title: The social determinants of tuberculosis treatment adherence in a remote region of Papua New Guinea.
abstract: Papua New Guinea (PNG) is a diverse and culturally-rich country with severe infrastructural and health problems. Tuberculosis (TB) is widespread, and the number of cases with drug resistance is rising. Treatment adherence is known to be important for both effective treatment and limiting the emergence of drug resistance. The aim of this study was to construct a matrix of the factors that act as facilitators or barriers to TB treatment adherence in a remote region of PNG.
  
  
  
  The study was based in the Balimo region of the Western Province. People known to have undergone TB treatment, as well as staff involved in managing people with TB, were asked to participate in an in-depth interview about their experiences. Purposive sampling was used to identify a diverse range of participants, from different geographic locations, social backgrounds, and with successful and unsuccessful treatment outcomes. The interview data was analysed based on grounded theory methodology.
  
  
  
  The study identified a range of factors that influence TB treatment adherence, with these being classified as personal, systems, and sociocultural. These factors are presented along with suggested recommendations for adaptations to DOTS-based treatment in this region. Barriers included the challenges associated with travel to treatment sites, and the difficulties of undertaking treatment alongside the daily need to maintain subsistence food production. However, facilitators were also identified, including the positive influence of religious beliefs, and high confidence in the ability of DOTS-based treatment to cure TB.
  
  
  
  Documenting the wide range of factors that influence treatment adherence in a severely affected remote population will assist in improving TB control. These results provide impetus for further community-based efforts aimed at improving access to TB diagnosis and treatment, and maintaining successful treatment outcomes in the face of emerging drug resistance.
authors.affiliation: College of Public Health, Medical & Veterinary Sciences, James Cook University, Townsville, QLD, 4811, Australia.|Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, 4811, Australia.
authors.forename: Tanya
authors.initials: T
authors.lastname: Diefenbach-Elstob
authors.affiliation: School of Medicine, Griffith University, Gold Coast, QLD, 4222, Australia.
authors.forename: David
authors.initials: D
authors.lastname: Plummer
authors.affiliation: Balimo District Hospital, Balimo, Western Province, Papua New Guinea.
authors.forename: Robert
authors.initials: R
authors.lastname: Dowi
authors.affiliation: Balimo District Hospital, Balimo, Western Province, Papua New Guinea.
authors.forename: Sinba
authors.initials: S
authors.lastname: Wamagi
authors.affiliation: Balimo District Hospital, Balimo, Western Province, Papua New Guinea.
authors.forename: Bisato
authors.initials: B
authors.lastname: Gula
authors.affiliation: District Health Services Hospital, Newtown-Balimo, Western Province, Papua New Guinea.
authors.forename: Keyanato
authors.initials: K
authors.lastname: Siwaeya
authors.affiliation: Balimo District Hospital, Balimo, Western Province, Papua New Guinea.
authors.forename: Daniel
authors.initials: D
authors.lastname: Pelowa
authors.affiliation: College of Public Health, Medical & Veterinary Sciences, James Cook University, Townsville, QLD, 4811, Australia.|Papua New Guinea Institute of Medical Research, Goroka, Eastern Highlands Province, Papua New Guinea.
authors.forename: Peter
authors.initials: P
authors.lastname: Siba
authors.affiliation: College of Public Health, Medical & Veterinary Sciences, James Cook University, Townsville, QLD, 4811, Australia. jeffrey.warner@jcu.edu.au.|Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, 4811, Australia. jeffrey.warner@jcu.edu.au.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Warner
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D055118:Medication Adherence / Q000523:psychology*; D008875:Middle Aged; D010219:Papua New Guinea / Q000453:epidemiology; D012424:Rural Population / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D016896:Treatment Outcome; D014376:Tuberculosis / Q000453:epidemiology / Q000628:therapy*; D014505:Urban Population / Q000706:statistics & numerical data*; D055815:Young Adult; D016903:Drug Monitoring
keywords: DOTS; Health education; Health systems; Papua New Guinea; Remote health; Subsistence; Treatment adherence; Tuberculosis; Witchcraft