Background: Tuberculosis (TB) and HIV are major public health problems in Botswana.
In the face of growing TB notification rates, a low cure rate, human resource constraints
and poor accessibility to health facilities, Botswana Ministry of Health decided to offer
home-based directly observed treatment (DOT) using community volunteers. Objectives: The aim of this study was to assess the outcomes of home-based directly observed treatment (HB-DOT) versus facility-based, directly observed treatment (FB-DOT) in the Kweneng West subdistrict in Botswana and to explore the acceptability of HB-DOT among TB patients, community volunteers and health workers. Method: A quantitative, observational study using routinely collected TB data from 405 TB patients was conducted and combined with 20 qualitative in-depth interviews. Results: The overall cure rate for smear-positive pulmonary TB patients was 78.5%. Treatment outcomes were not statistically different between FB-DOT and HB-DOT. Contact tracing was significantly better in FB-DOT patients. Interviews revealed advantages and disadvantages for both FB and HB options and that flexibility in the choice or mix of options was important. A number of suggestions were made by the interviewees to improve the HB-DOT programme. Conclusion: HB-DOT is at least as good as FB-DOT in terms of the treatment outcomes, but attention must be given to contact tracing. HB-DOT offers some patients the flexibility they need to adhere to TB treatment and community volunteers may be strengthened by ongoing training and support from health workers, financial incentives and provision of basic equipment.
Botswana has one of the highest Tuberculosis (TB) notification rates in the world (509 cases per 100 000),
with recent increases blamed mainly on the HIV epidemic. Multidrug-resistant TB (MDR TB) cases are also on
the rise and 60% - 86% of TB patients are co-infected by HIV.1,2 In 1975, in an attempt to halt
the rapid spread of TB in Botswana, the Ministry of Health established the Botswana National Tuberculosis Control
Programme (BNTP). Following this, short-course chemotherapy was introduced in 1986 and the Directly Observed Treatment
Short-course (DOTS) strategy was adopted in 1993.1 Despite the introduction of DOTS, the TB programme continued to struggle with low cure rates, human resource
constraints and difficult access to health facilities. The Botswana Ministry of Health therefore decided to offer
home-based care using volunteers or family members.2,3,4 This programme allows for the dispensing of
medications to TB patients at their respective homes under the daily supervision of a community volunteer. After
consultation with community representatives in their respective catchment areas, health facilities select local
volunteers to be trained in TB treatment supervision. At the onset of TB treatment, patients are introduced to
both home-based directly observed treatment (HB-DOT) and facility-based directly observed treatment (FB-DOT)
and are given the choice to continue with whichever of these methods they prefer.2 In Africa, there is a tradition of communities, and especially women, taking care of family members.2
The World Health Organization (WHO), through its Stop TB strategy, recognises community participation as one of
the principles of the Primary Health Care approach.2,4 The model has been successfully introduced for
home-based care with HIV patients and, in the case of TB, possible contributions are2,5: • supporting patients throughout the treatment • patient, family and community education on TB • case finding and case detection • recognition of adverse effects and follow up of defaulters. Countries that have well-functioning TB programmes can also benefit from community-based approaches,
as these may help them maintain their standards in the face of growing human resource deficiencies.3 Community
involvement in dispensing anti-tuberculosis treatment has been tried in urban and rural African and
Asian settings.3,6,
7,8,9,
10,11,12,13 Studies have used different community members, such as family members, volunteers, previous
TB patients or established community home-based care programmes with encouraging
results.7,8,
9,12,13,
14,15 Community TB care seems to be accepted by patients
because it helps improve their understanding of TB and reduce stigma in the
community.5,9,16 Finally,
community TB care can help to improve the cost-effectiveness of TB treatment, although there remains an issue of
incentives for volunteers to help sustain the programme.2,17,18 In Botswana, there has, to date, been little formal evaluation of the home-based programme. As such, the aim
of this study was to assess the success of HB-DOT versus FB-DOT in the Kweneng West subdistrict and to explore
the acceptability of HB-DOT amongst TB patients, TB treatment supervisors and health workers.
Ethical approval was received from the Human Research Ethics Committee, University of
Stellenbosch, as well as from the Ministry of Health and Local Government in Botswana.
A waiver of informed consent was obtained for use of routinely collected TB data. All
interviewees signed written informed consent. There were no other potential hazards or
health risks to the participants.
Study setting
The Kweneng West subdistrict, a rural area with approximately 40 000 inhabitants,
comprises 23 health facilities, with one primary hospital and eight main clinics
that offer TB treatment. Community volunteers dispense TB medications for a given
number of patients and are supervised in their respective catchment area by clinic nurses.
The volunteers are given weekly TB medication and are expected to report to the clinic nurses
once per week. Nurses are responsible for managing patient records, supervising medication intake
and guiding the volunteers.1 Nurses are also supported by health education assistants,
who are members of the community themselves and through whom health practitioners and facilities
can sustain a link with the communities.1 In the TB programme, health education
assistants also help to trace treatment defaulters and record all non-institutional deaths
in their respective communities.1 Medical doctors initiate TB treatment and
offer monthly follow-ups to all TB patients.1 TB programme data are captured at health facilities using two tools, (1) the TB register and
individual TB patient cards and (2) a manual and electronic TB register maintained at district
level.1 In particular situations, some patients may start TB treatment under FB-DOT
and end up in HB-DOT or vice versa; hence, a third mixed group (MX-DOT) has been considered in this study.
Study design
Mixed quantitative and qualitative techniques were used to evaluate the HB-DOT system.
Observational data was collected from the TB registers and patient TB cards. In addition,
in-depth interviews were held with TB patients, community volunteers and facility-based nurses
and health education assistants.
Study population
Only TB patients who were registered in the main clinics from June 2006 to
June 2008 were included in this study. Patients with MDR or extensively drug-resistant
(XDR) TB and who were transferred in or out of these clinics during this period were excluded.
Using a 5% precision with 95% confidence interval, the sample size required was estimated to be
at least 381 respondents. Interviewees were chosen purposefully from the same areas as the TB patients and were actively
involved in the TB programme at the time of research. Selection of TB patients aimed for a range
of age groups, both genders and individuals who were employed or unemployed. As such, the following
interviews were planned with the option of further interviews should the analysis suggest the need for
further exploration of themes: • five TB patients under HB-DOT • five TB patients under FB-DOT • five TB community volunteers • five health workers (three nurses and two health education assistants).
Data collection
After a short training session, research assistants collected and captured quantitative
data from the TB registers and patient cards. Research assistants were community volunteers
who were already acquainted with the TB programme and related ethical issues. Interviews were conducted by the principal researcher, who was fluent in English, with the help
of research assistants who were also fluent in Setswana. All interviews were recorded on audiotape.
Interview guides were created for each category of interviewees to explore their experience of the HB-DOT system.
For TB patients the opening question was: 'Can you please describe your experience of TB treatment and how you now
feel now about receiving TB treatment in this way?' For TB community volunteers the opening question was:
'Can you please describe your experience of supervising medication for a TB patient?' Similarly, for health workers,
the opening question was: 'Can you describe the impact of HB-DOT on the TB treatment programme in your facility?'
A list of further potential questions for each interview was also identified to ensure all aspects of the issue were
adequately explored.
Analysis
Quantitative data was collated in Excel and analysed by the Centre for Statistical
Consultation at the University of Stellenbosch, South Africa. Categorical data was
analysed in contingency tables and a maximum likelihood Chi square test. Analysis of
variance (ANOVA) was used for continuous variables and p-values obtained from a
Kruskal-Wallis test. Transcripts of the translated tapes were prepared in English and
qualitative data analysis followed the steps of the framework method,19 which are (1) familiarisation, (2)
create a thematic index, (3) indexing, (4) charting and (5) mapping and interpretation.
Quantitative results
The study included 405 TB patients whose characteristics are shown in Table 1. The mean age was
36.5 ± SD years and did not differ significantly between the categories of TB patients (p = 0.52). The TB programme encourages health workers to perform smear testing for the presence of acid- and
alcohol-fast bacilli (AAFB) in diagnosing pulmonary TB, in order to avoid excessive reliance on
chest radiography. In this study, 107 (33%) of patients did not have an AAFB recorded prior to treatment,
which is presumably related to the inclusion of extra-pulmonary cases, but could also be a reflection on the
adherence of the TB clinics to the BNTP. Similarly, 43 (11%) of patients did not have their HIV status determined. Table 1 also compares the characteristics of the study participants in terms of the different types of
DOT that they experienced. The late introduction of HB-DOT in some areas of the subdistrict may have
contributed to the uneven enrolment of the different DOT types. The groups receiving different DOT
types did not differ statistically in any of the characteristics, except in the category of TB treatment.
None of the re-treatment patients were considered for exclusive HB-DOT, while 17 (31%) received MX-DOT.
The main reason for this difference is the need for re-treatment patients to receive streptomycin injections
during the intensive phase of treatment. Table 2 compares the outcome of TB treatment across the three types of DOT and the efforts to trace TB contacts.
Overall, the successful treatment rate (i.e. the sum of the cured and completed cases) was 83%. Excluding the
re-treatment patients from the comparison of the types of DOT does not alter the overall findings regarding
treatment outcomes and contact tracing. The outcome of treatment did not differ significantly between any of the three groups; however,
health workers in the FB-DOT performed better in efforts to trace contacts of TB patients. Table 3 shows the cure rate in terms of the total number of patients who had an initial positive AAFB
(i.e. those pulmonary TB patients whose smear tested positive) as opposed to all registered patients. Again,
there was no significant difference between the DOT types.
Table 1: The characteristics of study participants in different DOT types
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Table 2: Comparison of overall outcome of TB treatment and contact tracing efforts among the different directly observed treatment types
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Qualitative results
Advantages of facility-based DOT
Some patients believed that the stricter environment of the clinic was more likely to ensure
their ongoing adherence. One of the interviewees expressed this belief: 'Because I feared getting tired of taking tablets and therefore become tempted to hide them
or throw them instead of taking them. At clinics I took them in the presence of the health care worker'. Others felt more secure knowing that more highly trained staff were theoretically available to
them at the FB-DOT service. As such, one of the interviewees who participated in FB-DOT said: 'I feel safe when I know the doctor is nearby and can intervene anytime if something goes wrong'. This was further corroborated by health care workers who felt that problems were more likely to
be detected early in FB-DOT: 'On-going counselling, direct supervision by highly trained health workers, daily assessment of
patients and therefore early detection of toxicity and side effects signs are of great importance'.
Disadvantages of facility-based DOT
Patients and community volunteers recognised that FB-DOT involved longer travel time and distances,
as well as longer waiting times for treatment at the clinic. Therefore, the effort and time needed
to obtain treatment at clinics might adversely affect adherence, especially at weekends and during
public holidays. A patient asserted: 'Weekly or fortnightly supply may help their experience be better. Having extra manpower over
weekends at clinics may reduce the nightmare faced by a single nurse and all patients'. Similarly, another volunteer opined that: 'Patients may choose to stay home and not go late to far away health facilities'. Another patient commented that: 'Waking up early in the morning to queue at the clinics is difficult and inconveniencing, we don't get enough rest'.
Advantages of home-based DOT
Obtaining treatment from a community volunteer was less stressful, as it required less effort and a
more convenient and flexible time schedule could be negotiated between the patient and volunteer. A patient under HB-DOT submitted: '[HB-DOT] allows us to rest enough and does not stress us as we would have usually agreed with
volunteers about a specific time to meet'. HB-DOT was also an advantage for those too sick to travel every day to a health facility and for those
who struggled to eat before taking medication at the clinics; not being able to eat might lead to more side
effects and reduce adherence. For example, a patient said: 'Community TB programme has come on time to help us. At times we are too sick to walk to the clinics everyday.
Clinics advise us to eat before medication intake but by the time we take tablets at clinics, the food would
have dissolved in the stomach. At home the volunteer deals with few people and gives time to patients to eat
some porridge in the morning before medication'. One volunteer interviewed illustrated the point that HB-DOT allows patients to engage more fully in other aspects of their lives: '[HB-DOT] is well designed to help workers or non-workers to take tablets at an agreed time with their
community supervisors. Patients may then have time to take care of other businesses instead of staying
at clinics the entire day'. Nurses also recognised these advantages and, in addition, perceived that their own workload and the need for
them to conduct home visits was reduced. They also recognised that attending a health facility might place an
additional financial burden on the patient: 'Of course HB-DOT reduces the travelling distance to clinics for patients, it reduces workload for nurses,
it reduces the daily transport cost of very ill patients to/from clinics for medication or the need
for home visits by nurses and the disturbance of visiting patients at home when they are still asleep'. HB-DOT was also an advantage on weekends when clinics may be closed.
Disadvantages of home-based DOT
Patients feared that being treated for TB under HB-DOT could affect their adherence to medication: 'We are however sometimes worried about our own safety as volunteers are perceived to be not fully
knowledgeable about doses and side effects of medication for instance'. Health care workers concurred with these fears and the possibility that volunteers were not
sufficiently knowledgeable, which led to one health care worker admitting that: '[p]atients may also have little trust in volunteers' and that HB-DOT unfortunately involves volunteers that are not perfect about TB management and may still
have problems with some aspects of TB management. There are also concerns about the change of
time of medication intake'. Health workers also worried that community volunteers may not always supervise strictly in the long term: 'Patients may relax and volunteers may be lenient to members of their community'. A further problem is that there is sometimes no substitute when community volunteers are not available; there is '[n]o back up plan when volunteers have funerals or are ill'. Volunteers, however, suggested that health workers pay regular visits to communities where they
could continue health education and reinforce what volunteers had taught: 'Nurses need not abandon us with the patients during the entire course of treatment. They need
to meet TB patients and communities regularly to re-enforce our education. It may even increase
confidence of patients in us as nurses would confirm what we usually say'.
Organisational issues
Interviews with patients on FB-DOT frequently revealed that they had incomplete knowledge about the existence of HB-DOT.
Sometimes they did not know that they were free to choose whether to receive medication at home or from health facilities: Interviewer: 'Did you know that at home you would take TB tablets in the presence of the community volunteers'? Patient: 'Is it? I didn't know. I thought I would just get a supply for few days and then swallow them at my own time'. Problem patients on HB-DOT may be referred back to the facility when supervision is difficult. As a volunteer noted: 'It is discouraging to look after patients who refuse to take medicines (hide them or throw them) or
patients who still take alcohol. Fortunately, difficult patients may be referred back to health
facilities for follow up'. In addition, patients might also take their medication at the home of the community volunteer,
which allows supervision to be more time-efficient for the volunteers: 'Patients walking to our places [volunteer's house] for medication has made supervision very
easy and gives us time to finish this work and deal with our personal activities'. Though not specifically allowed by the national TB programme, the provision of such flexibility
allows a combination of facility-, home- and even school-based supervision that can support adherence
and quality of life. The advantages of this flexibility were noted by a schoolboy undergoing TB treatment: 'I felt that taking TB tablets was disturbing my school attendance, hence I allowed my teacher to
keep my tablets and issue them to me daily. During weekends I instead take medication from the
clinic. I think this arrangement is advantageous to me'. Nevertheless, the need for even greater flexibility was still an issue for some patients: 'How can I go to plough the field some 25 km away from here if everyday I have to take the TB tablets
in the presence of a supervisor? What am I going to eat this year? Why don't they allow farmers to
go back to their work when they feel a bit better?' Although relying on unpaid volunteers appears to make HB-DOT cheaper, its long-term sustainability may be
threatened by volunteerism, as a volunteer points out: 'HB-DOT won't be sustainable as there is high turnover of volunteers due to no incentive. National
TB programme should tackle this issue urgently'. Despite this issue, community volunteers perceive the community TB programme to be acceptable to patients: 'It may go a long way, if a few problems are managed, as communities have generally accepted us
and take us like nurses'. Volunteers also appreciate the privileged position that their role in HB-DOT allows them to attain in
the community, but they agree that they need to be provided with some form of identification. Indeed,
identification and other clothing/equipment will ease their movement and encourage them to continue
their involvement in this programme. Three different volunteers suggested: 'Do you know that sometimes even clinic staff fails to identify us. We need uniform and some
form of sticker to write our names on to help people identify us'. 'People take us as nurses and that inspires respect, why then not have identification?' 'We need umbrellas and other protective cloths/boots to wear when it is raining, cold or very hot'. Health workers believe that the national TB programme has to take some bold decisions before
HB-DOT collapses. Among their recommendations for improvement were needs for: • financial incentives for volunteers • training of additional volunteers to cover more areas • organisation of regular refresher workshops for volunteers • regular supportive visits from the district TB coordinator, local government
and Ministry of Health officials to encourage them and make them feel appreciated • constant availability of data capturing/monitoring tools • reliable transportation to allow daily home visits of TB patients by nurses
(especially when injections are required).
Conclusion: Overall the choice of DOT appeared to be based on the need for injections,
patient preference and availability of different DOT options (Table 4).
Table 3: Comparison of cure rates for smear positive pulmonary TB patients among
different directly observed treatment types
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Table 4: Summary of the reasons for choosing different directly observed treatment types
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Main findings of the study
There was no difference in TB treatment outcomes between facility-based, home-based and mixed types of DOT.
It would appear, therefore, that HB-DOT is as good as FB-DOT. It is likely that providing greater choice
and matching the treatment plan more closely with patient preferences will lead to greater satisfaction and adherence to treatment. The overall cure rate for smear-positive pulmonary TB was 78.5%, which is below the WHO target as
well as the Botswana national TB programme target of 85%. The successful treatment rate was 83%,
which is close to the WHO target of 85% and above the Botswana target of 75%. Facility-based health workers were found to be more proactive in contact tracing than the
community volunteers. Given the volunteers' greater engagement and involvement in the community,
this is an unexpected finding. Further evaluation is required to explore whether this poor performance
is a reflection of a lack of trust in the relationship between patients and community volunteers, or a
lack of knowledge among community volunteers about contact tracing. Patients on MX-DOT showed even
worse contact tracing, perhaps because no single caretaker took the responsibility of screening close
contacts with TB patients.
Relation of findings to literature
The findings of this study concur with those obtained for community-based DOT from clinical trials
and observational studies conducted in different
settings3,6,
8,10,20 and support the
implementation of this type of DOT as a complementary intervention to traditional FB-DOT. Other studies demonstrated that outcomes from HB-DOT can be better than FB-DOT.7,9
These studies in Zambia and Uganda showed that, in TB programmes where FB-DOT was usually only strictly
implemented during the initial phase of treatment, the introduction of HB-DOT significantly improved outcomes. Other programmes have attempted to use family members instead of community volunteers for supervision.
In a developed country, the use of family members showed worse adherence to anti-tuberculosis treatment
(ATT) in the HB-DOT group,14 but in a developing country, better adherence to ATT suggests this
may be an option to explore in this context.15 The qualitative findings are similar to those reported from Tanzania,16 which emphasised the
benefit of HB-DOT in relieving overcrowding in clinics, as well as in providing a cost-effective, flexible
and time-conscious method of treatment. Another study in Uganda also supports the link between patients'
own choice of DOT type and their commitment to completing ATT.9
Strengths and weaknesses of study
A particular strength of this study is the combination of quantitative methods with exploratory
qualitative interviews, which captured a more complete picture of the process and the outcome of care.
This study also reports results from the actual health care setting, rather than from the more ideal
conditions created by a randomised clinical trial. The MX-DOT group was not expected and its analysis
was therefore affected by the small sample size. However, a limitation of this study is the potential effect of measured and unmeasured confounding
factors on outcomes between the different groups. In this study, only confounding factors registered
in the TB registers were considered. Other confounding factors that may have been relevant but were not
available were CD4 count, WHO clinical HIV staging and other co-morbidities. It is important to recall that interviews are, by nature, subjective and contain the potential for
misinterpretation of meaning through the process of translation and analysis.
Need for future research
Further evaluation of HB-DOT could investigate the surprising difference in contact tracing
efforts across the different DOT types, as well as the benefits of more flexibility and choice
for patients. Further investigations into these elements could result in a re-evaluation of the
community TB programme after addressing some of the issues raised by this study. Although the HB-DOT
programme might be improved by considering the suggestions made in the interviews, the following points
do need to be taken into account: • Health care workers need to speak to TB patients on a regular basis to reinforce on-going
counselling by community volunteers. • A focus on continuing professional development needs to be sustained and a education of volunteers
must be priority to ensure their skills and knowledge are competent and up-to-date. • Additional education and support for contact tracing by community volunteers needs to be provided. • The community volunteers should be provided with a uniform and some form of identification
to reinforce their position. • Financial incentives for community volunteers need to be considered. All of these suggestions would increase the cost of home-based DOT and so future studies should also
analyse the programme from a cost-effectiveness perspective.
HB-DOT is at least as good as FB-DOT in terms of the treatment outcomes, but attention must be given
to contact tracing. HB-DOT offers some patients the flexibility they need to adhere to TB treatment and
community volunteers might be strengthened by ongoing training and support from health workers, financial
incentives and provision of basic equipment.
1. Botswana Ministry of Health. National tuberculosis programme manual. 2nd ed. Gaborone: Ministry of Health; 2007. 2. Botswana national tuberculosis programme. Community TB care: Training guide for Health workers. Gaborone: Ministry of Health; 2007. 3. Wandwalo E, Kapalata N, Egwaga S, Morkve O. Effectiveness of community-based directly observed treatment for tuberculosis in urban setting in Tanzania: A randomised controlled trial. Int J Tubercul Lung Dis. 2004;8:1248-1254. 4. World Health Organization. The Stop TB strategy: Building on and enhancing DOTS to meet the TB-related millenium development goals. Geneva: World Health Organization; 2006. 5. Maher D. The role of the community in the control of tuberculosis. Tuberculosis. 2003;83(1-3):177-182. 6. Singh AA, Parasher D, Shekhavat GS, Sahu S, Wares DF, Granich R. Effectiveness of urban community volunteers in directly observed treatment of tuberculosis patients: A field report from Haryana, North India. Int J Tubercul Lung Dis. 2004;8(6):800-802. 7. Miti S, Mfungwe V, Reijer P, Mahers D. Integration of tuberculosis treatment in a community-based home care for persons living with HIV/AIDS in Ndola, Zambia. Int J Tubercul Lung Dis. 2003;7(9 Suppl 1):S92-98. 8. Kangangi JK, Kibuga D, Muli J, et al. Decentralisation of tuberculosis treament from the main hospitals to the peripheral health units and in the community within Machakos District, Kenya. Int J Tubercul Lung Dis. 2003;7(9 Suppl 1):S5-13. 9. Adatu F, Odeke R, Mugenyi M, et al. Implementation of the DOTS strategy for tuberculosis control in rural Kiboga District, Uganda: Offering patients the option of treatment supervision in the community, 1998-1999. Int J Tubercul Lung Dis. 2003;7(9 Suppl 1):S63-71. 10. Lwila F, Scellenberg D, Masanja H, et al. Evaluation of efficacy of community based vs institutional based direct observed short-course treatment for the control of tuberculosis in Kilomboro District, Tanzania. Trop Med Int Health. 2003;8(3):204-210. 11. Ngamvithayapong J, Yanai H, Winkvist A, Saisorn S, Diwan V. Feasibility of home based and health centre based DOT: Perspectives of TB care providers and clients in an HIV-endemic area of Thailand. Int J Tubercul Lung Dis. 2001;5(8):741-745. 12. Zwarenstein M, Schoeman JH, Vundule C, Lombard CJ, Tatley M. A randomized controlled trial of lay health workers as direct observers for treatment of tuberculosis. Int J Tubercul Lung Dis. 2000;4(6):550. 13. Akkslip S, Rasmithat S, Maher D, Sawert H. Direct observation of tuberculosis treatment by supervised family members in Yasothorn Province, Thailand. Int J Tubercul Lung Dis. 1999;3(12):1061-1065. 14. Maclntyre CR, Goebel K, Brown GV, Skull S, Starr M, Fullinfaw RO. A randomised controlled trial of the efficacy of family-based directly observation of anti-tuberculosis treatment in an urban, developed-country setting. Int J Tubercul Lung Dis. 2003;7(9):848-541. 15. Manders AJ, Banerjee A, Van den Borne HW, Harries AD, Kok GJ, Salaniponi FM. Can guardians supervise TB treatment as well as health workers? A study on adherence during the intensive phase. Int J Tubercul Lung Dis. 2001;5(9):848-854. 16. Wandwalo E, Makundi E, Hasler T, Morkve O. Acceptability of community and health facility-based directly observed treatment of tuberculosis in Tanzanian urban setting. Health Policy. 2006;78(2-3):284-294. 17. Sinanovic E, Floyd K, Dudley L, Azevedo V, Grant R, Maher R. Cost and cost effectiveness of community-based care for tuberculosis in Cape Town, South Africa. Int J Tubercul Lung Dis. 2003;7(9 Suppl 1):S56-62. 18. Dudley L, Azevedo V, Grant R, Schoeman H, Dikeveni L, Maher R. Evaluation of community contribution to tuberculosis control in Cape Town, South Africa. Int J Tubercul Lung Dis. 2003;7(9 Suppl 1):S48-55. 19. Ritchie J, Spencer E, editors. Qualitative data analysis for applied policy research. In: Bryman A, Burgers R. Analysing qualitative data. London: Routledge, 1994; p. 173-194. 20. Kironde S, Meintjies M. Tuberculosis treatment delivery in high burden setting: Does patient choice of supervision matter? Int J Tubercul Lung Dis. 2002:6(7):599-608.
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