Chapter 1

THE PROBLEM AND ITS SCOPE

INTRODUCTION
Rationale
Health is Wealth! This is one state"ent that the people #elie$e
on as the% li$e in the &i'erent &i"ensions o( the )orl&* &oin+ the $er%
#est to s,r$i$e (ro" the &i'erent &ile""as o( li(e in $ario,s aspe-ts!
.or so "an%/ #ein+ health% has not #een so &i0-,lt sin-e the -,res o(
so"e illness are (o,n& in o,r o)n #a-1%ar&s s,-h as (r,its/ $e+eta#les/
an& "an% "ore! We/ the people/ ha$e #een -onstantl% &oin+ those
tra&itional steps )hen )e -annot ha$e the opport,nit% to o#tain a
hi+her le$el o( treat"ent!
As &e2ne& #% the Worl& Health Or+ani3ation 4WHO5 on its 1678
Constit,tion* Health is the -on&ition )herein a person li$es a health%
li(est%le in either ph%si-al/ so-ial or in "ental aspe-ts an& )hen a
person &oes not a-9,ire an illness or &isease! Basi-all%/ it is o,r
li(eti"e in$est"ent an& helps ,s -on9,er the )orl& an& li$e the )a%
)e )ant it to #e! Besi&es/ it is o,r -hoi-e to #e-o"e one or not*
&epen&in+ on the sit,ation! The )orl&/ #ein+ "ol&e& )ith &i'erent
-atastrophes an& &isasters/ is #e-o"in+ e$en "ore -o"ple:! At the
sa"e ti"e/ o,r pop,lation starts an& -ontin,es to +ro) e$en #i++er!
.or this ti"e aro,n&/ )e -annot sa% that all o( the people are still
health%! Besi&es/ there are those -reat,res s,-h as "i-ro#es
-ontin,in+ to +ro) in s)ar"s an& are ,n-ontrolla#le!
Be-a,se o( this/ a &isease or an a#nor"al "e&i-al -on&ition is
&e$elope&! It a'e-ts #oth h,"ans an& ani"als as en&e"i-/ epi&e"i-/
or pan&e"i-! It #e-o"es a -on-ern to e$er% people in the )orl&! B,t
&espite the )a% &iseases o--,r in o,r en$iron"ent/ there are still )a%s
on ho) to treat an& pre$ent the"!
.a-tors that -an a++ra$ate the &isease an& -an "a1e a person
"ore s,s-epti#le to it in-l,&e ha$in+ a lo) i"",ne s%ste" as
espe-iall% i"",no-o"pro"ise& in&i$i&,als/ poor n,trition/
o$erpop,lation/ po$ert%/ ,r#ani3ation/ "i+ration/ #elo) a$era+e li$in+/
an& intera-tion )ith other patients -arr%in+ the &isease!
Literall%/ people in &i'erent -o"",nities are threatene& )hen
the% ha$e 1no)n s,-h &isease e$en i( the% ha$e onl% seen it in
tele$isions/ hear& it on the ra&io or ha$e rea& (ro" #oo1s! O(ten/ the
h,"anit% o,+ht to #elie$e e$er%thin+ a#o,t it #e-a,se e$er%one
1no)s it )ill #e har& to re-o$er i( ,ntreate&!
Ri;en state& in a ne)s arti-le last <=1= that re-or&s o(
Depart"ent o( Health>Central ?isa%as -hapter re$eale& Ce#, pro$in-e
)ith hi+hest pre$alen-e o( @A6B t,#er-,losis -ases )herein A61 o(
)hi-h o--,rre& in the -it% o( Lap,>Lap,! Lap, >Lap, Cit% is one o( the
pro$in-es o( Ce#, )here t,#er-,losis is ra"pant an& it -onsists o( 7=
#aran+a%s! As o( <=1@><=17/ re-ent statisti-s (ro" the Lap,>Lap, Cit%
Health O0-e state that a"on+ the 7= #aran+a%s/ Baran+a% Basa1 has
the hi+hest n,"#er o( TB -ases )ith a total o( <== patients!
The &isease #ein+ one o( the "aCor -a,ses o( si-1ness an& &eath
)hi-h a--o,nts the Philippines as one o( the << hi+hest TB>#,r&en
-o,ntries/ the +o$ern"ent a+en-ies responsi#le (or re+,latin+ health
la)s an& spe-ial pro+ra"s initiate another pro+ra" )hi-h )ill
era&i-ate an& lessen &eaths in o,r -o,ntr%! In this re+ar&/ DOTS or the
Dire-tl% O#ser$e& Treat"ent Short>Co,rse pro+ra" #e+an in earl%
166B an& nation)i&e -o$era+e )as a-hie$e& in <==@! This strate+%
la,n-hes a &ele+ate& set>,p settin+ thro,+h lo-al +o$ern"ent ,nits/
p,#li- an& pri$ate hospitals/ -o"",nities/ #aran+a%s/ an& re-entl% in
-o"",nit% phar"a-ies in i"ple"entin+ the strate+%! This &r,+
therap% (or t,#er-,losis is 1no)n to #e $er% e'e-ti$e/ pro$i&e& a stri-t
patientDs -o"plian-e to "e&i-ations!
It "a% #e a &i0-,lt/ -o"ple: an& prolon+e& treat"ent (or
in(e-te& patients* pro(essionals in$ol$e& in the -o,rse are &oin+
e$er%thin+ in their po)er to "aintain the e'e-ti$eness o( the pro+ra"
an& the +oo& health o( the patients! Ho)e$er/ TB &r,+ treat"ent
&epen&s +reatl% on the -olla#oration o( the patients (or sel(>
a&"inistration/ as patientDs -o"plian-e is an i"portant ele"ent
#et)een "e&i-al "eas,res an& treat"ent res,lts! I( the patient is a
non-o"pliant/ he or she )ill a-9,ire "ore -o"pli-ations an& (or )orse/
,n-ontrolle& &eath rate -ontin,es to e:ist!
On the +oo& si&e/ ho)e$er/ in(or"ation on the s,--ess o( TB
-ontrol in the Philippines has #een re-or&e& )ith si+ni2-ant
i"pro$e"ent )ith the &isease &ete-tion an& treat"ent! A--or&in+ to
The Philippine Star 4<=1@5/ &eath o( patients &,e to p,l"onar%
t,#er-,losis )ent &o)n #% 76 per-ent )hile the n,"#er o( .ilipinos
)ith TB &i"inishe& #% E< per-ent! Ho)e$er/ neither the set tar+et (or
TB &ete-tion rate nor the -,re rate has #een a--o"plishe& #% the
DOTS pro+ra" #e-a,se there )ere se$eral threats &epre-iatin+ its
e'e-ti$e i"ple"entation!
In rele$an-e to this/ o,r resear-h paper (eat,res one o( the "ost
-o""on in(e-tio,s &iseases that o--,r not onl% in the Philippines #,t
also in &i'erent parts o( the )orl&! In(or"ation on t,#er-,losis is o(
+reat i"portan-e sin-e it has alrea&% #een part o( the p,#li- healthDs
-on-ern! This paper &oes not onl% (o-,s on the &isease* #,t also the
relationship #et)een peopleDs 1no)le&+e an& their -o"plian-e on a
parti-,lar treat"ent re+i"en!
Bein+ 1no)le&+ea#le a#o,t &r,+s an& "e&i-ines/ "e&i-al
pro(essionals espe-iall% phar"a-ists an& phar"a-% st,&ents are $er%
",-h 9,ali2e& in a&"inisterin+ the "e&i-ations an& "onitorin+
patientDs -o"plian-e in this pro+ra" in or&er to lessen treat"ent
(ail,re! Co"plian-e or a&heren-e is &e2ne& #% WHO as the s-ope to
)hi-h it sho)s ho) a person #eha$es to "aintain a health% li(est%le
-orrespon&s to the health -are pro$i&erDs re-o""en&ations! In this
"atter/ it is s%non%"o,s to the patientDs a+ree"ent an& a-ti$e
parti-ipation!
Despite the (a-t that the +o$ern"ent* parti-,larl% the
Depart"ent o( Health an& other health a+en-ies/ pro$i&e e$er%thin+
an& all o( the ser$i-es nee&e& in this Dire-tl% O#ser$e& Treat"ent
Short>Co,rse Pro+ra"/ -o"plian-e has still #een an iss,e in P,#li-
Health #e-a,se there are still other people )ho (ail to -o"plete the
"e&i-ation in a +i$en ti"e! In this -ase/ non>-o"plian-e "a% lea& to
other -o"pli-ations!
The resear-hers )ho are (o,rth %ear le$el phar"a-% st,&ents/
ha$e +aine& 1no)le&+e on p,#li- health/ "i-ro#iolo+% an&
phar"a-e,ti-al -are/ are -apa#le o( -on&,-tin+ the ,n&er+ra&,ate
resear-h entitle& Fno)le&+e an& PatientsD Co"plian-e on TB>DOTS
Pro+ra" in the Health Center o( Baran+a% Basa1/ Lap,>Lap, Cit%/
Ce#,!
The resear-hers p,rposel% -hose the topi- (or resear-h &,e to
the (ollo)in+ reasonsG 2rst/ to e:a"ine the -hallen+es o( Dire-tl%
O#ser$e& Treat"ent Short Co,rse i"ple"entation strate+ies in the
treat"ent o( t,#er-,losis/ )ith the perspe-ti$e to &eter"ine (a-tors
inH,en-in+ a+ainst its e'e-ti$e i"ple"entation* se-on&/ to esta#lish
a)areness o( the &isease a"on+ patients )ith t,#er-,losis* thir&/ to
esta#lish an& loo1 (or the relationship #et)een 1no)le&+e an&
patientsD -o"plian-e on TB>DOTS Strate+%* an& lastl%/ to en-o,ra+e
the people in o,r -o"",nities to -o"pl% )ith an% treat"ent re+i"en
espe-iall% (or the TB &isease!
Theoreti-al Ba-1+ro,n&
This resear-h st,&% a#o,t Fno)le&+e an& PatientsD Co"plian-e
on T,#er-,losis> Dire-tl% O#ser$e& Treat"ent Short>Co,rse 4TB>DOTS5
Pro+ra" in the Health Center o( Baran+a% Basa1/ Lap,>Lap, Cit%/
Ce#,/ (o-,ses on t)o i"portant $aria#lesG 1no)le&+e an& patientsD
-o"plian-e!
Ro&ri+,e3 4<==6/ pp! <1@><1E5 state& that A#raha" Maslo)* a
ps%-holo+ist/ -reate& the Hierar-h% o( Nee&s )hi-h in-l,&esG
Ph%siolo+i-al nee&s/ se-,rit% an& sa(et% nee&s/ #elon+in+ nee&s/ sel(>
estee" an& lastl%/ the nee& (or sel(>a-t,ali3ation as state&! Health/
,n&er ph%siolo+i-al nee&s is -onsi&ere& to #e a #asi- or (,n&a"ental
nee& (or all o( ,s in or&er to a$oi&/ pre$ent/ an& treat illness that )o,l&
in-rease the ris1 o( "or#i&it% an& "ortalit% an& in relation )ith the
+oal o( the T,#er-,losis>Dire-tl% O#ser$e& Treat"ent Short>Co,rse #%
the Depart"ent o( Health 4DOH5 )hi-h is to -ontrol an& era&i-ate
t,#er-,losis!
A--or&in+ to Ia"es an& Ro$ers 4<==@/ p!1A75/ &e2nitions o(
health ha$e #een e$i&ent in (o,r "o&els! .irst/ the "e&i-al "o&el
states Health is the a#sen-e o( ph%si-al an& "ental &isease or
in2r"it%! Base& (ro" the WHO Mo&el/ health en-o"passes -o"plete
ph%si-al/ "ental/ an& so-ial )ell>#ein+! The thir& "o&el or the Wellness
Mo&el sa%s that health is the point at )hi-h an in&i$i&,al has
-oor&inate& his or her #o&%/ "in&/ an& spirit res,ltin+ to a #etter state
o( hi+her (,n-tionin+/ ener+%/ an& -o"(ort! En$iron"ental Mo&el
a0r"s that health% people -an a&C,st to ph%si-al an& so-ial
s,rro,n&in+s an& &o not e:perien-e the ,n&,e pain/ &is-o"(ort/ or
&isa#ilit%!
Her+enhann 4<==6/ p!7B5 e:plaine& that Plato "entione& in his
Re"inis-en-e Theor% o( Fno)le&+e/ that all 1no)le&+e is inherent
an& -an #e a-hie$e& onl% thro,+h sel(>-onte"plation or the sear-hin+
o( oneDs inner tho,+hts/ (eelin+s/ an& e:perien-es! Mostl%/ sensor%
e:perien-e -an onl% re"in& one o( )hat )as alrea&% 1no)n! There(ore/
(or Plato/ all 1no)le&+e -o"es (ro" re"inis-en-e/ (or" re"e"#erin+
the e:perien-es the so,l ha& #e(ore enterin+ the #o&%! He also
#elie$e& that that ,lti"ate realit% -onsiste& o( i&eas or (or"!
As -ite& #% Jreen)oo& 4<==6/ p! <@5/ Rene Des-artes/ a
rationalist/ state& that )e -an a-9,ire a prior 1no)le&+e/
in&epen&entl% o( e:perien-e/ #ase& on reason* )hile Lo-1e "aintaine&
that )e -an onl% ha$e a posterior 1no)le&+e #ase& on e:perien-e!
Episte"olo+% is a #ran-h o( philosoph% )hi-h &eals )ith the
st,&% o( 1no)le&+e an& ,n&erstan&in+! It is also re(erre& to as The
Theor% o( Fno)le&+e )hi-h (o-,ses on the ori+in/ nat,re an& li"its o(
1no)le&+e! 4Cr,3 et al!/ 16665
A%ers/ et!al 4<==B5 state& that $ario,s theories o( "oti$ation/
learnin+/ an& &e-ision>"a1in+ ser$e as a ,se(,l +,i&e in resear-hes
ai"e& at enhan-in+ an& ,n&erstan&in+ health>relate& #eha$io,rs an&
&e$elopin+ "ore e'e-ti$e #eha$ior -han+e strate+ies! Sin-e
-o"plian-e )ith "e&i-al re+i"en in$ol$es #eha$ior that i"pa-ts
health/ theories o( -o"plian-e ha$e #een ,se(,l in #oostin+ o,r
,n&erstan&in+ o( the ps%-hoso-ial an& en$iron"ental &eter"inants o(
health>relate& #eha$io,rs!
Le$enthal an& Ca"eron 416AB5 e:plain that "ost -o"plian-e
st,&ies ha$e #een +,i&e& #% one o( 2$e "aCor theoreti-al orientations/
)hi-h a&&resses the patientDs histor% o( illness/ per-eptions/ -opin+
strate+ies/ an& ha#it,al $ers,s reasone& &eter"inants o( #eha$ior
-han+eG 415 Bio"e&i-al "o&el/ )hi-h has #e-o"e a so-ietal (o,n&ation
o( illness/ 4<5 Operant #eha$ior an& so-ial learnin+ theories/ that &eals
)ith the sti",li or in&i-ates the ,na--epta#le #eha$ior/ a si+n o(
#eha$io,ral i"pro$e"ent thro,+h re)ar&s/ the +ra&,al shapin+ or
patternin+ o( the #eha$ior/ an& its a,to"ation a(ter s,0-ient
repetition/ 4@5 Rational #elie( theor%* )hi-h ass,"es that h,"an
#eha$ior is &eter"ine& #% an o#Ce-ti$e/ lo+i-al tho,+ht pro-ess* th,s
statin+ that non-o"plian-e res,lts (ro" the la-1 o( 1no)le&+e on the
possi#le ha3ar&s an& #ene2ts o( pres-ri#in+ #eha$io,rs or not/ 475
Co"",ni-ations approa-h* sees the patient as a #e+inner )ho loo1s
(or the "aster +,i&an-e an& treat"ent o( the -lini-ians an&/ 4E5 Sel(>
re+,lati$e s%ste"s theor%* a theor% that sees the sin+le person as
so"e#o&% )ho -an ta1e -are o( iss,es an& re(ers that #eha$io,r li1e
-o"plian-e is #ase& an& &epen&s in li+ht o( -o+niti$e $ie)points an&
the -,rrent stat,s o( ho) a -ir-,"stan-e a&$an-es! Ea-h o( these
$ie)s non>-o"plian-e pro#le"s (ro" &i'erent perspe-ti$es an& +i$es
"ore or less attention to illness -o+nition/ ris1 per-eption/ "oti$ation
to -o"pl%/ sele-tion an& a-9,isition o( -opin+ #eha$iors/ an& appraisal
pro-esses!
Re$ie) o( Relate& Literat,re
In the s-ope o( p,#li- health* &iseases/ espe-iall% those that are
-a,se& #% in(e-tio,s a+ents/ are the ra"pant an& still -ontin,in+
o#sta-les o( the so-iet%Ds health! A-9,irin+ a &isease "a% ha$e ris1s
an& #ene2ts to h,"ans in &i'erent aspe-ts! B,t the )or& &isease
itsel( spea1s har" an& (or )orse* &eath! Sit,ations -all as it -an #e
a--o,nta#le (or t,#er-,losis! Bein+ one o( the "ost &ea&l% &iseases/
the h,"anit%Ds health is p,t at sta1e &,e to the threats that it "a%
#rin+ an& "a% +i$e to the people! Be-a,se o( this/ it is $er% i"portant
(or the people to #e oriente& a#o,t the &isease an& its "e&i-ations!
T,#er-,losis* or in other ter"s TB/ is still -onsi&ere& as one o(
the "aCor health #,r&ens )hi-h roots to the s,'erin+s o( the people
)orl&)i&e! Ne$ertheless/ this has #een a lon+>ter" "ission an&
a&$o-a-% (or the health pro(essionals* alon+si&e )ith the +o$ern"ent/
to era&i-ate the pre$alen-e o( t,#er-,losis all o$er the )orl&! It is an
in(e-tio,s &isease a'e-tin+ so"e parts o( the h,"an #o&% s,-h as
paren-h%"a/ "enin+es/ 1i&ne%s/ #ones/ l%"ph no&es/ intestines! B,t
a"on+ these parts/ the l,n+ is the "ost -o""on site o( the in(e-tion!
Mycobacterium tuberculosis is an a-i&>(ast aero#i- o#li+ate ro&>
shape& #a-teri," that is -onsi&ere& the -,lprit o( the sit,ation! It
+ro)s slo)l% an& &i$i&es e$er% 18><= ho,rs* an& is also sensiti$e to
heat an& ,ltra$iolet li+ht! Another thin+ that "a1es it threatenin+ is its
hi+h lipi& -ontent on the -ell )all )hi-h -ontri#,tes to #a-terial
resistan-e to)ar&s &esi--ation an& stainin+! A--or&in+ to the Philippine
Phar"a-e,ti-al Dire-tor% 4<==6/ p! @E@5/ the #a-teri," -an )ithstan&
an& s,r$i$e in &r% state (or )ee1s #,t -an +ro) onl% )ithin a host
or+anis"!
A person in(e-te& )ith the t,#er-le #a-illi "a% e:perien-e
-o""on -lini-al "ani(estations s,-h as a #a& -o,+h that lasts three
)ee1s or lon+er* pain in the -hest* -o,+hin+ ,p #loo& or sp,t,"*
)ea1ness or (ati+,e* )ei+ht loss* no appetite* -hills* (e$er* an&
s)eatin+ at ni+ht as spe-i2e& #% Po""er$ille 4<==B/ p!<87><8E5!
Tierne% et al!/ 4<==8/ p! <EB5 state& in C,rrent Me&i-al Dia+nosis
an& Treat"ent 7E
th
e&ition that t,#er-,losis a'e-ts appro:i"atel% <=>
7@K o( the )orl&Ds pop,lation in-l,&in+ those people s,'erin+ (ro"
po$ert% li1e the ho"eless/ "alno,rishe&/ an& those people )itho,t
proper ho,sin+! M,llins 4<==15 state& that o$er 1 #illion TB -ases/ A to
1= "illion o( )hi-h o--,r ea-h %ear )orl&)i&e! Ro&a 4<=17/ p!B5
9,ote& that it is the si:th lea&in+ -a,se o( "or#i&it% an& "ortalit%
a"on+ h,"ans as state& #% the Depart"ent o( Health! The Philippines
is one o( the << -o,ntries e:perien-in+ the TB epi&e"i- an&
appro:i"atel% <8==== .ilipinos ten& to ha$e an a-ti$e TB! Philippines/
to+ether )ith other -o,ntries in the Western Pa-i2- s,-h as China/
Ca"#o&ia/ an& ?ietna"/ are a--o,nte& )ith 6@K o( the TB -ases #,t
&espite the hi+h TB in-i&en-e/ si+ni2-ant pro+ress has #een "a&e in
in-reasin+ -ase &ete-tion an& treat"ent in the -o,ntr%! The Worl&
Health Or+ani3ation 4WHO5 Jlo#al T,#er-,losis Report on the %ear
<=1< sho)e& the n,"#er o( .ilipinos aLi-te& )ith TB &e-rease& #% E<
per-ent an& TB -as,alties #% 76 per-ent! The el&erl%/ ,r#an poor/
s"o1ers an& those )ith -o"pro"ise& i"",ne s%ste"s are hi+hl% at
ris1 in t,#er-,losis! An appro:i"ate n,"#er o( 1=8== TB patients are
ha$in+ ",lti&r,+ resistant> t,#er-,losis/ lea&in+ to s,#stantial
so-ioe-ono"i- loss to o,r -o,ntr%!
S-haa( et al!/ 4<==6/ pp! @>75 a0r"e& that Mycobacterium
tuberculosis/ #ein+ the -a,sati$e a+ent o( t,#er-,losis/ )as &is-o$ere&
#% a (a"o,s "i-ro#iolo+ist Dr! Ro#ert Fo-h on the <7
th
o( Mar-h 1AA<!
Thro,+h his +er" theor%/ this has #een a help(,l -ontri#,tion in the
&e$elop"ent o( TB -ontrol "eas,res! S-haa( et al!/ 4<==6/ pre(a-e/
para! 15 also state that no)a&a%s E=== people are 1ille& #% the
&isease/ one o( )hi-h is 1ille& e$er% <= se-on&s! In << -o,ntries/
"ostl% ,n&er>reso,r-e& "ore than A=K o( TB -ases arise! One thir& o(
the )orl&Ds pop,lation is in(e-te& )ith Mycobacterium tuberculosis/
an& E>1=K o( in(e-te& people are li1el% to &e$elop a-ti$e TB!
S"elt3er/ et!al 4<==A/ p!87@5 state& that reporte& -ases o( TB in
the Unite& States (ro" the %ear 16E@>16AE ha$e &e-line& at an
a$era+e o( 8K ea-h %ear thro,+h the &e$elop"ent o( anti>TB &r,+s in
16E<! TB has #een pre&i-te& to #e eli"inate& in the Unite& States #%
the <1
st
-ent,r%! Instea&/ the n,"#er o( s,-h -ases ha$e ele$ate& ,pon
the re$ersal o( the tren& at 16AE &,e to (a-tors li1e in-rease&
i""i+ration/ the H,"an i"",no&e2-ien-% $ir,s 4HI?5 epi&e"i-/ the
i""er+en-e o( ",lti&r,+>resistant strains o( TB!
A--or&in+ to the Worl& Health Or+ani3ationDs 2n&in+s in <==6 4as
-ite& #% Fris1a/ <=11/ p! B15/ @7K o( the +lo#al -ases o( t,#er-,losis
happene& in So,theast Asia 4SEA5! Ho)e$er/ S,#>Saharan A(ri-an TB
-ases are al"ost &o,#le& that o( So,theast Asia an& @E= o( )hi-h
o--,r in 1===== people ea-h %ear!
Ro&a 4<=17/ p!A5 a0r"e& that ",lti&r,+>resistant t,#er-,losis
#e-o"es a "aCor -hallen+e in the treat"ent o( the &isease &,e to poor
-o"plian-e an& a&heren-e )ith the phar"a-otherap%/ sho)in+ that
patients (ail to ta1e their pres-ri#e& "e&i-ation e$er% &a% at the +i$en
appropriate s-he&,les )ithin si: "onths! In this instan-e/ the t,#er-le
#a-illi #e-o"es resistant to the "ost po)er(,l anti>TB &r,+s Isonia3i&
an& Ri(a"pi-in an& &i0-,lties in the treat"ent perio& +i$es "ore
-han-es o( spen&in+ "ore "one% (or the "e&i-ations! In-i&en-es o(
"issin+ TB -ases ha$e al)a%s #een another -hallen+e in the TB
-ontrol sin-e appro:i"atel% 8E== -ases re"ain ,n&ete-te& an&
,ntreate&! Ea-h %ear/ trans"ission o--,rs to 1= other .ilipinos!
The National T,#er-,losis Pro+ra" 4NTP5/ in -ooperation )ith
so"e sta1ehol&ers/ has esta#lishe& an& s,staine& its tar+ets on
&ete-tin+ -ases earl% an& to s,#se9,entl% treat the" #% <==B!
Thro,+h the NTP/ iss,es on &r,+ resistan-e an& -o>"or#i&ities are
a&&resse& to pre$ent trans"ission an& the in-rease o( patients in the
(,t,re! Part o( the National T,#er-,losis pro+ra" is the Dire-tl%
O#ser$e& Treat"ent Short Co,rse 4DOTS5 )hi-h is the "ain
inter$ention (or TB -ontrol! It is a stan&ar&i3e& -o,rse o( -o"#ine&
therap% )ith the ,se o( &r,+s )hi-h -o$ers the "ar+inali3e&
pop,lations an& $,lnera#le people! 4Depart"ent o( Health/ <=11/ para!
<5
Dr,+s an& "e&i-ines ha$e alrea&% #e-o"e an essential part o( a
s,--essi$e treat"ent o( a -ertain &isease (ro" the $er% #e+innin+!
A"eri-an So-iet% o( Health>S%ste" Phar"a-ist 4ASHP5/ 4<==B><==A/ p!
A<5 -ite& that the .e&eral .oo&/ Dr,+/ an& Cos"eti- A-t &e2ne& the
)or& &r,+ as s,#stan-es that eli-it either a therape,ti- or a to:i-
e'e-t to h,"ans an& ani"als an& are ,se& in the &ia+nosis/ -,re/
"iti+ation/ treat"ent/ or pre$ention o( &isease o( "an or other
ani"als! As (or the Dire-tl% O#ser$e& Treat"ent Short Co,rse o( DOHDs
National T,#er-,losis Pro+ra"/ A33opar&i 4<=1=/ p! <115 &es-ri#e& that
anti>t,#er-,lar &r,+s are &r,+s a&"inistere& to in(e-te& patients/
)hi-h treat &iseases -a,se& #% M%-o#a-teri," spe-ies s,-h as TB!
Isonia3i&/ Etha"#,tol/ Ri(a"pi-in/ an& P%ra3ina"i&e are e:a"ples o(
these &r,+s! Treat"ent o( TB sho,l& #e &one )ithin a spe-iali3e& tea"
&,e to the o--,rren-e o( resistan-e an& the in$ol$e"ent o( other
or+ans o,tsi&e the respirator% s%ste"!
In the Dire-tl% O#ser$e& Treat"ent Short Co,rse/ #% the ti"e
that the patient e:perien-es the pri"ar% hall"ar1 o( p,l"onar%
t,#er-,losis s,-h as re-,rrent -o,+h (or t)o )ee1s/ )ei+ht loss/ (e$er/
ni+ht s)eats/ an& e:pe-toration o( #loo&! On-e three o( the state&
s%"pto"s are present/ the patient is re(erre& to the Cit% Health O0-e
(or a (ree la#orator% e:a"ination o( sp,t," (or t)o &a%s! On-e the
res,lt is positi$e/ the patient )ill #e re+istere& in the TB>DOTS pro+ra"
in the Cit% Health O0-e! A(ter)ar&s/ the% )ill #e en&orse& in their
respe-ti$e #aran+a% health -enter #rin+in+ their sp,t," la#orator%
res,lts! A+ain/ the% )ill #e re+istere& in the health -enterDs TB Re+istr%
Re-or& Boo1 an& )ill #e +i$en a NTP treat"ent -ar& an& i&enti2-ation
-ar&! A(ter)ar&s/ the patient )ill #e oriente& a#o,t the pro+ra" an& its
re+i"en!
TB>DOTS in$ol$es t)o treat"ent -ate+ories I an& II )hi-h -o$er
intensi$e an& "aintenan-e phase! In Cate+or% I/ patients )ho -o"pl%
(aith(,ll% )ith the )hole re+i"en )ill #e +i$en "e&i-ation (or si:
"onths! The intensi$e phase in-l,&es one to t)o "onths o( e$er%&a%
treat"ent o( Ri(a"pi-in/ Isonia3i&/ P%ra3ina"i&e/ an& Etha"#,tol* an&
the "aintenan-e phase in-l,&e a treat"ent re+i"en (or (o,r "onths o(
Ri(a"pi-in an& Isonia3i&! I( the patients (ail to -o"pl% )ith the
Cate+or% I re+i"en/ Cate+or% II re+i"en )ill #e +i$en instea&! In
Cate+or% II/ the "e&i-ation re+i"en )ill #e +i$en (or ei+ht "onths! The
intensi$e phase in-l,&es one to three "onths o( &ail% treat"ent o(
Strepto"%-in inCe-ta#les* an& the "aintenan-e phase in-l,&es a
treat"ent re+i"en (or 2$e "onths o( Ri(a"pi-in/ Isonia3i&/ an&
Etha"#,tol! Un&er -ertain -ir-,"stan-es li1e $a-ations/ patients )ill
noti(% an& in(or" the health )or1ers ahea& o( ti"e so that the% -an
prepare "e&i-ations!
The s,--ess o( the TB>DOTS pro+ra"/ as e:plaine& #% the
Depart"ent o( Health 4<==@/ p!1=5/ is +o$erne& #% 2$e prin-iples
in-l,&in+ the -o""it"ent in ens,rin+ a "aintaine& an&
-o"prehensi$e a-ti$ities in TB -ontrol/ earl% -ase &ete-tion a"on+
sel(>reportin+ patients sho)in+ s%"pto"s o( TB #% sp,t,"> s"ear
"i-ros-op%/ stan&ar&i3e& &r,+ -he"otherap% (or si: to ei+ht "onths
&,ration/ a a&e9,ate an& ,ninterr,pte& s,ppl% o( all essential an&
ne-essar% anti>TB "e&i-ations an& s,pple"entar% tools/ an& lastl%/ an
,p&ate& an& stan&ar& re-or&in+ an& reportin+ s%ste" )hi-h ser$es as
a tool in patient -ase assess"ent on its 2n&in+s an& treat"ent res,lts/
an& as an e$al,ation o( the o$erall TB -ontrol pro+ra"!
A--or&in+ to one st,&% that ,tili3e& a sel(>a&"inistere&
treat"ent/ @6K o( the patients )ere lost (ro" the st,&% )ith a 8>
"onth anti>t,#er-,lar &r,+ therap% an& 76K )ith a nine> "onth
treat"ent re+i"en! In -ontrar%/ another st,&% states that those
patients that are ,n&er the 8>"onth re+i"en o( DOTS* (e)er than 1=K
o( the patients )ere lost to (,rther treat"ent! 4Tro% et al!/ <==8/ p!
16B85
.or instan-es* e$er% &r,+ therap%/ "a% it #e short> ter" or lon+>
ter"/ has its o)n ,lti"ate en&/ )hi-h is -o"plian-e! As &e2ne& #% the
Worl& Health Or+ani3ation 4WHO5/ -o"plian-e or a&heren-e is the
&is-ipline in )hi-h a personDs #eha$ior to)ar&s see1in+ health "atters
-orrespon&s to the pres-ri#erDs re-o""en&ations an& s,++estions! In
this "atter/ it is si"ilar to the patientDs a+ree"ent an& a-ti$e
parti-ipation! 4as -ite& #% Sellers et al!/ <=11/ p! 685 Ro$ers et al!/
4<==@/ p! 1A75 9,ote& that #asi-all%/ &r,+s an& "e&i-ations &o not
)or1 in patients )ho &o not ta1e the"! This has #een a -o""on
pro#le" to patients )ith non>-o"plian-e iss,es! Co"plian-e is
&e2nitel% a patientDs &e-ision an& other people -annot &i-tate )hat a
person ",st &o!
WHO 4<==@/ pp! 1<@/ 1<E>1<B5 state& that in ter"s o(
t,#er-,losis -ontrol/ a&heren-e to treat"ent "a% #e &e2ne& as the
e:tent to )hi-h the patientDs histor% o( therape,ti- &r,+ inta1e
-oin-i&es )ith the pres-ri#e& treat"ent! D,rin+ the 16E=s/ Walla-e .o:
&e$elope& the Dire-tl% O#ser$e& Treat"ent Short Co,rse in )hi-h
"e&i-ations (or TB patients are to #e a&"inistere& )ith the assistan-e
o( a health pro(essional! Sin-e DOT has -ontri#,te& to #etter
-o"plian-e o( patients/ it has #een a&opte& in In&ia an& Hon+>Fon+ in
the earl% 168=s respe-ti$el%!
Le$els o( -o"plian-e in-l,&eG Hi+h Co"plian-e/ a sit,ation )here
a patient (aith(,ll% -o"plies )ith the "e&i-ation re+i"en +i$en #%
,p&ate& re-or&in+ o( treat"ent/ o#e%in+ the assi+ne& s-he&,les in
re+,lar ter"s/ an& #% (oreseein+ the nee& to a"eliorate li(est%le/
health/ an& -han+e #a& ha#its to +oo& ones 4Ste-1el 8B5! Ne:t le$el is
the Mo&erate Co"plian-e* as -ite& #% Ste-1el 48A5/ is pro#a#l% the
sa"e as Hi+h Co"plian-e! B,t )hat "a1es it &istin-t is that the person
in$ol$e& has ta1en (or +rante& the therapies an& "e&i-ation +i$en #%
the health pra-titioners! He or she "a% -o"pl% )ith the "e&i-ations
(or the 2rst (e) &a%s #,t e$ent,all% stops it &,e to the int,ition o(
so"eone that it is not ne-essar% an%"ore/ a person is not intereste& to
ta1e the "e&i-ation thin1in+ that he or she has alrea&% #een treate&!
Lastl%/ Lo) Co"plian-e on-e a+ain e"phasi3e& #% Ste-1el 4865* are
those patients that &o not entirel% (ollo) an& a&here the +i$en s,ita#le
"o&es o( treat"ent an& -lini- s-he&,les o( treat"ent/ "iss &oses o(
+i$en "e&i-ations/ &o not ha$e the initiati$e to alter the a-ti$ities that
-an )orsen the illness an&/ &o not ha$e the )illin+ness to a"eliorate
health an& li(est%le!
S,pportin+ St,&ies
A 9,alitati$e resear-h #% M,nro et al!/ 4<==B/ ta#! 1>A5
ela#orate& a#o,t the (a-tors a'e-tin+ -o"plian-e o( a patient to a
"e&i-ation )hi-h are &i$i&e& into ei+ht -ate+oriesG Or+ani3ation o(
Treat"ent an& Care (or TB Patients/ Interpretations o( Illness an&
Wellness/ Fno)le&+e/ Attit,&es/ an& Belie(s a#o,t TB Treat"ent/
.inan-ial B,r&en o( TB Treat"ent/ La) an& I""i+ration/ Personal
Chara-teristi-s an& A&heren-e Beha$ior/ The InH,en-e o( Si&e E'e-ts
on Treat"ent A&heren-e/ an& .a"il%/ Co"",nit%/ an& Ho,sehol&
InH,en-es as res,lts! This sho)s that patients o(ten ta1e their TB
"e&i-ation ,n&er to,+h -ir-,"stan-es an& e:perien-e si+ni2-ant
&i0-,lties/ "an% o( )hi-h are o,tsi&e o( their &ire-t -ontrol! Ta1in+ a
len+th% "e&i-ation re+i"en is not -on$enient an& o(tenti"es in$ol$es
&i0-,lt C,&+"ent/ so"eti"es at si+ni2-ant personal an& so-ial -ost to
the patient! A&heren-e is a -o"ple:/ $ital pheno"enon* a #roa& ran+e
o( intera-tin+ (a-tors inH,en-e on treat"ent>ta1in+ a-tion/ an& patient
#eha$ior "a% "o&i(% &,rin+ the treat"ent pro+ra"! More patient>
-entere& inter$entions an& a (ar +reater o#ser$ation to str,-t,ral
#arriers/ are ne-essar% to enhan-e treat"ent a&heren-e an& &e-rease
the )orl&)i&e &isease! A--or&in+ to an arti-le #% Faona et al!/ 4<==7/
para! E5/ altho,+h t,#er-,losis treat"ent +,i&elines ha& #een
&isse"inate& (or the +o$ernan-e o( the &isease at health% (a-ilit% &o)n
to ho,sehol& le$els/ DOTS )as the onl% #est )a% o( #,il&in+ ,p
-o"plian-e a"on+ TB &r,+>ta1in+ patients in Ma"#ia! DOTS entails
that "e&i-ation is ta1en #% the patient )hile the health -are pro$i&er
is o#ser$in+! Dia+nosin+ t,#er-,losis patients at a health (a-ilit% an&
sen&in+ the" to -ontin,e ta1in+ their "e&i-ation at ho"e/ presents a
serio,s -hallen+e (or other "e"#ers o( the ho,sehol& )ho helps the
patient )ith the treat"ent!
Resear-he& #% M,nro et al!/ 4<==B5/ poor a&heren-e to the
treat"ent is -o""on re+ar&less o( $ario,s inter$entions &ire-te& at
i"pro$in+ treat"ent -o"pletion! The res,lts sho) that la-1 o( a
thoro,+h an& holisti- ,n&erstan&in+ o( the #arrier to an& (a-ilitators o(/
treat"ent a&heren-e is -,rrentl% a s,#stantial hin&ran-e to 2n&in+
e'e-ti$e sol,tions!
La-1 o( 1no)le&+e "a1es TB a serio,s p,#li- health pro#le"/
)hi-h nee&e& an ,r+ent attention! Po$ert% an& ina&e9,ate 1no)le&+e
a#o,t t,#er-,losis o( the people in N&ola/ Ma"#ia re"ains to #e one o(
the (a-tors that -o,l& in-rease the TB rate in the area! O$er B=K o( the
TB patients state& the (ollo)in+ s%"pto"sG s)eatin+ at ni+ht/ )ei+ht
loss/ loss o( appetite an& prolon+e& -o,+hin+/ )hi-h )as o(tenti"es
a--o"panie& #% #loo& in the sp,t,"! Fno)le&+e a#o,t the s%"pto"s
o( the &isease &i& not &i'er a--or&in+ to the &e+ree o( e&,-ation or
a+e! Fno)le&+e on "o&es o( trans"ission an& the s%ste" o(
pre$ention nee&s re$isitin+/ as -o"",nit% "e"#ers see"e& to ha$e
ha& 1no)le&+e that &i& not relate the &isease to the en$iron"ent! The
la-1 o( 1no)le&+e in pre-a,tionar% "eas,res in this +ro,p -o,l& #e
e:plaine& thro,+h or st,&% sa"ple itsel(! Altho,+h these a+e +ro,ps
)ere o( patients )ho -o,l& ha$e a-9,ire& the in(or"ation (ro" the
-lini- &,rin+ the ti"e the% )ere +atherin+ the &r,+s an& their (oo&
s,pplies/ )hi-h )ere o(tenti"es pro$i&e& to patients/ pre$ention &i&
not see" to ha$e #een stresse&>o,t #% the health -are pro$i&ers!
MaCorit% o( the patients )ent to spe-iali3e& health (a-ilit% on-e the%
)ere si-1! 4Faona et al!/ <==7/ para! @<5
.,n&a"ental in(or"ation )ith respe-t to &isease interr,ption/
trans"ission an& -o"plian-e to "e&i-ation re+i"en s,-h as the
&es-ription o( TB/ its -a,ses/ "o&es o( trans"ission/ "eas,res in
&e-reasin+ its trans"ission/ treat"ent to+ether )ith its i"portan-e/
&,ration/ possi#le -onse9,en-es to (a-e )hen the "e&i-ation is
&is-ontin,e&/ si&e e'e-ts an& its -o"pli-ations* has #een an i"portant
an& ,se(,l "eas,re that TB patients sho,l& #e 1no)le&+ea#le o(!
Sa"ar+an&i/ et al!/ 4<=1</ para!@/ p! <6>@=5/ state& in a st,&%
a#o,t Fno)le&+e o( P,l"onar% T,#er-,losis in the Sa,&i Co"",nit% o(
Ie&&ah that the 1no)le&+e a#o,t TB #e-o"es a (a-tor in ele$atin+ the
&e+ree o( -o"plian-e to treat"ent a"on+ TB patients an& an in-rease
in -,re rate! Le$el o( 1no)le&+e )ere &i$i&e& into lo) 4s-ore ran+in+
(ro" =>75/ inter"e&iate 4E>A5/ an& hi+h 4s-ore o( 6>115!
A--or&in+ to resear-hes 4as -ite& #% Moha"e& et al!/ <==B/
para!@/ p! <15/ ina&e9,ate 1no)le&+e an& ,n&erstan&in+ a#o,t a
-ertain illness an& its treat"ent -o,l& res,lt to non-o"plian-e to
treat"ent re+i"en! On the -ontrar%/ +reater 1no)le&+e in-reases
a--eptan-e to the -ontrol "eas,res )ith the res,ltant &e-rease in the
sprea& o( TB!
N&e1i 4<==8/ para! 7/ p! <5 state& in his resear-h so"e o( the
st,&% o,t-o"es are that "ales 4E<!7K5 )ere a'e-te& "ore than
(e"ales 47B!8K5/ )ith a "ale to (e"ale ratio o( 1G8G1!7 )hi-h +rossl%
$arie& )ith the Worl& Health Or+ani3ation 4WHO5 "ale to (e"ale ratio
o( 7G1* a+e +ro,p o( <E>@7 %ears ol& ha& the hi+hest (re9,en-% o(
respon&ents! The le$el o( 1no)le&+e o( pop,lation st,&% )as as lo) as
@A!7K ha& no (or"al e&,-ation! Jenerall%/ there )as rational
1no)le&+e on TB as 8=K o( the respon&ents are a)are that the
&isease is trans"itte& thro,+h air 4&roplet inhalation5 )hile B8!7K
1ne) it )as pre$enta#le! The respon&ents ha& so"e &isa+reea#le
attit,&e a#o,t TB as EAK isolate TB patients/ )hile 1@!@ K asso-iate&
TB )ith a -,rse an& E!8K )ith )it-h-ra(t!
Another resear-h st,&% -on&,-te& #% Nepal et al!/ 4<=1</ para!
@>75 sho)s res,lts )herein TB patients o( %o,n+er a+e +ro,ps )ere
(o,n& to #e "ore -o"pliant to the treat"ent 4pN=!=<5! Si&e e'e-t o(
the &r,+s )as the "aCor reason (or the non-o"plian-e 4@8!==5! More
than hal( o( the TB patients ha& ins,0-ient 1no)le&+e on TB an& its
treat"ent! Co"plian-e )as (o,n& to #e si+ni2-antl% asso-iate& )ith
1no)le&+e 4pN=!=<5 an& insi+ht 4pN=!=<5 o( the patient to)ar&s TB!
Si"ilarl%/ the st,&% sho)e& positi$e asso-iation #et)een the
-o"plian-e an& ser$i-e a--essi#ilit% 4&istan-eG pN=!==5/ a$aila#ilit% o(
treat"ent s,per$isor 4pN=!=15 an& health e&,-ation 4pN=!=<5!
PatientsD 1no)le&+e an& ,n&erstan&in+ re+ar&in+ TB an& its treat"ent
)as (o,n& to #e asso-iate& )ith their in-rease in -o"plian-e in the
treat"ent re+i"en! Health e&,-ation an& proper -o,nselin+ )as
-onsi&ere& to #e ne-essar% (or the patients! One o( the (a-tors that -an
in-rease patient -o"plian-e rate is the ser$i-e a--essi#ilit% alon+ )ith
-o"",ni-ation s1ills trainin+ to the pro$i&er in-l,&in+ -o"",nit%
health $ol,nteers!
Resear-h st,&ies -on&,-te& in Nepal re+ar&in+ TB>DOTS 4as
-ite& #% Bhatt et al!/ <=1=/ para! 75 sho)e& that "aCorit% o( the
patients are a)are that TB is a -,ra#le &isease #% (ollo)in+ the
treat"ent re+i"en "etho& re+,larl% an& reli+io,sl%! This )ill
ps%-holo+i-all% en-o,ra+e the" to a#i&e #% their treat"ent
instr,-tions! PatientsD 1no)le&+e a#o,t -onse9,en-es o( in-o"plete
treat"ent is (o,n& to #e poor/ th,s it i"plies that "ore e"phasis
sho,l& #e +i$en on the patient>tea-hin+ a#o,t -onse9,en-es o(
in-o"plete treat"ent! In-o"plete treat"ent o( TB is )orse than no
treat"ent at all #,t )hen people (ail to -o"plete stan&ar& treat"ent
re+i"ens/ the% "a% re"ain in(e-tio,s! The #a-illi in their l,n+s &e$elop
resistan-e to anti>TB &r,+s! People )ho in(e-t )ill ha$e the sa"e &r,+
resistant strain! While &r,+ resistant TB is treata#le/ it re9,ires
e:tensi$e -he"otherap% ,p to t)o %ears/ it is -ostl% an& "ore to:i- to
the patient!
In this ,n&er+ra&,ate resear-h/ it ,tili3es a t%pe a sa"plin+
"etho& -alle& as ,ni$ersal sa"plin+! Uni$ersal sa"plin+/ as -ite& #%
Ri-har& an& Mar+aret 4166=/ 1<E5/ points o,t to the -hoosin+ o(
sa"ples )herein not all the people in the pop,lation ha$e the sa"e
a&$anta+e an& s,ita#ilit% o( #ein+ -ontaine& in the sa"ple an& ea-h
one o( the"/ the o&&s o( #ein+ sele-te& is ,n&eter"ine&! It is the
-hosen sa"plin+ &esi+n sin-e this resear-h has in-l,sion -riteria
a"on+ the respon&ents in$ol$e& an& the% are 9,ali2e& to pro$i&e
,se(,l in(or"ation in or&er to &eter"ine the relationship #et)een
1no)le&+e an& patientsD -o"plian-e! It is also the "ost appropriate
sa"plin+ "etho& to ,se as to this st,&% #e-a,se the resear-hers
-annot -ontrol the e"er+en-e o( "ore TB -ases an& also to its risin+
pop,lation! Base& (ro" the st,&% o( Ninan 4<==1/ -hap! </ part <!E/
para @/ p!185/ "ost o( the &issertations relatin+ to -o"plian-e an&
non-o"plian-e state that the possi#ilit% to i&enti(% an& -o"pare the
pop,la-e o( an esta#lish"ent to t,#er-,losis> in(e-te& patients "a%
o--,r! Be that as it "a%/ this -an #e teste&/ parti-,larl% )ith
non-o"plian-e st,&ies! B,il&ers an& A+,)a 4<=1</ p! 87<5 also
a&opte& the ,ni$ersal sa"plin+ "etho& (or the st,&% nee&s a
pop,lation that )ill li1el% C,sti(% their proposition!
Con-ept,al .ra"e)or1
INDEPENDENT ?ARIABLE DEPENDENT ?ARIABLE
OUTPUT
Fno)le&+e o(
Patients a#o,t
T,#er-,losis>
Disease/ Ca,se/
Clini-al
Mani(estations/
Treat"ent/ an&
DOTS Pro+ra"
Deter"ination on
the .a-tors that
A'e-t PatientsD
Co"plian-e on the
TB>DOTS Pro+ra"
in relation to
Fno)le&+e
PatientsD
Co"plian-e on the
Me&i-ation
Re+i"en on the TB>
DOTS Pro+ra"
A+e
Jen&er
So-ioe-ono"i- stat,s
E&,-ational
#a-1+ro,n&
INTER?ENINJ ?ARIABLES
The -on-ept,al (ra"e)or1 o( this resear-h st,&% is -o"pose& o(
the in&epen&ent $aria#le* 1no)le&+e o( patients a#o,t T,#er-,losis>
&isease/ -a,se/ -lini-al "ani(estations/ treat"ent/ an& DOTS Pro+ra"!
The &epen&ent $aria#le &eter"ine& in this resear-h st,&% is patientsD
-o"plian-e on the "e&i-ation re+i"en on the TB>DOTS Pro+ra"!
Lastl%/ the possi#le o,tp,t (or the st,&% in-l,&es the &eter"ination on
the (a-tors that a'e-t patientsD -o"plian-e on the TB>DOTS Pro+ra" in
relation to 1no)le&+e!
This st,&% &oes not onl% (o-,s on the in&epen&ent an&
&epen&ent $aria#les na"el% 1no)le&+e an& patientsD -o"plian-e
respe-ti$el%! There are also other $aria#les that "a% pro$i&e a
relationship )ith #oth the in&epen&ent an& &epen&ent $aria#les )hi-h
are -alle& the inter$enin+ $aria#les! Inter$enin+ $aria#les or the
"o&i2ers ,se& in the st,&% are a+e/ +en&er/ so-ioe-ono"i- stat,s/ an&
e&,-ational #a-1+ro,n&!
THE PROBLEM
State"ent o( the Pro#le"
The ,n&er+ra&,ate st,&% +enerall% ai"s to &eter"ine the
relationship #et)een the 1no)le&+e an& patientsD -o"plian-e to)ar&s
the TB>DOTS pro+ra" in Basa1 health -enter/ Lap,>Lap, Cit%/ Ce#,!
Spe-i2-all%/ the resear-hers ai" to &eter"ine the (ollo)in+G
1! What is the &es-ription o( the respon&ents in ter"s o( theirG
1!a! a+e
1!#! +en&er
1!-! so-io>e-ono"i- stat,s
1!&! e&,-ational #a-1+ro,n&
<! What is the respon&entsD le$el o( 1no)le&+e a#o,t the &isease
t,#er-,losisO
@! What is the respon&entDs le$el o( -o"plian-eO
7! Is there a si+ni2-ant relationship #et)een 1no)le&+e o( the
&isease an& patientsD -o"plian-eO
E! Is there a si+ni2-ant relationship #et)een 1no)le&+e o( the
&isease to
respon&entsD a+e/ +en&er/ so-ioe-ono"i- stat,s/ an&
e&,-ational
#a-1+ro,n&O
8! Is there a si+ni2-ant relationship #et)een patientsD
-o"plian-e to their
a+e/ +en&er/ so-ioe-ono"i- stat,s/ an& e&,-ational
#a-1+ro,n&O
Si+ni2-an-e o( the St,&%
This resear-h st,&% is -ra(te& to #e #ene2-ial an& o( para"o,nt
i"portan-e to the (ollo)in+G
Resear-h Respon&ents! The% )ill #e a#le to +ain "ore 1no)le&+e
a#o,t T,#er-,losis an& the% )ill #e "ore "oti$ate& to -o"pl% )ith the
"e&i-ation re+i"en o'ere& #% the TB>DOTS pro+ra" to "aintain their
+oo& health!
DOTS O0-e o( Cit% Health! The% )ill #e "ore &e&i-ate& to o'er their
ser$i-es to the TB patients ,n&er the TB>DOTS pro+ra" an& the% )ill
#e a#le to share "ore 1no)le&+e an& -o,l& +,i&e the" in an% )a%!
Health pro(essionals an& pra-titioners! The% )ill #e also a)are o( the
possi#le iss,es that )o,l& o--,r alon+ the -o,rse o( the TB>DOTS
pro+ra" an& the% )o,l& #e also a#le to assist those that are in the
health -enters!
Me&i-al an& Para"e&i-al St,&ents! The% )ill #e a#le to +ain "ore
1no)le&+e o( T,#er-,losis an& the TB>DOTS pro+ra" an& the% )ill
#e-o"e a)are o( the sit,ation o( o,r -o,ntr% in ter"s o( p,#li- health!
Phar"a-% St,&ents! .or the% )ill #e a#le to ,se their #a-1+ro,n&
1no)le&+e o( the sai& &isease an& its "e&i-ations to ser$e those
patients in the near (,t,re an& the% )ill #e inspire& to e:plore on other
spe-ial 2el&s in phar"a-% not C,st in -o"",nit% &r,+stores/ hospitals/
an& "an,(a-t,rin+ 2r"s!
.,t,re resear-hers! The% )ill #e a#le to +et an i&ea on )hat to
resear-h i( their -hosen topi-s )o,l& still #e in line )ith p,#li- health
-o""on &iseases!
S-ope an& Li"itations o( the St,&%
The s-ope o( this st,&% )ill (o-,s on the (a-tors a'e-tin+
patientDs -o"plian-e on the TB>DOTS pro+ra" in the health -enter o(
Baran+a% Basa1/ Lap,>Lap, Cit%/ Ce#,! The st,&% -o$ers 1no)le&+e
an& patientDs -o"plian-e to)ar&s TB>DOTS! All in(or"ation )as ta1en
(ro" the patient/ patientDs "e&i-al re-or& in the health -enter/ #oo1s/
an& (ro" relia#le so,r-es! The st,&% )ill #e -on&,-te& (ro" De-e"#er
<=17 > Mar-h <=1E!
Honest% is the pri"ar% )ea1ness o( this st,&%! O(ten
respon&ents are #ias to )hat the% per-ei$e the resear-hers )ante& to
hear! Respon&ents "a% also #e apprehensi$e to ans)er 9,estions the%
&ee" to #e personal! .,rther"ore/ the i&ea that so"eone is )at-hin+
-an t,rn an o#ser$ation into an e$ent )here respon&ents are a-tin+
ho) the% per-ei$e the% sho,l& a-t!
RESEARCH METHODOLOJP
Resear-h Desi+n
This resear-h st,&% )ill ,tili3e the &es-ripti$e -orrelational
resear-h &esi+n a#o,t 1no)le&+e an& patientsD -o"plian-e!
Resear-h En$iron"ent
The st,&% )ill #e -on&,-te& at the health -enter o( Br+%! Basa1/
Lap,>Lap, Cit%/ Ce#,! It is sit,ate& in Ta"i%a #esi&e Iolli#ee (ast (oo&
-hain! A &o-tor/ n,rse/ "i&)i(e/ an& #aran+a% health )or1ers
s,per$ise an& assist the TB patients ,n&er the pro+ra"! Cons,ltations
are &one e$er% &a% (ro" Mon&a%s to .ri&a%s e$er% a(ternoon #e-a,se
TB patients are to #e isolate& (ro" other patients )ho -o"e to the
health -enter! Cons,ltation in the health -enter is &one #% +ettin+ their
$ital si+ns 4te"perat,re/ #loo& press,re an& )ei+ht5 an& re(erre& to
the &o-tor!
Resear-h Respon&ents
The resear-hers )ill ,tili3e all o( the <== t,#er-,losis patients
re+istere& in the health -enterDs TB Re+istr% Re-or& Boo1/ an& th,s
esta#lishe& the e:a-t n,"#er 4sa"plin+ (ra"e5! The respon&ents that
)ill 9,ali(% the in-l,sion -riteria )ill #e the s,#Ce-t (or the st,&% an&
these in-l,&esG a&,lts an& -hil&ren/ the patients &ia+nose& )ith
p,l"onar% t,#er-,losis an& sho)in+ positi$e res,lt o( T,#er-le #a-illi
on &ire-t s"ear an& -,lt,re ta1en (ro" patientDs "e&i-al re-or&!
P,l"onar% t,#er-,losis patients ,n&er treat"ent )ith ne+ati$e
M%-o#a-teri," t,#er-,losis s"ear are e:-l,&e& (ro" the st,&%!
Resear-h Instr,"ent
The resear-hers "a&e the 9,estionnaires! The ite"s are #ase&
on the in(or"ation +athere& (ro" the re$ie) o( relate& literat,re! There
)ere a#o,t 7E ite"s )hi-h are translate& to ?isa%an &iale-t (or
respon&entDs -on$enien-e! It )ill onl% -ons,"e @= "in,tes to (,ll%
ans)er the 9,estionnaire!
The 9,estionnaires ha$e three se+"ents that in-l,&e patientDs
in(or"ation )hi-h -ontains E 9,estions that i&enti(% the &e"o+raphi-
-hara-teristi-s o( the respon&ent! Another 9,estionnaire (or patientDs
1no)le&+e -o"prises o( 1E 9,estions )hi-h ,tili3es tr,e or (alse s-ale
(or s-orin+! .or patientDs -o"plian-e -o"prises <E 9,estions )hi-h
,tili3es a E>pointer Li1ert s-ale )hi-h &eter"ines the respon&entsD
1no)le&+e an& -o"plian-e on the TB>DOTS pro+ra"! The s-ales are as
(ollo)sG
JRAD
E
TITLE DESCRIPTION
1 Stron+l%
Disa+ree
The respon&ent is stron+l% not in (a$or o(
the state"ent
< Disa+ree The respon&ent is not in (a$or o( the
state"ent #,t )ith a little a+ree"ent
@ Neither a+ree
nor &isa+ree
The respon&ent "a% in (a$or nor not in
(a$or )ith the state"ent
7 A+ree The respon&ent (a$ors the state"ent #,t
)ith little &o,#t
E Stron+l% A+ree The respon&ents stron+l% (a$ors the
state"ent
Resear-h Pro-e&,re
Preli"inar% Preparation
A trans"ittal letter )as s,#"itte& to Dr! Iennil%n C!
Cor$era/ Dean o( the Colle+e o( Phar"a-% (or the proposal an&
appro$al o( the resear-h st,&%! Therea(ter/ a trans"ittal letter
)as also +i$en to Br+%! Captain Hon! Isa#elito L! Darna%la (or the
per"ission to -on&,-t the st,&% )ithin the $i-init%! A(ter)ar&s/ a
letter o( re9,est )as +i$en to Dr! Ro&ol(o C! Bera"e/ M!P!H / Cit%
Health O0-er o( Lap,>Lap, Cit%/ Ce#,/ (or the per"ission to
-on&,-t the st,&% in a -ertain #aran+a%!
?ali&ation o( Resear-h Instr,"ent
As (or the $ali&it% o( the resear-h instr,"ent that the
resear-hers "a&e / the resear-hers )ill 2rst e$al,ate the -ontent
o( the 9,estionnaire! A(ter the resear-hers ha$e e$al,ate& the
9,estionnaire/ the% )ill -on&,-t a pre>test (or the $ali&it% an&
relia#ilit% o( the 9,estionnaire on the <
n&
)ee1 o( No$e"#er
<=17! The resear-hers )ill ,tili3e E= respon&ents o( Br+%! P,so1/
Lap,>Lap, Cit%/ Ce#, )ith in-l,sion -riteria si"ilar to o,r
propose& st,&%! A pre>test )ill #e &one #% lettin+ the
respon&ents ans)er the resear-her>"a&e 9,estionnaire! The
9,estionnaires )ill #e -olle-te& an& -he-1e& to "a1e s,re that
there are no 9,estions le(t ,nans)ere& to -orre-t +ra""ati-
errors an& to &eter"ine the &e+ree o( ease in rea&in+/
,n&erstan&in+/ ans)erin+/ an& a&"inisterin+ the sets o(
9,estionnaires!
A-t,al Data Jatherin+
The resear-hers )ill i&enti(% patients in the health -entersD
TB Re+istr% Re-or& Boo1/ )hi-h re-or&s the patientDs na"e/
re+istration n,"#er/ &ate o( startin+ an& -o"pletion o(
treat"ent/ &e"o+raphi- &etails/ a&&ress an& &ia+nosis! Then/
the resear-hers )ill -oor&inate )ith the #aran+a% health n,rse
Lea T! Pelae3 one "onth prior to &ata +atherin+ to in(or" the
patients ahea& o( ti"e! The resear-hers )ill e:e-,te the a-t,al
&ata +atherin+ on the 1E
th
to 16
th
o( De-e"#er <=17 )herein the
respon&ents )ill ans)er the 9,estionnaires at the health -enterDs
-on(eren-e area! Upon $isitation o( the patients in the health
-enter/ the resear-her )ill orient an& e:plain to the respon&ent
the p,rpose o( the st,&% an& )ill reass,re pri$a-% an&
-on2&entialit%! In(or"e& -onsents )ill #e +i$en ri+ht a(ter their
appro$al! When it )ill #e appro$e&/ respon&ents )ill #e +i$en
9,estionnaires )hi-h )ill #e translate& to ?isa%an &iale-t! The
respon&ents )ill #e +i$en @= "in,tes to ans)er ea-h 9,estion!
While the respon&ents ans)er the resear-h instr,"ent/ the
resear-hers )ill sta% )ithin the $i-init% to entertain 9,estions (or
an% -lari2-ations )hile the resear-h "entor an& the "e&i-al sta'
)at-h o$er the"! Soon therea(ter/ all ite"s )ill #e -olle-te& an&
-he-1e& to see i( there are n,"#ers le(t ,nans)ere&! The
resear-hers )ill -ollate an& tall% the &ata! Res,lts (ro" the
9,estionnaires )ill #e en-o&e& an& presente& in a ta#,late&
(or"! Lastl%/ the res,lts o( the &ata )ill #e anal%3e& an&
interprete&!
Statisti-al Treat"ent o( Data
Anal%sis o( the -o"plete& 9,estionnaire )ill #e -arrie& o,t
,sin+ per-enta+es an& (re9,en-% &istri#,tion!
Per-enta+e &istri#,tion )ill #e -o"p,te& thro,+h this (or",laG
100 % x
n
f
=
WhereG
( N the (re9,en-% o( the respon&entDs s-ore
n N the total n,"#er o( respon&ents
.or the 1no)le&+e an& le$el o( -o"plian-e/ the "ean )as ,se&G
n
x
x

=
_
WhereG

_
x
N the o$erall "ean

N the s," o(
: N ea-h respon&entDs "ean s-ore
n N the total n,"#er o( respon&ents
Then the stan&ar& &e$iation )as -o"p,te& #% the (or",laG
WhereG
sN stan&ar& &e$iation

N the s," o(
: N ea-h $al,e in the &ata set
_
x
N "ean o( all $al,es in the &ata set
n N the n,"#er o( respon&ents
The relationship #et)een the t)o $aria#les in this st,&%
41no)le&+e an& patientsD -o"plian-e5 )ill #e &eter"ine& #%
-o"p,tin+ the Pearson -orrelation -oe0-ient!
WhereG
:N res,lt o( the le$el o( 1no)le&+e a"on+ t,#er-,losis
patients
%N res,lt o( the le$el o( patientsD -o"plian-e a"on+
t,#er-,losis
patients
:%N s," o( the -ross pro&,-t o( : an& %
:N s," o( the ratin+s #elon+in+ to :
%N s," o( the ratin+s #elon+in+ to %
:
<
N s," o( the s9,are& ratin+s o( :
%
<
N s," o( the s9,are& ratin+s o( %
NN total n,"#er o( the respon&ents
In or&er to +enerali3e the -orrelation #et)een 1no)le&+e
an& patientsD -o"plian-e/ a t)o>taile& t>test )ill #e &one!
The resear-hers 2rst set the si+ni2-an-e le$el o( =!=E (or
the si+ni2-an-e -orrelation o( the t)o $aria#les! Then/ the
&e+ree o( (ree&o" 4&( N <5 )ill #e -al-,late& to &eter"ine its
-riti-al $al,e!
A(ter the -riti-al $al,e has #een &eter"ine&/ this )o,l&
"ean that the -orrelation is +reater or lesser than the $al,e!
Then the t>$al,e )ill #e -o"p,te& ,sin+ the (or",la!
WhereG
tN t>$al,e
rN Pearson -orrelation -oe0-ient
nN n,"#er o( respon&ents
n><N &e+ree o( (ree&o"
r
<
N s9,are o( Pearson -orrelation -oe0-ient
A(ter &eter"inin+ the t>$al,e/ the p>$al,e )ill #e
&eter"ine&! I( = 0 Q / it "eans that there is no si+ni2-ant
-orrelation #et)een 1no)le&+e an& patientsD -o"plian-e! On the
other han&/ there is a si+ni2-ant relationship #et)een 1no)le&+e
an& patientsD -o"plian-e i( 0 Q !
DE.INITION O. TERMS
In or&er to ha$e a (,ll ,n&erstan&in+ o( the ter"s ,se& in the
st,&%/ the (ollo)in+ are operationall% &e2ne&G
DOTS! Dire-tl% O#ser$e& Treat"ent Short Co,rse is the pro+ra"
opene& #% the Depart"ent o( Health )hi-h has +i$en a lot o(
assistan-e to the t,#er-,losis patients!
Fno)le&+e! It is one o( the "eas,res to #e &eter"ine& in the st,&% i(
the respon&ents are 1no)le&+ea#le o( their &isease 4t,#er-,losis5 or
not! It is the in&epen&ent $aria#le ta1en into -onsi&eration (or this
resear-h st,&%!
PatientDs Co"plian-e! It is the stat,s o( patient i( he or she reli+io,sl%
-o"pl% )ith the +i$en treat"ent re+i"en at a +i$en ti"e! It is the
&epen&ent $aria#le ta1en into -onsi&eration (or this resear-h st,&%!
T,#er-,losis! It is a -o""on in(e-tio,s &isease )hi-h ser$es as the
+ro,n& (or -on&,-tin+ this resear-h st,&%!
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Fa#era/ La"#ert 4<==65! Chapter @G Metho&olo+%! The ,se o(
a--o,ntin+ ratios
in &e-ision "a1in+! Memoir 6nline! R)an&aG National Uni$ersit%
o( R)an&a! Chap! @/ para @!E! Retrie$e& O-to#er 1</ <=17 (ro"
httpGSS)))!"e"oireonline!-o"S1<S=6S@=EAS"TThe>,se>o(>
a--o,ntin+> ratios>in> &e-ision>"a1in+8!ht"l!
Faona/ .re&eri-1 AD/ T,#a/ Mar%/ Si3i%a/ Seter/ R Si1aona/ Le+anCii!
4<==75! An assess"ent o( (a-tors -ontri#,tin+ to treat"ent a&heren-e
an& 1no)le&+e o( TB trans"ission a"on+ patients on TB treat"ent!
BMC Public Health) USAG US National Li#rar% o( Me&i-ine! 7G8A
&oiG1=!11A8S17B1><7EA>7>8A! para! E/ @<! Retrie$e& I,l% <=17
(ro" httpGSS)))!n-#i!nl"!nih!+o$Sp"-Sarti-lesSPMCE7E=A1S5!
Moha"e& A!I!/ Po,si( M!A!/ Ottoa P!/ R Ba%o,"i/ A! 4<==B5! %no&lede
of Tuberculosis: A Sur3ey amon Tuberculosis Patients in
6mdurman" Sudan! S,&anG S,&anese Io,rnal o( P,#li- Health! $ol!
< 415! para!@ / p!<1! Retrie$e& A,+! <1/ <=17 (ro"
httpGSS)))!sCph!net!s&S2lesS$ol<i1p<1> <A!p&(!
M,nro/ Salla A!/ Le)in/ Si"on A!/ S"ith/ Helen I!/ En+el/ Mar1 E!/
.rethei" Atle/ R ?ol"in1/ Ii""%! 4<==B5! Patient adherence to
tuberculosis treatment: A systematic re3ie& of >ualitati3e
research! PLOS Me&i-ine! Mi-hi+an State Uni$ersit%G USA! <==B!
ta#! 1>A! Retrie$e& A,+,st <=/ <=17 (ro" PLos Me& 74B5G
e<@A!&oiG1=!1@B1SCo,rnal!p"e&!==7=<@A!
Nepal AF/ Shi%alap F/ Ser"sri S/ R Fei)1arn1a B! 4<=1<5! Compliance
&ith D6TS amon Tuberculosis patients under community based
D6TS stratey in Palpa District" $epal! No! 6AA! Para 7/ p!<! Int I
In(e-t Mi-ro#iol* 1415G 17>16!para! @>7
N&e1i/ Le1il,ai .re&ri-1! 4<==85! Assessment of the #e3el of %no&lede
and Attitudes To&ards Tuberculosis amon the patients in Maralal TB
Manyatta" Samburu District! Nairo#iG Fen%a Me&i-al Trainin+
Colle+e!
Ninan/ Bett% S,san 4<==15! Determinants of Treatment $on7
Compliance amon Pulmonary TB Patients in +$TCP7D6TS"
Tri3andrum" %erala" ,ndia! A-h,tha Menon Centre (or Health S-ien-e
St,&ies! In&iaG Sree Chitra Tir,nal Instit,te (or Me&i-al S-ien-es an&
Te-hnolo+%! -hap! </ part <!E/ para @/ p!18! Retrie$e& O-to#er 1</
<=17 (ro"
httpGSS&spa-e!s-ti"st!a-!inSCsp,iS#itstrea"S1<@7E8BA6S<<E7S1S81<!p&(
Ro&a/ Anthon% R! 4<=175! TB Mo$ieG .l%in+ Fiss! H-A#THbeat! Sta Cr,3/
ManilaG DOH! iss,e no! A1/ pp!B>A!
Sa"ar+an&i/ Osa"a A!/ A#,la#an/ Ah"a& A!/ El Dee1 Basee" S!/
Mir&a&/ L,Cain H!/ R Wali/ SiraC O! 4<=1<5! %no&lede of Pulmonary
tuberculosis in the Saudi Community of 8eddah! Ie&&ah/
Sa,&i Ara#iaG Sa,&i Io,rnal o(
Internal Me&i-ine! $ol! no! 1 17@@ H! para! @/ pp! <6>@=!
Internet So,r-es
Crisosto"o/ Sheila! 4<=1@5! TB -ases in Phl &e-linin+> WHO! The
Philippine Star! Man&al,%on+ Cit%/ PhilippinesG The Philippine Star!
Retrie$e& Septe"#er 16/ <=17 (ro"
httpGSS)))!philstar!-o"Shea&linesS<=1@S=7S<AS6@EB7=St#> -ases>phl>
&e-linin+>)ho!
Depart"ent o( Health! 4<==@5! Comprehensi3e and 2ni?ed Policy for
TB Control in the Philippines! PhilippinesG DOH! p!1=!
Depart"ent o( Health! 4<=115! $ational Tuberculosis Proram! Sta!
Cr,3/ ManilaG DOH! para! <! Retrie$e& Septe"#er 1A/ <=17 (ro"
httpGSS)))!&oh!+o$!phSno&eS@8B!ht"l!
USAID! 4<=115! Re&,-in+ Dela%s in TB Dia+nosisG Data Colle-tion Tools
to e$al,ate the -a,se an& (re9,en-% o( TB &ela%s! TB
Care ,,! USAG Unite& States A+en-% International De$elop"ent!
Retrie$e& A,+! <1/ <=17
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K<=IITDataK< =-olle-tionK<=toolTTBK<=PatientK<=Dela%TApril
K<=<=1<!p&(!
Ri;en/ .a%ette C! 4<=115! Rise in reporte& TB -ases in C? &,e to p,#li-
a)areness to see1 -ons,ltation! In(or"ation to E"po)er
.ilipinos! PIA Press Release!U,e3on Cit%/ PhilippinesG Philippine
In(or"ation A+en-%! para 7/E! Retrie$e& O-to#er 1</ <=17 (ro"
httpGSSar-hi$es!pia!+o$!phSO
"N1RtN1Ri&N76BE<R%N<=11R"oN=A!
Worl& Health Or+ani3ation! 416785! Health! Constitution of the 4orld
Health 6rani@ation! S)it3erlan&G WHO! p!1! Retrie$e& Septe"#er
16/ <=17 (ro"
httpGSS)))!)ho!intS+o$ernan-eSe#S)hoT-onstit,tionTen!p&(!