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Chapter 2: Literature Reviews
Introduction
Sumerson (2014:45) defines literature review as the process of presenting a theoretical explanation and empirical evidence regarding the problem under investigation. In any research attempt surveying the existing contemporary literature is key before embarking on the research project (Greenhalgh 2010:16). Thus, a study starts from variables, which are later translated into measurable constructs. These measureable constructs provide general shape and structure for the research (Sumerson 2014:18). Literature review helps the researcher to present empirical evidence to support and challenge the research questions and variables used in the research. The volume of available literature on medicine has grown at an unprecedented rate. Thus, searching for medical literature is as challenging as walking in a jungle. Therefore, searching and obtaining a literature that fits into the information need of a particular research objective need to be considered as a big task for a person pursuing research (Greenhalgh 2010:15). In this study, the literature review is guided by the aims, objectives, the research questions and hypotheses of the study.
The purpose of the literature review
In any study, the literature review plays an important role. First, it helps to bring clarity and focus to the research problem. Second, it helps to broaden the knowledge base of the researcher in his or her research area. Third, the literature review helps to contextualize the research results by comparing the results of the current research with the existing body of knowledge (Kumar 2011:27; Polit & Beck 2012:88).
In this study, the literature review presented an organized summary of the results from books, journals and other documents. The summary of results helped to describe the past and the current state of knowledge regarding tuberculosis and especially drug-resistant tuberculosis (Creswell 2012:105-6). Thus the empirical evidence obtained from various sources helped to gain insight about each of the variables and research questions used in the research. By providing an in-depth analysis of available scholarly sources on the topic of interest, literature reviews provide readers with the opportunity to understand what is being researched and why (Roush 2015:20-21).
The search strategy used in this study
For this study, the researcher searched for all English language studies on drug-resistant tuberculosis. The literature search was guided by the constructs included in the theoretical framework of the study. Resources used in this study were accessed from multiple sources. The researcher searched for relevant resources through the UNISA electronic library access, the Medline, PubMed, PLOS, Open Access, www.thelancet.com and the Google. Peer reviewed scholarly articles were researched for clinical and programmatic management of drug-resistant tuberculosis and on factors determining the treatment outcomes of patients with MDR-TB and factors determining patients’ perceived quality of care and patients’ satisfaction in the care given for MDR-TB. Furthermore, national programme guidelines of the Ministry of Health of Ethiopia and the Oromia Region of Ethiopia were obtained from National Ministry of Health and the Oromia Region Health Bureau respectively. The key words used for searching included the following:
MDR-TB, treatment outcomes of patients with MDR-TB, determinants of treatment outcomes, perceived quality of care, patient satisfaction.
Date delimitation for the literature review
Except for historical analysis of tuberculosis, the date delimitations of the articles and books used in this study focused on those published from 2011 to the present. Some articles and books used from those published before 2011 were for the purpose of describing the historical overview of MDR-TB and the global trend in the response to the problem.
Methodology used in reviewing the literature
The literature was reviewed based on the key themes relevant to the study topic. These key themes are presented in the theoretical framework of the study. As much literature as available on the topic under investigation was surveyed. To make sure that each article is relevant to the purpose of the study, each article was critically appraised using a checklist. Then all relevant and peer reviewed literatures were selected, organized, synthesized and discussed in relation to the study topic.
The basics of tuberculosis
Tuberculosis (TB) is a chronic infectious disease caused by the bacteria Mycobacterium Tuberculosis. This disease is rarely caused by the other species of the Mycobacterium tuberculosis complex including the Mycobacterium bovis and the Mycobacterium africanum (Heemskerk, Caws, Marais & Farra 2015:1). The Mycobacterium genus is taxonomically located in the Mycobacteriacea family. This genus comprises about 150 species of the mycobacteria (Ozcaglara, Shabbeera, Vandenbergc, Yenera & Bennetta 2012:77). Among members of the Mycobacterium tuberculosis complex, the Mycobacterium tuberculosis has paramount importance in terms of human disease (McHugh 2013:15).
The Mycobacterium tuberculosis is an oxygen-seeking organism. It grows most successfully in tissues with high oxygen content such as the apices of the human lung. The Mycobacterium tuberculosis attacks the host inducing transmission by leading the host to its own self destruction. The Mycobacterium tuberculosis is an intracellular pathogen, usually infecting cells of the immune system, which helps it to hide from the body’s defense mechanism.
The Mycobacterium tuberculosis is a slow-growing bacterium. The generation time of 12 to 18 hours for the Mycobacterium tuberculosis is by far longer than that of the 20-30 minutes for other common human bacterial pathogen like the Escherichia Coli (Adams et al 2015:122-23). This makes it a challenge to grow the Mycobacterium in culture media. Rather than having a culture result in two to three days, it can take two to twelve weeks for the Mycobacterium tuberculosis to grow. The Mycobacterium is called acid-fast bacteria due to its staining property (Pálfi, Dutour, Perrin, Sola & Zink 2015:2). This entails the use of special reagents to detect the Mycobacterium tuberculosis (Caminero 2013:14).
Tuberculosis can affect almost any organ of the human body. Nevertheless, 80 percent of all cases of tuberculosis worldwide are pulmonary (Ribon 2015:45-46). Extra-pulmonary tuberculosis (EPTB) occurs in less than 20% of the total tuberculosis cases. The most common forms of the extra-pulmonary tuberculosis are tuberculosis of the lymph nodes (tuberculosis lymphadenitis) and tuberculosis of the bones (osteoarticular tuberculosis, also known as Potts Disease when it affects the spine). The other form of extra pulmonary parts of the body affected by tuberculosis include the meninges, the intestine, peritoneum and the like (Babatunde, Elegbede, Ayodele, Fadare, Isinjaye, Ibirongbe & Kinyandenu 2013:2010). A person with tuberculosis classically presents as very thin, pale, feverish, and has a cough that produces bloody sputum. If not treated, up to two thirds of tuberculosis patients die of the disease (Bynum 2012:12).
Tuberculosis spreads through airborne transmission. When a person with infectious pulmonary tuberculosis coughs, sneezes, sings, or laughs, small infectious respiratory droplets are aerosolized and released into the airspace. These infectious droplet nuclei may only contain a few of the Mycobacterium tuberculosis bacilli, but a person needs to inhale only a few of these aerosolized droplets to be infected. Droplet nuclei can stay in the air for up to eight hours (Dye 2015:4). A dark room, over crowdedness, and poorly ventilated living quarters, create the perfect environment for tuberculosis transmission. In such an environment, one untreated person with infectious pulmonary tuberculosis, infects an average of ten to fifteen people in a year time (Adams et al (2015:123). The risk of acquiring tuberculosis infection is essentially determined by exogenous factors. These factors are largely social and economic in nature, including substance abuse, chronic illnesses like diabetes and HIV/AIDS, malnutrition and air pollution (Glaziou, Sismanidis, Floyd & Raviglione 2015:5; Heemskerk, Caws, Marais & Farra 2015:9).
Naturally, the Mycobacterium tuberculosis is resistant to cold temperature with the capacity to remain viable for weeks at 4 degrees Celsius. Moreover, due to its high lipid content, the bacterium is also resistant to chemical decontaminations with chemicals like sodium hydroxide or detergents (Caminero 2013:14). However, sunlight kills the Mycobacterium tuberculosis and good ventilation ensure that the droplet nuclei are dispersed and carried outside (Davies et al 2014:131). Unfortunately sunlight and ventilation do not exist in all places. Thus, persons living in confined conditions like the miners and prison inmates, suffer from high transmission of tuberculosis including drug-resistant tuberculosis. In this way, it is easy to guess how tuberculosis can be easily transmitted from person to person among the more than 10 million people currently living in prisons globally (Fazel & Baillargeon 2011:959). Despite the continuous effort for millennia, tuberculosis has not come under control (Kaufmann 2011:3).
The basics of multidrug-resistant tuberculosis
Multidrug-resistant tuberculosis is the strain of tuberculosis bacilli that is resistant to the two most potent first-line anti-tuberculosis drugs, i.e. isoniazid and rifampicin (Caminero, Sotgiu, Zumla & Migliori 2010:621; Dheda et al 2014:321). The re-emergence of tuberculosis as a global public health threat is associated with the emergence of multidrug-resistant strains of tuberculosis (Pálfi et al 2015:1; Sullivan & Amor 2013:373; Udwadia 2012:286; Migliori, Cantis, Lange, Richardson & Sotgiu 2010:171).
There is no difference between susceptible tuberculosis and drug-resistance in terms of their ways of transmission and clinical presentation. Moreover, the two strains could not be differentiated based on the results of smear microscopy and radiographic features (Scardigli & Caminero 2013:209). Nevertheless, MDR-TB is a serious public health problem (Nathanson, Nunn, Uplekar, Floyd, Jaramillo, Lönnroth, Weil & Raviglione 2010:1050; Zai, Haroon & Mehmood 2010:279-283). The development of MDR-TB, highly affects the diagnosis and clinical management of tuberculosis as well as patient monitoring parameters. Moreover, it highly compromises the effectiveness of the treatment given for tuberculosis (Caminero 2013:39-44; Vishakha & Sanjay 2013:57). MDR-TB does not respond to the standard six month tuberculosis treatment with first-line anti-tuberculosis drugs. Treatment of MDR-TB can take up to two years or more with second-line drugs. Moreover, second-line anti-tuberculosis drugs are less potent, more toxic and much more expensive than first-line anti-tuberculosis drugs (WHO 2011:1).
Currently, the combination of poverty, HIV/AIDS and drug resistance makes tuberculosis a challenging disease for many people. Moreover, the political and cultural conditions and stigma associated with the disease determine the occurrence of MDR-TB. Factors associated with the performance of the health system determine patients’ access to diagnosis and treatment services for the disease. The combination of these factors affects the outcomes of patients with MDR-TB (Davies et al 2014:3-4).
Spectrum of drug-resistance in the Mycobacterium tuberculosis
A strain of tuberculosis that is resistant to rifampicin detected using phenotypic or genotypic methods, with or without resistance to other anti-tuberculosis drugs is called rifampicin resistant (RR) tuberculosis (WHO 2014b:18; WHO 2013a:5). MDR-TB is that level of resistance with in-vitro resistance to the two most potent first-line anti-tuberculosis medications – isoniazid and rifampicin (Hatfull et al 2014:413). Moreover, there is a more resistant form of drug resistance called the extensively drug-resistant tuberculosis (XDR-TB). XDR-TB is defined as strains of Mycobacterium tuberculosis with in-vitro resistance not only to isoniazid and rifampicin but also to other classes of medications that comprise the backbone of the regimen used to treat MDR-TB, that is the injectables and fluoroquinolones (Behera 2012:190).
Chapter 1 Orientation to the study
1.1 Introduction
1.2 Background
1.3 Motivation of the study
1.4 Statement of the research problem
1.5 Aims, objectives and hypotheses of the study
1.6 Significance of the study
1.7 Conceptual and operational definitions
1.8 The theoretical framework of the study
1.9 The Donabedian framework for healthcare quality
1.10 The research paradigm – its assumptions
1.11 Research methodology and the research design
1.12 The concurrent mixed methods research design
1.13 Sampling and sampling methods
1.14 Methods of data collection
1.15 Methods of data analysis
1.16 Ethical considerations
1.17 Scope and limitations of the study
1.18 Chapter layout of the rest of the thesis
1.19 Summary
Chapter 2: Literature Reviews
2.1. Introduction
2.2. The basics of tuberculosis
2.3. The basics of multidrug-resistant tuberculosis
2.4. Spectrum of drug-resistance in the Mycobacterium tuberculosis
2.5. Risk factors for development of drug-resistant tuberculosis
2.6. Epidemiology of M(X)DR-TB
2.7. Epidemiology of drug-resistant tuberculosis in Ethiopia
2.8. Challenges associated with M(X)-DR-TB
2.9. Clinical management of multidrug-resistant tuberculosis
2.10. Factors determining the clinical management & the treatment outcomes of patients
with MDR-TB
2.11. Factors determining patients’ perceived quality of care and patient satisfaction with
care given for MDR-TB
2.12. Summary
Chapter 3: Research Design and Methods
3.1. Introduction
3.2. Study setting and study population
3.3. Study sites
3.4. The research design
3.5. The research paradigm- its assumptions
3.6. Research methods
3.7 The study population
3.8. Data collection
3.9. Data analysis
3.10. Quality of the study
3.11. Ethical considerations
3.12. Summary
Chapter 4: Research results
4.1. Introduction
4.2. Results for the quantitative component of the study ral
4.3. Results for the qualitative component of the study
4.4. Results for the mixed methods objectives component
4.5. Summary
Chapter 5: Model development
5.1. Introduction
5.2. The key concepts of a model
5.3. Data sources for the development of the model
5.4. Approaches used for concept analyses for model development
5.5. Description of the components of the model and its practical application
5.6. Strengths and limitations of the model
5.7. Summary
Chapter 6: Discussions
6.1. Introduction
6.2. Discussions on key results
6.3. Summary
Chapter 7: Conclusion and Recommendations
7.1. Introduction
7.2. Key results of the study
7.3. Contribution of the study
7.4. Scope and limitations of the study
7.5. Recommendations
7.6. Recommendations for future research
7.7. Conclusion
List of references
Annexe
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