Establishing a New Service Role in Tuberculosis Care - Essay Example

? Research Article Critique Introduction This paper focuses on the critique of the research article “Establishing a new service role in tuberculosis care: the tuberculosis link worker” which was written by 7 authors. The first author is Gillian M. Craig who is a BSc, MSc,Phd and Cphsychol. He is the senior research fellow and project coordinator at the University College London Centre for Infectious Diseases and International Health. The second author, Helen Booth, is an MBBS FRCP, she is a Consultant in Thoracic and General Medicine at the University College London Hospitals Trust. The third author is Jo Hall who is a BSc, MA and DipSW, he is a TB Link Worker also at the university college London centre for infectious diseases and international health. The fourth author Alistair Story is a MPH, RN specializing in TB nursing and works at the Health Protection Agency, Communicable Disease Surveillance Centre. The fifth one is Andrew Hayward a Bsc,Msc,MBBS and MFPHM he specializes as a lecturer and epidemiologist in infectious disease epidemiology at the same UCL centre mentioned above. The second last author is ANN Goodburn who is a RN & RHV and is the lead TB Nurse at the Camden and Islington Primary Care Trust and UCL Hospital’s NHS Trust’s TB Services. The last author is Alimuddin Zumla who is a MBChB, PhD and FRCP. He is the Director of Centre for Infectious Diseases and International Health,University College London, Windeyer Institute, London. This article was published in the journal of Advanced nursing 3 years back The title of the first article “Establishing a new service role in tuberculosis care: the tuberculosis link worker” is well suited with the content of the article, The abstract of the articles was well summarized and compiled in accordance with the entire body of the paper. All the data findings, conclusions were well described in the abstract and nothing was missing that was of dire importance. The author provides the rationale for the study in the introduction portion of the study which stresses more upon the rising incidence of tuberculosis in the world and also in England where the rise has been 15% in the last 2 years (Department of Health, 2006) and most of the concentration of these incidences has been in London which accounts for 42% of the total cases (Health Protection Agency, 2007). These statistics prove the importance of the disease of tuberculosis which is a challenging disease to treat in itself. Treating it has become difficult today because of the drug resistance issues related with TB medication as well as social issues which hinder patient compliance. This research paper focuses on these social issues which affect compliance and hence prevent the reduction of the TB prevalence. The authors describe issues like drug abuse, poverty, poor access to healthcare as a social factors. The international standards for TB require a thorough analysis of these social factors in conjunct with community based efforts. This paper focuses upon an effective model that can used to handle this challenging issue of social and health needs of patients with TB. This model includes a TB link worker who is assigned the duty to create a link between the community and the hospital. Hence the author stated the purpose of this research in clear pointers under a separate heading that they aimed to develop an effective social outreach model which incorporated the TB link worker in an optimal way. The research objectives were clearly defined which encompassed the management of these social issues and incorporating them within an effective model. The aims and objectives of the research were very clearly, discreetly and well stated within the research paper. . THE RESEARCH QUESTIONS The research questions focused on finding the patients needs to guide service development and define caseload, Develop a risk tool to identify those who might benefit from link worker support, Identify organizations that could contribute to the care of patients with tuberculosis, develop collaborative care pathways and map resource utilization, Identify barriers and enablers to these goals and Assessing whether the model was able to address need and mitigate some of the factors likely to complicate treatments. All these questions encompassed the evaluation of the model for TB care focused on solving the complex problem of social issues that complicate the treatment further more. RESEARCH DESIGN The research details occupy the greatest amount of space within this article which is a sign of a good research paper, since the authors have aimed to explain their mode of conduct in a very effective manner. The research details are listed under the major heading of “the study” under which the subheadings include aims, design, participants, developing the TB link workers role, implementing and evaluating collaborative care, ethical considerations, data analysis followed by the second major heading of results and after that discussion and conclusion. The design of the study was a prospective cohort study based on process evaluation method (Power R., 1991;Power R. & Nozhkina N., 2002) which was a good choice for the evaluation of the program although not the best since it focused on the effectiveness of the implementation of the program only and did not focus on the overall outcomes of such a program on the community. Probably such a choice was made based on the limited resources of the researchers or the intent of the researchers to take it one step at a time to generate a more effective intervention program. The next research in line with this by the same researchers should be based on checking the effectiveness of such a program at the community level. For only the evaluation of an intervention program this was the best and most optimal choice of research design as it involves structured interviews which is the strongest and best form of data to be collected in any research. THE SAMPLE The samples included both the patients of TB as well as community centers or agencies providing care to the community. The purpose was to link both the two in an effective manner which is described under the heading of development of TBLW role where the process of identification of these agencies was described in a more detailed fashion. Here a list of all the agencies and their roles provided could have been a more comprehensive description of the sample under study however the author provided a very narrow view of the agencies and has left it a bit unclear. IMPLEMENTATION & EVALUATION OF COLLABORATIVE CARE During the description of the implementation & evaluation of collaborative care the author mentions the risk referral tool which identifies the patients who could benefit from these link workers. The risk tool is designed from items that were considered important in another research by Craig et al (Craig G., 2007)these patients who were identified as being at risk through the risk tool were linked with the TBL workers and then a Performa was designed to checklist the things that could be achieved from this interaction. The author has described the slow development of this Performa over a period of 6 months as it was based on regular interaction between the TBLW and the researchers. The variables identified in the Performa as a result of this interaction are very clear, very goal oriented and exactly comply with the goals of this study. They have been very well designed and evaluated to be effective. ETHICAL CONSIDERATIONS The researchers have provided very meticulous details regarding the ethical considerations of this research which can be many considering the social aspect of this issue. Confidentiality and discreetness is the key here and that was maintained by keeping the patients personal details and name hidden. Also the consents were taken orally in the first contact with the patient, however a written consent could have also been possible. But probably the researchers feared a higher attrition rate if the patients were made to sign on something before they give their personal details. Hence an oral consent was considered satisfactory. DATA ANALYSIS 3 different types of tools were used for data analysis – the SPSS software for descriptive, the excel sheet for patient data management and the QSR NUDIST*Vivo 1.3 for the evaluation of interview questions. Although the interview questions since were structured could have also been entered in SPSS and evaluated, but the authors chose to use a more sophisticated statistical tool which improves the quality of the research paper further more. RESULTS The results were also described point wise just like they were mentioned in the methods portion of the paper. This produces a proper flow in the paper and makes it easier to understand. The structure of the paper is very good and the results are arranged in a very systematic fashion. In the part describing the implementation and evaluation of collaborative care, where the researchers could have jumped directly to the results of the variables which were identified in the Performa mentioned above, they chose to mention separately any deviations that occurred later on from the protocols that were described In the methods portion. This is an important check and balance in every study which keeps a record of every detail no matter how irrelevant it may seem because at some point in the research, even the most irrelevant things become relevant. The researchers very clearly defined these deviations however he did not title them as limitations of the paper as yet. The results describing the patients needs, the patient’s contacts with other service providers, the TBLW case loads, referral to other services and most importantly the results under the attained goals and outcomes describe the success of the program. How well the TBLWs were able to divert patients to the relevant agencies and their outcomes and goals achievement was evaluated. A lot of TB patients who were suffering from other issues had their problems resolved which were listed in a table format within the paper (table 2: outcomes). The result of the study were outstandingly good this provided the evidence of the impact of the program. The interprofessional working that was taken abreast during this research was also tending to and described separately in the results portion which is a very important aspect of this program. It described the role that other professional agencies played in providing this care to the TB patients. This was followed by a structured interview with these agencies to evaluate effectiveness of the TBLW. The result of this interview was a comprehensive list of the benefits of TBLW which has been provided in the form of a table (table 4) and is the gist of the study. This is the type of data that can be used to advocate for this program of TBLWs and mention the well recorded and well evidenced benefits point vice in a nutshell. these benefits are described separately for the patients and for the stakeholder agencies hence providing a wholesome view of the problem. DISCUSSION The results were followed by the other major heading of discussion where the subheadings were placed rather non conventionally and resulted in a repetition of the heading “discussion” . the portion of discussion has been divided into “ limitations” and “ discussion” however traditionally the title of limitations is explored after the discussion portion which is not the case in this paper. Probably the researcher considered the limitations is an important part of the research and should be described prior to everything else. However the traditional structures of a research paper do not allow this. The limitations described were in great detail describing even the minutest details which increase the sensitivity of the research mentioning all the small aspects and not over looking anything. This is the best form of a research when in relation to an intervention program since all the aspects are necessary to be considered. The limitations that have been described in this assignment in the design portion have also been mentioned by the author in the limitations section that the design of the research only aimed at identifying the outcomes of the program and didn’t aim at deriving a causal relationship between the TBLW and the outcomes. It is in this section of limitations that the researchers provide the entire list of agencies that were working in the selected community. This list would have been best described in the sampling part of the study. However the limitation that the researcher related to this provided the evidence of it being in this section. The limitations were much listed in this section and even the solutions were provided along with them, which is a rarity and again is a sign of a good research. The discussions portion describes all the relevant literature related to the topic and the graphic representation of all the points has a very good impact on all the readers. The authors mentioned the basis for conducting this research which entails from the fact that a social aspect is very important when considering the treatment for TB patients, (Noyes J., 2007;Balabanova Y., 2006;Sumartojo e., 1993) and mentioned the link workers as the missing piece in the puzzle. (Story A., 2006) The discussion has provided a more detailed explanation of the background and introduction of the research question. Although there are legislation that have already made it necessary for the social agencies to work in collaboration for the TB patients, (Tuberculosis Coalition for Technical Assisstance, 2006) most of the patients have been enrolled with these agencies but what was missing was a more effective evaluation and coordination between the two. This would be provided by the TBLWs. Evidence based intervention has been advocated here as the author mentions that Interprofessional practice appeared to work best where there was strategic commitment and support (Cameron A. & Lart R., 2003)(Cameron & Lart 2003), the discussion goes on to describe each point in the result in a more descriptive fashion and has been well structured, well researched and well written. The conclusion similarly describes this addition of TBLWs to the clinical team as a healthy and profitable addition. At the end of the article the authors have given a section on acknowledgements which is a very nice gesture towards the people who have helped throughout the research and contributed their lot. Also each of the 7 authors have listed their contributions describing the equal share of work which is also a good practice in research, and is mostly lacking in a lot of researches. REFERENCES Out of the total 36 references 12 were older than 5 years and 6 were even older than 10 years. But all these researches were important to be mentioned in order to create a clearer picture of this problem and enlist the entire work done on this topic no matter how old or new. CONCLUSION All in all the paper was a very well written research article which provided consideration to even the most minute details which often go overlooked. It provides us a good example to follow when planning a research based on an intervention. Although there are other designs and ways of doing researches on intervention program, but this is the best model that should be followed. Also the graphical representation of the data in form of tables and diagrams was very informative and catchy but one thing that was missing was graphs. Also the structure of the article was a little weak in some places like in the discussion; a structured discussion would have been a better choice. But all in all this was a very good research article, very well written and most importantly brought forth an issue that can be a very important factor in the treatment of TB cases. When such a concept is able to be generalized in other communities it would benefit the patients of TB to a great extent. Such projects that benefit the patients at the end of the day are the most rewarding and beneficial plans and researches as they are directly aiming to improve the quality of life of the most important element of healthcare – the patients. REFERENCES Balabanova Y., D. F. (2006). The Directly Observed Therapy Short-Course (DOTS) strategy in Samara Oblast, Russian Federation. . Respiratory Research , 7(44). Cameron A. & Lart R. (2003). Factors promoting and obstacles hindering joint working: a systematic review of the research evidence. Journal of Integrated Care . , 11(2), 9–17. Craig G., B. H. (2007). The impact of social factors on tuberculosis management. . Journal of Advanced Nursing , 58(5), 418–424. Department of Health. (2006). The NHS in England: The Operating Framework for 2007/2008. London: Department of Health. Health Protection Agency. (2007, March 22). Cases of Tuberculosis Continue to Rise During 2006. Retrieved december 11, 2011, from press statement: http://www.hpa.org.uk/hpa/news/articles/press_releases/ Noyes J., &. P. (2007). Directly observed therapy and tuberculosis:how can a systematic review of qualitative research contribute to improving services? A qualitative meta-synthesis. Journal of Advanced Nursing , 57(3), 227–243. Power R. & Nozhkina N. (2002). The value of process evaluation in sustaining HIV harm reduction in the Russian Federation. AIDS , 16(2), 303–304. Power R., D. A. (1991). Towards a process evaluation model for community-based initiatives aimed at preventing the spread of HIV amongst injecting drug users. . AIDS Care , 3(2), 123–135. Story A., v. H. (2006). Tuberculosis and social exclusion. . British Medical Journal , 333(7558), 57–58. Sumartojo e. (1993). When tuberculosis treatment fails. A social behavioral account of patient adherence. American Review of Respiratory Diseases , 147(5), 1311–1320. Tuberculosis Coalition for Technical Assisstance. (2006). International Standards for Tuberculosis Care (ISTC). The Hague: Tuberculosis Coalition for Technical Assistance,. Read More