spesialiseer in pasiënte wat gediagnoseer is met TB. Instrumentasie: ‘n Ouditinstrument gebaseer op die doelwitte is goedgekeur as die dataversamelingsinstrument. Na aanleiding van die voorgestelde studie is 10% (n=21) van die aantal ontslag pasiëntlêers getrek vir die doel van die loodsondersoek. Betroubaarheid en geldigheid is verseker deur gebruik te maak van deskundiges in die verplegingsveld, die navorsingsmetodologie en statistiek. Die loodsondersoek is ook uitgevoer om die betroubaarhied en geldigheid van die studie te rugsteun. Dataversameling: Die navorser het die data persoonlik gekollekteer met die bystand van vyf opgeleide veldwerkers wat slegs hulp verleen het by hospital B en wat teësinnig was om hulp te verleen by die tweede hospitaal. Data-analise: Data is geanaliseer met die hulp van ’n statistikus en is uitgedruk in frekwensies en tabelle. Resultate: Alle fases van die verpleegproses het nie voldoen aan die vereistes nie. Resultate dui daarop dat slegs n=90 (42%) van die geregistreerde professionele verpleegsters die aanvanklike assessering nagegaan en onderteken het, vervolgens het slegs n=53 (34%) getoon dat ’n opname gemaak was van alle verwysde dokumentasie van die pasiënt se opvolgbesoek aan die kliniek. Aanbevelings: Aanbevelings is gebaseer op die wetenskaplike bewys wat verkry is van die studie vir die implementering van ’n gehalte versekeringsprogram, naamlik standardisering, ouditering, gevallebestuur van pasiente, opvoeding en opleiding, erkenning aan die personeel, en voortgesette navorsing. Samevatting: Ter afsluiting gelei deur die navorsering’s vraag nl. “Is die geouditeerde verpleegdokumente in hospitale wat spesialiseer in die bestuur van pasiente gediagnoseer met TB in die Weskaap se Department van Gesondheid bygehou?” Die navorser bevestig dat die verpleegdokumente nie bygehou was nie.

South Africa is one of the countries with the highest burden of Mycobacterium tuberculosis (TB) in the world. The fact that adult patients diagnosed with TB frequently do not attend their primary healthcare clinics after discharge from hospital for continued treatment remains a challenge for public health in South Africa. This qualitative study employed semi-structured interviews, focus group discussions and observations explored the experiences of patients, their families, healthcare workers and policy makers, with continuity of TB care following diagnosis in hospital. The key research question was what factors were shaping patients’ attendance at primary healthcare clinics following TB diagnosis and start of treatment in tertiary and district hospitals. Sub questions were: how did patients diagnosed with TB interpret and act upon their diagnosis and treatment at the tertiary/district hospital? What roles did patients play in the discharge process? What were their home circumstances and experiences at the clinics they were referred to, regarding their registration and follow-up plan? What were the perceptions of patients, healthcare workers and policy makers on what influences patients’ attendance/non-attendance at clinics? The objective of this study was to contribute to our understanding of patients’ experiences and perceptions of treatment of TB and how services to patients could be improved to enhance better continuity of care. I drew on a three-fold theoretical framework: patient-centred care, Foucault’s concept of the 'medical gaze’ and social determinants of health. My study built upon previous and ongoing research on the topic of continuity of care for TB in Cape Town. I argued that problems in the provision of TB services to hospital patients could be understood as failures of the services at the hospital to achieve some of the core components of patient-centered care. Furthermore, I argued that better systems for following-up patients from the hospitals to their homes and clinics would provide more understanding of the challenges patients faced when they have been referred from a tertiary or district hospital to continue with their treatment. Insights gained from qualitatively following patients from diagnosis to discharge and their home circumstances helped to better understand the problem South Africa faced with continuity of care for TB treatment.

Publicación a texto completo no autorizada por el autor
Identifica las medidas de bioseguridad en el uso de la protección personal aplicadas por el personal de enfermería y así poder contar con una base informativa para que las autoridades respectivas puedan intervenir sobre los resultados obtenidos. El estudio es de tipo básica, descriptivo, observacional, de corte transversal. En 60 personales de enfermería mediante técnica de observación, se aplica una lista de cotejo (checklist). Los resultados revelan que el 41% cumplen el uso de gorros descartables y 17% no cumplen. En el cumplimiento de guantes, mandiles y respiradores descartables, 38% tienen un grado de cumplimiento total, 20% un cumplimiento parcial y ninguna persona en el criterio no cumple. La aplicación de las barreras químicas, con cumplimiento de lavados de manos 35% tienen un cumplimiento total, 23% un cumplimiento parcial y ninguna persona en el criterio no cumple.
Trabajo académico

Determina los factores de riesgo para tuberculosis pulmonar en personal de salud del Hospital Nacional Dos de Mayo. El tipo de estudio fue cuantitativo, analítico, de casos y controles; se incluyeron 192 trabajadores de salud, 96 casos con tuberculosis pulmonar y 96 trabajadores de salud sin la enfermedad, quienes formaron el grupo control; ambos grupos fueron pareados por grupo ocupacional. Se recolectaron datos de fuente secundaria a través de una ficha estructurada para tal fin. Para determinar los factores de riesgo se utilizó el modelo predictivo de regresión logística multivariada. Se consideró estadísticamente significativo un valor de p <0,05. Se encontraron 96 casos de tuberculosis pulmonar, la tasa de incidencia habitual fue de 3,48 x 1000 trabajadores de salud. Los factores asociados significativamente en el análisis univariado fueron: velocidad del flujo aéreo menor de 0,7m/seg, presencia de aire acondicionado en los ambientes hospitalarios, elevado grado de hacinamiento (espacio libre menor de 2m2 /persona), edad cronológica menor de 40 años, presencia de al menos una comorbilidad, y el tiempo de trabajo hospitalario menor de 20 años. Concluye que la presencia de alto grado de hacinamiento y el tiempo de trabajo hospitalario menor a 20 años constituyen factores de riesgo para tuberculosis pulmonar activa en trabajadores de salud del Hospital Nacional Dos de Mayo.
Tesis

Pneumocystis jiroveci, Mycoplasma pneumoniae and Mycobacterium tuberculosis are respiratory pathogens associated with pneumonia, with increasing prevalence of Pneumocystis pneumonia (PcP) and tuberculosis (TB) in AIDS patients. Increased resistance of M. tuberculosis has emphasized the need for rapid susceptibility testing, such as flow cytometry. Sputum specimens (102) were assessed by PCR employing primers directed at the following genes: P. jiroveci: mitochondrial large subunit ribosomal RNA (mtLSUrRNA), dihydropteroate synthase (DHPS) and dihydrofolate reductase (DHFR), and for M. pneumoniae: 16S rRNA and P1 adhesin. Positive P. jiroveci samples were genotyped by PCR-SSCP (single-strand conformation polymorphism) targeting the: internal transcribed spacer region (ITS), intron of the nuclear 26S rRNA gene (26S), variable region of the mitochondrial 26S rRNA gene (mt26S) and β-tubulin gene (β-tub). Multi-drug resistant (MDR-TB) cultures grown in the presence and absence of four antibiotics (rifampicin, isoniazid, ethambutol and ofloxacin) were heat killed, stained with SYTO16 and Propidium Iodide and analysed using flow cytometry. Rifampicin resistance gene mutations were screened by PCR and DNA sequencing. Details of patient’s gender, age, HIV and M. tuberculosis status were provided by the hospitals. Women were seen to be at high risk for community-acquired P. jiroveci colonisation. Overall, prevalence of P. jiroveci was 55.1 percent (54/102 patients). P. jiroveci was mainly associated with HIV (25/102 P. jiroveci positive patients for which clinical data was available) and co-colonisation with M. tuberculosis was observed in 11 cases. Sequence analysis of DHPS and DHFR products found no resistance associated mutations. M. pneumoniae was detected in one patient. Four simple SSCP patterns were identified and there were no co-infections with other P. jiroveci strains. Nine M. tuberculosis samples [8 MDR-TB isolates (NHLS) and M. tuberculosis ATCC® 27294TM] were tested. There was a 53 percent (19 out of 36 tests) agreement of flow cytometry with the BACTEC MGIT 960. Mutations (at two specific codons, namely 516 and 531) in the rifampicin resistance-determining region (RRDR) of the rpoB gene were observed in eight M. tuberculosis isolates. Evaluation of methods for genotyping and drug susceptibility testing of PcP and TB are imperative for epidemiology and drug resistance studies, and impact on treatment protocols.

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Thesis (MA (Psychology))--University of Stellenbosch, 2006.
AFRIKAANSE OPSOMMING: Hierdie studie ondersoek die uitvoerbaarheid van die implementering van 'n benadering genaamd Kort Motiverende Onderhoud (KMO) in die konteks van die behandeling van tuberkulose (TB) in Suid-Afrika. TB is 'n ernstige bedreiging vir wereldwye gesondheid en is nog nie onder beheer gebring nie, ten spyte van die feit dat dit geneesbaar is. Sedert die beskikbaarheid van effektiewe medisyne-middels, is die oorsaak vir die voortdurende verspreiding van die siekte gesien as 'n probleem van gebrekkige deurvoerbaarheid van die behandeling. Hierdie eng begrip van die epidemie is deur die psigologiese en sosiale wetenskappe, asook andere, verbreed. Daar is baie debatering oor en om die onderwerp van deurvoerbaarheid en die internasionale TB beheer beleid, bekend as Direkte Observerings-Behandeling, Kortkursus (DOBK). Sekere deskundiges argumenteer dat DOBK 'n onvoldoende respons is tot die uitdaging van die verbetering van deurvoerbaarheid en die kontrolering van TB. Dit skyn asof die meelewende aspekte van die TB behandeling nagelaat word in die TB beleide en protokol en sommige beweer dat hierdie faktor sowel as gebrekkige aandag aan ander sistemiese faktore verantwoordelik is vir swak programuitvoering. Suid-Afrika is 'n voorbeeld hiervan, waar die kommunikasie tussen verpleegsters en TB pasiente beskryf word as outoriter, verpleegstergesentreerd en taakgeorienteerd. 'n Pasientgesentreerde benadering (PGB) is 'n wyse waarop die pasientversorger kommunikasie en die bevredigingsvlak van die pasient bevorder word en sommige promoveer dit as a wyse om die behandelingsdeurvoerbaarheid en genesingsuitkomste te verbeter. Die uitdaging is egter dat die konsep van 'pasientgesentreerdheid' op verskeidenheid van wyses geinterpreteer en geimplimenteer kan word. KMO is 'n PGB tot kommunikasie wat bestem is om 'n gees van samewerking te bevorder en om mense se gemengde gevoelens oor gedragsverandering by te le. KMO as 'n aanpassing van Motiverende Onderhoudvoering, is 'n spyskaart van konkrete vaardighede of middels wat gesondheidsvoorsieners in onderhoude rakende geneeskundige gedragsverandering kan gebruik. KMO is gebaseer op teoriee oor gedragsverandering en word gebruik in 'n wye verskeidenheid van genesingsbehandeling, insluitende deurvoerbaarheidsbehandeling. Alhoewel dit selde in minder ontwikkelende lande toegepas is en nog nooit in TB, is KMO suksesvol toegepas in ander besige kontekste vir gesondheidsvoorsiening. Die ontwerp van die huidige studie oor die lewensvatbaarheid van KMO in die konteks van TB behandeling in Suid-Afrika het ontstaan uit die ontwerp van 'n groter studie wat ander intervensies vir 'n PGB ingesluit het. Die doelstellinge van die huidige studie was om die konteks te beskrywe en wat gebeur het gedurende die intervensietydperk en om die uitvoerbaarheid van KMO te verduidelik.
ENGLISH ABSTRACT: This thesis explores the feasibility of implementing an approach called Brief Motivational Interviewing (BMI) in the context of tuberculosis (TB) treatment in South Africa. TB is a serious threat to global health and has not been controlled despite the fact that it is curable. Ever since effective drugs became available, continued spread of the disease has been understood as a problem of poor adherence to treatment. This narrow understanding of the epidemic has been broadened by psychological and social science perspectives among others. There has been much debate around the topic of adherence and the international TB control policy known as Directly Observed Treatment, Short-course (DOTS), as some suggest that it is an incomplete response to the challenge of improving adherence and controlling TB. The caring aspects of TB treatment seem to be neglected in TB policies and protocols, and some argue that this and the lack of attention to other systemic factors are responsible for poor programme performance. South Africa is an example of this, where the communication between nurses and TB patients has been described as authoritarian, nursecentred and task-oriented. A patient-centred approach (PCA) is a way of improving patient-provider communication and patient satisfaction, and some promote it as a way of improving treatment adherence and health outcomes. The challenge, however, is that the concept of 'patient-centredness' can be interpreted and implemented in a variety of ways. BMI is a PCA to communication that is designed to promote a spirit of collaboration and resolve people's mixed feelings about behaviour change. An adaptation of Motivational Interviewing, BMI is a menu of concrete skills or tools that health providers can use in consultations about health behaviour change. BMI is based on theories about behaviour change and has been used to address a wide variety of health behaviours, including treatment adherence. Although seldom applied in less developed country settings and never before applied in TB, BMI has been successfully applied in other busy health care settings. The design of the present study of the feasibility of BMI in the context of TB treatment in South Africa evolved within the design of a larger study that included other interventions designed for a PeA. The present study aims were to describe the context and what happened during the intervention period and to describe BMI's feasibility. Using elements of participatory action research, BMI communication training was developed and implemented with TB staff based in four urban primary health care facilities. A grounded theory approach was used to describe the dynamics of the implementation process and generate a theory about what made BMI more or less feasible in this context. A multidisciplinary team contributed to the study design. Data were gathered largely through participant observation, focus groups and key informant interviews and generated volumes of diverse materials including field notes, training materials, video and audio-taped interactions. The data were analysed using the inductive approach to grounded theory analysis promoted by Glaser (1992) and relied on theoretical sampling and constant comparative analysis. The quality and trustworthiness of the data were ensured through an emphasis on researcher reflexivity and triangulation of the perspectives of different materials, participants and health facilities. The study was implemented as a pilot BMI training process at one facility in Port Elizabeth (Eastern Cape Province) followed by expanded training targeting TB staff of three facilities in Cape Town (Western Cape Province). Data analysis resulted in a categorised description of the research settings, the interactions and relationships among patients, providers, managers and researchers, the training interventions and the way participants responded to it during each phase of the process. Although seemingly similar at the outset, analysis began to show that dynamics of implementation at each facility were complex and multidimensional. The categories that were generated during each cycle of implementation were used to shape the categories selected for the next. Examining the categories across the four health facilities yielded a grounded theory with seven core categories regarding the role of: (1) the personal qualities of the TB staff involved, (2) the way staff moved in and out of the TB service, (3) the leadership, hierarchy and staff dynamics in the health facilities, (4) the pressurised working conditions of TB staff, (5) the poverty of patients, (6) mismatches between the TB programme's protocols and BMI, and (7) the capacity of staff to innovate and improve care. These findings are discussed in terms of the way they respond to the study's research questions and the way the grounded theory categories relate to each other. Their significance is understood from a social constructivist perspective as bound within the context of the study. The findings are also compared to the theoretical perspectives included in the study design and new literature on the diffusion of innovations in service organisations. Recommendations are made for future context-focused research and adherence related intervention development. If interventions like BMI are to be implemented successfully in contexts such as those included in this thesis, policy-makers and managers need to consider the ways in which working conditions, policies and protocols and patient poverty may be counter-productive, and focus on the innovative potential of health staff and teams for delivering patient-centred care.

En el Perú, según el MINSA, cada una hora cuatro ciudadanos peruanos son diagnosticados de TB, por ende, la exposición del personal de salud a pacientes infectados por el bacilo de Koch es un riesgo que ha incrementado asociado también a las malas condiciones de bioseguridad y limitadas medidas de prevención y control en todos los niveles de los servicios de atención. El objetivo fue describir el conocimiento y prácticas del personal médico e internos de medicina sobre normas de bioseguridad para prevención de tuberculosis en un hospital del MINSA durante el 2018. Fue un estudio descriptivo transversal con muestreo no probabilístico censal. De la población de 196 participantes se incluyó al personal médico e internos de medicina que desearon participar y estuvieron presentes durante la captación en el Hospital Docente Las Mercedes durante el año 2018, obteniéndose una muestra de 99 participantes. Se consideraron las variables “conocimientos” y “prácticas” en base a 5 dimensiones: conocimiento de la enfermedad, uso de mascarilla, lavado de manos, uso de guantes y uso de mandilón, las cuales fueron evaluadas por un cuestionario y una guía de observación previamente sometidos a juicio de expertos y una prueba piloto. En la muestra estudiada los médicos asistenciales demostraron un mayor conocimiento sobre bioseguridad para prevención de TB, sin embargo, fueron los médicos residentes los que en mayor proporción cumplieron con la práctica siendo el ítem más cumplido el uso correcto de guantes en un 66,7%. Se concluyó que los internos de medicina y los médicos asistenciales y residentes demostraron un adecuado conocimiento sobre normas de bioseguridad para la prevención de tuberculosis, sin embargo, sólo una minoría las cumplía durante la práctica médica.
Tesis

Determina los factores de riesgo ocupacional asociados a tuberculosis pulmonar en profesionales Tecnólogos Médicos en Radiología del Hospital Nacional Hipólito Unanue, año 2020. El presente estudio es de enfoque cualitativo, transversal, descriptivo, no experimental y prospectivo, en el cual se incluyó a 8 Tecnólogos Médicos en Radiología nombrados del “Hospital Nacional Hipólito Unanue”. Encuentra el siguiente estudio determinó que los factores de riesgo personales asociados a infección tuberculosa en los profesionales tecnólogos médicos en Radiología fueron la comorbilidad y tiempo de atención de un paciente; asimismo, los factores de riesgo ambientales fueron el deficiente o escaso sistema de ventilación, flujo de aire, RUVG y filtros HEPA. Finalmente, los factores de riesgo administrativos fueron las capacitaciones, ello por falta de información relevante. Concluye que la presente investigación encontró asociación entre infección tuberculosa y factores de riesgo en sus tres niveles (personales, ambientales y administrativos) en el “Hospital Nacional Hipólito Unanue”; no obstante, fueron los factores de riesgo ambientales los que más se hallaron en el nosocomio en mención.

Masters of Commerce
The provision of health care in South Africa is undergoing major restructuring. The aim is to achieve substantial, visible and sustainable improvements to the efficiency and accessibility of primary healthcare (PHC) services for all South Africans. One of the country's most critical problems is the weak and fragmented public sector PHC system. The most critical problems contributing to this are the maldistribution of resources (financial, physical and human) between hospitals and the primary care system, and between rural and urban areas. The health sector, therefore, faces the challenge of a complete restructuring and transformation of the national health care delivery system and related institutions. Choices need to be made about which services to cut, which to streamline and where savings can be made. Ways need to be found to use ALL of South Africa's resources optimally. This process of restructuring would be facilitated by the availability of accurate information on resource utilisation in the health sector. This study estimates the difference in the cost of primary diabetes treatment at dayhospitals and a provincial hospital in the Western Cape in 1992/93. Health economics is in its infancy in South Africa and serious data limitations exist. This study is therefore a pioneering effort in many ways. An appropriate methodological framework in which to conduct the costing had to be developed. The South African health sector, health spending arid the cost of primary diabetes treatment at day-hospitals and the provincial hospital are reviewed. Theoretical perspectives of the health care market and the methodologies of cost analysis are discussed. The cost analysis method of study is chosen, and arguments are advanced for its suitability in the South African context. A simple method of calculating the direct costs to obtain the average cost is proposed for the purpose of the study. Direct costs consist of staff costs and other related costs, such as medical supplies, non-medical supplies, building operations, equipment etc. These costs are then used to calculate the average costs per diabetic patient at the day-hospitals and the provincial hospital. The average cost per diabetic patient at day-hospitals amounted to R18.76, while at the provincial hospital the cost was R59.60. https://

There is on-going debate regarding if and how integrated service delivery might affect quality of care for infectious diseases traditionally delivered through vertical programmes. In China, tuberculosis (TB) care has recently been integrated into ‘designated’ public hospitals at the county level. However, the integration initiative has caused concerns among hospital providers about cost recovery for poorly funded public hospitals. These concerns are partially reflected in the prescription of non-standardized, non-free auxiliary treatment for TB patients, which increases patients’ financial burden and compromises quality of care. This study applies Complex Adaptive Systems (CAS) thinking to understand providers’ prescribing behaviour in the context of integrated service delivery in TB designated hospitals in Zhejiang province, China. A case study approach was applied to research conducted in two designated hospitals, where the TB clinic was subsidized through local government or the hospital respectively. This study started with a retrospective review of 340 medical charts of uncomplicated TB patients. Informed by the results of this review, 47 semi-structured interviews were conducted with health officials, public health officers, and hospital staff members such as managers and TB clinicians, radiologists, laboratory staff and nurses. The working environment of the TB health workers was also observed. A thematic approach was used to formulate the initial coding frame, as guided by the conceptual framework. Hospital-based integrated TB care is highly medicalised due to strong medical culture and values associated with the integrated care. In both hospitals, non-standardised, non-free prescription of drugs and interventions for uncomplicated TB is common, with no consistent patterns for the two hospitals. This can also be attributed to lack of clear guidelines, weak doctor-patient relationship and hidden financial incentives of TB doctors. Staff motivation is low due to the perceived poor opportunities for professional development in TB work, the perceived gap in salaries as compared to other clinical staff, and the limited provision of risk protection measures for TB health workers. Welfare of TB health workers, who generate limited income for hospitals, is accorded low priority. Professional differences and tension between public health and medical professionals remain the biggest barrier to ensuring clinical governance for TB control in the hospitals. This study suggests that non-standardised prescribing behaviour is a dynamic response to the systemic conditions generated by the current model of integrated service delivery in the designated hospitals in China. Delivering free and standardised integrated TB care in the designated hospitals is challenging in the context of highly fragmented disease control and clinical structures and market-orientated health services. Using CAS thinking has helped to shift attention from a functional analysis of the health systems ‘building blocks’ and their mechanical interactions towards a more dynamic way of examining emergence, feedback loops, adaptation and relationship management in the study of integrating a public health function (TB care) within a hospital setting. The study will inform the on-going discussion of strengthening the quality of integrated service delivery model in China and public-private mix for TB control in other similar contexts.

Depuis janvier 2001, nous travaillons au Programme national de Lutte contre la tuberculose du Burkina Faso en tant que son coordonnateur. Nous avons jugé utile d’analyser la détection des cas de tuberculose et leurs résultats de traitement après quelques années de mise en œuvre de ce Programme. Le constat de la faiblesse de nos résultats et la recherche de solution de leur amélioration nous a conduits à mettre en œuvre une recherche sur la base de l’hypothèse suivante.

Hypothèse

Le présent travail repose sur l’hypothèse qu’une organisation de la lutte contre la tuberculose prenant en compte les préoccupations et les propositions des acteurs (tuberculeux, membres de leurs familles, professionnels de santé, guérisseurs traditionnels, et membres des comité de gestion des services de santé) peut contribuer à améliorer les résultats du programme National Tuberculose (Détection des cas ;Taux de succès au traitement) et (Meilleure adhésion des professionnels de santé, des patients et de leur proches aux stratégies de prise en charge des malades tuberculeux).

Éléments de méthodologie

Figure 1 :Schématisation de notre travail

Les travaux ont été réalisés au Burkina Faso. La pauvreté et les conditions de vies difficiles (logement, nutrition, climat chaux et sec) favorisent l’installation de la tuberculose.

Dans le cadre de l’analyse de base de la lutte antituberculeuse avant l’intervention nous avons réalisé deux études:

• Une enquête rétrospective dans six districts sur la période du 1er janvier au 31 décembre 2001. Cette étude visait à identifier les difficultés du système de santé à diagnostiquer et mettre sous traitement les malades atteints de tuberculose.

• Une étude rétrospective de cohortes. Elle a couvert la période 1995- 2003. Cette étude a porté sur le suivi du traitement des tuberculeux pendant 9 ans de mise en œuvre du Programme National de lutte contre la Tuberculose au Burkina Faso.

Dans le cadre de notre intervention nous avons réalisé quatre études :

• Une étude qualitative :vingt-huit groupes focalisés et 68 entrevues approfondies avec (des patients tuberculeux, des représentants de la communauté, des membres du comité de gestion du centre de santé, des guérisseurs traditionnels et des professionnels de la santé) pour savoir leurs perceptions de la stratégie de prise en charge des cas de tuberculose appliquée par le Programme National de lutte contre la Tuberculose.

• Trois études descriptives à visée analytique en vue d’évaluer les résultats de deux ans d’intervention (Les résultats de la décentralisation de la prise en charge des tuberculeux de l’hôpital de district vers le centre de santé périphérique. Les effets de l’intervention sur les étapes de la détection des cas de tuberculose. Et la contribution des guérisseurs traditionnels au contrôle de la tuberculose au Burkina Faso).

• Nous avons fait une analyse de situation deux ans après la fin de l’intervention pour voir ce qu’il reste du processus et des résultats dans les districts d’intervention et aussi ce qui se passait dans les districts témoins.

Principaux résultats de ces études :

Avant intervention

• La première étude dans le cadre de l’analyse de base de la lutte antituberculeuse au Burkina Faso a montré que le niveau de dépistage des cas de tuberculose pulmonaire à microscopie positive est faible, du fait de la déperdition des cas dans chacune des étapes qui conduisent au diagnostic de la tuberculose. Le dépistage est dépendant de l’efficacité opérationnelle des personnels des services de santé, ainsi que du recourt au CDT (centre de diagnostic et de traitement de la tuberculose) par les patients suspects référés.

• La deuxième étude a analysé neuf ans de suivi des tuberculeux par le programme national de lutte contre la tuberculose et a trouvé que le taux de négativation des examens de crachats de contrôle du deuxième mois de traitement a baissé de façon régulière depuis 1997. Cela pourrait être du à certaines caractéristiques des patients telles que des affections associées ou surtout à un traitement incorrect (irrégularité dans la prise des médicaments, doses insuffisantes, apparition de résistances ?)

Les résultats de l’intervention

• L’intervention a commencé par l’étude de l’accessibilité et de l’adhésion au traitement de la tuberculose. Elle révèle que les patients tuberculeux expérimentent trois groupes interdépendants de difficultés pour terminer avec succès leur traitement (difficultés pour arriver au centre de santé, difficultés pour aller régulièrement au centre de traitement, difficultés à l’intérieur du centre de santé). Ces difficultés sont compliquées par des facteurs d’accessibilité géographique, de pauvreté et de genre.

La mise en œuvre pendant deux ans du paquet d’activités défini de façon consensuel par les acteurs (Patients tuberculeux, professionnels de santé, guérisseurs traditionnels, membres de la communauté) a apporté plusieurs résultats :

• Pendant les premiers ateliers qui réunissaient les représentants des malades, des professionnels de santé et des guérisseurs traditionnels, les échanges étaient quasiment impossibles. Les malades ne voulaient pas s’exprimer devant les professionnels de santé, les guérisseurs traditionnels se méfiaient des professionnels de santé et ceux-ci monopolisaient la parole comme s'ils étaient les détenteurs de tout le savoir. A partir du quatrième atelier, les échanges sont devenus vraiment interactifs et chaque type de participant disait vraiment ce qu’il pensait et abordait tous les sujets de la réunion sans se faire d’auto censure).

• L’identification des tousseurs et des tousseurs chroniques parmi les patients adultes de la consultation générale s’est améliorée (respectivement de 10,6% à 14% et de 1,1% à 1,8%). La référence des patients suspects de tuberculose vers le laboratoire pour les examens de crachats s’est aussi améliorée (de 66% à 78,3%). Cependant notre étude a mis en exergue un problème important et à résoudre qui est la faible accessibilité du laboratoire pour les patients suspects de tuberculose).

• En milieu rural plus de 46% des patients suspects ont opté pour la collecte de crachats sur place plutôt que de se rendre au laboratoire de l’hôpital pour les examens de crachats. La détection des cas de tuberculose a augmenté de (14 cas pour 100.000 habitants à 15) dans les districts témoins contre une augmentation de (14 cas pour 100.000 habitants à 26) pour les districts d’intervention. Nous n’avons pas noté de différence significative entre les taux de succès de traitement en comparant les districts d’intervention avec les districts témoins.

• Les associations des guérisseurs traditionnels ont identifié 248 patients suspects de tuberculose dont 44 (17,74%) ont été confirmés positifs. Ils ont ramené 87 malades absents au traitement. Justifiant ainsi de l’utilité de leur implication).

Nous avons fait une sortie de collecte de données et d’analyse de la situation dans les districts sites d’intervention en août 2008, soit plus de deux ans après la fin de l’intervention pour savoir ce qu’il en restait :

• La décentralisation de la prise en charge des cas de tuberculose de l’hôpital de district vers les centres de santé périphériques est reprise dans les plans d’action des districts concernés.

• Nous avons constaté que les outils de gestions des cas (fiche et carte de traitement du CSPS du tuberculeux, bulletin d’examen de crachats, fiche de rapport d’activités tuberculose du CSPS, registre transitoire de la tuberculose du CSPS) sont toujours là et utilisés par les professionnels de santé.

• Les associations d’anciens malades sont encore là. Elles tiennent leurs réunions périodiques même si elles sont irrégulières.

• Les associations de guérisseurs traditionnels mènent encore des activités de référence de patients suspects de tuberculose aux centres de santé dans le district de Gorom.

• La supervision croisée ne se fait plus entre les trois districts d’intervention. Elle a été jugée difficile à organiser par insuffisance de ressources humaines et matérielles selon les médecins chefs de district.

• Au Burkina Faso les directions régionales de la santé et les districts ont une certaine autonomie pour le choix des activités à inclure dans les plans d’action annuels. Dès 2006 les districts témoins ont planifié les activités suivantes (décentralisation de la collecte des crachats et du traitement des tuberculeux, implication des associations à base communautaire, utilisation des outils de gestion de la tuberculose dans les centres de santé périphériques. Ils ont aussi utilisé le module de formations des professionnels de santé de l’intervention dès 2006). La détection des cas de tuberculose était de 26 cas pour 100.000 habitants dans les districts sites de l’intervention contre 15 cas pour 100.000 habitants pour les témoins en fin de l’intervention. Deux ans environ après l’intervention, la détection est devenue 24,5 cas pour 100.000 habitants dans les districts d’intervention contre 23,9 cas pour 100.000 habitants dans les districts témoins pour une moyenne nationale de 20,5 cas. Le taux de succès au traitement était de 75% dans les districts témoins et de 74,3% dans les districts d’intervention pour une moyenne nationale de 72,8%.

Conclusion générale

Pour finir on peut dire que les éléments du paquet d’activités qui sont restés deux ans après la fin de l’intervention méritent d’être repris, organisés et intégrés dans la démarche de prise en charge des malades tuberculeux dans le Programme National de Lutte contre la Tuberculose.

Ce qui a manqué le plus, deux ans après l’intervention c’est la supervision des acteurs par une équipe de santé technique compétente et à effectif suffisant.

La tuberculose est une maladie et la prise en charge des cas est une activité d’abord médicale. Les activités peuvent être renforcées et les résultats améliorés par une collaboration de divers acteurs autour de l’équipe de santé. Le registre de la tuberculose du centre de santé qui se situe à l’hôpital de district doit rester la pièce principale du processus de prise en charge des malades tuberculeux. C’est dans ce registre que toutes les données de tous les tuberculeux pris en charge dans le district doivent figurer. L’équipe médicale responsable de ce registre est responsable du devenir de tous les patients tuberculeux dans le district. La décentralisation de la prise en charge des cas de l’hôpital de district vers le centre de santé périphérique implique des devoirs de l’équipe médicale du CDT à l’endroit des prestataires de soins des CSPS. A ce titre l’équipe médicale du CDT doit superviser et aider les CSPS dans une mise en œuvre efficace des taches qui leurs sont confiées.

Les membres organisés de la communauté peuvent apporter beaucoup dans l’information de la population sur la tuberculose, à condition que les contenus des messages soient élaborés sur une base d’informations techniques médicales vraies. La visite à domicile et l’accompagnement des malades graves par les associations seront utiles quand ils seront faits dans une synergie et une complémentarité de l’équipe médicale responsable du registre de la tuberculose. L’identification de plus de patients suspects de tuberculose et leur orientation vers les centres de santé par les associations n’aura de résultats que quand il existera un dispositif efficace de réponse dans le centre de santé ( laboratoires équipés animés par des techniciens de laboratoires motivés, compétents, en nombre suffisant et régulièrement supervisés par des superviseurs eux même compétents) ;(prestataires de soins formés à l’écoute des patients, motivés et supervisés régulièrement par des superviseurs compétents).

Notre étude nous enseigne qu’il est utile de prendre le temps nécessaire d’avoir les propositions des acteurs pour élaborer des stratégies qui rencontreront le plus possible leur adhésion. Notre étude nous enseigne aussi que plus il y a d’acteurs plus nous devons mettre en place des efforts de suivi, de supervision et d’accompagnement.

Le renforcement du système de santé (agents de santé compétents, motivés, équipés, supervisés et en nombre suffisant) est nécessaire pour la pérennisation de toute initiative et résultats de santé.

Since January in 2001, I am the National Tuberculosis Programme Manager in Burkina Faso. I thought it would be helpful to analyze TB cases detection and the outcomes of their treatment after a few years of tuberculosis control. Because of low results and looking how to improve them we made a research with the following hypothesis.

Hypothesis

This research is based on the hypothesis that organizing tuberculosis control buy taking into consideration the concerns and the propositions of the stakeholders (TB patients, members of their family, health workers, traditional healers, and members of the health centre Management committee) we can contribute to improving the results of the National Tuberculosis Control Programme (TB cases detection, treatment success) and (good adherence of health workers ,TB patients and their relatives to the strategies of health care to tuberculosis patients).

Figure 1 :Our work plan

The research was conducted in Burkina Faso. Poverty and difficult living conditions (accommodation, nutrition, hot and dry climate) are favorable for the spread of tuberculosis

As part of the basic analysis of tuberculosis control before the intervention, we carried out two researches:

• A retrospective research in six districts between 1st January and 31st December 2001. This research was aimed at analyzing the health system capacity to diagnose and to put patients infected with tuberculosis on treatment.

• A retrospective study of groups. It covered the period 1995- 2003. This study bordered on monitoring the treatment during the 9 years of implementation of the National Tuberculosis Control Programme in Burkina Faso.

As part of our intervention we carried out four studies:

• A qualitative study :twenty eight focused groups and 68 detailed discussions sessions with (tuberculosis patients, representatives of the community, members of the Health Centre Management Committee, traditional healers and health professionals) to sample their views on the tuberculosis treatment strategy applied by the National Tuberculosis Control Programme.

• Three analytic and descriptive studies, to evaluate the results of the two years of intervention. (Results of decentralisation of tuberculosis care, from district hospital to peripheral health centre’s. The effects of the intervention on the stages of detection of tuberculosis cases. And the contribution of traditional healers to tuberculosis control in Burkina Faso).

• We also looked for what was remaining from the process and the results of the intervention two years after the end of the intervention in the intervention district and what was happing in the witness districts.

Principal results of these studies

Before intervention

• The first study into the basic analysis of tuberculosis control in Burkina Faso showed that there is a low rate of positive microscopic pulmonary tuberculosis, because of losses in cases in each of the stages leading to the diagnosis of tuberculosis. Cases detection is dependent on the operational efficiency of health services staff, as well as the using of the CDT (Tuberculosis diagnosis and treatment centre’s) by the suspected tuberculosis patients.

• The second study before intervention which analyzed nine years of tuberculosis control by the National Tuberculosis Control Programme, discovered that the rate of negativation at the 2 month follow- up sputum examination has fallen steadily since 1997. This could be due to certain characteristics of patients due to an incorrect treatment (irregularity in taking medicines, insufficient dosages, and appearance of resistance?).

Results of the Intervention

• The intervention began with a study of accessibility and adherence to treatment of tuberculosis. It reveals that Tuberculosis patients experiment with three interdependent groups of difficulties for a successful treatment (difficulty in arriving at health centre’s, difficulties in regularly visiting treatment centre’s, difficulties within the health centre). These difficulties are further compounded by geographical accessibility factors, poverty and gender.

The two years of implementation of the packet of activities collectively defined by stakeholders (Tuberculosis patients, health services providers, and community members) has yield a lot of results:

• During the earlier workshops which brought together representatives of the patients, health services providers and traditional healers, deliberations were almost impossible. Patients did not want to talk in front of health service providers, traditional healer’s mistrusted health services providers and the latter monopolised all discussions, as if they were the only repository of all knowledge. From the fourth workshop however, discussions became really interactive and each type of participant expressed his thought and tackled all topics at the meeting without any ill-feeling.

• Identification of coughers and chronic coughers among adult patients of general consultation improved (respectively from 10.6% to 14% and from 1.1% to 1.8%). Reference of suspected tuberculosis patients to laboratories for sputum smear examination also improved (from 66% to 78.3%). However, our study highlighted an important problem which needs immediate solution. This problem is the low utilization of laboratories by suspected tuberculosis patients.

• In the rural areas more than 46% of suspected patients opted for the collection of sputum samples on the spot instead of going to the hospital laboratory for the sputum smear examination. Detection of tuberculosis cases increased from (14 cases per 100 000 inhabitants to 15) in pilot districts and it increase from (14 cases per 100 000 inhabitants to 26) in intervention districts. There was no significant difference between the two successful treatment rates, when we compared the intervention districts with the pilot districts.

• Traditional healers associations identified 248 suspected tuberculosis patients, out of whom 44 (17. 74%) were confirmed positive. They brought 87 absentee patients for treatment, thereby justifying the usefulness of their involvement.

We made the analysis of the situation in the intervention districts in august 2008, two years after the end of the intervention in order to know what was remaining:

• The decentralization of taking care of TB cases from the district hospital to the peripheral health center was written in the concerned districts year planning.

• We have noticed that the tools of cases management (CSPS therapy form and card of the TB patients, expectorations exams bulletin, CSPS TB activities report form, transitory register of the CSPS TB) are still there and used by the health care providers of this level.

• Associations of TB patients still exist. They hold their periodic meeting even if it is not regular.

• Associations of traditional healers are still holding activities to send patients suspected of TB to health center in the district of Gorom.

• Crossed supervision is not more done between the three districts of intervention. It has been judged difficult to organize because of insufficient human resources and material according to the chief’s doctors of the district.

• At the end of the intervention detection of TB cases was of 26 cases for 100 000 inhabitants in the districts of intervention against 15 cases for 100 000 inhabitants for the witnesses. Almost two years after the intervention the detection became 24, 5 cases for 100 000 inhabitants in the intervention district against 23, 9 case for 100 000 inhabitants in the witness districts. The significant difference that was existing between witnesses and intervention districts disappeared two years after the intervention.

General conclusion

As conclusion we can say that elements of activities that remained two years after the end of intervention are good to be taken, organized and integrated in the National Tuberculosis Program approach of taking care of TB Patients.

What lacked the most, two years after the intervention is the supervision of the stakeholders’ by a competent health technical team.

TB is a disease and taking care of the cases is first a medical activity. Activities can be reinforced and the results improved by a collaboration of various stakeholders around the health team. TB register of the health center that is located at the district hospital must remain the key piece of the TB patients managing process. It is in this register that all the data of all the TB patients cared in the district must be. The medical team responsible of this register is responsible of the becoming of all the TB patients in the district. The decentralization of taking care of TB cases from the district hospital to the peripheral health centers implies duties of the CDT medical team towards CSPS’ health care providers. Because of that the CDT medical team must monitor and help CSPS in the efficient implementation of the tasks assigned to them.

Members of organized community can bring a lot in the information of the population on TB, at the condition that the contents of messages are elaborated on a base of true technical medical information. Home visit and support to the patient seriously sick by the association will be useful when they will be done in a synergy and complementarily of the medical team responsible for the TB register. Identification of more patients suspected of TB and their orientation to health centers by the associations will only have results when there will be an efficient response in the health system (equipped laboratories animated by motivated, competent, and regularly monitored laboratories technicians by monitors who are also competent); (health care providers trained to listen to the patients, motivated and regularly monitored by competent monitors).

Our study teaches us how useful it is to take necessary time to have stakeholders’ proposals in order to elaborate strategies that will meet the most their adhesion. Our study teaches us also that the more there are players the more we must put in place follow up, monitoring and support efforts,

The building of a strong health system (competent, motivated, equipped, monitored health staffs) is necessary for the durability of all health initiative and results.
Doctorat en Sciences médicales
info:eu-repo/semantics/nonPublished

Compreendendo a tuberculose enquanto problema de saúde pública, desde meados dos anos 1990 a Organização Mundial da Saúde recomenda ações de controle da doença, dentre estas a Directly Observed Treatment Short-Course (DOTS) que, junto às demais recomendações, é transferida e executada em diferentes cenários, sendo essa transferência merecedora de atenção e aprofundamento, o que deve ocorrer por meio da utilização de métodos válidos e confiáveis. Trata-se de um estudo metodológico, cujo objetivo é elaborar e validar um instrumento voltado à avaliação da transferência da política do Tratamento Diretamente Observado, segundo a perspectiva de profissionais de saúde, por meio das dimensões \"Informação\", \"Conhecimento\" e \"Inovação\". O estudo foi realizado em três fases, a saber: validação semântica, primeira fase do estudo de campo e segunda fase do estudo de campo. A validação semântica contou com 24 profissionais; a primeira fase do estudo de campo, com 101 profissionais; e a segunda fase do estudo de campo, com 401 profissionais. Na validação semântica, o instrumento foi ajustado segundo as sugestões dos entrevistados, tendo ocorrido também a retirada de dois itens dos 49 inicialmente propostos. Na primeira fase do estudo de campo, o instrumento não apresentou efeito floor and ceiling e foram retirados 8 itens com carga fatorial < 0,30 na Análise Fatorial Exploratória. O instrumento apresentou um bom alfa de Cronbach (?=0,87), e a dimensão \"Conhecimento\" apresentou alfa baixo (?=0,645). Na segunda fase do estudo de campo, o efeito floor and ceiling manteve- se ausente, com baixo coeficiente de correlação linear de Pearson (r), baixo ajuste (55%) e baixo alfa de Cronbach (?=0,61) para a dimensão \"Conhecimento\", tendo as dimensões \"Informação\" e \"Inovação\" atingido valores aceitáveis. Para o instrumento como um todo, o Alfa de Cronbach foi de 0,872. O KMO e o Teste de Esfericidade de Bartlett foram satisfatórios, permitindo a Análise Fatorial Confirmatória. Entretanto, identificou-se baixo valor de ajuste do modelo no CFI e RMSEA (0,576 e 0,088, respectivamente), com uma baixa correlação entre as dimensões propostas. Conclui-se que o instrumento elaborado é capaz de avaliar a transferência do TDO segundo a perspectiva de profissionais de saúde de nível médio e superior de forma unidimensional, sem a utilização das três dimensões inicialmente propostas
Understanding tuberculosis as a public health problem since the mid-1990s, the World Health Organization recommended disease control actions, among them the Directly Observed Treatment Short-Course (DOTS) that, together with other recommendations, is transferred and executed in different scenarios, being this transfer worthy of attention and deepening, what should be made using valid and reliable methods. This is a methodological study, which aims to develop and validate a tool, which aims to assess the transfer of the Directly Observed Treatment policy, from the perspective of health professionals, through the dimensions \"Information\", \"Knowledge\" and \"Innovation \". The study was conducted in three stages, namely: semantic validation, the first phase of the field study and the second stage of the field study. The semantic validation was attended by 24 professionals; the first phase of the field study by 101 professionals; and the second phase of the field study by 401 professionals. In the semantic validation, the instrument was adjusted according to respondent\'s suggestions, having also been removed two of the 49 items initially proposed. In the first phase of the field study, the tool had no effect floor and ceiling, and were removed 8 items with factor loadings <0.30 in Exploratory Factor Analysis. The tool showed a good Cronbach\'s alpha (?=0.872), and the dimension \"Knowledge\" presented low alpha (?=0.645). In the second phase of the field study, the effect of floor and ceiling remained absent with a low Pearson\'s coefficient of linear correlation (r), a low fit (55%) and low Cronbach\'s alpha (?=0.61) for the dimension \"Knowledge\", having the dimensions \"Information\" and \"Innovation\" reached acceptable values, and the tool showed a good Cronhbach\'s Alpha (?=0,89). The KMO and Bartlett\'s sphericity test were satisfactory, allowing the Confirmatory Factor Analysis. However, it identified a low value of model\'s fit in CFI and RMSEA (0.576 and 0.088, respectively), with a low correlation between the proposed dimensions. It was concluded that the elaborated tool is able to assess the transfer of the Directly Observed Therapy from the perspective of mid and high-level health professionals in the unidimensional form, without the use of the three dimensions originally proposed

The focus of this study is to identify the potential prognostic factors and symptoms that are associated with Cryptococcal Meningitis and to establish a statistical model for the prediction of outcomes (survival and mortality) among in-hospital patients. Materials and Method: The hospital admission books in the medical wards and pharmacy of the East London Hospital Complex were searched to identify the folder numbers of all the patients that were admitted, diagnosed and or treated for Cryptococcal Meningitis at the hospital between the 1st of January 2009 and the 31st of August 2012. 237 folders out of 519 folders reviewed had confirmed cases of Cryptococcal Meningitis. Data on patients’ demographics, In-hospital care, and Concurrent infection/health condition were collected and analysed in a cross-sectional study, using the univariable and multiple logistic regression. Analysis of data was done with SAS version 9.1.3 and NCSS version 2007 software. Results: In a multivariable logistic analysis of variables found to be significantly associated with Cryptococcal Meningitis in a univariable logistic regression, Being Conscious (i.e. a Glasgow Coma score of 15) (OR= 5.34,CI=2.85-9.99 p =<0.000); Having no history of TB infection (OR=28.91, CI= 3.68-226.89, p = <0.001); No Fits (OR = 2.59, CI= 1.18-5.68 p = 0.017); Being a non-smoker (OR =2.22,CI=1.13-4.34 p = 0.020); and Adhering to treatment instruction and guidelines (OR = 2.38, 1.15-4.89, p = 0.019) were the variables found to be significantly associated with the survival of a Cryptococcal Meningitis patient. The uninterrupted use of Amphotericin B (OR=3.04, CI=1.06-8.72, P=0.038) as a first line regimen was also found to be significantly associated with survival.On the other hand, being unconscious (i.e. Glasgow Coma score <15) (OR =5.34, CI=2.85-9.99, p = < 0.000), Currently having a TB infection (OR = 9.20, CI=2.77-30.57, p = < 0.000), Not adhering to treatment guidelines (OR=2.38, CI=1.15-4.89, p=0.019 ); Being a smoker (OR = 2.22, CI=1.13-4.34, p = 0.020) and having Fits (OR=2.59 CI=1.18-5.68 p=0.017 ) were found to be significantly associated with mortality. Headache (p= 0.505) was found not to be a significant predictor of survival contrary to the findings in many publications on Cryptococcal Meningitis. Owing to time constraint, testing data was not collected to validate the prognostic models. However, model diagnostics was done and the relevant statistics confirmed the goodness of fit and the predictive ability of the model Conclusion: It has been established in this study that certain baseline variables can be helpful in the prognosis of Cryptococcal Meningitis infection. It is therefore believed that these variables will help in improving the prognosis of the infection especially at the East London Hospital Complex. Though the statistical models will work well in predicting the outcome of Cryptococcal Meningitis infection for patients admitted at the East London Hospital Complex, adequate precaution must be exercised while attempting to apply it in other geographical areas.

A tuberculose é considerada um importante problema na saúde global, sendo a segunda causa de morte entre as doenças infecciosas tendo como prioridade para o seu controle o diagnóstico precoce e tratamento adequado, necessitando de uma rede de atenção capaz de preservar a continuidade da assistência. Entre os tipos de continuidade, temos a relacional que implica o contato continuado entre o usuário e os serviços, com senso de responsabilidade com relação ao doente, dando sustentabilidade ao cuidado através do tempo. Assim, a análise de discurso de matriz Francesa, dentro desse contexto, torna-se um importante referencial teórico- metodológico capaz de compreender os elementos dessa continuidade presentes no discurso do doente. Esse estudo objetivou analisar a discursividade do doente sobre a continuidade da assistência durante o tratamento. Trata-se de uma pesquisa com abordagem qualitativa e delineamento descritivo. Foi realizada em um dos centros de referência para o atendimento da tuberculose no município de Ribeirão Preto, no período de julho à setembro de 2014. Os sujeitos do estudo foram dez doentes de tuberculose em tratamento diretamente observado e/ou em acompanhamento clínico nesse centro de referência. Para coleta de dados foram realizadas entrevistas em profundidades agendadas previamente. Esse estudo foi aprovado pelo Comitê de Ética em Pesquisa da Escola de Enfermagem de Ribeirão Preto, sendo ainda respeitados os preceitos éticos conforme recomendações contidas na resolução nº 466/2012 do Conselho Nacional de Saúde. A análise dos dados ocorreu por meio do referencial teórico- metodológico da análise de discurso de matriz Francesa, sendo que oito entrevistas foram utilizadas a fim de contemplar o objetivo do estudo. Ao estabelecermos o corpus para análise, quatro blocos discursivos foram identificados. O primeiro está relacionado com a produção de sentidos da doença para o doente, sendo eles o câncer, a aids, o uso de drogas, a população carcerária, o isolamento, o bicho de sete cabeças, o caráter punitivo por meio do discurso religioso e a normalidade do adoecimento por parte do profissional de saúde. O segundo está relacionado a produção de sentidos quanto ao vínculo entre doentes e profissionais de saúde, relacionados com a fragilidade do vínculo no que concerne a rotatividade dos profissionais, a objetivação do doente durante o atendimento e a não identificação de outras categorias profissionais, que não a médica, como integrantes do cuidado; e a potencialidade do mesmo a partir da acessibilidade, boa comunicação, e a disponibilização de incentivos (cesta básica e vale transporte). O terceiro está relacionado com a produção de sentidos quanto a modalidade de supervisão do tratamento e a regulação de autonomia do doente, visto tanto como fragilidade quanto como potencialidade. E como quarto bloco discursivo, o empoderamento foi identificado como um sentido circulante para continuidade do tratamento, sendo mediado pelo próprio sujeito por meio da internet ou como uma necessidade durante as consultas clínicas ou em visitas domiciliárias. Acreditamos que a compreensão desse processo pela perspectiva do doente com o aporte do referencial da análise de discurso trouxe subsídios importantes para a prática profissional com foco para qualificação do cuidado aos adoecidos por tuberculose
Tuberculosis is considered a major problem in global health, being the second cause of death among infectious diseases having as a priority for its control early diagnosis and proper treatment, and requiring a care network able to preserve the continuity of care. Among the types of continuity, we have the relational implying the continued contact between the user and services, with a sense of responsibility towards the patient, giving care sustainability over time. Therefore, the French pattern of discourse analysis, in this context, becomes an important theoretical and methodological framework able to understand the elements of the continuity presents in the patient\'s discourse. This study aimed to analyze the discourse of the patient about the continuity of care during his treatment. This is a research with qualitative and descriptive design approach. We held this research in one of the reference centers for care of tuberculosis in Ribeirão Preto, from July to September of 2014. The subjects of this were ten tuberculosis\' patients on directly observed treatment and/or clinical follow up in this reference center. For data collection we conducted depths interviews scheduled. This study was approved by the Ethics in Research Committee of the College of Nursing of Ribeirão Preto, being respected the ethical principles as recommendations contained in Resolution No. 466/2012 of the National Health Council. Data analysis was carried out through the theoretical and methodological framework of the French pattern of discourse analysis, and eight interviews were used in order to contemplate the purpose of this study. To establish the corpus for analysis, we identified four discursive blocks. The first is related to the production of meanings of the disease to the patient, they being cancer, aids, drug use, prison populations, isolation, \"bicho de sete cabeças\", the punitive character through religious discourse and the normality of illness by the health care professional. The second is related to production of meanings about the link between patients and healthcare professionals, related to the bond\'s weakness was the rotation of personnel, the objectification of the patient during care and the failure to identify other professions, not just medical, as care members; and the potential of it was the accessibility, good communication, and the provision of incentives (food basket and transportation vouchers). The third is associated with the production of meanings related to treatment supervisory mode and regulation of patient autonomy, seen as both fragility and potentiality. And as the fourth discursive block, empowerment has been identified as a current sense for continuity of care, being mediated by the subjects themselves through the Internet or as a necessity during clinic visits or home visits. We believe that understanding this process by the patient\'s perspective with the contribution of discourse analysis framework has brought important benefits for professional practice focused in qualification of care to diseased with tuberculosis

Profesionalna infektivna oboljenja nastaju kao posledica izloženosti mikroorganizama u radnoj sredini. Cilj ovog istraživanja je utvrđivanje vrsta profesionalnih štetnosti koje dovode do profesionalnih infektivnih oboljenja i njihove incidencije u privrednim delatnostima Autonomne Pokrajine Vojvodine, kao i predloga adekvatnih mera za njihovu prevenciju. Profesionalna infektivna oboljenja su činila 13,4% od ukupno 464 slučaja utvrđenih profesionalnih oboljenja u Autonomnoj Pokrajini Vojvodini u toku dvadesetogodišnjeg perioda od 1992. do 2011. godine. Od ukupno utvrđenih 62 slučaja profesionalnih infektivnih oboljenja dve trećine su činili profesionalni virusni hepatitisi, 31% profesionalne antropozoonoze i 3% profesionolana tuberkuloza. Dve trećine obolelih od profesionalnih infektivnih bolesti bile su osobe ženskog pola što je statistički značajno više u poređenju sa osobama muškog pola, dok su zaposleni muškog pola činili 57%, a ženskog 43% ukupno zaposlenih na teritoriji Vojvodine. Najčešća profesionalna infektivna oboljenja bila su virusni hepatits B 52%, kju groznica 18%, virusni hepatitis C 15%, lajmska bolest 6%, leptospiroza 5%. Utvrđeno je da je došlo do statistički značajnog sniženja incidencije profesionalnog virusnog hepatitisa B uperiodu nakon donošenja odluke o obaveznoj imunizaciji 2002. godine, sa 6,27 na 1,35 na 100.000 zaposlenih, dok nije bilo statistički značajne razlike kada je u pitanju incidencija virusnog hepatitisa C. Profesionalna infektivna oboljenja su u više od dve trećine slučajeva registrovana kod zdravstvenih radnika (69%) sa prosečnom incidencijom od 5,18 na 100.000 zaposlenih, znatno niža bila je incidencija u proizvodnji prehrambenih proizvoda (1,36) i poljoprivredi sa lovom, ribolovom i šumarstvom (1,11). Nešto više od trećine radnika bilo je privremeno nesposobno za rad u toku utvrđivanja profesionalnog oboljenja, jer je lečenje bilo u toku. Kod ovih radnika značajno je naknadno oceniti radnu sposobnost i utvrditi eventualne posledice oboljenja. Pored primene specifičnih mera imunizacije ukoliko postoje, kao i ličnih mera zaštita koje sprečavaju kontakt sa uzročnicima, značajno je sprovođenje edukacije radnika o rizicima i preventivnih lekarskih pregleda radi rane identifikacije obolelih radnika.
Occupational communicable diseases are caused by exposure to microorganism’s in working environment. The aim of this study is to determine the types of occupational hazards that lead to occupational communicable diseases and their incidence in the economic activities of the Autonomous Province of Vojvodina, as well as the proposal of adequate measures for their prevention. Occupational communicable diseases accounted for 13.4% of the total of 464 cases of occupational diseases identified in the Autonomous Province of Vojvodina during the twenty-year period from 1992 to 2011. In the total of 62 identified cases of occupational communicable diseases, occupational viral hepatitis accounted for two-thirds, occupational anthropozoonoses for 31%, occupational tuberculosis for 3%. Two-thirds of patients with occupational communicable diseases were females, significantly more compared to male, while male accounted for 57% and female for 43% of the total employees in Vojvodina. The most frequent occupational communicable diseases were viral hepatitis B 52%, Q fever 18%, viral hepatitis C 15%, Lyme disease 6%, leptospirosis 5%. It was found that there was a statistically significant decrease in the incidence of occupational viral hepatitis B in the period after the decision on obligatory immunization in 2002, from 6.27 to 1.35 per 100,000 employees, while there were no statistically significant differences in the incidence of viral hepatitis C. In more than two-thirds of the cases occupational communicable diseases were registered in health care workers (69%) with the average incidence of 5.18 per 100,000 employees, substantially lower the incidence was in the production of food (1.36), as well as in agriculture, hunting, fishing and forestry (1.11). Just over a third of workers were temporarily unable to work during the verification of occupational disease due to the ongoing treatment. In these workers it is important to assess working ability afterwards and identify the possible consequences of the disease. In addition to the application of specific measures of immunization if any available, as well as personal protection measures that prevent contact with pathogens it is important to implement risk education of workers and preventive medical examinations for early identification of affected employees.

碩士
臺北醫學大學
醫務管理學系
94
The Bureau of National Health Insurance (BNHI) implemented the pay-for-quality demonstration program in November 2001, targeting tuberculosis, breast cancer, cervical cancer, asthma, and diabetes. The aim of the program is to encourage health care organizations to adopt the strategy of disease management by assembling healthcare teams as to to improve the medical care outcomes of patients with the aforementioned chronic diseases. And the key successful factor of disease management is to establish a case management model. The purposes of this study were to investigate the current state of tuberculosis patient management in Taiwan’s hospitals, and identify components of tuberculosis case management models. Furthermore, the impact of hospital characteristics on the inclusion of various tuberculosis case management model components was analyzed. Using the 2001-2004 hospital accreditation data, the study population comprised 492 district hospitals or above in Taiwan, after excluding those hospitals that were no longer in operation. People who were in charge of tuberculosis patient management in those hospitals were explicitly asked to respond to the survey. In early March 2006, self-administered questionnaires were mailed out to those identified hospitals. Two rounds of follow-up mailings were carried out. In the end, there were 388 questionnaires returned by late May, representing a 78.9% response rate. Among those questionnaires, there were 244 hospitals (62.9%) engaging in treating tuberculosis patients; however, four of them declined to participated in this survey further. As such, the final effective sample size was 240. Chi-squared test and logistic regression analysis were conducted to examine the impact of hospital characteristics on the adoption of tuberculosis case management models. The results showed that sample hospitals’ tuberculosis case management model components could be classified as: manpower allocation, admission management, data buildup, treatment management, nursing instruction, revisit management, and referral management. Inferential statistics results were as follows. (1). Manpower allocation – Hospital level was significantly related to if sample hospitals would employ full-time tuberculosis case managers (χ2 = 69.1, p < 0.001). Medical centers were more likely to designate full-time tuberculosis case managers. On the other hand, district hospitals tended to appoint part-time tuberculosis case managers instead. Moreover, the likelihood of those hospitals that enrolled in the tuberculosis pay-for-quality demonstration program appointing full-time tuberculosis case managers was as high as four times that of non-enrolled hospitals (OR = 4.29, p < 0.001). (2). Admission management - Hospital level was also significantly related to if sample hospitals would prescribe rules regarding admitting tuberculosis patients (χ2 = 19.9, p < 0.001). Medical centers were less likely to lay down such kind of rules, compared to their counterparts. (3). Data buildup - Hospital level was significantly related to methods of data buildup of sample hospitals as well (χ2 = 23.8, p < 0.001). District hospitals tended to use the tuberculosis patient database management system provided by the Center for Disease Control (CDC) of Taiwan, rather than design their own systems, compared to their counterparts. In addition, compared to non-enrolled hospitals, hospitals that enrolled in the tuberculosis pay-for-quality demonstration program were more likely to design their own tuberculosis patient database management systems, along with using the existing system of the CDC (OR = 2.49, p < 0.01). (4). Treatment management - The results showed that the possibility of if sample hospitals would create an ad hoc committee to be responsible for treating tuberculosis patients differed significantly by hospital level (χ2 = 52.3, p < 0.001). District hospitals were less likely to establish such a committee, among all. Furthermore, hospitals that enrolled in the tuberculosis pay-for-quality demonstration program were more likely to create such a committee, compared to their counterparts (OR = 3.82, p < 0.001). (5). Nursing instruction – The results revealed that hospital level was not significantly related to if sample hospitals would designate tuberculosis case managers in charge of related nursing instruction. However, hospitals that enrolled in the tuberculosis pay-for-quality demonstration program were more likely to set up specific nursing instruction places for tuberculosis patients than non-enrolled hospitals (OR＝4.04, p < 0.001). (6). Revisit management - Hospital level was significantly related to if sample hospitals would actively arrange revisits for their tuberculosis patients (χ2 = 14.2, p < 0.001). District hospitals were more likely to have revisit management, compared to their counterparts. (7). Referral management – Finally, hospital level was significantly related to if sample hospitals would carry out referral management for their tuberculosis patients as well (χ2 = 14.4, p = 0.001). Among all levels of hospitals, district hospitals were most likely to notify those responsible community public nurses when their tuberculosis patients were discharged. In conclusion, this study demonstrated that hospital characteristics did exert impact on the inclusion of various tuberculosis case management model components by hospitals. According to research findings, the following policy recommendations were proposed: (1). The government should systematically develop tuberculosis management manpower. (2). Hospital accreditation items should include manpower allocation with respect to tuberculosis case management. (3). The government should establish a comprehensive medical care network for treating tuberculosis patients. (4). The government should promote tuberculosis case management models aggressively. (5). Various tuberculosis patient database management systems need to be integrated to increase the accessibility for users. (6). The role played by community public health nurses should be enhanced regarding treating tuberculosis patients.

Introduction Tuberculosis (TB) is a major cause of death worldwide. Control of Tuberculosis is a serious challenge to global health. A new and potentially devastating threat to TB control is the emergence of multi-drug resistant TB (MDR-TB). South Africa was ranked fourth among the countries with the highest number of confirmed MDR-TB cases. Aim The aim was to investigate the annual MDR-TB prevalence and associated risk factors for MDR-TB from 2001 to 2007 at the Prince Cyril Zulu Communicable Disease Centre. To investigate previous TB treatment duration, previous TB treatment outcome, and duration of previous TB treatment interruption in a subgroup of patients who were previously treated for TB. To determine the average length of time from diagnosis of TB to diagnosis of MDR-TB and commencement of MDR-TB treatment. Methods An observational analytic nested case-control study design was used. All patients who were diagnosed with pulmonary TB and who had a sputum culture performed between 2001 and 2007 were included in the study. The cases were all MDR-TB cases diagnosed on sputum culture between 2001 and 2007. The controls were drug susceptible TB cases which had a sputum culture done at diagnosis, and were diagnosed in the same month as the MDR-TB case Results There were 10 205 sputum cultures performed from 2001 to 2007. MDR-TB was found in 445 patients. An increase in the prevalence of MDR-TB occurred in 2007, due to a significant increase in prevalence among new TB cases. The MDR-TB prevalence was 11.7% among new TB cases and 4.7% among previously treated TB cases in 2007. There was no significant association between demographic characteristics and MDR-TB. Previous TB treatment failure and a duration of previous TB treatment of greater than 32 weeks was found to be significantly associated with MDR-TB. The median time from TB diagnosis to MDR-TB diagnosis was 98 day and from MDR-TB diagnosis to MDR-TB treatment 10 days. Discussion Delays in the diagnosis of MDR-TB, long waiting times before MDR-TB treatment commencement and lack of isolation have contributed to the spread of primary MDR-TB and was most likely responsible for the increase in prevalence of MDR-TB among new TB cases. Recommendations It was suggested that a sputum specimen should be obtained for culture and sensitivity from all new TB patients in areas which have an MDR-TB prevalence of greater than 3% among new TB patients. Ensure patient education on basic infection control measures. Improve MDR-TB diagnosis and reduce waiting times for MDR-TB treatment.
Thesis (M.Med.Sc.)-University of KwaZulu-Natal, Durban, 2011.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in part fulfillment of the requirements for the degree of MSc (Med) (Pharmaceutical Affairs) Johannesburg, 25 March 2013
The emergence of resistant forms of tuberculosis (TB) has not only caused continuous challenges on the world populations’ health, but has also attracted increased costs of primary health care for the infected and society at large. In 2005, when the South African public came to learn about another resistant form of TB other than multi-drug resistant (MDR), 53 patients had just died in a rural hospital in KwaZulu-Natal (KZN). The reports (SA DoH, 2006) came to announce this form of TB as extreme drug resistant tuberculosis (XDR-TB).

Tuberculosis is a disease of global importance and remains the leading cause of death in the developing world. In South Africa a weak notification system and poor occupational health services for health care workers has resulted in little information being available about the incidence of tuberculosis and the groups at highest risk of contracting tuberculosis amongst health care workers, the clinical presentation and management of workers infected with tuberculosis. The purpose of this study was to describe the incidence of tuberculosis, and the clinical and public health aspects of the management of tuberculosis among health care workers in eight public sector hospitals in the Ethekwini Municipality of KwaZulu-Natal. Data was collected through a retrospective review of hospital records for the study period January 1999 to June 2004. Study findings: Five hundred and eighty three (N=583) health care workers were diagnosed with tuberculosis for the period under review. The mean age of the HCWs was 38 years (95% Cl: 37-39). The mean cumulative incidence for the study period was 1040/100 000 HCW population (95% Cl: 838-1242). The mean cumulative incidence of TB was highest in males (1544/100 000 HCW population; 95% Cl 1228 -1859), the age group 25 to 34 years (1043/100 000 HCW population; 95% CI: 650 -1436) and in paramedical staff (1675/100 000 HCW population; 95%CI: 880-2470). The majority of health care workers presented with pulmonary tuberculosis (77%, n=322) and 3% (n=13) had multidrug resistant tuberculosis. Successful treatment outcomes were achieved in 63% (n=334) of health care workers. Only one hospital has a work place policy with regard tuberculosis in health care workers. Compensation for this occupational disease was sought as follows. Submissions of a first medical report were made in 107 (18%) of the 583 health care workers. In the 107 cases initially reported submission of progress reports (n=75; 70%) and final reports (n=60; 56%) decreased considerably. In conclusion, the incidence of tuberculosis in health care workers has increased annually since 1999 and the treatment outcomes among health care workers do not reach the targets set by the National Tuberculosis Control Programme. Recommendations based on the study findings include establishing a uniform provincial policy for the prevention and reduction of tuberculosis infections among health care workers for implementation in hospitals; the implementation of a medical surveillance system for health care workers with respect to tuberculosis and a provincial training programme for staff on the clinical and administrative management of TB in health care workers.
Thesis (M.Med.)-University of KwaZulu-Natal, 2006.

This study examined healthcare providers’ adherence to the national Tuberculosis guidelines (NTG) during the diagnosis and treatment of TB in Addis Ababa, Ethiopia using a descriptive, cross-sectional study design. Data were collected from 233 medical records using checklists. Adherence of healthcare providers to the NTG during the diagnosis of TB was 60.9% (n=67) for female and 56.1% (n=69) for male TB patients. However, 91.8% (n=101) female and 90.2% (n=111) male TB patients had been prescribed the correct numbers of anti-TB pills, complying with the NTG recommendations. There was an over-diagnosis of smear negative pulmonary Tuberculosis (PTB) as only 2.6% (n=2) of the 76 smear negative PTB patients were diagnosed correctly. Healthcare providers’ compliance with the NTG could be enhanced by providing appropriate in-service education, maintaining accurate records of all TB patients and providing supportive supervision to identify and address shortcomings.

碩士
元智大學
管理研究所
96
ABSTRACT Tuberculosis has become the emergent crisis which threaten global human health. Tuberculosis is still the most common and severe reported infectious disease with more than 10000 confirmed cases each year in recent 5 years in Taiwan. MDR-TB cases also increase steadily and make the treatment more difficult. Except from patient’s drug compliance , health education still play an import role. This study is to analyze medical staff’s knowledge attitude and behavior pattern toward tuberculosis in a TB special hospital and to explore the differences between each different medical group. This study collected 329 questionaires from 350 pieces with 324 effective samples obtained during 2008-2-13 till 2008-2-21. The result reveal attitude is interrelated to behavior and knowledge. Behavior is not related to knowledge. Data also show knowledge is related to gender, career age, department, nursing degree and training time. Attitude is related to age, marital status and nursing degree. Behavior is not related to any factor.The data also show the resign of medical personnel is related to the care of tuberculosis patient, about 43.5% families will persuade medical staff to resign or transfer to other wards if possible. This study can provide the present role playing of tuberculosis care by different medical staff, which can guide the training program design and promote care quality. Keywords：medical personnel ,Pulmonary Tuberculosis, Knowledge,Attitudes,behaviors

碩士
長榮大學
職業安全與衛生研究所
97
The contagious prevention system of tuberculosis has been changed in the recent years. Tuberculosis patients are admitted to the general hospital for treatment. Therefore the medical personnel in the general hospital, exposing in the environment of biological harm high risk of committing tuberculosis infection. If staffs in the hospitals have enough knowledge and are fully aware of tuberculosis, they can minimize the risk of being infected. The objective of this research is to study the risk of tuberculosis infection among staffs in the process of caring the patients. The present phase of the research is conducting questionnaire survey. 408 copies of questionnaires were collected from 14 hospitals that provided treatment to tuberculosis infected patients. The main subject of the questionnaire is the fundamental knowledge of tuberculosis, its infection path, treatment methods etc.The survey results can illustrate a general picture regarding with effectiveness of the present training program provided for the medical personnel in the hospital. The results of survey show the following picture: The order of different ranks from high to low is physician assistants, doctors, technologist, and radiologist. In addition, the cognition of tuberculosis for staffs in tuberculosis specialized hospital is higher than staffs in non tuberculosis specialized hospital in term of statistical significance.

Text in English
Aim: The aims of this study were to investigate the treatment outcomes of patients with MDRTB and its determinants at referral hospitals in Ethiopia. The study also aims to develop a conceptual model for enhancing treatment of patients with MDR-TB in Ethiopia. Design and methods: A concurrent mixed methods design with quantitative dominance was used to investigate treatment outcomes of patients with MDR-TB and its determinants. Results: A total of 136 (n=136) patients with MDR-TB participated in the study, 74 (54%) were male and 62 (46%) were female. Forty-one (31%) of the patients had some co-morbidity with MDR-TB at baseline, and 64% had body mass index less than 18.5kg/m2. Eight (6%) of the patients were diagnosed among household contacts. At 24 months, 76/110 (69%) of the patients had successfully completed treatment, but 30/110 (27%) were died of MDR-TB. Multivariable logistic regression revealed that the odds of unfavourable treatment outcomes were significantly higher among patients with low body mass index (BMI <18.5kg/m2) (AOR=2.734, 95% CI: 1.01-7.395; P<0.048); and those with some co-morbidity with MDR-TB at the baseline (AOR=4.260, 95%CI: 1.607-11.29; p<0.004). The majority of the patients were satisfied with the clinical care they received at hospitals. But as no doctor was exclusively dedicated for the MDR-TB centre, patients could not receive timely medical attention and this was especially the case with those with emergency medical conditions. The caring practice of caregivers at the hospitals was supportive and empathic but it was desperate and alienating at treatment follow up centres. Patients were dissatisfied with the quality and adequacy of the socio-economic support they got from the programme. Despite the high MDR-TB and HIV/AIDS co-infection rate, services for both diseases was not available under one roof. Conclusions: Low body mass index and the presence of any co-morbidity with MDR-TB at the baseline are independent predictors of death among patients with MDR-TB. Poor communication between patients and their caregivers and inadequate socio-economic support were found to determine patients’ perceived quality of care and patients’ satisfaction with care given for MDR-TB.
Health Studies
D. Litt et Phil. (Health Studies)

American tuberculosis sanitarium architecture developed largely from trends set by European health spas and sanitarium design. The first American tuberculosis sanitariums largely resembled European health spas and resorts and catered to rich clientele. The spread of the White Plague, however, urged American states to develop sanitarium institutions that could provide for all classes. These first sanitariums melded nineteenth century resort architecture with radial prison designs and Kirkbride insane asylums to create large hospital complexes devoted exclusively to tuberculosis treatment and research. By the 1920s and 1930s, the European modernist movement had created modern tuberculosis sanitariums that inspired American sanitarium design. Despite the important role these institutions played in curing consumptives and limiting the spread of the White Plague, the increased use of drug therapy made sanitariums obsolete by the 1970s. Today, many of these sanitariums have been abandoned, demolished, or rehabilitated for new uses.
History of the disease -- The European and American health spa movements -- The development of the European sanitarium movement -- The development of the American sanitarium movement -- The American sanitarium movement : borrowing from European modernist innovation.
Department of Architecture

Submitted in fulfillment of the requirements for the degree of Master’s of Technology: Radiography, Durban University of Technology, Durban, South Africa, 2015.
Introduction Tuberculosis remains a leading cause of death, second to the Human Immunodeficiency Virus. The risk of latent tuberculosis infection and active tuberculosis disease is a known occupational hazard. In South Africa, a high tuberculosis burden country, the potential of Mycobacterium tuberculosis transmission to health care workers is high. This includes diagnostic radiographers and other radiology staff working in radiology departments. Purpose of the Study This study aimed to investigate the association of demographic and occupational factors with latent tuberculosis infection in radiology staff in public sector hospitals of the eThekwini Health District. Methodology This cross-sectional study was conducted from 26 February 2013 to 07 June 2013. Quantitative methods were used to test for associations of demographic and occupational factors with latent tuberculosis infection in participants. A sample size of 181 participants for an estimated population of 340 radiology staff was recommended at the proposal stage. The study consisted of two phases; the questionnaire survey (phase one) and the administration of a two-step tuberculin skin test (phase two). Data was obtained with regard to demographics, occupational history, social behaviours, medical history; and family and home histories. Demographic and occupational associations with latent tuberculosis infection were made in relation to the size of the first tuberculin skin test induration. Frequency distributions were developed to describe data categories. Pearson’s and Spearman rho’ correlation coefficients were used to test for correlations between the independent variables. The chi-square test was used to determine associations between the categorical independent variables and the dependent variable. Bivariate analyses were performed using these tests. The multivariate analysis was performed using logistic and linear regression on the dependent variable. Results A total of 182 questionnaires were returned from approximately 280 radiology staff. At the outset, all doctors working in the radiology department had to be excluded due to numerous failed attempts to enlist their participation. Fifty-three (29.12 percent) participants were excluded from phase one of the study and a further thirteen participants were excluded from phase two. The total sample was 116 participants. Of the 116 participants, 86.2 percent tested positive for latent tuberculosis infection at the first step of the two-step testing method used. One (0.86 percent) participant went on to convert at the second step, testing positive at this level. Demographic associations with latent tuberculosis infection included age (older) as an associated factor. A significant demographic association with latent tuberculosis infection was the use of alcohol (p-value 0.033 on the multivariate analysis). Occupational associations with latent tuberculosis infection included longer durations of employment. The annual income (higher income earners) displayed significant associations with latent tuberculosis infection (p-value 0.048 on the multivariate analysis). It is necessary in this study to note that participants include support personnel (lower income earners) making up 37.8 percent of the study, diagnostic radiographers making up 48.3 percent; and radiography managers/assistant managers (highest income earners) making up 13.8 percent of the study. Conclusion and recommendations The risk of transmission of Mycobacterium Tuberculosis to health care workers is a known occupational hazard. This study has described the prevalence of latent tuberculosis infection in radiology staff, at district and regional hospitals within the eThekwini Health District. With 23.62 percent of all participants already having active TB disease and 86.2 percent of the tested group displaying positive results for latent tuberculosis infection, using the tuberculin skin tests, the need for tuberculosis screening is essential. The findings of this study will be used as a health improvement mechanism for stakeholders, having identified potential gaps in medical screening in healthcare in Kwa-Zulu Natal. This study makes recommendations for the early detection of active tuberculosis infection and the monitoring of health care workers that are latently infected, thus assisting in reducing the rate of conversion of latent tuberculosis infection to active tuberculosis disease in radiology staff. This reduces long-term exorbitant costs related to health care associated infections, such as tuberculosis. It also reduces rates of transmission and cross infection to both co-workers and already immunocompromised patients, helping to curb the overall epidemic in South Africa.

碩士
臺北醫學大學
全球衛生暨發展碩士學位學程
104
BACKGROUND : Multi drug-resistant tuberculosis (MDR TB) is a major global health problem. The World Health Organization (WHO) estimated that approximately half a million cases emerge every year. Several studies revealed that health care workers are at risk of being transmitted the disease at health care facilities. However, the risk of transmission can be minimized if health care workers have a good knowledge of the communicable disease and proper attitudes and practices when giving treatment and providing health services to patients. AIM : This study aims to determine the level of knowledge, attitudes and practices on multi drug-resistant tuberculosis among the health care workers at Zainoel Abidin General Hospital (a tertiary referral hospital) and Cut Nyak Dhien General Hospital (a secondary hospital) in Aceh, and to assess the association between the demographic characteristics and the levels of knowledge, attitudes and practices of the health care workers. SETTING : The research was conducted from August 2015-October 2015 in two general hospitals in Aceh Province, Indonesia - Zainoel Abidin Hospital in Banda Aceh City and Cut Nyak Dhien Hospital in West Aceh District. DESIGN AND METHODS : This cross-sectional study used a questionnaire survey to assess MDR TB-related knowledge, attitudes, and practices (KAP) among health care workers (HCWs). Data were collected using a simple-structured questionnaire, which was compiled from the KAP-survey guide from the WHO, and also adapted from other similar studies. A consent form was given to the participants before they filled out the questionnaire. A multivariate logistic regression model was used to determine the correlation between KAP and participants’ characteristics. RESULTS : A total of 214 HCWs were enrolled in this study; 126 HCWs were from Zainoel Abidin Hospital and 88 HCWs were from Cut Nyak Dhien Hospital. There were 34 doctors and 180 nurses. The KAP levels of doctors in Zainoel Abidin Hospital and Cut Nyak Dhien Hospital were not significantly different. The multivariate logistic regression analysis showed that nurses in Zainoel Abidin Hospital had better knowledge levels on MDR TB (OR=4.2, p<0.01) and attitudes (OR=3.6, p<0.01) when compared to nurses in Cut Nyak Dhien hospital. Moreover, nurses with a bachelor degree or higher had better levels of knowledge (OR=3.46, p<0.01) and attitudes (OR=2.23, p<0.01) than those with a diploma. Other demographic characteristics such as age, gender, department, and work period were not significantly associated with the KAP level of the participants. CONCLUSIONS : Nurses at Zainoel Abidin Hospital had better levels of knowledge and attitudes on MDR TB in comparison to nurses at Cut Nyak Dhien Hospital. In addition, nurses with higher levels of education possessed better knowledge and attitudes of MDR TB. Further study is needed to collect more samples from doctors.

INTRODUCTION: Providing sufficient quality nurses in resource strapped countries is a human resource management challenge which nurse managers’ experience on a daily basis. THE PURPOSE of this study was to analyse and to determine the issues which affect the the human resources management of nurse managers in selected hospitals in the eThekwini District of the Province of KwaZulu-Natal, South Africa, and to formulate draft guidelines to assist nurse managers with human resource management. METHODOLOGY: A constructionist, reflexive ethnographic approach was used. The ethnographer spent two years in the field collecting data from informants, who were nurse managers, in four (4) selected district hospitals. Data was collected using unstructured informant interviews, non-participant observation and confirmatory document analysis. Data analysis led to eliciting codes from the data, searching for semantic relationships, performing componential analyses and discovering the themes for discussion within the final ethnographic report. A nominal group process was used to develop the draft guidelines. FINDINGS: The findings showed that the human resources management around sick nurses is a complex task. The themes of nurse managers’ experiences were a “burden” of maintaining confidentiality, as well as an emotional burden. Administratively, they experience the burden of absenteeism and the burden of policy compliance. The final theme is the burden of the deaths of HIV and Tuberculosis affected/infected nurses. CONCLUSION AND RECOMMENDATIONS: Organizations should create a non-judgmental work environment where non- disclosure by employees is respected in order to promote disclosure. They should have an awareness of the emotional effect on nurse managers and provide them with support. Emphasis needs to be placed on an HIV and AIDS policy and programme, incapacity leave workplace strategies and return to work policies. It is also recommended that contingency plans be provided when the death or prolonged absence of an employee impacts the staffing of the organization; consideration to be given to piloting and refining the draft guidelines; the management of employees on prolonged sick leave be included in the Nursing Administration Curricula taught to future nurse managers; and further research be conducted to assess employee reluctance to report needle stick injuries (sharps injuries) as well as the related phenomenon of stigmatization.
Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2014.

The purpose of this study was to investigate the Isoniazid preventive therapy (IPT) initiation amongst eligible HIV positive patients at health facilities in the Polokwane subdistrict to identify key features in the knowledge and practice of health professionals as well as available resources at the health facilities. A quantitative non-experimental, descriptive, cross-sectional design was used to describe the practice of IPT initiation in health facilities. Data were collected using a structured questionnaire with medical doctors, operational managers and registered nurses from the district’s 34 health care facilities. The census sample was 124. Data were captured and analysed using Statistical Package for the Social Sciences (SPSS) Version 24. The results showed that the health care professionals knew the policy and procedures for the implementation of IPT but lacked knowledge on patient screening. The findings further suggest that record keeping and data capturing was not implemented sufficiently. Resources at the facilities were found to be sufficient.
Health Studies
M. P. H.

The purpose of this study is to explore and describe the knowledge, attitudes and experiences of health care workers who care for patients receiving treatment under DOTS strategy at public health facilities in the Windhoek District of the Khomas Region. A qualitative explorative, descriptive and contextual research design was used in this study. A purposive sampling was used to select participants who met the inclusion criteria for the study. The inclusion criteria was to be a health care worker who at the time of the study was working with patients who are on DOT for at least 6 months. A semi-structured interview guide was used to collect data. The study was conducted in the Windhoek district of the Khomas region, with a sample of 14 health care workers. Data was analysed by means of content analysis, a process of organizing and integrating narrative, qualitative data according to emerging themes and concepts. The three themes, which emerged from data analysis, were the knowledge of health care workers regarding the implementation of DOTS, the attitudes of health care workers towards patients on DOT which may affect the success of their treatments, and the experiences of health care workers when attending to patients on DOTS. The findings from the study may be used to engage stakeholders to address the shortcomings that exist in the implementation of the DOTS strategy in the district.
Health Studies
M.A. (Nursing Science)