Ten years on: highlights and challenges of directly observed treatment short-course as the recommended TB control strategy in four Pacific Island nations

Objectives: The internationally recommended tuberculosis (TB) control strategy, Directly Observed Treatment, Short course (DOTS) was implemented in most Pacific Island countries and territories during the year 2000, with expansion of DOTS into outer islands and rural areas over the past ten years. The objective of this study was to better understand successful strategies and challenges faced in implementing DOTS in outer islands and rural areas of selected high burden Pacific countries from the perspective of National TB Program (NTP) staff. Methods: National TB Program Managers or Coordinators from four Pacific countries, Solomon Islands, Vanuatu, Kiribati and Tuvalu, were surveyed and participated in in-depth interviews exploring what had been particularly effective and what challenges had emerged during DOTS implementation in outer islands and rural areas. Information from the interviews was analysed for shared experiences with data coded inductively using a thematic coding scheme. Results: The positive aspects of DOTS implementation in outer islands and rural areas were in three main themes: support from health workers and the community; enablers and incentives; and better treatment completion. The challenges could be categorised in five main themes: working with volunteers; stigma; traditional healers; distance and communication; and financial challenges. Local health workers, pastors, church leaders, chiefs and traditional healers were all key players in the TB Program in outer islands. Local health workers are integral to effective TB control due to accessibility and being known by the community. Conclusions: Reviewing the highlights and challenges of implementing DOTS in outer islands and rural areas in four Pacific countries has revealed some important issues. Increasing support to local health workers, actively engaging with pastors, church leaders, chiefs and traditional healers and addressing the barriers to communication and transport for people living in the outer islands are particular issues to address. Much has been achieved in TB control in outer islands but if the burden of TB is to be reduced and drug resistant TB is to be prevented, additional and ongoing investment is required.