Post on 21-Jul-2015
DETERMINANTS OF CLIENTS’ ADHERENCE TO PUBLIC-
PRIVATE MIX (PPMD)TREATMENT
John Carlo L. Divina, MSN, RNCebu Philippines
INTRODUCTION
One-third of the world’s population is infected withMycobacterium tuberculosis, mostly in developing countries,where 95% of the cases occur (Dye et al., 1999).
In 2012, the Philippines has recorded 93, 586 sputum positivepatients which could infect at least 10 – 20 persons a year, ifleft untreated (National Tuberculosis Control Program Manualof Procedure, 2004). Therefore, this major public healthconcern has been set as part of the target of the 6th
Millennium Development Goal which is to reduce theprevalence and mortality of Tuberculosis by half in 2015.
RATIONALE
Non-adherence to treatment may
reduce treatment efficacy and cause drug
resistance, resulting in increased
morbidity and mortality and further
infections (Raviglione et al., as cited by
the ISTC, 2006), hence, the need to
address this challenge.
PROBLEM
1. What are the characteristics of the
respondents categorized as adherent and
non-adherent in terms of the following
variables?
2. Which variables influence adherence toPPMD treatment?
3. Is there a significant relationship between
the selected predictors and the clients’adherence to PPMD treatment?
METHODOLOGY
Design: Descriptive Correlational
Locale: Mandaue City Health OfficePPMD South District
Respondents: 70 adherent and non-adherent PTB patients
Instrument: PPMD Treatment Adherence Index
RESULTSPercentage of Demographic Profile
60%
91%
94%
77%
69%
46%
66%
57%
83%
91%
63%
46%
31%
60%
0% 20% 40% 60% 80% 100%
Perceived Self-Efficacy: VeryEffective
Without Co-Morbidity
Accessible TB DOTS Unit
Sputum Smear Status :Negative
Income: Php 5,001 - 20,000
Educational Attainment: HSGraduate
Age: Young Adult
V
A
R
I
A
B
L
E
S
Non-Adherent
Adherent
RESULTSMean Scores of the Intrapersonal Variables
3.31 3.26
2.2
3.64
3.09
3.6
2.49
3.69
Perceived Quality ofHealth Services
Perceived SocialSupport
Perceived SocialStigma
Motivation toTreatmentAdherence
VARIABLES
Adherent Non-Adherent
RESULTSPercentage of Adverse Reactions to Treatment
0%
5%
10%
15%
20%
25%
30%
35%
Adherent
Non-Adherent
DISCUSSIONQuality of Health Services
Quality of health services with coefficient of 0.476directly influences adherence.
Health care service factors, such as long waitingtimes and inconvenient opening times in clinics,add to economic discomfort and social disruption forpatients and negatively influence adherence (Klink,1969, as cited by Munro, 2007).
DISCUSSIONIncome
Income at coefficient -0.381 inversely influences adherence.
Non-adherence related to high income levels maybe attributed to the increased capacity of thepatient to purchase medications and may notsignificantly rely on the free anti-tuberculosismedications provided by the PPMD unit.
DISCUSSIONPerceived Social Stigma
Perceived social stigma with coefficient of -0.376 likewise indirectly influences adherence.
Stigma makes patients reluctant to attendingtreatment in clinics located in their neighborhoodswhich may lead to non-disclosure of illness, hence,is considered a potential barrier to treatment(Gebremariam et al., 2010).
DISCUSSIONDiscriminant Analysis Coefficient Function
Discriminant analysis coefficient function (D) = income + (2.139 x quality of health services) +
(-0.242 x perceived social stigma)) + -0.388.****
This equation can help discriminate whether apatient with tuberculosis will be adherent or not.However, the model can only explain 33.29% of thetime as reflected in the over-all Wilk’s Lambdascore.
DISCUSSIONOver-all Wilk’s Lambda_Score
66.70 % of the variation cannot be explained by the model at significant p value of 0.024.
The percentage is quite high noting that majority ofthe independent variables does not have a significantrelationship across groups of the dependent variable.Other cofounding variables not evaluated by thisstudy may have bearing on adherence.
DISCUSSIONClassification Results
Classification results which revealed that 72. 94% ofthe respondents were classified correctly intoadherent and non-adherent groups.
Adherent respondents were classified with slightlybetter accuracy (80%) than non-adherent (65.7%).However, cross-validation indicated that 61.4% ofthe group cases were correctly classified, thus, thisdata provided a more reliable function than theoriginal group classification.
CONCLUSION
Income and perceived social stigma
are good screening parameters in
assessing clients’ adherence. Quality of
health services should be considered
when providing treatment since it is a
good determinant of clients’ likelihood oftreatment adherence.
RECOMMENDATIONS
Evaluation Tool – be developed by National
TB Program Managers in Assessing provision
on Quality of Health Services
Frequent Counselling and Assistance – be
readily available to all clients
Future Research – be conducted in a larger
population with more detailed items in the
significant variables and considering other co-
founding variables.
REFERENCES
1. Department of Health. (2004). National tuberculosis control program manual of procedure. Philippines: Department of Health
2. Dye C., Scheele S., Dolin P., Pathania V., RaviglioneM.C.(1999). Consensus statement. Global burden of tuberculosis: estimated incidence, prevalence, and mortality by country. WHO Global Surveillance and Monitoring Project. Journal of American Medical Association,282(7):677-86.
3. Klink, W.B. (1969). Problems of regimen compliance in tuberculosis treatment. New York (NY): Columbia University
REFERENCES
4. Gebremariam, M., Bjune, G., Frich, J. (2010). Barriers and facilitators of adherence to TB treatment in patients on concomitant TB and HIV treatment: a qualitative study. Retrieved from http://www.biomedcentral.com/1471-2458/10/651
5. Munro, Salla et al, (2007). Patient adherence to Tuberculosis treatment: a systematic review of qualitative research. Retrieved from http://www.plosmedicine.org/article/info%3Adoi%2F
10.1371%2Fjournal.pmed.00402386. Pender, N. J. (2006). Health promotion in nursing practice
(5th edition). Singapore: Pearson Education South Asia
REFERENCES
7. Raviglione M, Snider D, Kochi A. (1995). Global epidemiology of tuberculosis : Morbidity and mortality of a worldwide epidemic. Journal of American Medical Association, 273:220-226. Publisher Full Text.
8. Tuberculosis Coalition for Technical Assistance. (2006). International standards for Tuberculosis care (ISTC).The Hague: Tuberculosis Coalition for Technical Assistance
9. World Health Organization. (2003) Adherence to long-term therapies. Evidence for action. Geneva: World Health Organization.
ACKNOWLEDGEMENT
My heartfelt gratitude goes to the
research respondents for their trust and
time, the barangay health workers who
have volunteered their services in
accompanying me to locate the
respondents, the PPMD Nurses who
have assisted me in many ways.
To my colleagues , family and
friends, a million thanks for inspiring me
to reach my dreams.
ABOUT THE RESEARCHER
JOHN CARLO L. DIVINA, MSN, RNResearcher & PPMD Nurse, South General Hospital PPMD Unit
Contact Information:South General Hospital PPMD UnitNational Highway, Tuyan, City of Naga, Cebu, Philippines 6037Cellular Number: +63933 325 2888Email: dvynejc2000@yahoo.com