Sagbakken Mette, Bjune Gunnar A, Frich Jan C
Department of Nursing, Faculty of Health Sciences, Oslo and Akershus University College of Applied Sciences, Oslo, Norway.
Scand J Caring Sci. 2012 Jun;26(2):313-23. doi: 10.1111/j.1471-6712.2011.00935.x. Epub 2011 Nov 2.
Directly observed treatment (DOT) has been implemented globally as a strategy in treatment of tuberculosis. Studies from high-endemic settings show that DOT involves social and economical burdens for patients, but little is known about experiences with practicing DOT in low-endemic settings. The present study explores patients' and health professionals' views and experiences with DOT in Norway.
In-depth interviews were conducted with 22 patients originating from Somalia and Ethiopia and with 20 health professionals. Data from the interviews were analysed using systematic text condensation.
We found that there was little room for patients to negotiate whether or not to consent to the organization of treatment (DOT). Patients told that it was difficult to question the way treatment was organized, as they got the impression that there was no other way of gaining access to medication. Both patients and health professionals reported that persuasion based on authority and subtle threats was used as means to facilitate patients' acceptance of DOT. A majority of patients experienced DOT as humiliating and discriminating, while some had the experience of being cared for. Patients who attended school or had occupational obligations reported high social costs related to the treatment. Patients with positive experiences told that they had been given an opportunity to negotiate flexible treatment schedules and emphasized the importance of continuity among health professionals. Health professionals had divergent views and practices. Some argued that patients should be treated equally, while others argued for an individualized and flexible approach.
The practice of DOT reflects societal power structures that influence the clinical interactions between health professionals and patients. To avoid experiences of disempowerment and humiliation among patients, treatment and care should be organized in a way that safeguards patients' right to consent to treatment and that allows patients to negotiate an individualized treatment schedule.
直接观察治疗（DOT）已在全球范围内作为结核病治疗策略实施。来自高流行地区的研究表明，DOT给患者带来社会和经济负担，但对于在低流行地区实施DOT的经验知之甚少。本研究探讨了挪威患者和卫生专业人员对DOT的看法和经验。
对22名来自索马里和埃塞俄比亚的患者以及20名卫生专业人员进行了深入访谈。使用系统文本浓缩法分析访谈数据。
我们发现患者在是否同意组织治疗（DOT）方面几乎没有协商空间。患者表示很难质疑治疗的组织方式，因为他们觉得没有其他获得药物的途径。患者和卫生专业人员都报告说，基于权威的劝说和微妙的威胁被用作促使患者接受DOT的手段。大多数患者认为DOT是羞辱性和歧视性的，而一些患者有被照顾的体验。上学或有工作义务的患者报告治疗带来的社会成本很高。有积极体验的患者表示他们有机会协商灵活的治疗时间表，并强调卫生专业人员连续性的重要性。卫生专业人员有不同的观点和做法。一些人认为应该平等对待患者，而另一些人则主张采用个性化和灵活的方法。
DOT的实施反映了影响卫生专业人员与患者临床互动的社会权力结构。为避免患者产生被剥夺权力和羞辱的体验，治疗和护理的组织方式应保障患者同意治疗的权利，并允许患者协商个性化的治疗时间表。
