Arakelyan Stella, Karat Aaron S, Jones Annie S K, Vidal Nicole, Stagg Helen R, Darvell Marcia, Horne Robert, Lipman Marc C I, Kielmann Karina
Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK.
TB Centre, London School of Hygiene & Tropical Medicine, London, UK.
Patient Prefer Adherence. 2021 Sep 21;15:2137-2154. doi: 10.2147/PPA.S313633. eCollection 2021.
Although tuberculosis (TB) incidence has significantly declined in high-income, low-incidence (HILI) countries, challenges remain in managing TB in vulnerable populations who may struggle to stay on anti-TB treatment (ATT). Factors associated with non-adherence to ATT are well documented; however, adherence is often narrowly conceived as a fixed binary variable that places emphasis on individual agency and the act of taking medicines, rather than on the demands of being on treatment more broadly. Further, the mechanisms through which documented factors act upon the experience of being on treatment are poorly understood. Adopting a relational approach that emphasizes the embeddedness of individuals within dynamic social, structural, and health systems contexts, this scoping review aims to synthesize qualitative evidence on experiences of being on ATT and mechanisms through which socio-ecological factors influence adherence in HILI countries. Six electronic databases were searched for peer-reviewed literature published in English between January 1990 and May 2020. Additional studies were obtained by searching references of included studies. Narrative synthesis was used to analyze qualitative data extracted from included studies. Of 28 included studies, the majority (86%) reported on health systems factors, followed by personal characteristics (82%), structural influences (61%), social factors (57%), and treatment-related factors (50%). Included studies highlighted three points that underpin a relational approach to ATT behavior: 1) individual motivation and capacity to take ATT is dynamic and intertwined with, rather than separate from, social, health systems, and structural factors; 2) individuals' pre-existing experiences of health-seeking influence their views on treatment and their ability to commit to long-term regular medicine-taking; and 3) social, cultural, and political contexts play an important role in mediating how specific factors work to support or hinder ATT adherence behavior in different settings. Based on our analysis, we suggest that person-centered clinical management of tuberculosis should 1) acknowledge the ways in which ATT both disrupts and is managed within the everyday lives of individuals with TB; 2) appreciate that individuals' circumstances and the support and resources they can access may change over the course of treatment; and 3) display sensitivity towards context-specific social and cultural norms affecting individual and collective experiences of being on ATT.
尽管在高收入、低发病率（HILI）国家，结核病（TB）发病率已显著下降，但在管理可能难以坚持接受抗结核治疗（ATT）的弱势群体的结核病方面，挑战依然存在。与不坚持ATT相关的因素已有充分记录；然而，依从性通常被狭义地视为一个固定的二元变量，强调个人能动性和服药行为，而不是更广泛地关注接受治疗的需求。此外，已记录的因素作用于治疗体验的机制尚不清楚。本综述采用一种关系方法，强调个体在动态社会、结构和卫生系统背景中的嵌入性，旨在综合关于接受ATT体验以及社会生态因素影响HILI国家依从性的机制的定性证据。检索了六个电子数据库，以查找1990年1月至2020年5月期间以英文发表的同行评审文献。通过检索纳入研究的参考文献获得了其他研究。采用叙述性综合分析从纳入研究中提取的定性数据。在纳入的28项研究中，大多数（86%）报告了卫生系统因素，其次是个人特征（82%）、结构影响（61%）、社会因素（57%）和治疗相关因素（50%）。纳入研究强调了支撑ATT行为关系方法的三个要点：1）个体接受ATT的动机和能力是动态的，与社会、卫生系统和结构因素相互交织，而不是与之分离；2）个体先前的求医经历影响他们对治疗的看法以及他们坚持长期规律服药的能力；3）社会、文化和政治背景在调节特定因素如何在不同环境中支持或阻碍ATT依从行为方面发挥重要作用。基于我们的分析，我们建议以患者为中心的结核病临床管理应：1）认识到ATT在结核病患者日常生活中既造成干扰又得到管理的方式；2）认识到个体情况以及他们可获得的支持和资源在治疗过程中可能会发生变化；3）对影响个体和集体接受ATT体验的特定社会和文化规范保持敏感。
