title: [Contextual factors regarding the effectiveness of tuberculosis control in Madagascar: a nationwide validity study].
abstract: BACKGROUND
  This study assesses the nationwide applicability of results from a study in the tuberculosis (TB) diagnostic and treatment centers (DTCs) in a sample of six districts in Madagascar, which identified adaptations of national guidelines and local initiatives that might explain the effectiveness of individual DTCs in improving adherence to TB treatment and thus reducing treatment default.
  
  
  OBJECTIVE
  To assess, at a national level, the importance of these adaptations/initiatives for TB treatment adherence.
  
  
  METHODS
  This analytical cross-sectional study assessed the responses to a questionnaire based on the previously identified adaptations/initiatives, which was sent to the heads of all 205 DTCs in Madagascar.
  
  
  RESULTS
  Decentralization of TB care decreased the rate of patient default. The private DTCs report better results than public DTCs. Adaptations/initiatives in relation to local contexts often lead to good results. The relation between some adaptations/initiatives and continued adherence sometimes varies with the local context of the DTC; the same initiatives can result in better adherence or in higher of treatment default rates, depending on the setting.
  
  
  CONCLUSIONS
  These initiatives should be applied after adaptation to the context.
authors.affiliation: Institut national de santé publique et communautaire (INSPC), Befelatanana. BP 176, 101 Antananarivo, Madagascar, Centre hospitalier universitaire de soins et de santé publique Analakely, Antananarivo, Madagascar.
authors.forename: E J
authors.initials: EJ
authors.lastname: Rakotonirina
authors.affiliation: Institut national de santé publique et communautaire (INSPC), Befelatanana. BP 176, 101 Antananarivo, Madagascar.
authors.forename: L
authors.initials: L
authors.lastname: Ravaoarisoa
authors.affiliation: Département santé publique, faculté de médecine, Antananarivo, Madagascar.
authors.forename: A
authors.initials: A
authors.lastname: Raherinandrasana
authors.affiliation: Département santé publique, faculté de médecine, Antananarivo, Madagascar.
authors.forename: B
authors.initials: B
authors.lastname: Vololonarivelo
authors.affiliation: Programme national de lutte contre la tuberculose, Antananarivo, Madagascar.
authors.forename: M
authors.initials: M
authors.lastname: Rakotonjanahary
authors.affiliation: Institut national de santé publique et communautaire (INSPC), Befelatanana. BP 176, 101 Antananarivo, Madagascar, Département santé publique, faculté de médecine, Antananarivo, Madagascar.
authors.forename: J D M
authors.initials: JD
authors.lastname: Rakotomanga
authors.affiliation: Institut de recherche santé et société, université catholique de Louvain, Belgique.
authors.forename: J
authors.initials: J
authors.lastname: Macq
mesh_terms: D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000592:standards; D006801:Humans; D008270:Madagascar; D015203:Reproducibility of Results; D014376:Tuberculosis / Q000517:prevention & control*
keywords: Madagascar; TB treatment follow-up; local initiatives