DOES DI RECTLY OBSERVED TREATMENT ( “DOTS”) CONTRI BUTE TO TUBERCULOSI S
TREATMENT COMPLI ANCE?
Maria Fernanda Terra1 Maria Rit a Bert olozzi2
Ter ra MF, Ber t olozzi MR. Does dir ect ly obser v ed t r eat m ent ( “ DOTS” ) cont r ibut e t o t uber culosis t r eat m ent com pliance? Rev Lat ino- am Enferm agem 2008 j ulho- agost o; 16( 4) : 659- 64.
This is a qualitative study perform ed in the theoretical fram ework of the Theory of Social Determ ination of the Health- Disease process and the concept of Com pliance. The goal was to analyze m eanings of DOTS in com pliance wit h t uberculosis t reat m ent , according t o healt hcare professionals of t he Technical Healt hcare Supervision of Butantã ( SUVI S) , a region of the São Paulo City Healthcare Secretariat, Brazil. The proj ect was subm itted to the Et hics Com m it t ee of t he São Paulo Municipal Healt h Secret ariat . All professionals ( 22 people) developing DOTS were int erviewed, including service coordinat ors, healt hcare professionals and t he DOTS coordinat or for t he region. The statem ents were analyzed with an appropriate technique for discourse analysis. The results appoint t hat t he st rat egy present s m ore pot ent ialit ies t han lim it s and is effect ive regarding com pliance, since it allows t he professionals t o welcom e and m onit or t he pat ient s, considering t heir needs. The im port ance of increasing t he under st anding of com pliance is also not ed, so t hat it can go bey ond t he sim ple int ake of m edicat ion, int egr at ing t he car e for t he sick per son and his or her necessit ies by t r anscending t hose r est r ict ed t o t he biological dim ension.
DESCRI PTORS: t uberculosis; epidem iology; direct ly observed t herapy
¿EL TRATAMI ENTO CON SUPERVI SI ÓN DI RECTA ( “DOTS”) CONTRI BUYE PARA LA
ADHESI ÓN AL TRATAMI ENTO DE LA TUBERCULOSI S?
Se t rat a de un est udio cualit at ivo realizado baj o el m arco t eórico de la Teoría de la Det erm inación Social del Proceso Salud Enferm edad y el concepto de Adhesión. El obj etivo fue analizar los significados de la DOTS en la adhesión al t r at am ient o de la t uber culosis, según la v isión de pr ofesionales de la salud de la Super v isión Técnica de la salud del Butanta de la Secretaría de la salud del Municipio de San Pablo. El proyecto fue som etido al Com it é de Ét ica. Se ent revist aron la t ot alidad de los profesionales ( 22 personas) que desarrollaban la DOTS incluyendo coordinadores de servicios, profesionales asist enciales y el coordinador de la DOTS en la región. Se analizaron las declaraciones según la t écnica de análisis de discurso apropiada. Los result ados apunt an que la estrategia presenta m ás potencialidad que lím ites y es efectiva en la adhesión, por perm itir acoger y m onitorear el enferm o considerando sus necesidades. Se apunta la im portancia de am pliar el entendim iento de la adhesión, m ás allá de la ingest ión de la m edicación, int egr ando el cuidado del enfer m o a par t ir de sus necesidades, t rascendiendo aquellas rest rict as a la dim ensión biológica.
DESCRI PTORES: t uberculosis; epidem iología; t erapía por obsrevación direct a
O TRATAMENTO DI RETAMENTE SUPERVI SI ONADO ( DOTS) CONTRI BUI PARA A ADESÃO
AO TRATAMENTO DA TUBERCULOSE?
Est udo qualit at ivo, realizado sob o m arco t eórico da Teoria da Det erm inação Social do Processo Saúde Doença e conceit o Adesão. O obj et iv o foi analisar significados da DOTS na adesão ao t r at am ent o da t uber culose, segundo profissionais de saúde da Supervisão Técnica de Saúde do Butantã da Secretaria de Saúde do Município de São Paulo. O proj et o foi subm et ido ao Com it ê de Ét ica. Ent revist ou- se a t ot alidade dos profissionais ( 22 pessoas) que desenvolviam DOTS, incluindo coordenadores de serviços, profissionais assistenciais e coordenador da DOTS na r egião. Analisou- se os depoim ent os, segundo a t écnica de análise de discur so apr opr iada. Os result ados apont am que a est rat égia apresent a m ais pot encialidades do que lim it es e efet ividade na adesão, por perm itir acolher e m onitorar o doente considerando suas necessidades. Aponta- se a im portância da am pliação do ent endim ent o da adesão para além da ingest a da m edicação, int egrando o cuidado do doent e a part ir de suas necessidades, t ranscendendo aquelas rest rit as à dim ensão biológica.
DESCRI TORES: t uberculose; epidem iologia; t erapia diret am ent e observada
1 RN, M.Sc. in Nursing, e- m ail: m ft erra@gm ail.com ; 2 RN, Facult y, Free Lect ure, Universit y of São Paulo School of Nursing, Brazil.
I NTRODUCTI ON
T
he st udy is part of a research group t hat uses t he analyt ical cat egory com pliance, one of t he branches of t he CNPq Research Group “ Com pliance, n ecessit ies an d v u ln erabilit y in Collect iv e Healt h ”. St u d i es( 1 - 3 ) n ot e t h at com p l i an ce w i t h t r eat m en tex t r apolat es t he appr oach t hat r educes t he healt h needs t o clinical and biological aspect s, especially w h en it com es t o t u b er cu losis, w h ich is d ir ect ly associat ed t o social st ruct ure. People’s insert ion int o societ y det erm ines condit ions for t he st rengt hening/ lim iting of life, and social inequalities m ake individuals vulnerable t o t he developm ent of a disease( 4- 5). One
of t he m ain issues, which m akes t he problem of t he disease even m ore com plex, is t he abandonm ent of t r e a t m e n t , w i t h se r i o u s r e p e r cu ssi o n s i n t h e ep i d em i o l o g i ca l scen a r i o . Th er e i s an i m p o r t a n t am ount of scientific contributions pointing out that the abandonm ent of t r eat m ent is associat ed t o cer t ain behaviors, HI V co- infect ion and a hist ory of previous t reat m ent for t uberculosis( 4- 7). However, it should be
considered that com pliance with treatm ent transcends the traditional clinic, and is related to how the patients conceive t he disease and how t hey live, as w ell as t he organizat ion of healt hcare services( 1- 2).
As a r esu lt of t h e w or ld w id e sit u at ion of t uberculosis, in 1993, t he World Healt h Organizat ion r ecom m ended t he im plem ent at ion of DOTS, aim ing t o guarant ee t reat m ent com pliance. A st udy( 8) shows
t h at t h e am ou n t of in t er n at ion al ou t n u m b er s t h e n a t i o n a l p u b l i ca t i o n s, w h i ch , h o w e v e r, p r e se n t sim ilar it ies, since t heir analy ses happen w it hin t he scopes of m u lt icau salit y. Th ey fact or ialize, an d do n o t a t t r i b u t e h i e r a r c h i e s a n d w e i g h t s i n t h e det er m inat ion of t he disease in t er m s of t r eat m ent su ccess or f ailu r e.
Tu b e r cu l o si s i s o n e o f t h e m o st f a m o u s exam ples t hat evidences t he social product ion of t he disease. I n a count r y lik e Br azil, t he m agnit ude of social inequalit ies t hat m ak e indiv iduals v ulner able t o t he developm ent of t uberculosis should be t aken into account. Particularly in the city of São Paulo, there is a significant gap in r esear ch t er m s, a fact t hat j u st if ied t h e p r esen t st u d y. As su ch , t h e au t h or s a t t e m p t e d t o i d e n t i f y t h e m e a n i n g s o f D OTS , accor ding t o healt hcar e pr ofessionals w or k ing w it h t he SUVI S in But ant ã- SP, aim ing t o appr ehend it s l i m i t s a n d p o t e n t i a l i t i e s r e g a r d i n g t r e a t m e n t co m p l i an ce.
METHOD
Th i s i s a q u a l i t a t i v e st u d y, u si n g t h e st at em en t s of h ealt h car e pr of ession als w or k in g in m anagem ent or care areas of a Tuberculosis Cont rol Pr o g r a m . Th e a n a l y si s o f t h e st u d y o b j ect , t h e oper at ion alizat ion of DOTS, an d it s im pact on t h e process of com pliance w it h t reat m ent are based on t he t heoret ical reference of t he Social Det erm inat ion Theory of the Health- Disease Process, which considers disease as a part- whole of the social process and the concept of com pliance( 1- 2). The aut hor proposes t hat com pliance t ranscends t he act of m edicat ion int ake, an d is dir ect ly r elat ed t o t h e place t h e in div idu al occu p ies in t h e p r ocess of social p r od u ct ion an d reproduction, as favorable or lim iting conditions occur for t he conclusion of t herapeut ic( 1- 2). Furt herm ore, it
r efer s t o t he concept ion of healt h- disease t hat sick individuals present , as well as t o aspect s relat ed t o t he organizat ion of t he healt hcare services.
Th e p r o j ect w as su b m i t t ed t o t h e Et h i cs Com m it t ee of t he São Paulo Cit y Healt h Secret ariat and received aut horizat ion for it s execut ion wit h t he SUVI S of But ant ã, São Paulo. Dat a w er e collect ed w it h a pr e- t est ed, sem i- st r uct ur ed int er v iew scr ipt , an d t h e st at em en t s w er e in t eg r ally r ecor d ed an d t r an scr ibed. Th e discou r se an aly sis t ech n iqu e w as u sed t o d eco d e t h e em p i r i ca l m a t er i a l , a n d t h e st a t e m e n t s y i e l d e d t h e m a t i c se n t e n ce s( 9 - 1 0 ). Al l
pr ofessionals w or k ing w it h t he DOTS in t he SUVI S Butantã region were interviewed, totaling 22 subj ects: n i n e Ba si c He a l t h ca r e Un i t ( BHU) co o r d i n a t o r s ( m anagers) , t hirt een healt hcare professionals: t hree phy sicians, fiv e nur ses and fiv e nur sing aux iliar ies, besides t he Coor dinat or of t he Tuber culosis Cont r ol Program and DOTS at SUVI S Butantã. The interviews were held from May to July/ 2006. The study field was com posed of seven BHU of SUVI S But ant ã.
RESULTS
w i t h t u b e r cu l o si s. Am o n g t h e 1 3 h e a l t h ca r e pr ofessionals w or king dir ect ly w it h t he pat ient s, 11 w er e fem ale. The t hr ee physicians st at ed t hat t hey had received t raining, and all of t hem held specialist degrees in public health. Am ong the five nurses, only one m ent ioned not having experience and t raining in t h is ar ea, w h ile t h e ot h er s m en t ion ed t h at t h eir learning was t he result eit her of daily work pract ice or becau se t h ey h ad been or ien t ed by t h e SUVI S But ant ã. All fiv e nur sing aux iliar ies m ent ioned t hat t hey had not been t r ained for DOTS, but t hey said t hat t hey were supervised by t he BHU nurse.
Th e m a t i c se n t e n ce s e m e r g e d f r o m t h e analysis of the statem ents, which are briefly presented below . When t he subj ect s’ expression is considered t o illust r at e t he pr esent at ion of t he findings m or e effect iv ely, t h e st at em en t pr esen t ed in it alics w as p r eser v ed .
The m eanings of Observed Treat m ent ( OT)
The BHU coordinators and the coordinator of PCT and DOTS in the region
OT is con sid er ed an ef f icien t st r at eg y t o control difficulties of low com pliance with tuberculosis t reat m ent , and an invest m ent t o increase cure rat es and decr ease abandonm ent . As for t heir m eaning, t h e r e w e r e m e n t i o n s t h a t i t r e f e r s t o se e i n g , co n t r o l l i n g a n d o b se r v i n g m e d i ca t i o n i n t a k e ,
guarant eeing t reat m ent com pliance. I t is possible t o break the transm ission chain, achieve cure and avoid
con sequ en ces of in cor r ect t r eat m en t by pr ov idin g com m u n ican t f ollow - u p, ad d r essin g d if f icu lt ies in t r eat m en t , d ecr easi n g r esi st an ce t o m ed i cat i o n ,
organizing healthcare services and allowing everybody t o speak t he sam e language.
Reg ar d i n g t h e i n d i cat i o n o f OT, i t i s t h e healt hcar e pr ofessional w ho defines w hich pat ient s should be kept under the strategy, which is generally recom m ended to patients presenting a disease relapse o r a b a n d o n m e n t o f p r e v i o u s t r e a t m e n t , a n d t o p a t i e n t s w h o a r e t r o u b l e so m e. H o w e v e r, so m e statem ents appointed that OT should be offered to all pat ient s. On t he ot her hand, som e consider t hat OT does not allow for patient autonom y. Still, there were m e n t i o n s t h a t , d u e t o t h e cu r r e n t si t u a t i o n o f tuberculosis, it should be m andatory and a priority at t h e BHU, per m it t in g t h ese pat ien t s t o decide how t reat m ent can be perform ed.
Regarding the frequency of OT, som e subj ects noted that it was perform ed daily. About that, several subj ect s m ent ioned t hat t he OT assum es police- like
ch a r a ct e r i st i cs, a f f e ct i n g p a t i e n t p r i v a cy. So m e coordinat ors advocat e t hat it should be done weekly, or every t wo or t hree days.
The healt hcar e pr ofessionals
These subj ects’ statem ents reveal that DOTS m eans seeing, dem anding, guarant eeing com pliance, a v o i d i n g a b a n d o n m e n t , g u a r a n t e e i n g a cu r e , cont r olling t he t r ansm ission of TB, and t hat it is a m om ent to create bonds. As for the indication of DOTS, it was said that it should be m andatory for everybody. Ot h er p r of ession als m en t ion ed t h at it sh ou ld b e i n d i ca t e d o n l y t o t h o se w h o a r e r e b e l l i o u s, com plicat ed, com plex , unaw ar e of t he disease and resist ant t o m edicat ion. The st at em ent s appoint t hat m ak i n g DOTS o p er at i o n al i n v o l v es o r i en t i n g t h e pat ient s and t heir fam ilies about t he t reat m ent and gravit y of t he disease.
Th e r ole of t h e h ealt h car e t eam , b esid es supervising m edicat ion int ake, involves receiving and accom p an y in g t h e p at ien t d u r in g t h e t h er ap eu t ic p r o ce ss. As f o r t h e p l a ce w h e r e OT sh o u l d b e perform ed, the BHU or the patient’s hom e was alluded to, with the BHU being noted as the appropriate place, since it has good physical st ruct ure.
Regar ding OT fr equency, it w as m ent ioned t hat som e of t he BHU perform it daily, preferably in t he m orning period. I n ot her unit s, OT is perform ed three tim es a week. According to the statem ents, the BHU execut e OT in different ways, aim ing at seeing t o t he pat ient s’ needs.
I t w as also seen t hat t he pat ient s engage
t h em selv es in DOTS. Th e h ealt h car e pr ofession als when possible, involve t he pat ient ´ s fam ily m em bers i n t h e p r o ce ss, m a k i n g t h e m r e sp o n si b l e f o r supervising m edication intake at weekends. When the p at ien t d oes n ot at t en d OT, t h e h ealt h car e t eam contacts the patient or the fam ily, by telephone or by having either a Com m unity Health Agent or the nursing t eam visit t he pat ient ’s hom e.
The incent ives offered t o t he DOTS pat ient s a r e i m p o r t a n t f o r t r e a t m e n t co m p l i a n ce . Th e
As for t he m ent ioned lim it at ions of DOTS, t h e r e w e r e r e f e r e n ce s t h a t t h e st r a t e g y i s bureaucrat ic, t hat it is not offered by all healt hcare p r of ession als, t h at k n ow led g e ab ou t t h e st r at eg y am ong t he healt hcar e pr ofessionals is not enough, and t hat t he irregular provision of incent ives causes p r o b l e m s f o r t h e r e l a t i o n s a m o n g h e a l t h ca r e professionals, pat ient and fam ily m em bers, since t he lat t er ar e con sid er ed r esp on sib le f or t h is f ailu r e. Besides, it was point ed out t hat OT does not enable t h e pat ien t s t o becom e r espon sible f or t h eir ow n t reat m ent , at t ribut ed t o t he healt hcare t eam , which ends up carrying t he pat ient .
DI SCUSSI ON
Usu a l l y, t h e i n t e r p r e t a t i o n s o f t h e BHU coordinat ors and healt hcare professionals perform ing DOTS at t he BHU do not differ. I n t he st at em ent s, t hey m ent ion t hat DOTS suppor t s com pliance w it h treatm ent, even though it is not enough to overcom e t he problem of t uberculosis.
By m ak ing t he cont inuous follow - up of t he pat ient possible, DOTS allows for t he est ablishm ent of a relat ionship wit h t he healt hcare professional. As a r esult , pat ient s feel w elcom e w hen pr esent ing a com plaint and, also, have easier access to the health pr ofessionals.
The m aint enance of high com pliance rat es is indicat ed as a consequence of DOTS and healt hcare p r o f e ssi o n a l s’ e f f o r t s t o m a i n t a i n a d e q u a t e com m u n icat ion w it h t h e pat ien t s( 1 1 ). As su ch , t h e
com m unicat ion process is not const rained t o a one-dim en sion al logic, bu t assu m es an open list en in g channel. Hence, OT is not restricted to the observation of m edicat ion in t ak e, bu t ex pan ds t o sh ar in g an d list ening t o t he necessit ies( 2).
As sh o w n b y t h e t e st i m o n i a l s, OT i s in t er pr et ed as an y act iv it y t h at m ay “ assu r e” t h e m aint enance of t reat m ent and should be kept at t he BHU, which does not negat ively affect it s dynam ics, despit e requiring special infrast ruct ure, which is st ill precarious. The statem ents reveal that OT is a practice t h at st ar t s w it h t h e r ecep t ion of t h e p at ien t an d cont inues wit h t he observat ion of m edicat ion int ake, a l l o w i n g f o r b o n d i n g b e t w e e n t h e h e a l t h ca r e p r o f e ssi o n a l a n d t h e p a t i e n t . Fu r t h e r m o r e , t h e healt hcar e pr ofessionals see OT as a st r at egy t hat m akes the BHU m ore welcom ing, since it perm its close
cont act wit h t he pat ient and involves t he healt hcare p r of ession al an d t h e p at ien t in a r elat ion sh ip of understanding, capture and referral of the needs that em erge from t heir int eract ion.
TS w a s a l so sa i d t o co n st i t u t e a g o o d opport unit y for t he pat ient t o share doubt s, feelings, problem s and needs, allowing t he t herapeut ic focus to be enlarged beyond the m edical diagnosis( 12). The
healt hcar e pr ofessional m ay t ake advant age of t his m om ent as a space to clarify certain points about the disease and t o st rengt hen pat ient s t o cope wit h t he healt h- disease process, encouraging t hen t o exercise their citizenship, i.e. to be aware of their rights( 1).
For t he healt hcare professionals, com pliance is not a linear but a com plex process, directly related t o t he bond est ablished bet ween t he pat ient and t he professional. On the one hand, the bond should com e f r o m t h e h eal t h car e p r o f essi o n al an d sh o u l d b e constructed on relationship bases that perm it patients t o e x p r e ss t h e i r f e e l i n g s a n d n e e d s. As su ch , com pliance is a process built on everyday act ivit ies: i t i s a co n se q u e n ce o f o f f e r i n g m e d i ca t i o n , orientations, the insertion of the patients in the service, t heir access t o t he service every t im e it is necessary and the availability of a professional that is a reference f or h ealt h car e. On t h e ot h er h an d , com p lian ce is t hr eat ened w hen healt hcar e pr act ices do now allow for flexibilizat ion, in t erm s of changes in schedules, for ex am ple, w it h st r ict pr act ices in t he pr ocess of ser v ice pr oduct ion infr inging on cit izenship and t he exercise of freedom as a right .
Heal t h car e p r o f essi o n al s co m m i t t ed w i t h healt hcare work and wit h pat ient s aim t o overcom e t h e dif f icu lt ies pr esen t ed by t h e pat ien t s an d t h e service, in order t o collaborat e wit h t he com pliance process. Seeing to such necessities dem ands a broader, hum anized v iew , w hich ex t r apolat es t he biological dim ension of t he healt h- disease pr ocess( 12- 15). The
healt hcare t eam should offer support t o t he pat ient s and their fam ilies in the therapeutic process, allowing t hem t o be hear d, as w ell as pr ov iding or ient at ion a b o u t t h e i r i l l n e ss a n d m e d i ca t i o n . Lo n g - t e r m t reat m ent plans, in general, are associat ed t o follow-up difficult ies.
Scientific reports showing the m ultiple factors of abandonm ent are widely available wit h respect t o ch r o n i c- d e g e n e r a t i v e d i se a se s o r t r a n sm i t t a b l e diseases requiring cont inuous t reat m ent( 1). I n order
el em en t s w i t h r el at i o n s o f i n t er d ep en d en ce an d subordinat ion. As such, com pliance, according t o t he concept suppor t ing t he pr esent st udy, should focus on how the patients interpret their own health- disease pr ocess and under st and t heir posit ion in t he social pr ocess of pr oduct ion and r epr oduct ion, w hich w ill prom ote differentiated potentialities in term s of access to the elem ents that m ake up life and work. Moreover, it incorporates the understanding that the organization of the healthcare services m ust be oriented to answer the needs of the patients( 1- 2).
At t e n t i o n t o p a t i e n t s r e q u i r e s t h e est ablishm ent of a bond, indispensable for effect ive co m p l i a n ce , a n d i t b e co m e s a n o p p o r t u n i t y f o r em ancipat ion. I n t his pr ocess, t he pat ient s expr ess their disease, allowing the professionals to get to know how t he user s conceiv e t he healt h- disease pr ocess and t o build st rat egies t hat will facilit at e com pliance. Besides, t he healt hcare professionals’ availabilit y t o k n o w t h e p a t i en t s’ l i v i n g si t u a t i o n m a y p r o v i d e possibilit ies for coping in t he healt h- disease process, even t o t he ext ent of st r engt hening som e pat ient s’ social inclusion, since a large part of the subj ects live in poor social condit ions( 2).
I n the present study, the im portance of having Com m unit y Healt h Agent s working in t he process of com pliance wit h t he t reat m ent was highlight ed. They act as facilitators by closely knowing the patients’ daily lif e an d sh ow ed t o be m or e open t o assu m e n ew st rat egies, a t ype of behavior t hat differs from ot her healt hcare professionals, hist orically incorporat ed in t he healt hcar e t eam . Such char act er ist ics favor t he developm ent of OT( 13).
Regarding the incentives given to the patients, according t o t he healt hcare professionals, t hey help in t he com pliance process, especially because of t he social r est r ict ion s p r esen t . How ev er, act ion s an d policies should be considered that will m ake it possible t o insert t hese individuals socially, because t hese are benefits that, as a group, support the process, but do not change the reality of life( 13,16).
St ill, in t he present st udy, it is believed t hat t h e sid e ef f ect s of t h e m ed icat ion also in f lu en ce co m p l i a n ce . Th e r e f o r e , i t i s i m p o r t a n t f o r t h e healt hcare professionals t o be available t o list en t o the patients and solve their doubts, if any( 16).
I n a perspective that enlarges the traditional concept of t r eat m ent abandonm ent , it is said t hat com pliance, in daily healt hcare, should consider t he individuals’ way of life and fam ily dynam ics, as well
as their beliefs, opinions, knowledge about the disease and t reat m ent( 1- 2).
FI NAL CONSI DERATI ONS
Th e f ollow in g con sid er at ion s r ef er t o t h e realit y of t he locat ion where t he dat a were collect ed, wit h som e warning about undue generalizat ions. The analysis of t he st at em ent s, based on t he Theory of Social Det erm inat ion of t he Healt h- Disease process, shows how changes are needed in the considerations of processes t hat m ake individuals fall sick and die.
fr am ew or k in t his st udy( 1- 2). This happens because
com pliance is relat ed t o t he subj ect s’ life and w ork p r o cesses. I n t h i s p er sp ect i v e, so m e h eal t h car e professionals defend that it is fundam ental to broaden the view of the patients’ needs, considering their daily life as an im por t ant t herapeut ic pr ocess. Finally, it should be r est at ed t hat t he concept of com pliance requires changes in t he com prehension of healt hcare professionals, going beyond t he disease, as w ell as t heir involvem ent wit h t he healt hcare work, so t hat t h e n ecessit ies of t h e in d iv id u als an d g r ou p s ar e considered, seeking to understand the processes why p eop le f all ill an d d ie. Th er ef or e, t h e h ealt h car e
pr ofessionals need t o ident ify t he v ulner abilit ies of t he indiv iduals, fam ilies and social gr oups t hat ar e par t of t he t er r it or y, so t hat t hey m ay becom e t he focus of interventions shared with the com m unity and ot her social sect ors.
Tuberculosis should be considered a socially-d e t e r m i n e socially-d socially-d i se a se , a n socially-d co m p l i a n ce w i t h t h e t r eat m ent is dir ect ly associat ed t o how t he pat ient under st ands t he disease. Ther efor e, it is necessar y t o t ranscend t he under st anding of t he st rat egy, so t hat it goes beyond m edicat ion int ake and considers individuals’ ways of life, their fam ily dynam ics, beliefs, opinions and knowledge about t he disease.
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