An ontology-driven approach for structuring scientific knowledge for predicting treatment adherence behaviour: a case study of tuberculosis in Sub-Saharan African communities.

Doctor of Philosophy in Mathematics, Statistics and Computer Science. University of KwaZulu-Natal, Durban 2016.Poor adherence to prescribed treatment is a complex phenomenon and has been identified as a major contributor to patients developing drug resistance and failing treatment in sub-Saharan African countries. Treatment adherence behaviour is influenced by diverse personal, cultural and socio-economic factors that may vary drastically between communities in different regions. Computer based predictive models can be used to identify individuals and communities at risk of non-adherence and aid in supporting resource allocation and intervention planning in disease control programs. However, constructing effective predictive models is challenging, and requires detailed expert knowledge to identify factors and determine their influence on treatment adherence in specific communities. While many clinical studies and abstract conceptual models exist in the literature, there is no known concrete, unambiguous and comprehensive computer based conceptual model that categorises factors that influence treatment adherence behaviour. The aim of this research was to develop an ontology-driven approach for structuring knowledge of factors that influence treatment adherence behaviour and for constructing adherence risk prediction models for specific communities. Tuberculosis treatment adherence in sub-Saharan Africa was used as a case study to explore and validate the approach. The approach provides guidance for knowledge acquisition, for building a comprehensive conceptual model, its formalisation into an OWL ontology, and generation of probabilistic risk prediction models. The ontology was evaluated for its comprehensiveness and correctness, and its effectiveness for constructing Bayesian decision networks for predicting adherence risk. The approach introduces a novel knowledge acquisition step that guides the capturing of influencing factors from peer-reviewed clinical studies and the scientific literature. Furthermore, the ontology takes an evidence based approach by explicitly relating each factor to published clinical studies, an important consideration for health practitioners. The approach was shown to be effective in constructing a flexible and extendable ontology and automatically generating the structure of a Bayesian decision network, a crucial step towards automated, computer based prediction of adherence risk for individuals in specific communities

Building Semantic Causal Models to Predict Treatment Adherence for Tuberculosis Patients in Sub-Saharan Africa

Poor adherence to prescribed treatment is a major factor contributing to tuberculosis patients developing drug resistance and failing treatment. Treatment adherence behaviour is influenced by diverse personal, cultural and socio-economic factors that vary between regions and communities. Decision network models can potentially be used to predict treatment adherence behaviour. However, determining the network structure (identifying the factors and their causal relations) and the conditional probabilities is a challenging task. To resolve the former we developed an ontology supported by current scientific literature to categorise and clarify the similarity and granularity of factors

Treatment outcomes of patients with MDR-TB and its determinants at referral hospitals in Ethiopia

Text in EnglishAim: The aims of this study were to investigate the treatment outcomes of patients with MDRTB and its determinants at referral hospitals in Ethiopia. The study also aims to develop a conceptual model for enhancing treatment of patients with MDR-TB in Ethiopia. Design and methods: A concurrent mixed methods design with quantitative dominance was used to investigate treatment outcomes of patients with MDR-TB and its determinants. Results: A total of 136 (n=136) patients with MDR-TB participated in the study, 74 (54%) were male and 62 (46%) were female. Forty-one (31%) of the patients had some co-morbidity with MDR-TB at baseline, and 64% had body mass index less than 18.5kg/m2. Eight (6%) of the patients were diagnosed among household contacts. At 24 months, 76/110 (69%) of the patients had successfully completed treatment, but 30/110 (27%) were died of MDR-TB. Multivariable logistic regression revealed that the odds of unfavourable treatment outcomes were significantly higher among patients with low body mass index (BMI <18.5kg/m2) (AOR=2.734, 95% CI: 1.01-7.395; P<0.048); and those with some co-morbidity with MDR-TB at the baseline (AOR=4.260, 95%CI: 1.607-11.29; p<0.004). The majority of the patients were satisfied with the clinical care they received at hospitals. But as no doctor was exclusively dedicated for the MDR-TB centre, patients could not receive timely medical attention and this was especially the case with those with emergency medical conditions. The caring practice of caregivers at the hospitals was supportive and empathic but it was desperate and alienating at treatment follow up centres. Patients were dissatisfied with the quality and adequacy of the socio-economic support they got from the programme. Despite the high MDR-TB and HIV/AIDS co-infection rate, services for both diseases was not available under one roof. Conclusions: Low body mass index and the presence of any co-morbidity with MDR-TB at the baseline are independent predictors of death among patients with MDR-TB. Poor communication between patients and their caregivers and inadequate socio-economic support were found to determine patients’ perceived quality of care and patients’ satisfaction with care given for MDR-TB.Health StudiesD. Litt et Phil. (Health Studies

A phenomenological investigation of patients' lived experiences of medicines adherence: a novel perspective for future intervention development

Approximately 50% of medications are not used as prescribed, this phenomenon is known as non-adherence. The literature concerning this phenomenon focuses on reasons medicines are not taken, dissecting experiences to identify mechanisms that act as barriers and facilitators to using medicines as prescribed. Theoretical frameworks and models have been developed that conceptualise the phenomenon, enabling interventions to be established to improve medicines use. However these interventions have yet to demonstrate sustainable improvements in adherence. A novel perspective of the adherence phenomenon may direct future intervention development that will lead to improved adherence. This project evaluated current literature concerning the adherence phenomenon; concluding that a largely ‘biomedical perspective’ had been taken to understanding patients’ medicines use and that further work was needed that approached the phenomenon from with a novel outlook. A systematic review and thematic synthesis was conducted of evidence that, through phenomenological methods, rejected previously held beliefs and concluded that adherence was experienced by patients as an interaction between the patient’s and the medicine’s identity. The systematic review identified a gap in the literature that described adherence from patients’ lived experiences across different disease states. Using phenomenology, empirical research included forty-one interviews that explored patients’ experiences of medicines use across five disease areas, namely cardiovascular disease, gout, chronic obstructive pulmonary disease, cancer and diabetes. This uncovered a novel description of the phenomenon as a construct of social interaction between the patient, their product and wider society (embodied as family and friends, healthcare professionals, the media and policy). Three focus groups were conducted to validate these findings and locate patients’ perspectives of interventions within this novel description. Analyses from these focus groups identified that current adherence interventions represented micro-social interactions between the patient and the product, with few interventions developed that utilise patients’ interactions with wider society. These works are synthesised to present new directions for future intervention development that might seek to utilise patients’ interactions with friends, family, healthcare professionals and policy to improve adherence

Factors related to reduced adherence to TB treatment in Keetmanshoop Namibia

The purpose of this study was to explore factors related to poor adherence to TB treatment in Keetmanshoop municipal area in Namibia. A qualitative, exploratory design was used to explore basic information about the study. Participants were using purposive sampling technique. The researcher-implemented triangulation, based on three different categories of participants, namely Field Promoters (preferred). DOT supporters (more preferred), and TB patients (most preferred). Participants were chosen in a ratio of preference. 1:2:3 respectively. The transcripts and audio tapes from interviews were analysed using the thematic content analysis. Five main themes emerged. In order of descending prominence, these themes included: factors leading to lack of adherence to TB treatment, support to enhance adherence to treatment, existing behaviours determining adherence, suggestions to promote adherence to treatment and practices to promote adherence to treatment.Health StudiesM.A. (Public Health

TB STIGMA – MEASUREMENT GUIDANCE

TB is the most deadly infectious disease in the world, and stigma continues to play a significant role in worsening the epidemic. Stigma and discrimination not only stop people from seeking care but also make it more difficult for those on treatment to continue, both of which make the disease more difficult to treat in the long-term and mean those infected are more likely to transmit the disease to those around them. TB Stigma – Measurement Guidance is a manual to help generate enough information about stigma issues to design and monitor and evaluate efforts to reduce TB stigma. It can help in planning TB stigma baseline measurements and monitoring trends to capture the outcomes of TB stigma reduction efforts. This manual is designed for health workers, professional or management staff, people who advocate for those with TB, and all who need to understand and respond to TB stigma

A Enhanced Approach for Identification of Tuberculosis for Chest X-Ray Image using Machine Learning

Lungs are the primary organs affected by the infectious illness tuberculosis (TB). Mycobacterium tuberculosis, often known as Mtb, is the bacterium that causes tuberculosis. When a person speaks, spits, coughs, or breathes in, active tuberculosis can quickly spread through the air. Early TB diagnosis takes some time. Early detection of the bacilli allows for straightforward therapy. Chest X-ray images, sputum images, computer-assisted identification, feature selection, neural networks, and active contour technologies are used to diagnose human tuberculosis. Even when several approaches are used in conjunction, a more accurate early TB diagnosis can still be made. Worldwide, this leads to a large number of fatalities. An efficient technology known as the Deep Learning approach is used to diagnose tuberculosis microorganisms. Because this technology outperforms the present methods for early TB diagnosis, Despite the fact that death cannot be prevented, it is possible to lessen its effects

Conflicted cure: explorting concepts of default and adherence in drug resistant tuberculosis patients in Khayelitsha

Includes abstract.Includes bibliographical references.This dissertation examines default and adherence in drug-resistant tuberculosis (DR-TB) patients in Khayelitsha, Cape Town, South Africa. The ethnographic data is drawn from three and a half months of participant-observation, illness-narrative interviews, in-depth interviews, focus groups, support-group sessions and creative methodologies such as collage and emotional mapping. The various methods revealed some contradictory experiences with treatment and cure that some patients faced when undergoing treatment for DR-TB. Through an analytical framework of affect and emotions, this paper traces the complexities and disparate conceptions of default and adherence that circulate amongst patients. This paper argues that default and adherence do not operate in isolation but are part of dynamic entanglements of relationships and self-introspection that surface throughout the course of treatment for DR-TB

NEEDS ASSESSMENT FOR A TUBERCULOSIS (TB) AND HUMAN IMMUNODEFICIENCY VIRUS/ACQUIRED IMMUNODEFICIENCY SYNDROME (HIV/AIDS) COLLABORATIVE PROGRAM IN SASKATCHEWAN

ABSTRACT The purpose of this thesis is to assess the need for TB/HIV collaborative programming in Saskatchewan through a needs assessment process. Globally, the occurrence of Tuberculosis (TB) and Human Immunodeficiency Virus/Acquired Immunodeficiency Deficiency Syndrome (HIV/AIDS) in a population has always turned out to be a deadly combination with each disease entity potentiating the prevalence, morbidity and death rate of the other. According to the World Health Organization (WHO, 2012) this syndemic and synergistic interaction between both diseases resulted in one-third of people living with HIV/AIDS worldwide being infected with TB. HIV-positive people are nearly twenty times more probable to develop TB when compared to HIV- negative people (WHO, 2012). Thus, both diseases acts in synergy to potentiate the deterioration of immunological functions thereby leading to an elevated mortality rate. According to the Public Health Agency of Canada (PHAC), in 2015, the prevalence of TB and HIV in Saskatchewan was two times the national average, and the Indigenous peoples were over-represented in incidence and prevalence (PHAC, 2016). Therefore, these infections are of significant public health importance for Saskatchewan and require urgent intervention. The needs assessment employed qualitative research methods by conducting semi-structured interviews with 19 participants who were either administrators or clients in either the TB or HIV programs in Saskatchewan. Participants were interviewed using questions derived from the PRECEDE framework of the PRECEDE-PROCEED model. A combination of both deductive and inductive analytical processes using the PRECEDE model as the framework were utilized to analyze and interpret the results with apriori themes derived from the PRECEDE model, and emergent themes from the data. The results show that the PRECEDE model was effective as a needs assessment tool for TB and HIV co-programming. The PRECEDE model allowed development of an effective assessment tool including appropriate range of interview questions and apriori and emergent evaluation codes within the areas of social, epidemiologic, behavioral, environmental, educational, ecological, administrative, and policy. The results enunciated cultural, socio-economic, behavioral and administrative factors that increase the transmission of TB and HIV in Saskatchewan, particularly among the Indigenous peoples. The socioeconomic conditions identified were poverty, adverse effects of residential school system, low level of education, and abuse (physical, sexual and emotional). Behavioral factors of importance included a highly mobile population; living chaotic lifestyles as a result of drug addiction, prostitution, alcoholism; unprotected sex; and needle sharing. Environmental factors that were identified included the large geographical area in Saskatchewan and a large patient population in the rural and remote areas of the province. Educational factors identified were comprised of predisposing, reinforcing and enabling factors. The predisposing factors were related to inadequate knowledge about the mode of transmission of TB and HIV. Stigmatization was a significant reinforcing factor of importance such that patients received minimal support from peers and community members. Enabling factors for consideration included inadequate qualified health personnel and a poor staffing situation made worse by large turnover. Furthermore, recruitment of specialists to work in rural and remote areas of Saskatchewan is very challenging. Therefore, health facilities depend mostly on visiting specialists. The financial resources are inadequate, and this situation is compounded by multijurisdictional funding in off/on reserve communities in northern Saskatchewan. Appointments to see service providers or specialists are difficult to arrange due to chaotic lifestyle, high mobility, lack of telephone services and homelessness. Diagnosis of administrative and policy factors reveal areas of gaps in the implementation of present programs. Gaps enumerated by participants are lack of coordination between separate TB and HIV programs, especially in data gathering. Other gaps are different locations of TB and HIV laboratories in Saskatchewan, difficulty with transportation in rural and remote areas, and difficulty getting TB and HIV medication. There is a consensus among the participants about the desirability of establishing at least some form of TB/HIV collaborative program in Saskatchewan, but the ideal model of collaboration is not established. Program officers favored the referral model while patients in the study favored the integrated model (one-stop). No matter the model, the desired goal of all participants was to reduce TB and HIV in Saskatchewan. To achieve this end, the results reveal that it is vital that there is effective coordination between TB and HIV programs to ensure that patients can access the care they need from both services. It is recommended that the various social, epidemiological, educational, behavioral and administrative factors that affect the epidemiology of TB and HIV in Saskatchewan, as identified in the PRECEDE model, be taken into consideration in the design of appropriate intervention and evaluation strategies. Furthermore, the entire planning and implementation of collaborative programming should follow WHO’s (2012) guidelines on TB/HIV collaborative services. A Saskatchewan TB/HIV collaborative program that addresses the unique nature of the two diseases in the province, which is well designed, implemented, adequately funded, and purposefully evaluated, would result in a sustainable reduction of TB and HIV diseases in Saskatchewan

Is the promise of methadone Kenya's solution to managing HIV and addiction? A mixed-method mathematical modelling and qualitative study.

BACKGROUND AND OBJECTIVES: Promoted globally as an evidence-based intervention in the prevention of HIV and treatment of heroin addiction among people who inject drugs (PWID), opioid substitution treatment (OST) can help control emerging HIV epidemics among PWID. With implementation in December 2014, Kenya is the third Sub-Saharan African country to have introduced OST. We combine dynamic mathematical modelling with qualitative sociological research to examine the 'promise of methadone' to Kenya. METHODS, SETTING AND PARTICIPANTS: We model the HIV prevention impact of OST in Nairobi, Kenya, at different levels of intervention coverage. We draw on thematic analyses of 109 qualitative interviews with PWID, and 43 with stakeholders, to chart their narratives of expectation in relation to the promise of methadone. RESULTS: The modelled impact of OST shows relatively slight reductions in HIV incidence (5-10%) and prevalence (2-4%) over 5 years at coverage levels (around 10%) anticipated in the planned roll-out of OST. However, there is a higher impact with increased coverage, with 40% coverage producing a 20% reduction in HIV incidence, even when accounting for relatively high sexual transmissions. Qualitative findings emphasise a culture of 'rationed expectation' in relation to access to care and a 'poverty of drug treatment opportunity'. In this context, the promise of methadone may be narrated as a symbol of hope-both for individuals and community-in relation to addiction recovery. CONCLUSIONS: Methadone offers HIV prevention potential, but there is a need to better model the effects of sexual HIV transmission in mediating the impact of OST among PWID in settings characterised by a combination of generalised and concentrated epidemics. We find that individual and community narratives of methadone as hope for recovery coexist with policy narratives positioning methadone primarily in relation to HIV prevention. Our analyses show the value of mixed methods approaches to investigating newly-introduced interventions