title: Adherence to tuberculosis care in Canadian Aboriginal populations, Part 2: a comprehensive approach to fostering adherent behaviour.
abstract: OBJECTIVE
  In a 2-part series, the current literature with respect to adherence to tuberculosis care among Canadian Aboriginal populations is reviewed. In the current paper, which comprises part 2 of this review, strategies to remove barriers to TB adherence and to sustain and improve adherence are explored. Study design. Literature review.
  
  
  METHODS
  The biomedical and social science literature, including electronic databases (PubMed, PsychINFO, MEDLINE, Native Health Database. Scopus, Social Science Citation Index) were searched and reviewed with regard to relevant studies on adherence to health care, and to tuberculosis care specifically.
  
  
  RESULTS
  The majority of published studies of interventions to remove barriers to TB adherence are focused on the health service system and on the individual. The former include enhanced programs of directly observed therapy and directly observed preventive therapy, as well as "permeable" health services that require minimal negotiation. At the personal level, effort must be made to develop a shared knowledge of and care plan for TB, which includes Indigenous and Western scientific health beliefs and practice. The quality of the relationship between health care provider and patient is critical to the outcome of educational efforts that support adherence. Few studies address interventions within the social context, and few have used participatory methodologies in partnership with families and communities. Social supports such as assistance with childcare, transportation and shelter have been shown to be associated with improved adherence to care for other conditions. TB programs may wish to use techniques used in other health programs, such as the identification of patient "sponsors" or mentors, or the use of verbal and/or written "contracts."
  
  
  CONCLUSIONS
  Many of the interventional studies addressing health system barriers to TB adherence are grounded in the view that the problem rests with the patient. What is required is an approach that is responsive to the patient's needs while holding the patient to his or her personal and societal responsibilities. Adherence to therapy is unlikely to improve in a substantial way unless Indigenous beliefs about causation and care are incorporated into a program which has meaning for the patient.
authors.affiliation: Departments of Medicine, Medical Microbiology and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, R3A 1R9, Canada. POrr@hsc.mb.ca
authors.forename: Pamela
authors.initials: P
authors.lastname: Orr
mesh_terms: D002170:Canada; D006801:Humans; D007198:Indians, North American; D009042:Motivation; D010349:Patient Compliance / Q000208:ethnology*; D020377:Self Efficacy; D014376:Tuberculosis / Q000188:drug therapy* / Q000208:ethnology