BEYOND DOTS ( DI RECTLY OBSERVED TREATMENT SHORT-COURSE) I N TUBERCULOSI S’
CONTROL: I NTERFACI NG AND SHARI NG NEEDS
Alba I daly Muñoz Sanchez1
Maria Rit a Bert olozzi2
Sanchez AI M, Bertolozzi MR. Beyond DOTS ( Directly Observed Treatm ent Short- Course) in tuberculosis’ control: int erfacing and sharing needs. Rev Lat ino- am Enferm agem 2009 set em bro- out ubro; 17( 5) : 689- 94.
This study analyzes m eanings that health workers attribute to DOTS and points out alternatives that contribute t o it s perform ance. Aft er t he Research Et hics Com m it t ee approved t he proj ect , a sem i- st ruct ured int erview was applied to 15 health workers from the central region of the city of São Paulo, SP, Brazil between August and Decem ber 2004. This st udy used herm eneut ic- dialect ic reference and t he t heory of social det erm inant s of t he healt h- disease process. DOTS cont ribut es t o t reat m ent adherence and prom ot es int erfacing in encount ers and conversat ions bet ween workers and users at t he inst it ut ional and t errit orial levels, which perm it s ident ifying healt h needs and im plem ent ing appropriat e int ervent ions. One of t he m ain challenges t o it s im plem ent at ion is t o becom e a space t hat enables gr asping, decoding and r econst r uct ing m eanings in r elat ion t o t he healt h-disease process including t he t reat m ent and life proj ect s of pat ient s wit h t uberculosis.
DESCRI PTORS: t uberculosis; com m unicable disease cont rol; professional- pat ient relat ions
MÁS ALLÁ DEL DOTS ( DI RECTLY OBSERVED TREATMENT SHORT- COURSE) EN EL
CONTROL DE LA TUBERCULOSI S: MEDI O QUE PROMUEVE LA COMUNI CACI ÓN Y LA
I DENTI FI CACI ÓN DE LAS NECESI DADES
El presente estudio buscó analizar los significados que los trabaj adores de la salud presentan sobre la estrategia en el cont rol de la t uberculosis, y apunt ar alt ernat ivas que cont ribuyan para su desem peño. Después de la aprobación del proyect o por el Com it é de Ét ica en I nvest igación, fueron ent revist ados 15 t rabaj adores de la salud del Subm unicipio de la Sé, de la Secretaría de Salud del Municipio de Sao Paulo, de agosto a diciem bre de 2004, por m edio de un guión sem iest ruct urado. El est udio fue conducido baj o el m arco de la herm enéut ica dialéct ica y la t eoría de la det erm inación social del proceso salud enferm edad. La DOTS cont ribuye para la adhesión al t rat am ient o, prom ueve la com unicación de encuent ros y conversa ent re t rabaj adores y usuarios, en el ám bit o inst it ucional y t er r it or ial, lo que posibilit a la ident ificación de las necesidades de salud y el encam inam ient o para int ervenciones apropiadas. Uno de los desafíos de su im plem ent ación es concret izarse com o espacio qu e per m it a apr en der , decodif icar y r econ st r u ir sign if icados en r elación al pr oceso salu d enferm edad, incluyendo el t rat am ient o y los proyect os de vida de las personas acom et idas por la t uberculosis.
DESCRI PTORES: t uberculosis; cont rol de enferm edades t ransm isibles; relaciones profesional- pacient e
ALÉM DA DOTS ( DI RECTLY OBSERVED TREATMENT SHORT-COURSE) NO CONTROLE DA
TUBERCULOSE: I NTERFACE E COMPARTI LHAMENTO DE NECESSI DADES
O present e est udo buscou analisar os significados que t rabalhadores da saúde apresent am sobre a est rat égia no cont role da t uberculose, e apont ar alt ernat ivas que cont ribuam para o seu desem penho. Após aprovação do proj et o por Com it ê de Ét ica em Pesquisa, foram ent revist ados 15 t rabalhadores da saúde da Subprefeit ura da Sé da Secretaria de Saúde do Município de São Paulo, de agosto a dezem bro de 2004, por m eio de roteiro sem iestruturado. O estudo foi conduzido sob o referencial da herm enêutica- dialética e a teoria de determ inação social do pr ocesso saúde- doença. A DOTS cont r ibui par a a adesão ao t r at am ent o, pr om ov e a int er face de encont ro e conversa ent re t rabalhadores e usuários, no âm bit o inst it ucional e t errit orial, o que possibilit a a ident ificação de necessidades de saúde e o encam inham ent o para int ervenções apropriadas. Um dos desafios de sua im plem ent ação é concret izar- se com o espaço que perm it a apreender- decodificar- reconst ruir significados em relação ao processo saúde- doença, incluindo o t rat am ent o e os proj et os de vida das pessoas acom et idas pela t uber culose.
DESCRI TORES: t uberculose; cont role de doenças t ransm issíveis; relações profissional- pacient e
1RN, Ph.D., Facult y, Facult ad de Enferm ería, Universidad Nacional de Colôm bia, Colom bia, e- m ail: aim unoz@unal.edu.co, lyiballa@usp.br; 2RN, Ph.D., Faculty, Escola de Enferm agem , Universidade de São Paulo, Brazil, e- m ail: m rbert ol@usp.br.
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I NTRODUCTI ON
D
espit e t he availabilit y of abundant healt h technology in the m odern world and that an efficacious therapy was discovered so long ago, tuberculosis still r em ains a par t of global epidem iological scenar ios. According t o t he World Healt h Organizat ion ( WHO) , t h er e w er e 8 . 8 m illion n ew cases an d 1 . 6 m illion deaths due to the disease in 2005( 1- 2).Non- adherence to treatm ent is one of the m ain obst acles t o t h e con t r ol of t h e disease becau se it cont ribut es t o increasing t he chance of t ransm it t ing t he bacillus, resist ance t o m edicat ion and leads t o a great er chance of recurrence( 3).
W HO d e f i n e s ‘ t r e a t m e n t d e f a u l t ’ ( n o n -a d h e r e n ce ) -a s -a t r e -a t m e n t i n t e r r u p t e d f o r t w o consecut iv e m ont hs. I t also st r esses t hat it is w ell docum ent ed t hat 30% of all pat ient s who are under self - adm in ist er ed t r eat m en t do n ot adh er e t o t h e t h e r a p y i n t h e f i r st t w o o r t h r e e m o n t h s. Th e im m ediat e con sequ en ce of poor adh er en ce is t h e failure of the treatm ent and another of the results, in t erm s of public healt h as already point ed out , is t he em ergence of m ult i- resist ance t o ant ibiot ics, one of t he m ost im port ant problem s faced in t he sphere of public healt h( 4).
Several sit uat ions have been associat ed wit h t reat m ent adherence and involve social, cult ural and dem ographic barriers, in addit ion t o t hose relat ed t o m edicat ion and also t o t he pr ocess of healt h car e delivery. The patients’ poor social condition, their lack o f t i m e t o sea r ch f o r ca r e ser v i ces a n d l a ck o f in f or m at ion ab ou t t h e d isease an d it s t r eat m en t , cou p led w it h t h e f r eq u en t ly d if f icu lt r elat ion sh ip between the health team and patients are other factors t hat hinder adherence t o t uberculosis t reat m ent( 5).
A study that focused on adherence to DOTS, carried out in I ndia, verified the need to focus research on addr essing t he disease fr om t he per spect iv e of p a t i e n t s a n d h e a l t h p r o f e ssi o n a l s, w h o a r e t h e essent ial elem ent s in t his process. Researchers point out that research can guide health practices in addition t o indicat e effect ive and sust ainable policies for t he cont rol of t he disease( 6).
I n v iew of t h e d issem in at ion of DOTS in Br a zi l a s a st r a t eg y t o i m p r o v e a d h er en ce w i t h p o s i t i v e c o n s e q u e n c e s t o t h e i n d i c a t o r s o f m or bim or t alit y in r elat ion t o t uber culosis, t his st udy aim ed t o analy ze t he m eanings healt h pr ofessionals h old r eg ar d in g t h e st r at eg y an d it s in f lu en ce on
t r e a t m e n t a d h e r e n ce . I t a l so a i m e d t o i n d i ca t e alt er nat iv es t hat cont r ibut e t o t he per for m ance of t h e Tu b er cu losis Con t r ol Pr og r am .
METHOD
The t heoret ical reference of t his st udy relies on t w o su p p or t in g ap p r oach es: t h e h er m en eu t ic-dialect ic and t he social det erm inat ion of t he healt h-disease pr ocess. The her m eneut ic “ ( …) is occupied with the art of understanding texts; the term ‘text’ is used her e in a br oad sense: biogr aphy, nar rat iv e, interview….”. I t is based on the understanding and, in the case of this study, in the understanding of accounts of protagonists in the process of health production in r el a t i o n t o t u b er cu l o si s. I t i s cl o sel y r el a t ed t o intersubj ectivity, which refers to the “ capacity of putting oneself in the place of another” ( 7).
Herm eneut ics requires t he underst anding of t h e w h ole f r om t h e p ar t s, an d v ice v er sa, w h ich enables the em ergence of a dialetic relation: “ ( …) the an t i ci p at i o n o f t h e sen se t h at d i r ect s t h e w h o l e achieves an explicit underst anding t hrough t he fact t hat t he part s t hat are det erm ined from t he whole, also det er m in e t h e w h ole”( 8 ). Th u s, u n der st an din g occurs when there is consistency between the general and t he part icular dim ensions of t he life.
The concept of dialectic is related to critique, change and cont radict ion. The principles adopt ed by the dialectic m ethod focus on the process and on the chain of processes in a spiral, ever renewing, never the sam e: things are com posed in contradiction( 9). The linkage bet ween t hese t wo approaches, t he dialect ic an d h er m en eu t ic, p er m it s on e t o p r oceed t o t h e an aly sis of r ealit y, w h er eas b ot h d ep en d on an d com plem ent each ot her.
Th e t h eor y of social d et er m in at ion of t h e healt h- disease process const it ut es anot her t heoret ical support since once such process is intrinsically linked t o societ y’s st ruct ure “ ( …) individual condit ions and possibilit ies m er ge in a social w hole, in a gener al, average or com m on out com e, which does not cancel individual participation, since all individuals contribute to the result”( 10).
Th u s, t h e social ch ar act er of t h e h ealt h -disease pr ocess can be em pir ically v er if ied in t h e expression of the pathological profile of hum an groups and t heir differ ences in social cont ex t s, w hich ar e dist inguished by t he part icular way t hey relat e wit h t he form of work and developm ent of life.
Beyond DOTS (Directly Observed Treatment Short-Course)… Sanchez AIM, Bertolozzi MR.
Based on this principle, the reports of health professionals working in prim ary care were analyzed as well as t he report s of t hose responsible for care delivery and epidem iological surveillance of five basic health units that had the DOTS strategy im plem ented an d a Sex u ally Tr an sm it t ed Diseases ( STD) / AI DS Specialized Car e Ser v ice.
Such healt h unit s com pr ised t he Mid- West Health Coordination, the city’s central region from the Mu n icipal Healt h Secr et ar y of São Pau lo: t h e “ Sé region”, with a total of 339,269 inhabitants( 11- 12). This r e g i o n w a s ch o se n b e ca u se o f t h e d i se a se ’ s m agnit ude at t he t im e of t he st udy, w it h a rat e of incidence of 169.1/ 100,000 inhabitants, in addition to the poor living and working conditions of the m aj ority of it s populat ion.
Th e pr oj ect w as in it ially su bm it t ed t o an d appr ov ed by t he Resear ch Et hics Com m it t ee of t he Municipal Healt h Secretary of São Paulo ( process No. 213/ 2004) . The workers were invited to participate in t he st udy and signed a fr ee and infor m ed consent agr eem en t . Dat a w er e collect ed t h r ou gh r ecor ded int erview s; anonym it y of int erview ees’ w as ensured and all recom m endat ions of t he Resolut ion No. 196/ 96 of t he Nat ional Healt h Council were followed( 13).
Accor ding t o t he adopt ed m et hodology, t he num ber of t he st udy’s par t icipant s w as not defined beforehand and its lim it was reached when inform ation acquired t hrough report s st art ed t o repeat .
Data were collected through a sem i- structure int er v iew , w hich w as subm it t ed t o a pilot t est and a n a l y ze d b y q u a l i f i e d r e se a r ch e r s b e f o r e d a t a collect ion was init iat ed. Som e of t he quest ions t hat guided the interviews are the following: “ tell m e about your daily routine here at the service. What is it like t o deal wit h people wit h t uberculosis? Tell m e about direct ly supervised t reat m ent . What are t he posit ive aspect s of t he super vised t r eat m ent ? What ar e t he n eg at i v e asp ect s ( d i f f i cu l t i es) o f t h e su p er v i sed treatm ent? How can these aspects be overcom e? Does su p e r v i se d t r e a t m e n t co n t r i b u t e t o t r e a t m e n t adh er en ce?”
Rep o r t s w er e a n a l y zed a cco r d i n g t o t h e discourse analysis technique, based on the Generative Theory of Meaning, which holds t hat discourses have a st r u ct u r e , a sy n t a x , t h a t p r e se n t s a ce r t a i n au t on om y in r elat ion t o social f or m at ion su ch as d i scu r si v e se m a n t i cs b u t a t t h e sa m e t i m e a r e d e p e n d e n t o n t h e m , t h a t i s, o n t h e i d e o l o g i ca l dim ension( 14).
All reports were analyzed aim ing to m axim ize their rationality and m eaning, focusing on the health-d i sease p r o cess, o n t h e t r eat m en t , em p h asi zi n g d i r e ct l y su p e r v i se d t r e a t m e n t a n d t r e a t m e n t adh er en ce.
The dept h and lit er alness of t he indiv iduals’ st a t e m e n t s w e r e p r i v i l e g e d t h r o u g h o u t se v e r a l r e a d i n g s o f e a ch i n t e r v i e w , se e k i n g u n d e r l y i n g t h e m e s a n d f i g u r e s . T h e i n t e r v i e w s w e r e sy n t h esized in t o t h em at ic sen t en ces, w h ich w er e g r o u p e d a c c o r d i n g t o a n a l y t i c a l c a t e g o r i e s pr ov idin g a t h em at ic cor pu s.
I nt erviews were recorded and dat a collect ion was carried out between August and Decem ber 2004.
RESULTS AND DI SCUSSI ON
Fifteen health professionals were interviewed: si x n u r si n g a u x i l i a r i e s, f i v e n u r se s, a n d f o u r phy sicians.
Meanings attributed by the health workers to t uber culosis v er ified t he ex ist ence of at t it udes and beliefs t hat st ill reveal st igm a and fear in relat ion t o disease. They also perm itted visualizing the poor social condit ions of t he m aj orit y of users cared for in t he basic health units that com posed this study, who were m ainly hom eless and host el users.
Th e in t er v iew ed w or k er s p oin t ed ou t t h e following st rengt hs in relat ion t o DOTS:
- I t enables the creation of bonds, dialogue and sharing bet ween professionals and pat ient s.
- I t enables t he ident ificat ion of pat ient s’ needs. - I t gives t he opport unit y of social int egrat ion in t he case of hom eless and host el users.
- I t dim inishes t he chance of relapse.
- I t co n t r i b u t es t o t h e co r r ect ad m i n i st r at i o n o f m edicat ion.
- I t dim inishes resist ance t o m edicat ion.
- I t en ab les p r of ession als t o p r ov id e ed u cat ion al infor m at ion.
On the other hand, lim itations of this strategy were also indicat ed and t hese refer m ore specifically t o it s operat ion, such as:
- a r est r i ct ed n u m b er o f em p l o y ees an d l ack o f int er disciplinar y t eam s;
- lim ited resources ( snack, basic basket food) to m eet pat ient s’ needs;
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- deficiencies in t he referral net work and t he syst em of healt h inform at ion;
- deficiencies in the units’ infrastructure, especially in term s of physical space, which lim it biosafety actions; - overload of work due t o bureaucrat ic act ions t hat int egr at e super v ised t r eat m ent , such as filling out form s and t he delivery of t ransport at ion vouchers t o t he pat ient s.
Even wit h such lim it at ions, we verified t hat , in t he encount er bet w een healt h pr ofessionals and p at i en t s, D OTS co u l d b e an o p p o r t u n i t y f o r t h e m anifest at ion of subj ect iv it ies and t o help pat ient s wit h t uberculosis t o recover t heir capabilit ies for life dur ing r egular consult at ions. At t he sam e t im e, it allows ident ifying vulnerabilit ies and needs t hat can be dealt wit h during t he process so as t o overcom e t hem( 15).
Th e l a ck o f co n d i t i o n s t o su p p o r t t h e d ev elop m en t of a d ecen t lif e f or t h e m aj or it y of pat ient s should be considered a crucial issue in t he understanding of tuberculosis. One cannot fail to grasp it, and thus we defend the position that health workers should use instrum ents such as DOTS to derive a clear approach t o t reat m ent and go beyond list ening and int er v ent ions, cooper at ing w it h t he const r uct ion of ci t i zen sh i p p r oj ect s, i n t eg r at i n g k n ow l ed g e f r om different disciplines so as to m eet the needs of people wit h vulnerabilit ies.
Under the proposal of regionalization included in the Brazilian Unified Health System , the basic health
units would expand so as to be present where the life and t he work of pat ient s are em bodied. I n t his way, DOTS w ould be an inst r um ent used t o under st and needs and t o im plem ent alt ernat ives wit h a view t o overcom e the illness experience. Health dem ands that e m e r g e f r o m t h e se sce n a r i o s g o b e y o n d t h e biom edical ones, which points to the need for actions within a m ultiprofessional team . Moreover, DOTS could in fact becom e a relat ional t echnology( 16).
Based on t he pr oposed m odel( 17), Figur e 1 sh ow s t h at DOTS can becom e an “ in t er f ace”. Th e aut hor cit es Pier r e Lev y, a r esear cher of collect iv e in t elligen ce, an d st r esses t h at : “ [ …] All in t er faces condition the way inform at ion is grasped, inform ation t hat is offered t o t he aut hors of t he ‘com m unicat ion’ it enables. I nt er face opens, closes and, m or eov er, guides the dom ains of action and signification ( em otion and language) , w hich ar e t he pot ent ial uses of t he ‘m eans’ wit h which it ‘int erfaces’ [ ...] ”
DOTS is im plem ent ed in t he healt h services in the Tuberculosis Control Program and such services function as “ network interfaces”( 17). Thus, the strategy cou ld b e also con f ig u r ed as an in t er f ace t h at b e co m p o se d o f o t h e r i n t e r f a ce s b e ca u se i t i s int erconnect ed wit h ot her act ivit ies/ sect ors, which in t urn, are influenced by ot her int erfaces int ernal and ext ernal t o t he service.
Thus, in t his st udy DOTS is proposed as an interface possibility in the network that integrates the process of healt h product ion ( Figure 1) .
Figure 1 – Supervised t reat m ent : int erface in t he net work of t he process of healt h product ion Beyond DOTS (Directly Observed Treatment Short-Course)…
Sanchez AIM, Bertolozzi MR.
The cent ral circle t hat corresponds t o DOTS and the circles that follow it can be interpreted as the d i f f e r e n t se r v i ce s, m e a n s a n d i n st r u m e n t s t h a t i n t eg r at e t h e b asi c h eal t h u n i t s ( BHS) : m ed i cal consultation, nursing consultation, the laboratory, and health program s, am ong others. All these interact with t he Tuber culosis Cont r ol Pr ogr am . The cir cles t hat follow represent int erfaces in a broader sphere and refer to the relation between the BHU and other health and social elem ent s ( churches, schools and ot hers) ; m or eover, it encom passes t he cir cle t hat int egrat es t he knowledge t o act on t he com plex t opic, which is healt h.
D OTS h a s t h e p o t e n t i a l t o u se t h e m eetings( 16), conversations and relationships, and this interface should be based on openness and availability t o u n d e r st a n d t h e n e e d s o f i n d i v i d u a l s w i t h t u b er cu losis. I n t h is in t er f ace, t h e d aily m eet in g bet ween individuals perm it s developing welcom ing as a sh ar i n g p r o cess( 1 8 ), l i n k ag e an d p act b et w een workers and users so as to prom ote autonom y of the latter in their daily lives, always keeping in m ind the t wo faces, t he individual and t he collect ive.
Th u s, t h e g r e a t ch a l l e n g e f o r D OTS, i n addit ion t o con t r ibu t in g t o t u ber cu losis t r eat m en t adherence, is to becom e a space that allows grasping, decoding and reconst ruct ing m eanings in relat ion t o t he healt h- disease pr ocess, including t he t r eat m ent an d t h e lif e p r oj ect s of p eop le w it h t u b er cu losis. Therefore, adherence is conceived here as a process, not of im position, but rather of exchange and m eeting, one t hat uses t he under st anding of t he cont ex t of pat ient s’ lives as a t rigger t o m eet social and healt h needs( 16).
The analysis of healt h workers’ report s also indicat es t he need t o review policies and st rat egies f o r co p i n g w i t h t u b e r cu l o si s, su ch a s h o w t h e h ealt h car e d eliv er y p r ocess is d ev elop ed in b asic h ealt h u n it s, con sider in g t h at t h e pat ien t s’ social p r ob lem s g o b ey on d t h e b iolog ical an d in d iv id u al spher es and phar m acological m easur es. We cannot ignore the concerted efforts to put the DOTS strategy i n t o o p e r a t i o n i n t h e ci t i e s co n si d e r e d p r i o r i t y locales( 19 ). How ev er, it is im perat iv e t o r ev iew t he m anagem ent of r esour ces and planning of healt h-orient ed act ions t o offer DOTS in different scenarios in addit ion t o basic healt h unit s, im proving access t o other levels and services of the health system , taking int o account t he social needs of pat ient s and t heir fam ilies( 20).
I t is im portant to highlight that the adoption o f D OTS d o es n o t r ep l ace t h e n eed t o r ad i cal l y t ransform t he processes t hat generat e illness, in t his case, t u b er cu losis. On e- t im e act ion s t h at m er ely consider individuals as arithm etic units, the traditional g o a l o f g e n e r a l l y p r o g r a m m e d a ct i o n s, w i l l n o t ach iev e t h e g oals p r op osed b y g ov er n m en t s an d int ernat ional organizat ions for disease cont rol, rat her t hey will only cont ribut e t o pat ient s’ suffering.
I n t he specific case of t uber culosis, healt h workers interact in the daily production of health care in basic healt h unit s w it h people w ho are generally living in poor conditions and som e very close to social exclusion. This m eet ing is an opport unit y t hat should be used by the team to share inform ation that guides people in t he healt h- disease process, t o clarify how the health system functions, and the rights they should dem and, exercise and defend.
FI NAL CONSI DERATI ONS
This st udy ev idenced t he pot ent ial of DOTS in t he st udied healt h unit s. The m ain st r engt h t hat em er ges fr om DOTS, in addit ion t o it s cont r ibut ion t o t he im pr ov ed indicat or s of t r eat m ent adher ence, r ef er s t o it s ab ilit y t o b r in g ou t h ealt h n eed s t h at m a y b e co m e t h e t a r g e t o f t h e d e v e l o p m e n t o f j o i n t i n t er v en t i o n s b et w een h ea l t h w o r k er s a n d p a t i e n t s.
On t he ot her side, we have t o point out t he m any gaps in the organization of health services that have t o be grasped, underst ood and becom e obj ect o f t r a n sf o r m a t i o n . Am o n g t h e se , t h e f a ct t h a t hier ar chical st r uct ur es need t o be t r ansfor m ed int o interfaces and m eetings, in which the contribution each professional cat egory can offer in t he daily pract ice of healt h services is acknowledged.
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DOTS, in t he Tuber culosis Cont r ol Pr ogram , should follow t he body of pr inciples t hat guides t he Un if ied Healt h Sy st em . Th ese pr in ciples h old t h at h ealt h is a cit izen s’ r igh t an d t h is pr in ciple is an a d v a n c e t h a t p e r m i t s g l i m p s i n g h o p e o f r econst r uct ion, t r ansfor m at ion and r eor ient at ion of healt h policies and pr act ices. I t is in t he spher e of
basic h ealt h u n it s an d in t h eir ar eas of in f lu en ce t h a t h e a l t h p r o f e ssi o n a l s sh o u l d v i e w u se r s a s subj ect s w it h bot h v ulner abilit ies and pot ent ialit ies. T h i s i s o n e o f t h e w a y s t o o v e r c o m e t h e n at u r alizat ion of t h e h ealt h - d isease p r ocess an d t o p r o m o t e l eg i t i m at e h eal t h as a r i g h t i n d ai l y h ealt h p r act ice.
REFERENCES
1. World Healt h Organizat ion ( WHO) . The st op t uberculosis est r at egy. Bu ildin g on an d en h an cin g DOTS t o m eet t h e t uberculosis–relat ed m illennium developm ent goals. Geneva: WHO; 2 0 0 6 .
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Recebido em : 17.12.2008 Aprovado em : 18.6.2009
Beyond DOTS (Directly Observed Treatment Short-Course)… Sanchez AIM, Bertolozzi MR.
