There is debate over the effectiveness of directly observed treatment (DOT) for tuberculosis (TB). But is this argument too simplistic? Research co-ordinated by the Université Libre de Bruxelles in Belgium suggests that we should look instead at how to make DOT more patient-friendly.

TB treatment is long and involves taking a lot of drugs, even when the patient feels better. DOT is part of a five-pronged strategy promoted by the World Health Organisation (WHO) for TB treatment. According to the WHO: ‘the treatment provider – anyone who is willing, trained, responsible, acceptable to the patient and accountable to TB control services – watches patients take their medication’. The strategy may prevent the spread of multi-drug resistant TB, but opponents question its effectiveness and ethical soundness.

Researchers reviewed the recent research and interviewed 19 key stakeholders and more than 50 health workers from 26 countries attending a DOT course. They found that:

• DOT providers are healthcare professionals, community health workers or relatives of the patient. They are seen either as a ‘supervisor’ – implying control over the patient – or a ‘supporter’ – suggesting a closer, more trusting relationship.
• DOT can occur in TB clinics, TB hostels, hospitals, health centres or patients’ homes. When it is supplied through formal health services, the opportunity costs, opening hours and distance can make access difficult. Providing DOT at community level can increase stigma and make it hard to find support within the family.
• Implementation of DOT often involves a wider package of support, information and advocacy, plus incentives or enablers for TB patients or DOT providers.

The research reveals two progressive shifts. Medical professionals initially provided DOT in health institutions; now it is often given by lay people in the community. DOT used to be applied in a fairly rigid way; now in some situations it is increasingly tailored to the local context and needs of specific patients in order to make it more accessible and equitable.

The researchers recommend that policy-makers seeking to maximise the benefits from DOT programmes should:

• identify community DOT providers who are trusted by the National TB Programme but are also accepted and understood by the patient
• seek new and creative ways to make DOT more accessible to the most disadvantaged
• deliver resources to primary health services to enable decentralisation of treatment and more flexible and patient-centred DOT
• expand the debate beyond simplistic, bipolarised discussions about the effectiveness of DOT
• learn from experiences in the management of other chronic diseases.

Source(s):
‘An exploration of the concept of directly observed treatment (DOT) for tuberculosis patients: from a uniform to a customised approach’, International Journal of Tuberculosis and Lung Disease 7 (1): 1-7, by J. Macq et al., 2003

Funded by: European Union

id21 Research Highlight: 24 March 2003

Further Information:
Jean Macq
Ecole de Sante Publique
ULB, CP597
Route de Lennik, 808
1070 Bruxelles
Belgium

Tel: +32 2 555 4071
Fax: +32 2 555 4049
Contact the contributor: jmacq@ulb.ac.be

Universite Libre de Bruxelles

Liverpool School of Tropical Medicine (LSTM), UK

Other related links:
See id21's collection of links relevant to infectious diseases.