Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom.
Centre for Tuberculosis and Lung Disease, Riga East University Hospital, Riga, Latvia.
PLoS One. 2018 Oct 17;13(10):e0203937. doi: 10.1371/journal.pone.0203937. eCollection 2018.
Vulnerable individuals with tuberculosis (TB) struggle to access and stay on treatment. While patient-related and social barriers to TB treatment adherence are well documented, less is known about how the organisation and delivery of TB care influences adherence behaviour.
To examine the influence of TB service organisation and culture on patients' experience of starting and staying on treatment in Riga, Latvia.
An intervention package to support adherence to TB treatment amongst vulnerable patients in Riga, Latvia was piloted between August 2016 and March 2017. Qualitative observations (5), interviews with staff (20) and with TB patients (10) were conducted mid-way and at the end of the intervention to understand perceptions, processes, and experiences of TB care.
The organisation of TB services is strongly influenced by a divide between medical and social aspects of TB care. Communication and care practices are geared towards addressing individual risk factors for non-adherence rather than the structural vulnerabilities that patients experience in accessing care. Support for vulnerable patients is limited because of standardised programmatic approaches, resource constraints and restricted job descriptions for non-medical staff.
Providing support for vulnerable patients is challenged in this setting by the strict division between medical and social aspects of TB care, and the organisational focus on patient-related rather than systems-related barriers to access and adherence. Potential systems interventions include the introduction of multi-disciplinary approaches and teams in TB care, strengthening patient literacy at the point of treatment initiation, as well as stronger linkages with social care organisations.
患有结核病（TB）的弱势群体在接受治疗方面存在困难。虽然人们已经充分了解了影响结核病患者治疗依从性的患者相关和社会障碍，但对于结核病护理的组织和提供方式如何影响患者的治疗依从性行为，人们的了解还比较有限。
在拉脱维亚里加，研究结核病服务组织和文化对患者开始和坚持治疗的体验的影响。
在拉脱维亚里加，一项支持弱势结核病患者治疗依从性的干预措施于 2016 年 8 月至 2017 年 3 月进行了试点。在干预措施进行到一半和结束时，进行了 5 次定性观察、20 次与工作人员的访谈和 10 次与结核病患者的访谈，以了解对结核病护理的看法、过程和经验。
结核病服务的组织受到将结核病医疗和社会方面分开的强烈影响。沟通和护理实践主要针对解决患者在获得护理方面的非依从性的个人风险因素，而不是针对患者在获得护理方面面临的结构性脆弱性。由于标准化的方案方法、资源限制和非医疗工作人员的受限工作描述，为弱势患者提供支持的能力有限。
在这种情况下，严格的医疗和社会方面的结核病护理分工，以及组织对与患者相关而非与系统相关的获取和依从性障碍的关注，对为弱势患者提供支持构成了挑战。潜在的系统干预措施包括在结核病护理中引入多学科方法和团队，在治疗开始时加强患者的读写能力，以及与社会关怀组织建立更强的联系。
