Chapter Two
3.8 Ethical Considerations
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difficult to discern) aspects of the information (Boyatzis, 1998). However the approach of developing a code on the basis of prior research places the researcher approximately in the middle of the continuum. The theory driven approach is one of the more highly popular approaches, and in this approach the researcher begins with the theory of what occurs and then formulates the signals, or indicators, of evidence that would support the theory. The wording of the themes emerges from the theorist's construction of the meaning and style of communication or expression of the elements of the theory (Boyatzis, 1998).
Combining this approach with the plior data driven approach, provided the researcher with a broader knowledge base when developing themes that were investigated, and such preliminary investigations of existing phenomena increases intelTater reliability.
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Chapter Four
Discussion of Results
The aim of the study is to understand the health-seeking behaviour of multi-drug resistant tuberculosis patients in an in-patient hospital setting. The emergent themes were derived from the focus group discussions. Through the process of analysis which has been explicated in Chapter Three (Methodology) and using the conceptual framework discussed in the same chapter, the following emergent themes were conceptualized in understanding MDR-TB patients health-seeking behaviour.
4.1. Lack of Power in Decision Making Process Regarding Health Care
Most of the patients related their experience of treatment within health care settings as disempowering. Participants described the process whereby they were sent from one clinic/hospital to another for peliods of time ranging from two to eighteen months, without receiving 'adequate' treatment to control the disease which resulted in their admission to King George Y Hospital (KGY), where they had been diagnosed as suffering from MDR-TB. The majority of participants (both male and female) felt that they had inadequate power in terms of health care decisions when being treated at health care facilities.
Patient (male): I had TB first and was put on treatment for six months, and went back for follow-up appointment and was told that I was resistant to TB medication.
Treatment was continued for four months and the visiting sister told me that I had MDR-TB, thereafter I went to the city and was transferred to KGY.
Most of the male participants argued that they were not adequately informed about their health status during in-patient treatment and believed that they had a right to have access
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to such information. These patients reported feeling disempowered by the level of non- communication by health professionals, believing that it reflected a lack of respect for them as responsible adults regarding their treatment.
Patient (male): Even if medication doses change, I am not told prior. I feel paralysed to challenge the staff because of fear that they may chase me away
Patient (male): I need to be respected. I feel that I was belittled, the staff are not being genuine and we are treated discriminately.
Patient (male): Even if your spit (sputum) converts to negative, nobody tells you about it
Patient (male): We are not even allowed to view our own files
These lived experiences of denial of power to patients in the decision making process regarding treatment could possibly be due to assumptions made by health care professionals that the patients current health status was as a result of treatment defaultationlnon-adherence.
Therefore without fully understanding the factors that contribute to treatment defaultation (for those who did default treatment), and the factors that contributed to the development of the condition (e.g. delays in diagnosis, mismanagement of TB cases, socio-cultural influences, etc), health care professionals assumptions about patients who have contracted the disease may have a negative influence on patients ability to make informed health care decisions.
With regard to the DOT regimen, while the majority of male participants believed that DOT was useful as a treatment strategy and was beneficial in the control of TB, a number of them took the view that DOT made them feel irresponsible and untrustworthy.
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Patient (male): It had a negative impact on me, because I became an object of ridicule and I felt dehumanized.
Patient (male): It makes you feel less responsible and other people look down upon you with a condescending attitude.
These responses throw light on the issue of TB control through DOT, reflecting a prevailing attitude amongst both of the above participants of feeling dehumanized and stigmatized for being 'unable' to manage the treatment regimen, given that the responsibility for treatment has been taken away from the patient and is now supervised by third party/parties. Such attitudes were characteristic of males who were treated using DOT.
On the other hand, five other male participants overtly supported the use of DOT as a useful strategy in the control of TB. They viewed DOT as providing support, especially given perceptions of in'esponsibility on their part in adhering to treatment protocols. One·
male participant elaborated that he felt quite fearful of some of his medication and felt that it was quite unpleasant to swallow. He believed that the supervision component of DOT was beneficial in helping him take his medication appropriately.
Similarly, the majority of female participants supported the use of DOT as an appropriate treatment strategy. This majority also alluded to the supportive component of DOT in aiding them to tolerate taking their medication and in providing emotional support.
Patient (female): DOT helped me a great deal as I would not have been able to take my tablets regularly on my own. The supervision aspect of DOT helped because it ensured that I took my tablets as per the instructions.
Patient (female): I benefited from DOT because it made me withstand the difficulty in swallowing the tablets.
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Patient (female): I found that DOT was helpful since I would have nearly vomited them all. The mere presence of another person helped me a great deal.
One female participant reported that she received support during the DOT intervention from her employers, where she worked as a domestic.
Patient (female): My employers took me to the hospital and were actively involved in my treatment (DOT). I was happy with them issuing my treatment because they took good care of me.