University of Luzon, Graduate School

Dagupan City

Chapter V

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

This chapter presents the summary of findings, conclusions and

recommendations of the study.

The study was conducted to determine the adherence of tuberculosis

patients in the community-based Directly Observed Treatment Short Course

offered in rural health units and barangay health stations in Bugallon,

Pangasinan, where results of the study were used to develop a program

implementation plan of a patient-centered approach in the directly observed

treatment short course for tuberculosis which can be adapted by cities or

municipalities implementing the National Tuberculosis Control Program.

Specifically, it sought to answer the following questions:

1. How are the tuberculosis patients’ biopsychosocial frames described in

terms of:

1.1. clinical profile;

1.2. coping mechanism; and

1.3. social support?

2. What is the level of treatment adherence of tuberculosis patients to the

community-based DOTS?

161
 University of Luzon, Graduate School
Dagupan City

3. What significant relationship exists across the tuberculosis patients’

biopsychosocial frames to their level of treatment adherence?

4. What program implementation plan can be proposed to promote a

patient-centered approach in the directly observed treatment short

course for tuberculosis?

A quantitative exploratory correlational research design was employed,

where researcher-based questionnaires were utilized based on three

standardized measuring scales namely the brief COPE inventory by Carver

(1997) for extracting coping mechanisms used, “Multidimensional Scale of

Perceived Social Support” by Zimet, et. al. (1988) for gauging the perceived

social support, and the Medication Adherence Questionnaire by Morisky and

DiMatteo (2011) for measuring the level of treatment adherence. Each

standardized questionnaire was locally modified and translated with a

tabulated CVI of 0.902 and Cronbach’s alpha of 0.990, hence, the instrument

was reliable and was accepted to measure representativeness. Following the

correlational nature of the study, tuberculosis patients’ biopsychosocial frames

were represented by the respondents’ clinical profile, coping mechanisms and

perceived social support respectively which further stand as the study’s

independent variables. On the other hand, measured adherence level was

positioned as the dependent variable under study.

162
 University of Luzon, Graduate School
Dagupan City

There were 57 patients currently enrolled in the community-based DOTS

program of Bugallon during the conduct of the study but only 50 patients were

counted in following the research’s inclusion and exclusion criteria. Patients

included were geographically distributed in the two main health centers and 11

DOH-registered barangay health stations of the municipality providing the

anti-tuberculosis chemotherapy.

After securing permission from the municipal health office of Bugallon,

the researcher together with the municipal NTP coordinator located and

reviewed the tuberculosis registry. Two research enumerators were asked,

alongside the community health partners and the barangay health workers,

aided the researcher in the actual floating of the questionnaire. Confidentiality

and patient anonymity was reassured to the respondents. Quantitative data

were tabulated, analyzed, and correlated one variable to another.

Salient Findings of the Study

Clinical Profile

1. As regards to demographic data, almost all of the respondents are

distributed in the three latter psychological age groups. Most (42%) of the

respondents are in their middle adulthood (40-64 years old).

Subsequently, 32% (16 respondents) belong to the young adulthood (22-

163
 University of Luzon, Graduate School
Dagupan City

39 years) age group while one out of five respondents are in the late

adulthood (65 years and above). The respondents have a mean age of

46.7 years. Moreover, there is a preponderance of males where they

comprise a great majority (60% or 30) of the respondents while females

constitute 40% of their entirety. There is a 3:2 male-to-female ratio

among the patients under study. Married respondents (48%) are twice as

much as those who were widowed (24%) while unmarried individuals

comprised 28% or 14 of the respondents.

2. As to highest educational attainment, almost half (46%) of the

respondents finished high school, two out five (40%) graduated from

elementary and 14% earned a baccalaureate degree. On the other hand,

a large majority (66%) of the respondents have less than four household

members. Patients who shared a house to five to nine individuals

account for 30% of the respondents while only two patients (4%) have

more than ten household members. The respondents have an average of

four household members.

3. Under tuberculosis category, a large majority (60%) of the respondents

are clinically-diagnosed with pulmonary tuberculosis while

bacteriologically-confirmed cases of pulmonary TB accounts to 36% of

the respondents. Only 4% of the respondents were extra-pulmonary

cases, one has hepatic tuberculosis (TB of the liver) and the other was

164
 University of Luzon, Graduate School
Dagupan City

clinically-diagnosed with Pott’s disease (TB of the vertebrae). On the

other hand, almost all (82%) of the respondents are under the Category I

treatment, this includes new pulmonary and extra-pulmonary (except

CNS/bones or joints) TB cases whether bacteriologically-confirmed or

clinically-diagnosed, and are currently undergoing a six-month treatment

course. Likewise, patients under Category II account to 16% of the

respondents. This involves only previously treated drug-susceptible

pulmonary or extra-pulmonary cases whether bacteriologically-confirmed

or clinically-diagnosed and are currently under an eight-month

chemotherapy. The patient diagnosed with Pott’s disease is registered

under Category Ia and is receiving a one-year treatment program under

the DOTS strategy. Furthermore, 64% of the respondents are under the

continuation phase (two months onward) which is 1.8 times than the

respondents in the intensive (first two months) treatment accounting for

36% of the entirety.

Coping Mechanism

4. Respondents always rely on faith or religious affiliation as a way to cope

during the month-long anti-tuberculosis treatment regimen with an

average weighted mean of 3.26. Positive reframing ensued closely

followed in third by acceptance, both are sometimes utilized by the

respodents, with pooled means of 3.21 and 3.11 respectively. Coming in

165
 University of Luzon, Graduate School
Dagupan City

fourth is planning succeeded by the use of emotional support with

average weighted means of 3.08 and 3.02 respectively. These five

topmost used coping mechanisms are above the 3.00 pooled mean mark.

Moreover, active coping and the use of instrumental support are

occasionally used by the respondents garnering a similar 2.91 arithmetic

mean. Respondents also occasionally self-distract as a way to cope up

with a situation with an average weighted mean of 2.88.

5. On the other hand, respondents rarely vent emotions regarding the

disease and treatment process with a pooled mean of 2.48. Self-blame is

seldom used by the respondents with an average mean of 2.38.

Moreover, humor and denial are used infrequently with pooled means of

2.36 and 2.28 respectively. Nonetheless, the four coping mechanisms

mentioned are rarely utilized by the respondents.

6. Remarkably, respondents do not depend on drugs, alcohol and smoking

to cope with situation with an average weighted mean of 1.73. Also,

respondents never withdraw in any actions in order to cope with the

stressor with a pooled mean of 1.62. Both coping mechanisms rank last

and are never utilized by the respondents in entirety.

Perceived Social Support

7. As to perceived social support, the highest weighted mean of 3.41 came

from the respondent’s immediate family members and treatment

166
 University of Luzon, Graduate School
Dagupan City

partners. The support coming from their respective family and healthcare

providers are highly perceived by the respondents. Significantly, social

support from friends of the respondents is moderately perceived with a

pooled mean of 2.61.

Adherence

8. Generally, a large majority (62%) of the respondents have high adherence

while one-fifth (20%) of the respondents are moderately compliant to the

anti-tuberculosis chemotherapy. Remarkably, 18% of the registered

patients are poorly adherent to the community-based DOTS strategy.

9. As to age, young adult (22-39 years old) respondents are the most

adherent in the community-based DOTS strategy with an average

weighted mean of 1.46. A large majority (68.75%) of young adult

respondents have high adherence. Respondents in their middle

adulthood (40-64 years) have high adherence with a pooled mean of 1.61

while respondents at the late adulthood age group (65 years and above)

have moderate adherence with an average weighted mean of 1.77. In the

contrary, patients aged 21 and below are moderately adherent with an

average weighted mean of 2.33. Remarkably, 66.67% of the adolescent

respondents have poor adherence in the TB-DOTS strategy.

10. As to sex, male respondents are highly compliant with an average

weighted mean of 1.53. Two in every three males are highly adherent,

167
 University of Luzon, Graduate School
Dagupan City

20% registered a moderate adherence and only four males (13.33%) are

poorly compliant. Contrariwise, female respondents scored an overall

moderate compliance with a pooled mean of 1.78. One in every four

female respondents are poorly adherent while 20% are moderately

compliant.

11. As to civil status, unmarried patients are the most adherent in the

community-based DOTS strategy with a pooled mean of 1.61. Nine out of

fourteen respondents who are single are highly adherent, 14.29% are

moderately compliant while three are poorly adherent. Married

respondents registered an average mean of 1.63 and are highly compliant

to their anti-tuberculosis therapy while widowed patients are the least

adherent when grouped as to marital status with an average weighted

mean of 1.69. Remarkably, one in every four widowed respondents have

poor adherence in the TB-DOTS strategy.

12. As to household members, respondents who live with less than

four individuals are the most compliant with an average weighted mean

of 1.63. Twenty-one out of these thirty-three patients are highly

adherent. Moreover, respondents with a family size of five to nine scored

an overall high compliance rate with a pooled mean of 1.67. Remarkably,

one in every five respondents with household members of 5 to 9 is either

poorly or moderately adherent.

168
 University of Luzon, Graduate School
Dagupan City

13. As to tuberculosis category, extra-pulmonary tuberculosis

patients, either bacteriologically-confirmed or clinically diagnosed, are

the most adherent in the community-based DOTS strategy with a perfect

average weighted mean of 1.00. Clinically-diagnosed and

bacteriologically-confirmed respondents with pulmonary tuberculosis

ensued closely with pooled means of 1.66 and 1.67 respectively.

14. As to treatment category and phase, respondents under Category

Ia are the most adherent in the community-based DOTS strategy with a

perfect pooled mean of 1.00. Meanwhile, patients under Category II are

the least adherent when grouped as to treatment category with an

average weighted mean of 2.10. Remarkably, only two relapse patients

are highly adherent while the remaining three-fourth of the respondents

are moderately to poorly compliant. Furthermore, respondents under

intensive treatment phase are highly compliant with an average weighted

mean of 1.50. Likewise, respondents under continuation phase scored an

overall high compliance with a pooled mean of 1.71, with 18 out of 32

respondents are highly adherent in the maintenance treatment.

15. As to coping mechanism, respondents with high adherence always

rely on faith or religious affiliation as a way to cope during the month-

long anti-tuberculosis treatment regimen with an average weighted mean

of 3.45. Acceptance ensued closely with an average weighted mean of

169
 University of Luzon, Graduate School
Dagupan City

3.19 followed in third by positive reframing with a pooled mean of 3.16,

both are rated to be utilized from time to time by the respondents. On

the other hand, respondents with moderate adherence always depend on

positive reframing as a coping mechanism with a pooled mean of 3.45.

Acceptance and religion followed narrowly with similar average weighted

mean of 3.29. Substance abuse is never used as a coping mechanism of

respondents with high to moderate compliance with a pooled mean of

1.39 and 1.35 respectively. Contrariwise, the most frequently used

coping mechanism of respondents with poor adherence is substance

abuse with a pooled mean of 3.33 while humor was ranked last with an

average weighted mean of 2.67.

16. As to perceived social support, highly adherent respondents

perceived a high social support from their family with an average

weighted mean of 3.61. On the other hand, patients with moderate

adherence remarked the highest weighted mean of 3.50 from their

treatment partners who give high social support. Respondent with high

to moderate compliance both observed a moderate social support from

friends with pooled means of 2.75 and 2.73 respectively. Remarkably,

patients with poor adherence recognized high social support both from

family and treatment partners with average weighted means of 2.78 and

2.67 respectively but perceived a low social support from friends with a

pooled mean of 2.33.

170
 University of Luzon, Graduate School
Dagupan City

Relationship of Tuberculosis Patients’ Clinical Profile to their Treatment

Adherence Level

17. Across age, computed Spearman’s coefficient of 0.141 at 0.05 level

of significance confirmed that there is no significant relationship between

the patients’ age and their level of treatment adherence. However, a very

weak, positive, monotonic association between the two variables can be

inferred.

18. Across sex, using Analysis of Variance with Eta Coefficient,

tabulated F-value of 1.421 at 0.05 level of significance revealed that

there is no significant relationship between the patients’ sex and their

level of treatment adherence. Moreover, the eta squared (2) of 0.029

reflects that the interaction between the respondents’ sex and their

adherence accounted for 2.9% of the total variability in the level of

adherence in the community-based DOTS strategy hence, the effect size

of sex to their level of adherence is small.

19. Across civil status, utilizing Analysis of Variance with Eta

Coefficient, computed F-value of 0.327 at 0.05 level of significance

revealed that there is no significant relationship between the patients’

civil status and their level of treatment adherence. Moreover, the eta

squared (2) of 0.021 reflects that the interaction between the

respondents’ civil status and their adherence accounted for 2.9% of the

171
 University of Luzon, Graduate School
Dagupan City

total variability in the level of adherence in the community-based DOTS

strategy hence, the effect size of civil status to their level of adherence is

small.

20. Across highest educational attainment, applying Analysis of

Variance with Eta Coefficient, calculated F-value of 1.232 at 0.05 level of

significance proved that there is no significant relationship between the

patients’ educational attainment and their level of treatment adherence.

Moreover, the eta squared (2) of 0.099 reflects that the interaction

between the respondents’ educational attainment and their adherence

accounted for 9.9% of the total variability in the level of adherence in the

community-based DOTS strategy hence, the effect size of educational

attainment to their level of adherence is almost large.

21. Across the number of household members, using Kolmogorov-

Smirnov Test with Poisson Regression Coefficient, tabulated Z value of

1.185 at 0.05 level of significance confirmed that there is no significant

relationship between the patients’ number of household members and

their level of treatment adherence. Moreover, the calculated absolute

value of Poisson coefficient at 0.168 revealed that if a patient’s

household member were to increase by one, his adherence rate in the

community-based DOTS strategy would be expected to decrease by a

factor of 0.168, while holding all other variables constant.

172
 University of Luzon, Graduate School
Dagupan City

22. Across tuberculosis category, utilizing Analysis of Variance with

Eta Coefficient, computed F-value of 0.606 at 0.05 level of significance

revealed that there is no significant relationship between the patients’

tuberculosis category and their level of treatment adherence. Moreover,

the eta squared (2) of 0.038 reflects that the interaction between the

respondents’ tuberculosis category and their adherence accounted for

3.8% of the total variability in the level of adherence in the community-

based DOTS strategy hence, the effect size of tuberculosis category to

their level of adherence is small.

23. Across treatment category, applying Analysis of Variance with Eta

Coefficient, calculated F-value of 3.265 at 0.05 level of significance

proved that there is a significant relationship between the patients’

treatment category and their level of treatment adherence. Moreover, the

eta squared (2) of 0.122 reflects that the interaction between the

respondents’ treatment category and their adherence accounted for

12.2% of the total variability in the level of adherence in the community-

based DOTS strategy hence, the effect size of treatment category to their

level of adherence is very large.

24. Across treatment phase, using Analysis of Variance with Eta

Coefficient, tabulated F-value of 1.162 at 0.05 level of significance

proved that there is no significant relationship between the patients’

173
 University of Luzon, Graduate School
Dagupan City

treatment phase and their level of treatment adherence. Moreover, the

eta squared (2) of 0.024 reflects that the interaction between the

respondents’ treatment phase and their adherence accounted for 2.4%

of the total variability in the level of adherence in the community-based

DOTS strategy hence, the effect size of treatment phase to their level of

adherence is very large.

Relationship of Tuberculosis Patients’ Coping Mechanisms to their

Treatment Adherence Level

25. Using Spearman’s Rho Correlation Coefficient, denial, as coping

mechanism, registered a rho coefficient of 0.248 at 0.05 level of

significance which a weak, positive, monotonic association between the

patients’ coping mechanism particularly denial and their level of

treatment adherence. On the other hand, self-blame (rs = 0.166), use of

emotional support (rs = 0.142), venting (rs = 0.057), and humor (rs =

0.038), denote very weak, positive, monotonic associations between these

coping mechanisms to their treatment adherence. These coefficients

resulted to significance levels of 0.250 (self-blame), 0.325 (use of

emotional support), 0.696 (venting), and 0.792 (humor) respectively; all

are not within the significance level 0.05. Hence, there is no significant

relationships across the patients’ coping mechanisms namely self-blame,

174
 University of Luzon, Graduate School
Dagupan City

use of emotional support, venting and humor, and their level of

treatment adherence.

26. Contrariwise, the calculated correlation coefficients of active coping

(rs = -0.125), religion (rs = -0.106), acceptance (rs = -0.094), self-distract (rs

= -0.091), use of instrumental support (rs = -0.076), positive reframing (rs

= -0.036), and planning (rs = -0.033), denote very weak, negative,

monotonic associations between these coping mechanisms to their

treatment adherence. These coefficients resulted to significance levels of

0.389 (active coping), 0.462 (religion), 0.518 (acceptance), 0.530 (self-

distract), 0.598 (use of instrumental support), 0.804 (positive reframing)

and 0.822 (planning) respectively; all are not within the significance level

0.05. Hence, there is no significant relationships across the patients’

coping mechanisms namely active coping, religion, acceptance, self-

distract, use of instrumental support, positive reframing, and planning,

and their level of treatment adherence.

27. Furthermore, the calculated correlation coefficients of behavioral-

disengagement (0.526) and substance abuse (0.464) denote a moderate,

positive, monotonic associations between these coping mechanisms and

treatment adherence. This resulted to significance values of 0.000 for

behavioral-disengagement and 0.001 for substance abuse, both are

within the significance level of 0.01. Hence, there is a significant

175
 University of Luzon, Graduate School
Dagupan City

relationship between the patients’ coping mechanisms namely

behavioral-disengagement and substance abuse and their level of

treatment adherence.

Relationship of Tuberculosis Patients’ Social Support to their Treatment

Adherence Level

28. Utilizing Spearman’s Rho Correlation Coefficient, calculated

correlation coefficients of perceived social support from family (-0.462)

denotes a moderate, negative, monotonic association between family’s

social support and treatment adherence. This resulted to a significance

value of 0.001, within the significance level of 0.01. Hence, there is a

significant relationship between the patients’ perceived social support

from family and their level of treatment adherence.

29. Likewise, the computed correlation coefficient of perceived social

support from treatment partners (-0.413) denotes a moderate, negative,

association between treatment partners’ social support and treatment

adherence. This resulted to a significance value of 0.003, within the

significance level of 0.01. Hence, there is a significant relationship

between the patients’ perceived social support from treatment partners

and their level of treatment adherence.

30. On the other hand, tabulated correlation coefficient of perceived

social support from friends (-0.097) denotes a very weak, negative,

176
 University of Luzon, Graduate School
Dagupan City

monotonic association between friends’ social support and treatment

adherence. This resulted to a significance value of 0.503, not within the

significance level of 0.05. Hence, there is no significant relationship

between the patients’ perceived social support from friends and their

level of treatment adherence.

31. Collectively, computed correlation coefficients of perceived social

support (-0.343) denotes a weak, negative, monotonic association

between perceived social support in entirety and treatment adherence.

This resulted to a significance value of 0.015, within the significance

level of 0.05. Hence, there is a significant relationship between the

patients’ perceived collective social support and their level of treatment

adherence.

Predictive Model for Tuberculosis Patients’ Adherence in the Community-

Based Directly Observed Treatment Short Course

32. Using multiple linear regression model, the tabulated R value of

0.799 indicates that a patient’s highest educational attainment and the

use of instrumental support, behavioral disengagement, venting,

substance abuse and positive reframing as coping mechanisms are

strong predictors of adherence in the community-based DOTS strategy.

The R squared (R2) of 0.639 depicts that the interaction between the

respondents’ highest educational attainment and the five named coping

177
 University of Luzon, Graduate School
Dagupan City

mechanisms accounted for 63.9% of the total variability in the level of

adherence in the community-based DOTS strategy.

33. The regression model, where six out forty-nine variables were held

constant, statistically significantly predicts the adherence level in the

community-based DOTS strategy.

34. Based on the predictive model, the respondents’ highest

educational attainment and coping mechanisms namely the use of

instrumental support, behavioral disengagement, venting, substance

abuse and positive reframing, have a strong, significant relationship to

treatment adherence in reference to the tabulated significance level of

0.003, within the 0.01 level of significance. Furthermore, as patients

attain higher education and use of instrumental support, positive

reframing, and venting as coping mechanisms, the higher the level of

adherence in the anti-tuberculosis treatment. Contrariwise, as patients

use behavioral disengagement and substance abuse as coping

mechanisms, the lower the level of adherence in the anti-tuberculosis

treatment.

Conclusions

178
 University of Luzon, Graduate School
Dagupan City

Based on the salient findings of the study, it can be inferred that

patient’s highest educational attainment and the use of instrumental

support, positive reframing, venting, behavioral disengagement, and substance

abuse as coping mechanisms, had strong, significant influences on patient’s

adherence to the community-based DOTS strategy. Educated patients are more

likely to adhere in the treatment process, hence, health education on TB and

its treatment is most crucial. Moreover, maladaptive coping mechanisms like

substance abuse and behavioral disengagement had a negative outcome on

patient adherence. Thus, alternative coping mechanisms like positive

reframing, venting and the use of instrumental support in particular, are

encouraged to be utilized by patients to have a positive outcome on reducing

poor adherence to TB treatment. Furthermore, patient-related factors identified

corroborate that TB treatment should move forward to become more patient-

centered. The proposed implementation plan for a patient-centered approach in

the DOTS strategy is deemed to result in the best quality of care that is based

on needs and individual experiences for increase treatment adherence and

ultimately cure.

Recommendations

179
 University of Luzon, Graduate School
Dagupan City

Based on the findings and conclusions of this research study, the

following are recommended to improve adherence in the community-based

DOTS strategy:

1. Tuberculosis patients should be encouraged to actively engage in the

treatment process to develop greater sense of control over disease

management. The proposed patient-centered approach will guide

program implementers of TB-DOTS to do so.

2. Development of TB social support group within the community, which

could include patients who successfully finished the treatment and

declared cured, would be beneficial to patients currently enrolled in a

community-based DOTS strategy. Support groups could boost the

morale of the patient, hence, strengthening one’s resolve to complete

the treatment and successfully recuperate from the disease.

3. Healthcare providers should provide holistic care to tuberculosis

patients with prime consideration on the biological, psychological and

social aspects of the disease and its treatment.

4. Public health practitioners should incorporate health teachings,

health promotiong activities and TB control management measures

according to patient characteristics to facilitate learning for patients,

household members, and treatment partners.

180
 University of Luzon, Graduate School
Dagupan City

5. Public health practitioners should revisit the National Tuberculosis

Control Program Manual of Procedures and adopt schemes for strict

implementation of these policies.

6. Other researchers should rummage deeper in the context of the

implementation of the community-based DOTS strategy to improve

treatment adherence but correlating it to one domain of the

biopsychosocial frame only so a focal purview is emphasized.

7. Other researchers are also encouraged to conduct a qualitative study

on the lived experiences of tuberculosis patients under community-

based DOTS strategy and explore other factors affecting patient’s

compliance.

8. Once the tuberculosis treatment management has been restructured

to secure high treatment success rate, other researchers may study

the different practices at several inter-local health zones to determine

best practices in the management of tuberculosis treatment at the

grass-root level.

181