Towards an empowerment approach in tuberculosis treatment in Cape Town, South Africa: a qualitative analysis of programmatic change

Figures & data

Table 1. Comparison of the directly observed therapy (DOT) and enhanced tuberculosis adherence treatment programme (ETA)

DOT	ETA
Training: Standard nurse training for nurses, 5-day training for DOT supporters	Training: Additional 1 day induction to the ETA for nurses; additional 3-day induction to the programme for DOT supporters (now called treatment supporters); adherence counsellor training for ex-DOT supporters including 5 days of programme training and 5 days of counselling training
Patient is initiated onto directly observed therapy in the clinic (takes treatment once a day under supervision of the TB nurse)	Patient is placed on directly observed therapy in the clinic for a short period (takes treatment once a day under supervision of the TB nurse for approximately 2 weeks)
Mode of treatment delivery: directly observed therapy	Mode of treatment delivery: self administration at home with pill counts by treatment supporter
Short information session about TB, and its treatment given by the TB nurse	Trained lay adherence counsellor gives TB information to participant in 3–4 counselling sessions, of half an hour each, focusing on treatment education, side effects, healthy living and adherence planning, and TB and HIV
No visits are made routinely to patients’ homes	A treatment supporter conducts a home assessment in which the patient's home circumstances are documented and their address verified. TB contacts, immunocompromised persons and children under 5 in the household are also referred to the clinic for testing and vaccinations
No meeting of different roleplayers to discuss treatment support	Nurse, adherence counsellor and treatment supporter meet to discuss each patient's eligibility for self administration
Patient can receive DOT in the workplace, or by visiting a DOT supporter in the community	Patient can take treatment in the workplace, or at a clinic, but can also obtain a one-month supply of tablets from the clinic and self-supervise their treatment
Nurse sees patient at diagnosis, for DOT, for 2/3 month sputum and at the end of treatment	Nurse sees patient at diagnosis, DOT for 2 weeks and, if the patient is eligible for self-administration, once per month until end of treatment and for 2/3 month sputum and end of treatment sputum
If the patient is placed on community based DOT, s/he visits a treatment supporter once a day to receive treatment	A treatment supporter visits the patient three times in the first week and once a week thereafter to monitor treatment taking
No formal integration of family or friends into the treatment plan	Treatment ‘buddy’ has an important role – s/he attends counselling and acts as a support and reminder to the patient. The buddy can be a friend, family member or neighbour of the patient

Table 2. An example of the analysis methods

Meaning unit	Condensed meaning unit	Sub-theme	Theme	Kingdon stream
… depression that you'd sort of experience with health workers in key positions. And overburdened and, ja [yes], almost burnt out	Workers in facilities depressed, overburdened and burnt out	Staff overburdened and burnt out	Human resource constraints	Problem
I think we have actually empowered patients more. I think the roles and what the clinic is responsible for and what the patient is responsible for and whatever has been outlined a lot more clearly. And maybe we are doing away with that absolute dependence	Empowerment for patients, in terms of defined roles and responsibilities, and imparting knowledge	Empowering patients – information, roles and responsibilities	A community empowerment perspective	Solution
We've got more resources for what they want	Western Cape has more resources to change programmes	Western Cape has resources	A setting with considerable resources and interest in TB control	Politics
And we've got a long history of an interest in tuberculosis control. And if you look back in history there have been lots of people who have done very exciting research. And, ja [yes], I think it's a combination of those sort of factors	Western Cape has an interest in TB control	Western Cape has an interest

Fig. 1.  Timeline of key events in TB control in South Africa from 1995 to 2010. *No calculated incidence rate was available from the WHO. ART, Antiretroviral treatment; DOT, Directly Observed Therapy; DOTS, Directly Observed Therapy, Short Course; ETA, Enhanced Tuberculosis Adherence; HIV, Human immunodeficiency virus; TB, tuberculosis.

Table 3. Summary of main findings

Stream	Themes	Sub-themes
Problems	Management of the existing DOT programme	Overburdened clinics/rising caseloads/complex relations with the NGO/existing unsupervised treatment
	Mismatch between patient needs and the existing TB programme	Questioning the benefits of observation/DOT not implemented as planned
	TB–HIV co-epidemic changing the disease landscape	Close involvement of the two programmes/risk of infection/long waiting times/conflicting treatment models
Policies/solutions	A community empowerment perspective	Involving the patient/NGO participation
	Human resources	More skilled lay health workers/increased teamworking
	Improved management	Increased accountability/increased teamworking/decrease in workload for professional staff
Politics	Dissident province	History of academics, policymakers and practitioners resisting national policies/interactions between academics and service providers
	Need for services to adopt an empowerment approach	Empowerment as a national theme/workers rights/empowerment of lay health workers
	Community/lay health worker policy	Shift towards a generalist lay health worker approach/broader model of lay health workers providing TB, HIV and health promotion services
	The growing ART programme	Increasing rates of co-infection/political lobbying for attention to TB/sustainability and affordability of disease-specific interventions

Note: This table presents the main themes found during the analysis. Many of these themes are interdependent. Detail on each theme is found in the text.