Background:There is increasing evidence that the substantial global burden of disease for tuberculosis unfolds in concert with dimensions of common mental disorders.Person-centred care holds much promise to ameliorate...Background:There is increasing evidence that the substantial global burden of disease for tuberculosis unfolds in concert with dimensions of common mental disorders.Person-centred care holds much promise to ameliorate these comorbidities in low-to-middle income countries(LMICs)and emerging economies.Towards this end,this paper aims to review 1)the nature and extent of tuberculosis and common mental disorder comorbidity and 2)person-centred tuberculosis care in low-to-middle income countries and emerging economies.Main text:A scoping review of 100 articles was conducted of English-language studies published from 2000 to 2019 in peer-reviewed and grey literature,using established guidelines,for each of the study objectives.Four broad tuberculosis/mental disorder comorbidities were described in the literature,namely alcohol use and tuberculosis,depression and tuberculosis,anxiety and tuberculosis,and general mental health and tuberculosis.Rates of comorbidity varied widely across countries for depression,anxiety,alcohol use and general mental health.Alcohol use and tuberculosis were significantly related,especially in the context of poverty.The initial tuberculosis diagnostic episode had substantial sociopsychological effects on service users.While men tended to report higher rates of alcohol use and treatment default,women in general had worse mental health outcomes.Older age and a history of mental illness were also associated with pronounced tuberculosis and mental disorder comorbidity.Person-centred tuberculosis care interventions were almost absent,with only one study from Nepal identified.Conclusions:There is an emerging body of evidence describing the nature and extent of tuberculosis and mental disorders comorbidity in low-to-middle income countries.Despite the potential of person-centred interventions,evidence is limited.This review highlights a pronounced need to address psychosocial comorbidities with tuberculosis in LMICs,where models of person-centred tuberculosis care in routine care platforms may yield promising outcomes.展开更多
Background:Despite progress towards End TB Strategy targets for reducing tuberculosis(TB)incidence and deaths by 2035,South Africa remains among the top ten high-burden tuberculosis countries globally.A large challeng...Background:Despite progress towards End TB Strategy targets for reducing tuberculosis(TB)incidence and deaths by 2035,South Africa remains among the top ten high-burden tuberculosis countries globally.A large challenge lies in how policies to improve detection,diagnosis and treatment completion interact with social and structural drivers ofTB.Detailed understanding and theoretical development of the contextual determinants of problems inTB care is required for developing effective interventions.This article reports findings from the pre-implementation phase of a study ofTB care in South Africa,contributing to HeAlth System StrEngThening in Sub-Saharan Africa(ASSET)-a five-year research programme developing and evaluating health system strengthening interventions in sub-Saharan Africa.The study aimed to develop hypothetical propositions regarding contextual determinants of problems inTB care to inform intervention development to reduce TB deaths and incidence whilst ensuring the delivery of quality integrated,person-centred care.Methods:Theory-building case study design using the Context and Implementation of Complex Interventions(CICI)framework to identify contextual determinants of problems in TB care.Between February and November 2019,we used mixed methods in six public-sector primary healthcare facilities and one public-sector hospital serving impoverished urban and rural communities in the Amajuba District of KwaZulu-Natal Province,South Africa.Qualitative data included stakeholder interviews,observations and documentary analysis.Quantitative data included routine data on sputum testing andTB deaths.Data were inductively analysed and mapped onto the seven CICI contextual domains.Results:Delayed diagnosis was caused by interactions between fragmented healthcare provision;limited resources;verticalised care;poorTB screening,sputum collection and record-keeping.One nurse responsible forTB care,with limited integration ofTB with other conditions,and policy focused on treatment adherence contributed to staff stress and limited consideration of patientsz psychosocial needs.Patients were lost to follow up due to discontinuity of information,poverty,employment restrictions and limited support for treatment side-effects.Infection control measures appeared to be compromised by efforts to integrate care.Conclusions:Delayed diagnosis,limited psychosocial support for patients and staff,patients lost to follow-up and inadequate infection control are caused by an interaction between multiple interacting contextual determinants.TB policy needs to resolve tensions between treating TB as epidemic and individually-experienced social problem supporting interventions which strengthen case detection,infection control and treatment,and also promote person-centred support for healthcare professionals and patients.展开更多
Objective To analyse temporal trends in diagnosis and treatment of mental disorders in primary care following implementation of a collaborative care intervention(matrix support).Design Dynamic cohort design with retro...Objective To analyse temporal trends in diagnosis and treatment of mental disorders in primary care following implementation of a collaborative care intervention(matrix support).Design Dynamic cohort design with retrospective time-series analysis.Structured secondary data on medical visits to general practitioners of all study clinics were extracted from the municipal electronic records database.Annual changes in the odds of mental disorders diagnoses and antidepressants prescriptions were estimated by multiple logistic regression at visit and patient-year levels with diagnoses or prescriptions as outcomes.Annual changes during two distinct stages of the intervention(stage 1 when it was restricted to mental health(2005-2009),and stage 2 when it was expanded to other areas(2010-2015))were compared by adding year-period interaction terms to each model.Setting 49 primary care clinics in the city of Florianópolis,Brazil.Participants All adults attending primary care clinics of the study setting between 2005 and 2015.Results 3131983 visits representing 322100 patients were analysed.At visit level,the odds of mental disorder diagnosis increased by 13%per year during stage 1(OR 1.13,95%CI 1.11 to 1.14,p<0.001)and decreased by 5%thereafter(OR 0.95,95%CI 0.94 to 0.95,p<0.001).The odds of incident mental disorder diagnoses decreased by 1%per year during stage 1(OR 0.99,95%CI 0.98 to 1.00,p=0.012)and decreased by 7%per year during stage 2(OR 0.93,95%CI 0.92 to 0.93,p<0.001).The odds of antidepressant prescriptions in patients with a mental disorder diagnosis increased by 7%per year during stage 1(OR 1.07,95%CI 1.05 to 1.20,p<0.001);this was driven by selective serotonin reuptake inhibitor prescriptions which increased 14%per year during stage 1(OR 1.14,95%CI 1.12 to 1.18,p<0.001)and 9%during stage 2(OR 1.09,95%CI 1.08 to 1.10,p<0.001).The odds of incident antidepressant prescriptions did not increase during stage 1(OR 1.00,95%CI 0.97 to 1.02,p=0.665)and increased by 3%during stage 2(OR 1.03,95%CI 1.00 to 1.04,p<0.001).Changes per year were all significantly greater during stage 1 than stage 2(p values for interaction terms<0.05),except for antidepressant prescriptions during visits(p=0.172).展开更多
文摘Background:There is increasing evidence that the substantial global burden of disease for tuberculosis unfolds in concert with dimensions of common mental disorders.Person-centred care holds much promise to ameliorate these comorbidities in low-to-middle income countries(LMICs)and emerging economies.Towards this end,this paper aims to review 1)the nature and extent of tuberculosis and common mental disorder comorbidity and 2)person-centred tuberculosis care in low-to-middle income countries and emerging economies.Main text:A scoping review of 100 articles was conducted of English-language studies published from 2000 to 2019 in peer-reviewed and grey literature,using established guidelines,for each of the study objectives.Four broad tuberculosis/mental disorder comorbidities were described in the literature,namely alcohol use and tuberculosis,depression and tuberculosis,anxiety and tuberculosis,and general mental health and tuberculosis.Rates of comorbidity varied widely across countries for depression,anxiety,alcohol use and general mental health.Alcohol use and tuberculosis were significantly related,especially in the context of poverty.The initial tuberculosis diagnostic episode had substantial sociopsychological effects on service users.While men tended to report higher rates of alcohol use and treatment default,women in general had worse mental health outcomes.Older age and a history of mental illness were also associated with pronounced tuberculosis and mental disorder comorbidity.Person-centred tuberculosis care interventions were almost absent,with only one study from Nepal identified.Conclusions:There is an emerging body of evidence describing the nature and extent of tuberculosis and mental disorders comorbidity in low-to-middle income countries.Despite the potential of person-centred interventions,evidence is limited.This review highlights a pronounced need to address psychosocial comorbidities with tuberculosis in LMICs,where models of person-centred tuberculosis care in routine care platforms may yield promising outcomes.
基金funded by the National Institute for Health Research(NIHR)Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa,King's College London(GHRU 16/136/54)using UK aid from the UK Government to support global health research.The views expressed in this publication are those of the author(s)and not necessarily those of the NIHR or the Department of Health and Social Care.
文摘Background:Despite progress towards End TB Strategy targets for reducing tuberculosis(TB)incidence and deaths by 2035,South Africa remains among the top ten high-burden tuberculosis countries globally.A large challenge lies in how policies to improve detection,diagnosis and treatment completion interact with social and structural drivers ofTB.Detailed understanding and theoretical development of the contextual determinants of problems inTB care is required for developing effective interventions.This article reports findings from the pre-implementation phase of a study ofTB care in South Africa,contributing to HeAlth System StrEngThening in Sub-Saharan Africa(ASSET)-a five-year research programme developing and evaluating health system strengthening interventions in sub-Saharan Africa.The study aimed to develop hypothetical propositions regarding contextual determinants of problems inTB care to inform intervention development to reduce TB deaths and incidence whilst ensuring the delivery of quality integrated,person-centred care.Methods:Theory-building case study design using the Context and Implementation of Complex Interventions(CICI)framework to identify contextual determinants of problems in TB care.Between February and November 2019,we used mixed methods in six public-sector primary healthcare facilities and one public-sector hospital serving impoverished urban and rural communities in the Amajuba District of KwaZulu-Natal Province,South Africa.Qualitative data included stakeholder interviews,observations and documentary analysis.Quantitative data included routine data on sputum testing andTB deaths.Data were inductively analysed and mapped onto the seven CICI contextual domains.Results:Delayed diagnosis was caused by interactions between fragmented healthcare provision;limited resources;verticalised care;poorTB screening,sputum collection and record-keeping.One nurse responsible forTB care,with limited integration ofTB with other conditions,and policy focused on treatment adherence contributed to staff stress and limited consideration of patientsz psychosocial needs.Patients were lost to follow up due to discontinuity of information,poverty,employment restrictions and limited support for treatment side-effects.Infection control measures appeared to be compromised by efforts to integrate care.Conclusions:Delayed diagnosis,limited psychosocial support for patients and staff,patients lost to follow-up and inadequate infection control are caused by an interaction between multiple interacting contextual determinants.TB policy needs to resolve tensions between treating TB as epidemic and individually-experienced social problem supporting interventions which strengthen case detection,infection control and treatment,and also promote person-centred support for healthcare professionals and patients.
基金the Research Committee of the Municipal Secretary of Health of Florianópolis and by the Brazilian National Research Ethics Committee(reference number 25748313.7.0000.0118).
文摘Objective To analyse temporal trends in diagnosis and treatment of mental disorders in primary care following implementation of a collaborative care intervention(matrix support).Design Dynamic cohort design with retrospective time-series analysis.Structured secondary data on medical visits to general practitioners of all study clinics were extracted from the municipal electronic records database.Annual changes in the odds of mental disorders diagnoses and antidepressants prescriptions were estimated by multiple logistic regression at visit and patient-year levels with diagnoses or prescriptions as outcomes.Annual changes during two distinct stages of the intervention(stage 1 when it was restricted to mental health(2005-2009),and stage 2 when it was expanded to other areas(2010-2015))were compared by adding year-period interaction terms to each model.Setting 49 primary care clinics in the city of Florianópolis,Brazil.Participants All adults attending primary care clinics of the study setting between 2005 and 2015.Results 3131983 visits representing 322100 patients were analysed.At visit level,the odds of mental disorder diagnosis increased by 13%per year during stage 1(OR 1.13,95%CI 1.11 to 1.14,p<0.001)and decreased by 5%thereafter(OR 0.95,95%CI 0.94 to 0.95,p<0.001).The odds of incident mental disorder diagnoses decreased by 1%per year during stage 1(OR 0.99,95%CI 0.98 to 1.00,p=0.012)and decreased by 7%per year during stage 2(OR 0.93,95%CI 0.92 to 0.93,p<0.001).The odds of antidepressant prescriptions in patients with a mental disorder diagnosis increased by 7%per year during stage 1(OR 1.07,95%CI 1.05 to 1.20,p<0.001);this was driven by selective serotonin reuptake inhibitor prescriptions which increased 14%per year during stage 1(OR 1.14,95%CI 1.12 to 1.18,p<0.001)and 9%during stage 2(OR 1.09,95%CI 1.08 to 1.10,p<0.001).The odds of incident antidepressant prescriptions did not increase during stage 1(OR 1.00,95%CI 0.97 to 1.02,p=0.665)and increased by 3%during stage 2(OR 1.03,95%CI 1.00 to 1.04,p<0.001).Changes per year were all significantly greater during stage 1 than stage 2(p values for interaction terms<0.05),except for antidepressant prescriptions during visits(p=0.172).
