Exploring opportunities to strengthen rural tuberculosis health service delivery: a qualitative study with health workers in Tibet autonomous region, China.

OBJECTIVES: This qualitative study aimed to explore opportunities to strengthen tuberculosis (TB) health service delivery from the perspectives of health workers providing TB care in Shigatse prefecture of Tibet Autonomous Region, China. DESIGN: Qualitative research, semi-structured in-depth interviews. SETTING: The TB care ecosystem in Shigatse, including primary and community care. PARTICIPANTS: Participants: 37 semi-structured interviews were conducted with village doctors (14), township doctors and nurses (14), county hospital doctors (7) and Shigatse Centre for Disease Control staff (2). RESULTS: The three main themes reported include (1) the importance of training primary and community health workers to identify people with symptoms of TB, ensure TB is diagnosed and link people with TB to further care; (2) the need to engage community health workers to ensure retention in care and adherence to TB medications; and (3) the opportunity for innovative technologies to support coordinated care, retention in care and adherence to medication in Shigatse. CONCLUSIONS: The quality of TB care could be improved across the care cascade in Tibet and other high-burden, remote settings by strengthening primary care through ongoing training, greater support and inclusion of community health workers and by leveraging technology to create a circle of care. Future formative and implementation research should include the perspectives of health workers at all levels to improve care organisation and delivery.

Effectiveness of a comprehensive package based on electronic medication monitors at improving treatment outcomes among tuberculosis patients in Tibet: a multicentre randomised controlled trial.

BACKGROUND: WHO recommends that electronic medication monitors, a form of digital adherence technology, be used as a complement to directly observed treatment (DOT) for tuberculosis, as DOT is inconvenient and costly. However, existing evidence about the effectiveness of these monitors is inconclusive. Therefore, we evaluated the effectiveness of a comprehensive package based on electronic medication monitors among patients with tuberculosis in Tibet Autonomous Region (hereafter Tibet), China. METHODS: This multicentre, randomised controlled trial recruited patients from six counties in Shigatse, Tibet. Eligible participants had drug-susceptible tuberculosis and were aged 15 years or older when starting standard tuberculosis treatment. Tuberculosis doctors recruited patients from the public tuberculosis dispensary in each county and the study statistician randomly assigned them to the intervention or control group based on the predetermined randomised allocation sequence. Intervention patients received an electronic medication monitor box. The box included audio medication-adherence reminders and recorded box-opening data, which were transmitted to a cloud-based server and were accessible to health-care providers to allow remote adherence monitoring. A linked smartphone app enabled text, audio, and video communication between patients and health-care providers. Patients were also provided with a free data plan. Patients selected a treatment supporter (often a family member) who was trained to support patients with using the electronic medication monitor and app. Patients in the control group received usual care plus a deactivated electronic medication monitor, which only recorded and transmitted box-opening data that was not made available to health-care providers. The control group also had no access to the app or trained treatment supporters. The primary outcome was a binary indicator of poor monthly adherence, defined as missing 20% or more of planned doses in the treatment month, measured using electronic medication monitor opening data, and verified by counting used medication blister packages during consultations. We recorded other secondary treatment outcomes based on national tuberculosis reporting data. We analysed the primary outcome based on the intention-to-treat population. This trial is registered at ISRCTN, 52132803. FINDINGS: Between Nov 17, 2018, and April 5, 2021, 278 patients were enrolled into the study. 143 patients were randomly assigned to the intervention group and 135 patients to the control group. Follow-up ended when the final patient completed treatment on Oct 4, 2021. In the intervention group, 87 (10%) of the 854 treatment months showed poor adherence compared with 290 (37%) of the 795 months in the control group. The corresponding adjusted risk difference for the intervention versus control was -29·2 percentage points (95% CI -35·3 to -22·2; p<0·0001). Five of the six secondary treatment outcomes also showed clear improvements, including treatment success, which was found for 133 (94%) of the 142 individuals in the intervention arm and 98 (73%) of the 134 individuals in the control arm, with an adjusted risk difference of 21 percentage points (95% CI 12·4-29·4); p<0·0001. INTERPRETATION: The interventions were effective at improving tuberculosis treatment adherence and outcomes, and the trial suggests that a comprehensive package involving electronic medication monitors might positively affect tuberculosis programmes in high-burden and low-resource settings. FUNDING: TB REACH.

Factors Associated with Elderly Health-Related Quality of Life in Tibet: A Cross-Sectional Study from a Health Ecological Perspective.

Background: Aging and its consequences are receiving considerable global attention in developed and developing countries. The health-related quality of life (HRQoL) of elderly individuals is crucial for public health and social welfare. Despite advances in understanding the health status of the elderly population in Tibet, a region located on China's southwest border, a significant research gap remains regarding their HRQoL. Methods: We conducted a cross-sectional study in Tibet, China, in 2018, which thoroughly examined HRQoL and its determinants in individuals aged 60 and above. The EQ-5D-VAS instrument, consisting of two standardized scales (EQ-5D-3L and EQ-VAS), was utilized to measure HRQoL. We based the selection of potential determinants on a novel health ecological model encompassing various environmental and personal factors. We employed the Least Absolute Shrinkage and Selection Operator regression to systematically pinpoint key predictive factors for dimensionality reduction. The Tobit regression analysis further elucidated the relationship between these factors and the EQ-VAS and EQ-5D-index scores. Results: Our study encompassed 1604 elderly participants. They presented varying severity levels across all five dimensions of the EQ-5D-3L. The most commonly observed issue was pain/discomfort, with a prevalence of 40.27%. The average EQ-VAS score was 56.15 (SD=21.15), and the mean EQ-5D-index score was 0.78 (SD=0.25). Our multivariate analysis revealed that determinants such as age, sex, number of chronic illnesses, vision problems, hearing problems, physical activity, employment status, social participation, place of residence, and insurance type were significantly associated with HRQoL. Conclusion: The HRQoL of Tibet's elderly population presents significant concerns, especially given the region's challenging natural conditions. This underscores the urgent need for focused policy interventions at the socio-economic strata to extend vital support and aid.

Factors Influencing Medication Adherence in Elderly Patients with Hypertension: A Single Center Study in Western China.

Purpose: To develop and empirically test a conceptual model that explains the factors influencing antihypertensive medication adherence behavior in elderly patients in a city in western China. Patients and Methods: The conceptual model was based on the Theory of Planned Behavior and the Health Belief Model and was empirically tested using cross-sectional survey data from Nanchong City, a city in western China, collected between October and December 2020. Data were analyzed using structural equation modeling. Results: Behavioral intentions were the main predictor of medication adherence behavior (path coefficient of 0.353). Perceived benefits and perceived barriers directly (path coefficient = 0.201 and -0.150, respectively), and indirectly (path coefficient = 0.118 and -0.060) through behavioral intentions, influenced medication adherence behavior. Perceived susceptibility (path coefficient = 0.390) and perceived severity (path coefficient = 0.408) influenced behavioral attitudes, which influenced behavioral intentions (path coefficient = 0.298). Conclusion: The conceptual model demonstrates a robust ability to predict and explain medication adherence behavior among elderly patients with hypertension, facilitating the adoption and maintenance of changes in adherence behavior and the potential for preventing disease progression and improving quality of life.

DoMYB5 and DobHLH24, Transcription Factors Involved in Regulating Anthocyanin Accumulation in Dendrobium officinale.

As a kind of orchid plant with both medicinal and ornamental value, Dendrobium officinale has garnered increasing research attention in recent years. The MYB and bHLH transcription factors play important roles in the synthesis and accumulation of anthocyanin. However, how MYB and bHLH transcription factors work in the synthesis and accumulation of anthocyanin in D. officinale is still unclear. In this study, we cloned and characterized one MYB and one bHLH transcription factor, namely, D. officinale MYB5 (DoMYB5) and D. officinaleb bHLH24 (DobHLH24), respectively. Their expression levels were positively correlated with the anthocyanin content in the flowers, stems, and leaves of D. officinale varieties with different colors. The transient expression of DoMYB5 and DobHLH24 in D. officinale leaf and their stable expression in tobacco significantly promoted the accumulation of anthocyanin. Both DoMYB5 and DobHLH24 could directly bind to the promoters of D. officinale CHS (DoCHS) and D. officinale DFR (DoDFR) and regulate DoCHS and DoDFR expression. The co-transformation of the two transcription factors significantly enhanced the expression levels of DoCHS and DoDFR. DoMYB5 and DobHLH24 may enhance the regulatory effect by forming heterodimers. Drawing on the results of our experiments, we propose that DobHLH24 may function as a regulatory partner by interacting directly with DoMYB5 to stimulate anthocyanin accumulation in D. officinale.

A qualitative study of perspectives on access to tuberculosis health services in Xigaze, China.

BACKGROUND: Tuberculosis (TB) is a major global health threat and the leading infectious disease cause of death worldwide. Access to and retention in TB care remains a challenge for patients, particularly those living in rural and remote settings. This qualitative study explored barriers and facilitators to accessing and maintaining contact with TB care services in communities in Xigaze (Shigatse) prefecture, Xizang Autonomous Region (Tibet Autonomous Region), China from the perspective of persons impacted by TB. METHODS: We conduced in-depth interviews with 23 participants impacted by TB in four rural districts in Xigaze prefecture, Xizang Autonomous Region, China between April 2019 and November 2020. Interviews were conducted in Tibetan and Mandarin, transcribed in Mandarin and translated into English. Transcripts were checked against recordings by native Tibetan and Mandarin speakers. QSR NVivo12 software was used for framework analysis guided by an access to care conceptual framework by Levesque et al. RESULTS: Overall patients reported low awareness of and an indifferent attitude towards TB, although all reported understanding the need to adhere to treatment. Participants reported complex pathways to care, often requiring visits to multiple healthcare facilities. Some participants reported visiting traditional Tibetan medicine (TTM) providers. Participants reported various barriers to accessing care including challenges physically reaching care, out-of-pocket payments for tests, diagnostics and transport. Barriers to maintaining care included medication side effects and worry about treatment effectiveness. Enablers to accessing care identified included knowledge or past experience with TB, integrated models of TTM and western care, supportive village doctors who conducted home visits, free TB treatment and other subsidies, as well as having family support with care and social support as barriers and facilitators to maintaining treatment. CONCLUSIONS: We identified barriers and facilitators to accessing services in rural communities in Xigaze from the perspective of persons impacted by TB. Challenges include complex pathways to care, travel distances, wait times and low awareness. Tuberculosis care in the region could be strengthened by ongoing culturally tailored educational campaigns to increase awareness, partnerships with TTM providers, providing comprehensive treatment subsidies and strengthening the role of family members in comprehensive TB care.