DIRECTLY OBSERVED TREATMENT, SHORT COURSE (DOTS) STRATEGY

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CHAPTER 3 CONCEPTUAL FRAMEWORK

INTRODUCTION

Chapter 2 presented literature review on TB, DOTS, PCC and its predictors, and patient satisfaction with possible predictors from different data bases. The review also shows the presence of limited information about DOTS strategy patient centeredness’ and TB patient satisfaction with DOTS strategy. Moreover, the review identified lack of PC-TB care model that can support TB care delivery particularly in the context of developing countries.
George (2010:4) describes that conceptual framework is a thought that could shape perceptions, reality and an enquiry. It is useful to identify how concepts and theories are related; and the propositions that explain the relationships between different and or similar concepts. According to Burns and Grove (2011:239), in every quantitative driven study, conceptual framework that guide and depict the interaction of variables is inevitable

REVIEW OF PCC FRAMEWORKS

The term PCC is often used in health literature at different times and is defined differently by authors. Redman (2004:11) describes PCC as caring for the patient as an inimitable individual and is also defined as a criterion of practice that demonstrates a respect for the patient as a person (Schaller 2007). PCC definition is, beyond the respect of the individual, a care that respect and take action to individual patient preferences, needs, values, and goals” (Greene et al 2012:49).
PCC focuses on considering the patient’s point of view, situations in the decision-making process and goes far beyond simply setting target with the patient. Most PCC descriptions and definitions’ core concept rotates on patient’s value. The patient’s value is considered as a goal of health care delivery with defined treatment outcome even with complex conditions. PCC is asserted as a care, which respects and reacts to individual patient preferences, needs, values and goals (Greene et al 2012:49).
In addition, PCC takes into account respect, compassion, concern, shared decision making and communication. It regards patients as a complete person with biological, psychological and social needs, thus PCC approach required to be an integrated part of the health care system (Pelzang 2010:913).
Patient-centeredness refers to an approach of health care provider-patient encounter explained by responsiveness to patient needs and preferences, using the patient’s informed wishes to guide activity, interaction and information-giving, and shared decision-making (Scholl, Zill, Harter & Dirmaier 2014:3).
Patient centeredness is supposed to improve the quality of patient care, reduce the cost of care, and increase satisfaction among HCP and patients through strengthening professional practice and maintaining the values of the patient and health care providers (Pelzang 2010:916). PCC offers a higher level of quality health care and improves patients health care experiences. Measuring its value adjusts risks that may face and used for relevant comparisons among the patients’ results, including comparisons of providers’ ability to care for patients (Porter 2010:2478).
Patient centeredness is one of the indicators used to measure quality of health service delivery (WHO 2008:14). Patient-centeredness is beyond quality indicator for low and middle-income countries, it is an essential component of quality health care. It is time to promote and optimise patient centeredness, beyond the micro scale interaction (HCP and patient communication), integration at the macro level (health care system) of both low and middle income countries to gearing up for universal health coverage (Mahendradhata, Souares, Phalkey & Sauerborn 2014:5).

Models and dimensions of PCC

At different times, different models and dimensions of PCC have been proposed and used. Mead & Bower (2002:60) propose Bio psychosocial perspective, patient-as-person, sharing power and responsibility, therapeutic alliance, and doctor-as-person as five dimensions of patient centeredness in health care setting.
The Picker Institute of Health identified and projected eight dimensions of PCC. The dimension included access; respect for patients’ values and preferences; coordination of care; information, communication and education; physical comfort; emotional support; involvement of friends and family; and preparation of discharge and transitions in care (Shaller 2013).
Similarly, the Institute of Medicine (IOM) in the United States has put in place six measurements: values and preferences; coordination of care; information, communication and education; physical comfort; emotional support; and involvement of friends and family (Little, Everitt, Williamson, Warner, Moore, Gould, Ferrier & Payne 2011:909).
In 2014, a systematic review and concept analysis on existing patient-centeredness model was done by Scholl et al (2014:5-6), as a result they propose an integrative model of patient-centeredness. The proposed model encompasses 15 dimensions of patient-centeredness classified into principles, enablers and activities. Acknowledged dimensions in principles are essential characteristics of clinician, clinician-patient relationship, clinician-patient communication, patient as a unique person and biopsychosocial perspective. Enablers are clinician-patient communication, integration of medical and non-medical care, teamwork and team building, access and coordination and continuity of care. The Provision of information to the patient, involving the patient and patient’s relative or friends to the degree that the patient prefers are considered activities that facilitate informed decision in PCC. Further, emotional and physical support with recognition and active support of the patient’s ability and responsibility to self-manage his or her disease are stated in the activity category of the dimension (Scholl et al 2014:5-6).
Although no universally accepted conceptual framework or model of PCC existed, health promotion, communication and partnership have been considered in the framework or a model across multiple areas of clinical practice to avail PCC (Constand, MacDermid, Dal Bello-Haas & Law 2014:7).
Researchers used different PCC models, which they considered appropriate for the representation of PCC for TB treatment. Provision of the TB treatment at home (Horter, Stringer, Reynolds, Shoaib, Kasozi, Casas, Verputten & Du Cros 2014:3), in the community (Gabriel & Mercado 2011:2178) and self-administering (Yen et al 2012:179) were considered the PCC intervention model for TB treatment by different scholars.
Moreover, provision of information, choice where to take treatment and enough time to patients and treatment supporter choice were also considered as components of PCC of TB treatment strategy (Mkopi et al 2013:3).
A study conducted in Tanzania on TB control programme, provision of choice where either HCPs or family member, types were considered as PCC intervention dimensions to DOTS strategy (Egwaga, Mkopi, Range, Haag-Arbenz, Baraka, Grewal, Cobelens, Mshinda, Lwilla & Van Leth 2009:3). Another study that assessed the level of internalised stigma and TB treatment outcome used TB patients’ home visit to increase power sharing between the health personnel and TB patients as an intervention of PCC provision (Macq, Solis, Martinez & Martiny 2008:2).
The concept of PCC is described in many ways. The term PCC described as consumer centred care to engage people as partners, in health sector this term seems active and aligns with clients (Silow-Carroll, Alteras & Stepnick 2006:10). Redman (2004:11) describes PCC as caring the patient as an inimitable individual. PCC is a criterion of practice that demonstrates a respect for the patient as a person (Schaller 2007:).
WHO uses the term ‘responsiveness’ in preference to ‘PCC’ to describe how a health care system meets people’s complaints. The response to the complaints is based on in recognised or acceptable rules, standards and ethical norm regarding respect for people and their wishes. In addition, the responses consider waiting time of patients and good communication between health workers and patients.
PCC focuses on considering the patient’s point of view and situations in the decision-making process and goes far beyond from simply setting a target with the patient (Ponte, Conlin, Conway, Grant, Medeiros, Nies, Shulman, Branowicki & Conley 2003:83). PCC is a care, which respects and reacts to individual patient preferences, needs, values and goals and considers a patient as a complete person with biological, psychological and social needs (Greene et al 2012:49).
Most PCC descriptions and definitions’ core concept rotates and focuses on patient’s value. Patient’s value is recommended to be a goal of health care delivery with defined treatment outcome even within a complex health conditions. PCC offers a higher level of quality health care and improves patient health care experiences. Measuring patients’ value adjusts risks and can be used for relevant comparisons among the patients’ results, including comparisons of providers’ ability to care for patients (Porter 2010:2478; Pelzang 2010:917).
The existed PCC models and frameworks which focus on individuals consider respect and values for patients’, preferences and expressed needs as a core notion (Gertels Edgman-Levitah, Daley & Debanco 1993; Piker Institute of Health 2001; WHO 2000), while the PCC frameworks that focus on system approach, consider structural, process, the outcome of HCO as components of the PCC (McCormack & McCane 2006).
The existence of organisational self-care and partner involvement scheme recognised as the axles that determine the patient centeredness of a care (Flarey 1995). Whereas, some of the PCC frameworks give high attention on the communication of HCP with the patients and HCPs’ characteristics to provide PCC by disregarding the technical competency of HCPs and convenience of the premise of HCOs (Jayadevappa & Chatter 2011:21; Greene et al 2012:50; Scholl et al 2014:7) without integrating and due attention to the outcome of the model and predictors of PCC.
Despite the similarity of the core concepts among the models and frameworks of PCC, it is difficult to get a single framework or model that could fit with TB care delivery at HCO due to lack of clarity and homogeneity of the existed PCC models toward TB care provision (Constand et al 2014:8). The details of the reviewed models and frameworks are described in Table 3.1.

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CONCEPTUAL FRAMEWORK OF THE STUDY

Considering the purpose and specific objectives of the study the following frameworks were selected: WHO’s people centred policy health care framework (WHO 2007:1-14) to guide patient centeredness of DOTS strategy and Donabedian’s quality of health care model (Donabedian 2005: 672-679) to guide TB patients’ satisfaction level.

People-centred health care policy framework

People-centered health care policy framework is intended to provide general principles and guidance for countries and areas in identifying and adapting policy reforms and interventions to their unique settings at national and local levels in the broader health care challenges. The framework contains four domains of dimensions. The dimensions are individuals, family and community; health care delivery system; HCPs and HCO (WHO 2007b:7).

Individuals, families and communities

Individuals, families and communities are the framework’s dimension, placed within a service delivery context that supports universal, equitable, people-centred and integrated health services. These are delivered through integrated networks and linkages within the health sector, as well as direct inputs from communities (WHO 2007b:9).
The construct that reflect the PCC in Individuals, families and communities dimension include health literacy, communication and negotiation skills and patient capacity for self-management and self-care. A capacity of the volunteer, and promoting social infrastructure that supports community participation explain patient centeredness’ level to the patient side in the framework (WHO 2007b:10).
Patients cannot access health service and make informed decisions without being well informed. Safe and equitable PCC services need health literacy of a patient to meet and achieve quality health services (Brach, Dreyer, Schyve, Hernandez, Baur, Lemerise & Parker 2012:2). Health literacy of people can increase through active community and mass media education campaigns; skills-oriented health education programmes; written information in conjunction with verbal information in clinical consultations; and evidence-based health education (WHO 2007b:10). Moreover, empowerment of the community and TB patients throughout their treatment follow-up time is one of the recommended approaches to improve TB treatment outcome (Boateng, Kodama, Sata, Bonsu & Osawa 2012:364).
Communication skills are one of the core components which pave a way to put in PCC services. Communication skills existed almost in all framework or models of patient centeredness in common (Constand et al 2014:1). Among PCC’s fundamental components, communication skills account for a major share. These skills help to foster healing relationships; exchanging and know what patients want and need; responding to patients’ emotions; engaging in informed and collaborative decision and enables patient’s self-management (Levinson, Lesser & Epstein 2010:1311). Communication skills has a positive impact, beyond making a health service patient centred, on important PCC outcomes, including patient satisfaction, adherence to recommended treatment and self-management of chronic disease (Levinson et al 2010:1312).
Building patients’ capacity to manage and care for themselves through training and health education are a determinant of existence of PCC in health care service organisation. Self-management and care can reduce symptoms; improve physical activity and less need for medical treatment. Building the capacity of the volunteers who support the patient and the community can strengthen the patient centredness of the care (Bensberg 2007:17).

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Health care providers (HCPs)

The ability and commitment of HCPs for holistic, ethical and compassionate care are required components to provide PCC services. HCPs need to understand their patients within a broader context, beyond clinical findings and patient’s illness, by exploring each patient’s unique biological, psychological, and social context (Scholl et al 2014:3). The communication skills of HCPs help to extract information beyond clinical findings and convey the information which helps the patients to make informed decisions.
Relationship building capacity of the HCPs with patients and families gives a way to understand on what problems the patient is most concerned with and how the patient’s illness or has affected his/her life beyond the clinical manifestations. The relationship also required Inter professionals to put in a team based PCC approach in health care provision (Constand et al 2014:2-3).
Respect for the patient’s values, preferences, and expressed needs; provision of information and education; being accessible to care; emotional support; involving family and friends; continued support and securing transition between health care settings are expected from HCPs (Pelzang 2010:914).

Health care organisations (HCOs)

Health care environment design is expected to provide comfort and safety to the patients. HCOs are expected to provide access to social, emotional and spiritual support for patients. Appropriate and flexible visiting and risk management policies that protect the public, patients and staff; waiting rooms and other public spaces within the premises of health care facilities for health education are required to provide PCC (WHO 2007b:12). Patient centeredness is associated with patients’ perceived conducive and comfort of HCO such as cleanliness and reduced noise level of the HCOs’ premises to receive care (Locatelli, Turcios & Lavela 2015:24).
Scholl et al (2014:6) states that effective and efficient coordination of front-line patient care with ancillary support services can ensures continuity of care to patients. Strong coordination and collaborative health care service is a root to implement cost effective PCC and overcome the ever-increasing PCC demand (Carver & Jessie 2011:4). The framework also include transparent, accessible and understandable service protocols that improve patient flow; appropriate scheduling of appointments; reminder notices for specific interventions; public announcements, lose or wall-mounted printed materials and signage to guide health service navigation; hand-held patient health records and protocols for discharge and referral (WHO 2007b:12).
The presence of multi-disciplinary care team which has a formal job description with delineated and functional communication channel is one of the requirements to provide PCC (WHO 2007b:13). Multi-disciplinary care team in HCO should be a high-performing team able to provide truly PCC to reliably work together with patients, respond to an individual’s need, preference value, and experience in managing beyond clinical care. Multi-disciplinary care team includes teams which address the psychosocial context, financial and support resources, ability to self-manage, and barriers to self-care (Sevin, Moore, Shepherd, Jacobs & Hupke 2009:25). In addition, the presence of multidisciplinary care team in HCOs helps the patients to get and stay well, and reduce back and forth of the patients (Parish 2015:2).
The HCOs need to fulfil staffs’ requirement. They also need to have targeted monitoring and evaluation of individual and team performance for continuous quality improvement. They should ensure that their staffs are getting competitive and performance based incentive packages, including opportunity for continuing medical education, training, and recognition and awards (WHO 2007b:14).
Enhancing leadership capacity of health services managers through training and one another experience sharing is required strategies to foster PCC in the health care facilities. Strong and committed senior leaderships are a strong attribute to implementation of PCC (Luxford et al 2011:513).

TABLE OF CONTENTS
CHAPTER 1  OVERVIEW OF THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND
1.3 STATEMENT OF THE RESEARCH PROBLEM
1.4 AIM OF THE STUDY
1.5 SIGNIFICANCE OF THE STUDY
1.6 DEFINITION OF TERMS
1.7 PARADIGMATIC PERSPECTIVE OF THE RESEARCH
1.8 RESEARCH METHOD AND DESIGN
1.9 ETHICAL CONSIDERATION
1.10 SCOPE OF THE STUDY
1.11 STRUCTURE OF THE THESIS
1.12 CONCLUSION
CHAPTER 2 LITERATURE REVIEW
2.1 INTRODUCTION
2.2 TUBERCULOSIS
2.3 DIRECTLY OBSERVED TREATMENT, SHORT COURSE (DOTS) STRATEGY
2.4 PATIENT-CENTRED CARE (PCC)
2.5 PATIENT SATISFACTION
2.6 CONCLUSION
CHAPTER 3 CONCEPTUAL FRAMEWORK
3.1 INTRODUCTION
3.2 REVIEW OF PCC FRAMEWORKS
3.3 CONCEPTUAL FRAMEWORK OF THE STUDY
3.4 CONCLUSION
CHAPTER 4 RESEARCH APPROACH, DESIGN AND METHOD
4.1 INTRODUCTION
4.2 RESEARCH APPROACH
4.3 RESEARCH DESIGN
4.4 RESEARCH METHOD
4.5 VALIDITY AND TRUSTWORTHINESS
4.6 CONCLUSION
CHAPTER 5 DATA PRESENTATION AND ANALYSIS
5.1 INTRODUCTION
5.2 SECTION 1: QUANTITATIVE DATA ANALYSIS AND PRESENTATION
5.3 SECTION 2: QUALITATIVE DATA ANALYSIS AND PRESENTATION
5.4 CONCLUSION
CHAPTER 6 DISCUSSION, CONCLUSION AND RECOMMENDATIONS
6.1 INTRODUCTION
6.2 RESEARCH APPROACH, DESIGN AND METHOD
6.4 CONTRIBUTION OF THE STUDY
6.5 LIMITATION OF THE STUDY
6.6 RECOMMENDATIONS
6.7 CONCLUSION
CHAPTER 7 MODEL TO ENHANCE TB PATIENT CENTEREDNESS OF TB CARE
7.1 INTRODUCTION
7.2 TRIANGULATED FINDINGS
7.3 BACKGROUND TO THE PROPOSED MODEL
7.4 DESCRIPTION OF THE MODEL
7.5 CONCLUSION
REFERENCES
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