#1 APA Determinants TB.docx

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I. TITLE

Determinants of Poor Adherence to Tuberculosis Treatment

II. INTRODUCTION

A. Bac!round of the "tud#

The intention of this study is to meet an academic requirement which is a

research project regarding management in the nursing eld. Initially, the research

would have been a simple one just to pass a piece of required papers. But the

prevalence of Tuberculosis in the Philippines pered our inquisitive minds to do the

otherwise. Tuberculosis or TB !according the "epartment of #ealth$ is the %th

leadingcause of illness and also the %thleading cause of deaths among &ilipinos.

TB is a curable disease. The treatment is comprehensive in order for an

infected person to be considered non'infective. (anaging the treatment program

with the appropriate regimen will produce as high as )*+ cure rate !#-, ))/$.

This is done by ".-.T.0. !"irectly'-bserved 0hort'1ourse$. It is a comprehensive

strategy endorsed by the orld #ealth -rgani2ation !#-$ and International 3nion

4gainst Tuberculosis and 5ung "iseases !I34T5"$ to detect and cure TB patients.

"-T0 was implemented in the Philippines in ))%.

There are ve elements of "-T0 that need to be fullled. These are6

. political commitment7. quality sputum microscopy for diagnosis8. regular supply of anti'TB drugs9. standardi2ed recording and reporting of TB data*. supervised treatment by a treatment partner

#ere in the Philippines, the :ational TB Program !:TP$ is the government;scommitment to address the TB problem. The :TP is implemented in all government

health centers and government hospitals. Its objectives are to detect active TB

cases !at least /


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B. Ob$ecti%es of the "tud#

>enerally, the purpose of this research is to investigate the determinants of

poor adherence to TB'"-T0 Program among PTB patients in a public ? private

hospital community specically Taculing Barangay #ealth 1enter and Bacolod

4dventist (edical 1enter respectively. 0pecically, this study aims to answer the

following questions6

. hat is the prole of the study group when grouped according to the

following variables6a. >ender

b. 4gec. (arital 0tatusd. occupatione. @ducation

7. hat is the level of adherence of the study group to TB'"-T0 programs in

Taculing Barangay #ealth 1enter and Bacolod 4dventist (edical 1enter when

they are taen altogether in the following factors predicting poor adherenceAa. >enderb. 4gec. @ducation

d. &amily 0i2ee. -ccupationf. Travel'relatedg. "rug supplyh. "rug side eects

8. Is there a signicant dierence between the levels of poor adherence to TB'

"-T0 programs of the study group in Taculing Barangay #ealth 1enter and

Bacolod 4dventist (edical 1enterA9. Is there any signicant relationship between the levels of poor adherence to

TB'"-T0 programs of the study group in Taculing Barangay #ealth 1enterand Bacolod 4dventist (edical 1enterA

C. 'othesis of the "tud#


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The researchers have advanced the following hypotheses6

#-6 There is no signicant dierence between the levels of poor adherence to

TB'"-T0 programs of the study group in Taculing Barangay #ealth 1enter and

Bacolod 4dventist (edical 1enter

#-6 There is no signicant dierence between the levels of poor adherence to

TB'"-T0 programs of the study group in Taculing Barangay #ealth 1enter and

Bacolod 4dventist (edical 1enter

D. "tud# (ariables) Indicators and Cate!ories

E. Assum'tions

The following are the assumptions of the study6

. The level of adherence to TB'"-T0 programs vary among PTB Patients

undergoing treatment in public and private hospitals.

7. Intensive TB'"-T0 program orientation plays an important role in the adherence

status of PTB patients both in public and private hospitals.

*. Theoretical *rame+or

,. Conce'tual *rame+or

&. "co'e and Limitations

The scope of the study covers factors that lead in poor adherence to TB'"-T0

Program among PTB patients in a public ? private hospital community specically


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Taculing Barangay #ealth 1enter and Bacolod 4dventist (edical 1enter respectively.

The data on poor adherence status will be taen from a questionnaire given to the

PTB patients undergoing treatment in Taculing Barangay #ealth 1enter and Bacolod

4dventist (edical 1enter. It is limited only to PTB patients undergoing treatment on

CCCCCCCCCCCCCCC !please decide the specic year or months$.

I. De-nition of e# Terms

41# 4ir 1hanges per #our4&B 4cid'&ast Bacilli

4II 4irborne Infection IsolationB1> Bacillus of 1almette and >uerinB45 Bronchoaleveolar 5avage1"1 1enters for "isease 1ontrol ? Prevention"-T "irectly -bserved Therapy":4 "eoDyribonucleic 4cid@(0 @mergency (edical 0ervices#1s #eath 1are orers##1 #ome #ealth 1are#IE #uman Immunodeciency Eirus#@P4 #igh @Fciency Particulate 4ir &ilter5T1 5ong Term 1are

("GTB (ultidrug Gesistant Tuberculosis:I-0# :ational Institute for -ccupational 0afety ? #ealth:I# :ational Institutes of #ealth:TP :ational TB Program-G -perating GoomPP" Puried Protein "erivativeTB TuberculosisT0T Tuberculin 0creening Test!ing$3E 3ltra Eiolet5& orld 5ung &oundation

Active TB disease an illness in which TB bacteria are multiplying and attacking a part of the body, usually the

lungs. The symptoms of active TB disease include weakness, weight loss, fever, no appetite, chills, and sweating at

night. Other symptoms of active TB disease depend on where in the body the bacteria are growing. If active TB

disease is in the lungs (pulmonary TB, the symptoms may include a bad cough, pain in the chest, and coughing up

blood. ! person with active TB disease may be infectious and spread TB bacteria to others.


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Antibiotic Therapy the use of antimicrobial agents which has the ability to destroy or interfere with the

development of living organisms, use generally to treat infections.

BCG a vaccine for TB named after the "rench scientists who developed it, #almette and $u%rin. B#$ is rarely

used in the &nited 'tates, but it is often given to infants and small children in other countries where TB is common.

Bloodstream any of the networks of tubes that carry blood, such as arteries, capillaries and veins.

Bronchoscope a curved, fleible tube for visual eamination of the bronchi or inside the lungs.

Cavity a hole in the lung where TB bacteria have eaten away the surrounding tissue. If a cavity shows up in )*

ray, a person is more likely to cough out bacteria and be infectious.

Chest x-ray a picture of the inside of your chest. ! chest *ray is made by eposing a film to *rays that pass

through the chest. ! doctor can look at this film to see whether TB bacteria have damaged the lungs.

Contact a person who has spent time with a person with infectious TB.

Culture a test to see whether there are TB bacteria in your phlegm or other body fluids. This test can take + to

weeks in most laboratories.

Directly observed therapy (DOT) a way of helping patients take their medicines for TB. If you get -OT, you

will meet with a health care worker every day or several times a week. ou will meet at a place you both agree on.

This can be the TB clinic, your home or work, or any other convenient location. ou will take your medicines while

the health care worker watches.

Extensively dru-resistant TB (!D" TB)* a rare type of TB disease that is resistant to nearly all medicines

used to treat TB.

Extrapulmonary TB active TB disease in any part of the body other than the lungs (for eample, the kidney,

spine, brain, or lymph nodes.

Germicidal a drug that kills pathogenic microorganisms.

#C$ % /ealth #are 0orker

#E&A % /igh 1fficiency 2articulate "ilters


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#' inection infection with the human immunodeficiency virus, the virus that causes !I-' (ac3uired

immunodeficiency syndrome. ! person with both latent TB infection and /I4 infection is at very high risk for active

TB disease.

'nectious TB TB disease of the lungs or throat, which can be spread to other people.

'*# or isonia+id a medicine used to prevent active TB disease in people who have latent TB infection. I5/ is

also one of the four medicines often used to treat active TB disease. It is considered a first*line drug.

,atent TB inection a condition in which TB bacteria are alive but inactive in the body. 2eople with latent TB

infection have no symptoms, don6t feel sick, can6t spread TB bacteria to others, and usually have a positive TB test.

But they may develop active TB disease if they do not receive treatment for latent TB infection.

iliary TB % TB disease that has spread to the whole body through thr bloodstream.

ultidru-resistant TB (D" TB) active TB disease caused by bacteria resistant to two of the most important

medicines7 I5/ and 8I".

ycobacterium tuberculosis bacteria that cause latent TB infection and active TB disease.

*eative usually refers to a test result. If you have a negative TB skin test reaction, you probably do not have

TB infection.

&ositive usually refers to a test result. If you have a positive TB skin test reaction, you probably have TB

infection.

&ulmonary TB active TB disease that occurs in the lungs, usually producing a cough that lasts 9 weeks or

longer. :ost active TB disease is pulmonary.

"esistant bacteria bacteria that can no longer be killed by a certain medicine.

"iampin ("'.) one of the four medicines often used to treat active TB disease. It is considered a first*line drug.

/mear a test to see whether there are TB bacteria in your phlegm (sputum. To do this test, lab workers smear

the sputum on a glass slide, stain the slide with a special stain, and look for any TB bacteria on the slide. This test

usually takes ; day to get the results.

/putum phlegm coughed up from deep inside the lungs. 'putum is eamined for TB bacteria using a smearuanti"18O5?*TB $old (>"T*$, >uanti"18O5?*TB $old In*Tube test (>"T*$IT #-(@ 4:" 1-((3:IT'B40@" 14G@

Teaching Patients 0elf'1are

The nurse plays a vital role in caring for the patient with TB and the family,

which includes assessing the patient;s ability to continue therapy at home. The

nurse instructs the patient and family about infection control procedures, such as

proper disposal of tissues, covering the mouth during coughing, and hand hygiene.

4ssessment of the patient;s adherence to the medication regimen is imperative

because of the ris of developing resistant strains of TB if the regimen is not


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followed faithfully. In some cases, when the patient;s ability to comply with the

medication regimen is in question, referral to an outpatient clinic for daily

medication administration may be required. This is referred to as directly observed

therapy !"-T$.

2Collins) 6nd Edition5

&ailure to complete treatment regimens is a major problem in TB

management because it increases the spread of the disease and the amount of

drug'resistant disease in a community. There is more diFculty with getting clients

to complete treatment for latent infection than for active disease. Identifying and

treating 5TBI requires several steps, including administering and reading sin tests,

obtaining medical evaluations of infected persons, and initiating, monitoring, and

completing treatment. :onadherence is common in all of these aspects. :umerous

strategies have been proposed to increase adherence, including6

. Patient0famil#0contact education. This may be especially important with

treatment of 5TBI. (ost people are more motivated to tae medications and

schedule follow'up care when they have symptoms than when they feel well and

have no symptoms. The importance of treatment for the future health of the

individual, signicant others and the community must be emphasi2ed. In addition,

clients should be informed about common and potential adverse eects of drug

therapy and what to do if they occur.

7. Pro%idin! su''ort ser%ices and resources. These require substantialnancial resources and may include more worers to provide "-T therapy at the

client;s locationJ KeDible clinic hoursJ reducing waiting times for patientsJ and

assisting clients with child care, transportation, or other social service needs that

encourage them to initiate and continue treatment. 5ac of these services !eg,

clinics far from clients; homes, with inconvenient hours, long waiting times, and

unsupportive sta$ may deter clients from being evaluated for a positive sin test,

initiating treatment, or completing the prescribed treatment and follow'up care.


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8. Indi%iduali7in! treatment re!imens) when possible, to increase client

convenience and minimi2e disruption of usual activities of daily living. 0hort'course

regimens, intermittent dosing !eg, 7 or 8 times weely rather than daily$, and Ded'

dose combinations of drugs !eg, Gifater or Gifamate$ reduce the number of pills andthe duration of therapy.

9. Promotin! communication and continuit# of care. ith clients for who

@nglish is not their primary language, it is desirable to have a health care worer

who speas their language or who belongs to their ethnic group. This worer may

be able to more eectively teach clients and others, elicit cooperation with

treatment, administer "-T, and be a consistent support person.

Isonia2id, Gifampin, and Pyra2inamide

The importance of taing medications as prescribed cannot be overemphasi2ed.

If not taen in the doses and for the length of time needed, there is a high lielihood

for development of tuberculosis infection that is resistant to the most eective

antituberculosis drugs. If this happens, treatment is much longer, very eDpensive,

and requires strong drugs that cause more adverse eects. In addition, this very

serious infection can be spread to family members and other close contacts. Thus,

avoiding drug'resistant tuberculosis should be a strong incentive to complete the

full course of treatment.

2A!uinaldo) 64465

Tae 8our 9edicines Re!ularl#

TB bacteria die very slowly. It taes at least % months for the medicine to ill

all the TB bacteria. ou will probably start feeling well after only a few wees of

treatment. But bewareL The TB bacteria are still alive in your body. ou must


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continue to tae your medicine until all the TB bacteria are dead, even though you

may feel better and have no more symptoms of TB disease.

If you don;t continue taing your medicine or you aren;t taing your medicine

regularly, this can be very dangerous. The TB bacteria will grow again and you will

remain sic for a longer time. The bacteria may also become resistant to the drugs

you are taing. ou may need new, dierent drugs to ill the TB bacteria if the old

drugs no longer wor. These new drugs must be taen for a longer time and usually

have more serious side eects.

If you become infectious again, you could give TB bacteria to your family,

friends, or anyone else who spends time with you. It is very important to tae your

medicine the way your doctor or nurse tells you.

The only way to get well is to tae your medicine eDactly as your doctor or

nurse tells you. This may not be easyL ou will be taing your medicine for a long

time !%months or longer$, so you should get into a routine. #ere are some ways to

remember to tae your medicine6

Participate in the directly observed therapy (DOT) program or any

programs that actively monitors your condition. Tae your pills at the same time everyday' for eDample, you can tae

them before eating breafast, during a coee brea, or after brushing your

teeth.

4s a family member or a friend to remind you to tae your pills.

(ar o each day on a calendar as you tae your medicine.

Put your pills in a weely pill dispenser. Meep it by your bed or in your

purse or pocet.

Gemember to eep all medicine out of reach of children.


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If you forget to tae your pills one day, sip that dose and tae the neDt

scheduled dose. Tell your doctor or nurse that you missed a dose. ou may

also call your doctor or nurse for instruction.

B. Research Literature

Dr. "hashiant "ri%asta%a and Dr. /otam ,. Pasi'anod#a 264345

4 3niversity of TeDas, 0outhwestern (edical 1enter study using a

sophisticated Nglass mouseO research model has found that multidrug'resistant

tuberculosis !TB$ is more liely caused in patients by speedy drug metabolism

rather than inconsistent doses, as is widely believed.

If the study published in The ournal of Infectious "iseases is borne out in future

investigations, it may lead to better ways to treat one of the world;s major

infectious diseases. #ealth worers worldwide currently are required to witness each

administration of the combination of drugs during months of therapy.

NTuberculosis is a common ailment, accounting for up to 8 percent of all deaths in

many countries. 4lthough eective therapy eDists, there are still cases of treatment

failure and drug resistance remains a threat,O says "r. Tawanda >umbo, associate

professor of internal medicine and senior author of the study.

The results seem to challenge the current approach endorsed by the orld #ealth

-rgani2ation. 3nder that method, directly observed therapy'short'course strategy


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!"-T0$, TB that responds to medication is treated with a coctail of drugs under the

supervision of health care worers, who in many countries must travel to isolated

villages Q a costly and time'consuming process.

N@very TB patient is supposed to be watched as they swallow their pills in order to

increase adherence and decrease emergence of drug resistance. This is the most

eDpensive part of the program, but has been felt to be cost'eective since it

improves compliance,O says >umbo, administrative director of research programs

for the -Fce of >lobal #ealth at 3T 0outhwestern.

In this study, 3T 0outhwestern researchers created a sophisticated system of high'

tech test tubes, which they called a Nglass mouse,O that mimiced standard therapy

being given daily for 7= to *% days, with dosing adherence varying between umbo

says. 4 population of individuals with a genetic trait that speeds the process has

been found in one area of 0outh 4frica that has a high rate of multidrug'resistant

TB. In that population, patients who receive standard doses of drugs end up with

concentrations in their bodies that are too low to ill the TB bacillus and drug

resistance develops, he adds.

4 ournal of Infectious "iseases editorial that accompanies the study suggests that

monitoring the levels of TB drugs in a patient;s blood could be as important as

monitoring compliance with therapy Q in contrast to current #- guidelines.

NThese data, based on our preclinical model, show that non'adherence alone is

insuFcient for the emergence of multidrug'resistant TB,O >umbo says. NIt might be

more cost'eective to measure patients; drug concentrations during treatment and

intervene with dosage increases in those who quicly clear the drugs from their

systems.O

The wor was supported by a grant from the :ational Institute of 4llergy and

Infectious "iseases of the :ational Institutes of #ealth.

-ther 3T 0outhwestern investigators involved in the study are lead author "r.

0hashiant 0rivastava, former postdoctoral researcher, and "r. otam >.


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Pasipanodya, research scientist in internal medicine. Gesearchers from the 0chool of

Pharmacy at TeDas Tech 3niversity #ealth 0cience 1enter, "allas, also participated

9a#o Clinic "ta: "tud# 2644;5

Com'letin! treatment is essential. 4fter a few wees, the patient wonRt

be contagious and may start to feel better. It might be tempting to stop taing the

TB drugs. But it is crucial that the patient nish the full course of therapy and tae

the medications eDactly as prescribed by doctor. 0topping treatment too soon or

sipping doses can allow the bacteria that are still alive to become resistant to

those drugs, leading to TB that is much more dangerous and diFcult to treat.

To help people stic with their treatment, a program called directly observed

therapy !"-T$ is sometimes recommended. In this approach, a health care worer

administers your medication so that the patient doesn;t have to remember to tae it

on their own.

Dr. Thelma Tu'asi 264345

"r. Tupasi, one of the worldRs foremost infectious disease eDperts, has been a

central force in TB control in the Philippines for the past 9< years, recently leading

implementation of "-T0'Plus treatment for patients with multi


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improves the health and productivity of the worforce.S @very dollar spent on TB

control returns < to 7< times that amount in economic benets.

"r. TupasiRs oversaw the opening of the rst International Tuberculosis 1enter in 4sia

to combat ("G'TB. The 1enter provides treatment, research, training, and a steady

supply of anti'TB medications in the Philippines and throughout 4sia. SThe Tropical

"isease &oundation is grateful to 1orld Lun! *oundationand other donors who

have made it possible for us to increase our capacity,S says "r. Tupasi. STheir

funding pacage enabled us to leverage a land donation to build and equip this new

center. :ow, we can provide better treatment to ("G'TB patients, as well as share

information and train people from across 4sia to start self'sustaining programs in

their own countries.S

"r. Tupasi is condent about the prospects for tuberculosis control in the Philippines

and globally. S#owever, it taes political commitment to provide the necessary

budgetary and human resources to implement well'managed tuberculosis control

programs,S she says. SBecause most TB patients are poor, they need access to

treatment that is free of charge and locally accessible. 1uring the disease is an

important public health intervention that benets patients and their families, as well

as their communities.

4lthough tuberculosis is preventable and treatment has been available for the past

%< years, it continues to be a major cause of illness and death worldwide. 4bout 7.7

billion people, a third of the worldRs population, are infected with TB. (ore than =

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