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Background and Objectives: People receiving treatment for multidrug-resistant tuberculosis (MDR-TB) have high rates of depression. Psychosocial support in general, and treatments for depression in particular, form an important but neglected area of patient-centred care, and a key pillar in the global End TB strategy. We assessed the feasibility and acceptability of a psychosocial support package for people receiving treatment for MDR-TB in Nepal., Methods: This feasibility study used a mixed quantitative and qualitative approach. We implemented the intervention package in two National Tuberculosis Programme (NTP) MDR-TB treatment centres and 8 sub-centres. We screened patients monthly for depression and anxiety (cut-off ≥24 and ≥17 respectively on the Hopkins Symptom Checklist) and also for low social support (cut-off ≤3 on the Multidimensional Scale of Perceived Social Support). Those who screened positive on either screening tool received the Healthy Activity Program (HAP), which uses brief counselling based on behavioural activation theory. Other aspects of the psychosocial package were information/education materials and group interactions with other patients., Results: We screened 135 patients, of whom 12 (9%) received HAP counselling, 115 (85%) received information materials, 80 (59%) received an education session and 49 (36%) received at least one group session. Eight group sessions were conducted in total. All aspects of the intervention package were acceptable to patients, including the screening, information, group work and counselling. Patients particularly valued having someone to talk to about their concerns and worries. We were able to successfully train individuals with no experience of psychological counselling to deliver HAP., Conclusion: This psychosocial support package is acceptable to patients. The information materials we developed are feasible to deliver in the current NTP. However, the structured psychological counselling (HAP), is not feasible in the current NTP due to time constraints. This requires additional investment of counsellors in TB clinics., Competing Interests: The authors have declared that no competing interests exist.

Objective: To establish which of the many possible linkages between tuberculosis (TB), direct observation of treatment (DOTS), and the social reality of migrant workers in Kathmandu are the most relevant to the health outcomes and economic and social well-being of these populations, and which are amenable to possible interventions and high-yield policy changes., Methods: Fourteen semi-structured in-depth interviews were conducted through an interpreter with male migrant TB patients aged 18-50 years recruited from three DOTS clinics in the Kathmandu valley in May 2005. The interviews were coded using constant comparison and analysed using a grounded theory method., Results: The economic burden of TB treatment is far greater than the financial reserve of migrants. Consequently remittances sent to families are reduced and migrants remain in debt long after treatment completion, tied to the treatment location paying off high interest loans. Forced to attend clinics far away from their home, and isolated by the stigma associated with TB, migrants are vulnerable without social support networks. Migrants find that daily clinic visits are incompatible with working schedules and important cultural festivals, which forces them into defaulting., Conclusion: The needs of migrant workers with TB living in Kathmandu are not being adequately met. Current service provision needs to be reviewed to build in greater flexibility and support for migrant men.

Background: In the new Stop TB Strategy for Tuberculosis (TB) Care, direct observation of treatment has been replaced by "supervision and patient support". However, it is still unclear what patient support means and how it is to be best implemented. The objective of this study was to accurately document patients' support needs during TB treatment from their own perspectives, to inform development of appropriate support and supervision strategies that meet patients' needs., Methods: In-depth individual interviews and focus group discussions were conducted in three districts in Nepal. Analysis took place concurrently with data collection to allow emerging issues to guide selection of subsequent interviewees. In total 23 patients, 15 male and 8 female, were interviewed and six focus group discussions were held. Issues from these interviews were grouped into emergent themes., Results: Respondents reported that the burden of treatment for TB was high, particularly in terms of difficulties with social and psychological aspects of undergoing treatment. They saw three main areas for support during their treatment: relevant information for them and their families about their disease, its treatment, potential side-effects and what they should do if side-effects arise; approachable and supportive healthcare staff with whom patients feel comfortable discussing (often non-medical) problems that arise during treatment; and some flexibility in treatment to allow essential elements of patients' lives (such as income generation, food-growing and childcare) to continue. They were anxious to ensure that family support did not absolve healthcare workers from their own support responsibilities., Conclusion: In order to support people with TB more during their treatment, health policy and practice must appreciate that TB affects all aspects of TB patients' lives. A focus on caring for each patient as an individual should underlie all aspects of treatment. Improved communication between healthcare providers and patients and increased patient knowledge and understanding of the treatment programme would give those receiving treatment a sense of individual empowerment and raise their confidence in treatment.

Background: Tuberculosis (TB) is a major cause of death. The condition is highly stigmatised, with considerable discrimination towards sufferers. Although there have been several studies assessing the extent of such discrimination, there is little published research explicitly investigating the causes of the stigma and discrimination associated with TB. The objectives of our research were therefore to take the first steps towards determining the causes of discrimination associated with TB., Methods: Data collection was performed in Kathmandu, Nepal. Thirty four in-depth interviews were performed with TB patients, family members of patients, and members of the community., Results: Causes of self-discrimination identified included fear of transmitting TB, and avoiding gossip and potential discrimination. Causes of discrimination by members of the general public included: fear of a perceived risk of infection; perceived links between TB and other causes of discrimination, particularly poverty and low caste; perceived links between TB and disreputable behaviour; and perceptions that TB was a divine punishment. Furthermore, some patients felt they were discriminated against by health workers, Conclusion: A comprehensive package of interventions, tailored to the local context, will be needed to address the multiple causes of discrimination identified: basic population-wide health education is unlikely to be effective.

Background: In South Asia a large number of patients seek treatment for TB from private practitioners (PPs), and there is increasing international interest in involving PPs in TB control. To evaluate the feasibility, effectiveness and costs of public-private partnerships (PPPs) for TB control, a PPP was developed in Lalitpur municipality, Nepal, where it is estimated that 50% of patients with TB are managed in the private sector. From the clinical perspective the PPP was shown to be effective. The aim of this paper is to assess and report on the costs involved in the PPP scheme., Methods: The approach to costing took a comprehensive view, with inclusion of costs not only incurred by health facilities but also social costs borne by patients and their escorts. Semi-structured questionnaires and guided interviews were used to collect start-up and recurrent costs for the scheme., Results: Overall costs for treating a TB patient under the PPP scheme averaged US$89.60. Start-up costs per patient represented 12% of the total budget. Half of recurrent costs were incurred by patients and their escorts, with institutional costs representing most of the rest. Female patients tended to spend more and patients referred from the private sector had the highest reported costs., Conclusion: Treating TB patients in the PPP scheme had a low additional cost, while doubling the case notification rate and maintaining a high success rate. Costs incurred by patients and their escorts were the largest contributors to the overall total. This suggests a focus for follow-up studies and for cost-minimisation strategies.

Purpose: The purpose of the paper is to show that, despite comprehensive coverage of services for TB provided by a public-private partnership for TB control in Patan, a city in Nepal, case finding is low, compared with the target based on an Annual Risk of Tuberculosis Infection (ARTI) of 4 per cent. Doubts have been raised as to the appropriateness of the target. The objective of the study was to estimate the number of new TB cases occurring in Patan, to assess whether the target was appropriate., Design/methodology/approach: In the paper doorstep interviews were conducted with all households in the study area, followed by in-depth interviews of households with possible or probable TB cases. The survey findings were validated against the patient registers of the five DOTS centres in Patan., Findings: The paper finds that, among the study population of 36,918, the household survey identified 17 smear-positive TB cases (none privately-treated) and 24 smear-negative/extra-pulmonary cases (including four privately-treated cases). Validation against the DOTS patient registers indicated that the survey was 54 per cent complete. After adjusting for incompleteness, the number of smear-positive cases in the study area was estimated as 31, equivalent to an incidence of 85 smear positives per 100,000 population and an ARTI of 1.7 per cent., Originality/value: The paper shows that using the ARTI may lead to misleadingly high targets for urban TB control. Unrealistically high targets may cause TB workers to become demoralised, and useful strategies to be abandoned. Therefore, further work is needed to identify better ways of setting targets.

Purpose: The purpose of the paper is to show that community involvement is a successful way of overcoming certain barriers to the successful management of the current tuberculosis epidemic, namely delayed presentation and non-completion of treatment. Volunteers are an important resource for engaging with the community. This research, conducted in an urban TB treatment centre in Nepal, seeks to investigate the motivations of TB volunteers, and how these motivations can be increased to involve volunteers, and the community, in fulfilling their maximum potential in delivering successful TB treatment programmes., Design/methodology/approach: Semi-structured interviews were carried out with 26 TB volunteers, followed by volunteer discussion groups. Topics covered included: detailed accounts of the volunteers' many and varied roles; motivations - how they initially became involved and why they continue to be involved; incentives for volunteering; problems they have encountered; family and friends' attitudes to their volunteering, and the future of TB volunteering., Findings: The findings show that the TB volunteers are involved in many important roles. Volunteers initially became involved, having been asked or informed about the programme by area committee members, staff or friends. Most were also involved in other voluntary work., Originality/value: This paper gives recommendations for volunteer programmes in developing countries including: sustained communication and contact between volunteers and the organisation; volunteer programmes based in a centre with an established community focus; flexibility of time commitment; regular recruitment drives for volunteers from different generations and status levels; and the use of training as a possible incentive for volunteering.

Background: A key component of the DOTS strategy for tuberculosis control (short-course chemotherapy following WHO guidelines) is direct observation of treatment. WHO technical guidelines recommend that health workers should undertake this part of the strategy, but will also accept direct observation of treatment in the community; WHO does not think that a family member should undertake this role. Supporting evidence for these recommendations is not available. The Nepal national tuberculosis programme asked us to develop and test a strategy of direct observation of treatment for the hill districts of Nepal, where direct observation of treatment by health workers is not feasible. We aimed to assess the success rates of two DOTS strategies developed for such areas., Methods: Between mid-July, 2002, and mid-July, 2003, we undertook a cluster-randomised controlled trial to compare two strategies-community DOTS and family-member DOTS--in ten hill and mountain districts of Nepal. Districts were used as the unit of randomisation. Primary outcome was success rate (proportion of registered patients who achieved cure or completed treatment), and analysis was by intention to treat., Findings: Five districts (549 patients) were allocated to community DOTS and five (358 patients) were allocated family-member DOTS. Community DOTS and family-member DOTS achieved success rates of 85% and 89%, respectively (odds ratio of success for community DOTS relative to family-member DOTS, 0.67 [95% CI 0.41-1.10]; p=0.09). Estimated case-finding rates were 63% with the community strategy and 44% with family-member DOTS., Interpretation: The family-member DOTS and community DOTS strategies can both attain international targets for treatment success under programme conditions, and thus are appropriate for the hill and mountain districts of Nepal. Both strategies might also be appropriate in other parts of the world where directly observed treatment by health workers is not feasible. Our findings lend support to adoption of this patient-responsive approach to direct observation of treatment within global tuberculosis control policy.

Experience shows that planners need to consider the effect of the process of decentralisation on national health programmes. The aim of this article is to explore the relationship between decentralisation and a national disease control programme by seeking to understand the views and attitudes of staff working in a national TB control programme on the process of change and their involvement in that change. The study to which this paper refers was performed in Nepal, where, in common with several low- and middle-income countries, a Local Self Governance Act has been passed and decentralisation is in the process of being introduced in the health sector. The aim of the study was to develop a process of initial dialogue among programme staff with a view to exemplifying those enabling and disabling factors which could influence the process and content of health systems development and its impact on health and health care. The study used individual interviews and group discussions to increase our understanding of the experience of different stakeholders at both national and district levels. Important problems identified include: confused lines of authority, difficulties of integrated supervision, poor career paths and promotion possibilities, unclear performance management, lack of priority to be given to health and TB control, lack of local accountability, lack of capacity and the risk to the drug supply. The study highlights the need to (a) develop consensus techniques, achieve a balanced appreciation and include all stakeholders in the process of change and (b) define central and local responsibilities, limiting political bias, maintaining quality control, organising different lines of authority, maintaining priorities and programme integration.