Directly observed therapy and tuberculosis: how can a systematic review of qualitative research contribute to improving services? A qualitative meta‐synthesis

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Abstract
Aim. This paper reports the findings from a qualitative meta-synthesis concerning people with, or at risk of, tuberculosis, service providers and policymakers and their experiences and perceptions of tuberculosis and treatment. Background. Directly observed therapy is part of a package of interventions to improve tuberculosis treatment and adherence. A Cochrane systematic review of trials showed an absence of evidence for or against directly observed therapy compared with people treating themselves. Method. Qualitative systematic review methods were used to search, screen, appraise and extract data thematic analysis was used to synthesize data from 1990 to 2002, and an update of literature to December 2005. Two questions were addressed: ‘What does qualitative research tell us about the facilitators and barriers to accessing and complying with tuberculosis treatment?’ and ‘What does qualitative research tell us about the diverse results and effect sizes of the randomized controlled trials included in the Cochrane review?’ Findings help explain the diverse trial results in a Cochrane systematic review of directly observed therapy and tuberculosis and consider implications for research, policy and practice. Findings. Five themes emerged from the 1990 to 2002 synthesis: socio-economic circumstances, material resources and individual agency; explanatory models and knowledge systems in relation to tuberculosis and its treatment; the experience of stigma and public discourses around tuberculosis; sanctions, incentives and support, and the social organization and social relationships of care. Two additional themes emerged from the 2005 update. Conclusion. The qualitative meta-synthesis improved the relevance and scope of the Cochrane review of trials. The findings make a major contribution to the development of theory concerning global WHO-branded disease control and the practicality of local delivery to people