i n d i a n j o u r n a l o f t u b e r c u l o s i s 6 6 ( 2 0 1 9 ) 3 6 4 e3 6 9

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: http://www.journals.elsevier.com/

indian-journal-of-tuberculosis/

Original article

Impact of pharmacist counseling and leaflet on the

adherence of pulmonary tuberculosis patients in
lungs hospital in Indonesia

Hidayah Karuniawati*, Okta Nama Putra, Erindyah Retno Wikantyasning

Faculty of Pharmacy, Universitas Muhammadiyah Surakarta, Jl. A. Yani Tromol Pos 1, Pabelan, Kartasura,
Surakarta, 57102, Indonesia

article info abstract

Article history: Background: One of the goals of counseling in patients with chronic diseases including
Received 8 November 2018 tuberculosis patients is to improve adherence to taking medication. By patient adherence,
Accepted 28 February 2019 therapeutic results are more optimal. Additional counseling alternatives such as leaflets
Available online 6 March 2019 may be needed to make easier for patients to obtain information about their treatment.
This study aimed to analyze the effectiveness of counseling with and without leaflets on
Keywords: the adherence on taking tuberculosis (TB) drugs.
Counseling Methods: This study was a quantitative research conducted using a quasi-experiment
Leaflet method with a control group for pre-test and post-test design. Data was taken by
Adherence consecutive sampling. The number of samples in this study was 75 respondents which
Tuberculosis divided into three groups: counseling, counseling with leaflets, and control that is a usual
care in hospital. The inclusion criteria were patients diagnosed with pulmonary tubercu-
losis with age 25e55 years, who has been taking TB medicines for at least one month and
can communicate well. Data was analyzed using Wilcoxon and KruskaleWallis with post
hoc ManneWhitney due to abnormality of the distributed data.
Results: Before the intervention, of 20 respondents (42.6%) out of 75 respondents were
obedient to their TB medicines, whereas after the intervention the number of obedient
patients was 33 respondents (70.2%). There was a significant increase in adherence be-
tween before and after two weeks of counseling intervention with a p-value of 0.029 before
and after two weeks of counseling with leaflets with a p-value of 0.003. Counseling and
counseling with leaflets improved patients' adherence compare to control group with p-
values of 0.028 and 0.001 respectively.
Conclusion: Counseling and counseling with leaflet impact in patients' adherence to
tuberculosis medication.
© 2019 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.

* Corresponding author. þ6285642158302 (mobile).

E-mail address: [email protected] (H. Karuniawati).
https://doi.org/10.1016/j.ijtb.2019.02.015
0019-5707/© 2019 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.
 i n d i a n j o u r n a l o f t u b e r c u l o s i s 6 6 ( 2 0 1 9 ) 3 6 4 e3 6 9 365

1. Introduction 2. Methods

Pulmonary tuberculosis (TB) is one of the infectious diseases 2.1. Study setting
which is a public health problem in the world. TB is one of
the top ten cases of death worldwide. In 2017, 1.6 million This study was conducted in a lung hospital in Surakarta
died from this disease including 0.3 million among people Indonesia. This hospital is a referral hospital especially in lung
with HIV. TB is leading killer of HIV patients.1 Indonesia has disease in Central Java Province, Indonesia.
the second highest burden in the world which the number of
TB cases is estimated to have 1 million TB cases per year. 2.2. Study design and sampling
Around 7500 of the notified cases die and probably there are
more than 100,000 deaths every year among those not This research was a quantitative study with a research design
notified.2 using quasi-experimental method with pre-test and post-test
Tuberculosis is caused by bacteria that call Mycobacterium control group design. The sampling method was conducted by
tuberculosis. This bacterium most affect lungs.1 Treatment of convenience sampling. The focus of this study was examined
TB disease is carried out for at least six months and is given the level of compliance, the effect of counseling and coun-
in two phases.3,4 To achieve healing is very important for seling with leaflets on patient adherence to TB treatment
patients with pulmonary TB to have knowledge of the dis- compared to the control group. The independent variable of
ease. This knowledge is in terms of regularity, complete- this study was counseling and leaflets. The dependent vari-
ness, and compliance in taking TB medicines. Non- able was the adherence in TB medicines.
adherence of patients to treatment is a major risk factor
that causes multidrug resistance tuberculosis (MDR-TB). 2.3. Ethical consideration
Non-adherence increases MDR risk 7.75 times compared to
obedient patients.5 Approval of the study was obtained from Health Research
Based on the results of a previous study of 80 respondents Ethics committee, Faculty of Medicine of Universitas
in the lung hospital in Surakarta, it was found that there Muhammadiyah Surakarta No. 1084/C.1/KEPK-FKUMS/II/2018
were 30 respondents who were not compliant in the treat- before the commencement of the study. Informed concerned
ment of pulmonary tuberculosis (37.5%).6 Although the was done and participants' confidentiality was maintained
number of non-compliance patients is 37.5% there is a during and after collecting data.
greater likelihood that there will be a resistance problem in
therapy. Treatment of tuberculosis resistance is more diffi- 2.4. Tool
cult, expensive, and a relatively low cure rate.1,7 The impact
of MDR is not only in the difficulty on treatment but also its The adherence questionnaire contains 13 questions or items.
impact on economic, social and psychological.8,9 Disobedi- The adherence questionnaire was reviewed by two academics
ence of pulmonary TB patients on TB treatment can be in clinical pharmacy background and community pharmacy
caused by several factors including lack of knowledge, lack of and a physician in infectious disease, while the leaflet was
social support, a side effect of TB drugs, believing about reviewed by two pharmacists and a physician in infectious
medicines, and forgetfulness.6,10,11 disease. After reviewed by panel experts, adherence ques-
For improving better treatment adherence, comprehensive tionnaire was pretested on 30 respondents as a pilot study to
health education, especially for patients at treatment sites, clarify any ambiguities. The validation and reliability of the
need to be addressed. Pharmacist counseling lead to questionnaire was then analyzed statistically with Pearson
improving patients adherence.12e16 Additional media such as Correlation and Cronbach Alfa. The questionnaire is valid if r-
leaflet may be needed to make it easier for patients to get the count is more than r-table or p-value <0.05 and reliable if
information to be related to the treatment being undertaken. Cronbach alfa more than 0.6.17
Patients can read leaflet about their medication anywhere and
anytime and it may minimize their forgetfulness about their 2.5. Data collection
TB medication and improve their knowledge. Improving pa-
tient knowledge can increase patients' awareness of the dis- The primary data was collected from the patients by interview
ease and the risk of complications so that patients become method and the secondary data was taken from patient
obedient. Although there have been several studies related to medical records. Subjects were 75 outpatients with pulmo-
the influence of counseling on adherence in some countries, nary tuberculosis at the Center for Lung Health, Surakarta,
but research on the effect of counseling and leaflets on TB divided into three groups: patients received counseling, pa-
patient compliance has never been done in Indonesia. tients received counseling with leaflets, and patients with
Further, it is inappropriate to extrapolate the finding of neither counseling nor leaflet intervention. The inclusion
counseling effect conducted in different disease and other criteria were:
countries to the local situation because of differences cul-
tures. Therefore, it is necessary to study the effect of coun- a. Patients diagnosed with pulmonary tuberculosis at Lung
seling and leaflets on the compliance of pulmonary TB Hospital Surakarta.
patients in their treatment at the Community Lung Health b. Adult patients aged 25e55 years because they are able to
Center in Surakarta Indonesia. make their own decisions.
366 i n d i a n j o u r n a l o f t u b e r c u l o s i s 6 6 ( 2 0 1 9 ) 3 6 4 e3 6 9

c. Tuberculosis patient outpatient who have undergone TB intervention for counseling, and the third group was control
medicine for at least 1 month. group. The characteristic of respondents is presented in Table
d. Willing to be a respondent, follow research procedures 2, level of patients' compliance to take TB medicine before and
e. Be able to communicate. after intervention is in Table 3, and result of KruskaleWallis
post hoc Mann Whitney Test for Comparison of intervention
The exclusion criteria was TB patients who pregnant. and control on medication adherence can be seen in Table 4.
The steps of collecting data can be seen in Fig. 1.

2.6. Data analysis 4. Discussion

Data was analyzed by Kolmogorov-Smirnoff. If p-value <0.05 In this study, the number of male patients (54.7%) is more than
the data was not in normal distribution and vice versa. In this females (45.3%). This result was similar as the other re-
study data was not normally distributed, non-parametric an- searches.5,18,19 A man has a higher risk to be infected tuber-
alyses were approached. Wilcoxon analysis was used for culosis because of differences in social roles, risk behaviors,
groups of paired data which was analyzing the relationship and activities. Males may travel more frequently; have more
between before and after intervention (pre-test and post-test). social contacts; spend more time in settings that may be
While the KruskaleWallis post hoc ManneWhitney analysis conducive to TB transmission. On the other hand, women
was used for groups of unpaired data, namely analyzing dif- have more-robust immune responses to infection.20 Of the 48
ferences between intervention groups and the control group. respondents, (64%) were underweight. In this study showed
that the most TB patients at the age of 25e45 years amounted
to 56 respondents (74.7%) while the age of 46e55 years
3. Result amounted to 19 respondents (25.3%). This result was in
agreement with the other studies. All age groups are at risk of
Before the adherence questionnaire was used, it has been tuberculosis infection, but TB disease mostly affects adults in
validated and this questionnaire was valid and reliable to use their most productive years.1
as a tool to know the patients' adherence. Of 30 respondents The education level category in this study shows that ju-
for the validity test, the r table is 0.301. The question is valid if nior and senior high school education is higher with the
the r > 0.301. The result of r > 0.301 so that all the questions in incidence of pulmonary TB compared to higher education.
the adherence questionnaire are valid. The result can be seen Junior high school education level was 22 respondents (29.4%),
in Table 1. This questionnaire also reliable because Cronbach a senior high school with 36 respondents (48%) while with a
alfa was 0.686 > 0.6. Adherence questionnaire consists of 13 higher education level only 6 respondents (8%). Level educa-
items with yes or no answers. Items number 2, 4, 13 each score tion significantly associated with a higher risk of TB21 and
1 if the answer is “no”, while items number 1, 3, 5, 6, 7, 8, 9, 10, educational status were significantly associated with knowl-
11, 12 each score 1 if the answer is “yes”. The total score is 13. edge level.22
During the period of study on JulyeDecember 2017, 75 pa- Based on Table 3, in the intervention group of counseling
tients were recruited as respondents. Respondents divided by with leaflets, before the intervention, non-compliance pa-
three groups each group consist of 25 patients. First group was tients were 14 patients (56%) and after the intervention, the
intervention for counseling and leaflet, the second group was number of non-adherence patients significantly decreased to

TB paents Eligible Informed concern

3 groups

Group 1 Group 2 Group 3

Intervenon Intervenon Control

Pre-test Pre-test Pre-test

Counseling and leaflet counseling Without counseling and leaflet

Post-test Post -test Post -test

Fig. 1 e The step of collecting data.

 i n d i a n j o u r n a l o f t u b e r c u l o s i s 6 6 ( 2 0 1 9 ) 3 6 4 e3 6 9 367

Table 1 e Test of validation of adherence questionnaire.

Item Questions r note
1 Have you ever forgotten to take TB medication? 0.464 Valid
2 Do you take TB medication on time and regularly every day? 0.375 Valid
3 Have you ever reduced or overestimated the amount of medicinal from 0.527 Valid
the amount you should drink?
4. Did you yesterday/the day after taking TB medicine? 0.412 Valid
5 Have you ever forgotten to take TB medicine when traveling or leave 0.474 Valid
home, so you don't take medicine?
6. When you feel better, have you ever stopped take TB medicine? 0.412 Valid
7 When you feel worsen, have you ever stopped drinking TB medicines? 0.375 Valid
8 Have you ever taken TB medication not according to the recommended 0.441 Valid
frequency?
9 Have you ever in intentional not taken TB medicine? 0.469 Valid
10 Have you ever discarded pulmonary TB medicine? 0.476 Valid
11 Have you ever replaced TB medicine given by a doctor with herbal 0.377 Valid
medicine?
12 Do you take TB medicine only when you feel sick? 0.516 Valid
13 Do you immediately come for treatment to take the medicine before the 0.691 Valid
medicine runs out?

Table 2 e Patients' demographics. post-test. There is influence statistically significant giving

counseling and leaflets or counseling to the level of compli-
No Demographics Number Percentage
ance of pulmonary TB patients in taking TB medicine before
1 Gender
and 2 weeks after intervention. On the other hand, in the
Male 41 54.7
control group, the number of patients who adhered to treat-
Female 34 45.3
2 BMI ment at the time of post-test decreased from 19 patients (40%)
Underweight 48 64 to only 6 patients (24%).
Normal 23 30.7 In Table 4 result of KruskaleWallis test shows that p-value
Overweight 4 5.3 is 0.001. It means that there is a statistically difference among
3 Age groups. Post hoc test with ManneWhitney is needed to
25e45 56 74.7
compare among groups and this test shows there is a signifi-
46e55 19 25.3
4 Occupation
cant difference on interventions between counseling with
Private Employees/Employees 37 49.3 leaflets group compare to control group on the level of
Entrepreneur 18 24 adherence to taking TB medication for pulmonary TB patients
Housewife 11 14.7 because the p-value is 0.001 < 0.05. Giving counseling with
Others 9 12 leaflets has an influence on increasing TB patient compliance
5 Education
in taking medicine. Similarly, there is a significant difference
No school 1 1.3
in the impact of giving a counseling intervention to control
Elementary school 10 13.3
Junior School 22 29.4 group on the level of adherence to taking TB medicine for
Senior high school 36 48 pulmonary TB patients because P value is 0.028 < 0.05. In-
Diploma 6 8 terventions between counseling with leaflets compare to
6 Treatment phase counseling interventions on the level of adherence is statis-
Intensive phase 35 46.7 tically significant difference as well with p-value 0.026.
Continuation phase 31 41.3
Regarding this issue, similar results obtained from the
Category 2 9 12
study in Tehran and New Jersey in the year 2016 and 2014
7 Type of medicine
FDC 69 92 respectively which shows counseling patients improves pa-
Anti-TB drugs 6 8 tient's medication adherence and treatment satisfaction and
consequently improves clinical outcomes. Counseling activity
BMI¼Body Mass Index; FDC¼Fixed-Dose Combination.
was beneficial in helping patients understand their medica-
tion.12,23 There are many advantages of pharmacist coun-
seling can be obtained: ensure the safety and effectiveness of
4 respondents (16%) with p-value 0.003. On the other word, treatment, patients get additional explanations about the
the number of adherence patients increased more than two disease, helps solve therapeutic problems in certain situa-
times before and 2 weeks after the intervention of counseling tions, can reduce drug use errors, improve compliance in
and leaflet in 11 patients (44%) to 21 patients (84%). The sig- carrying out therapy, avoid unwanted drug reactions, and
nificant increase of compliance patients was the same as a improve the effectiveness & efficiency of health costs.24 In a
group of counseling intervention with p-value was 0.029. In systematic review revealed that pharmacist education has a
pre-test, 9 patients (36%) were compliance with their TB positive impact on the adherence and completion of pre-
medicines and 14 patients (56%) were adhere in 2 weeks of scribed tuberculosis medications.25 Medication counseling is
368 i n d i a n j o u r n a l o f t u b e r c u l o s i s 6 6 ( 2 0 1 9 ) 3 6 4 e3 6 9

Table 3 e Level of patient compliance in taking medicine before and after the intervention.
No Groups Pre-test Post-test P value
Number Percentage Number Percentage
1 Counseling and Leaflet
Adherence 11 44 21 84 0.003
Non-adherence 14 56 4 16
2 Counseling
Adherence 9 36 14 56 0.029
Non-adherence 16 64 11 44
3 Control
Adherence 10 40 6 24 0.537
Non-adherence 15 60 19 76

Table 4 e KruskaleWallis Test Results Comparison of medicine. Improving adherence is not only patient's re-
Counseling and counseling with leaflets and control on sponsibility, but also it is needed to good cooperation among
medication adherence level. the government, health professionals, community and pa-
No Groups Number Adherence P value tients' family to achieve therapeutic goals, minimize of TB
1 Counseling and Leaflet 25 13 (12e13) <0.001 transmission to the other people, and prevent the occurrence
2 Counseling 25 13 (10e13) of bacterial resistance or multidrug resistance.
3 Control 25 12 (10e13)

KruskaleWallis test. Test of post hoc ManneWhitney: counseling

and leaflet versus counseling p ¼ 0.026; counseling and leaflet Conflicts of interest
versus control p ¼ 0.001; counseling versus control p ¼ 0.028. The
data was in median (minimumemaximum). All authors have none to declare.

one of the key interventions to enhance patients' knowledge

and understanding of their medications and how and why to
Author contribution
take them, hence improving adherence.26
Hidayah Karuniawati
Alternative media additional counseling is needed to make
✓Had the idea of this study and designed the proposal.
it easier for patients to get the information needed to be
✓Developed the protocol.
related to the treatment being undertaken. One alternative is
✓Read and approved the manuscript.
the use of leaflets so that patients can read them wherever
and whenever. Leaflets can help patients improve self-efficacy
and self-management. Improving patient knowledge can in-
crease patient awareness about the disease and risk of com-
Author contribution
plications so that patients become obedient. Similar to a study
Okta Nama Putra
performed by Kayalli in 2014, which was done on 486 patients,
✓Took data from medical record.
patients wanted to receive information orally and in writing.
✓Interviewed patients and gave intervention.
More than half of the patients (60%) read the leaflet and found
✓Entry data and analysis.
it a useful source.
✓Read and approved the manuscript.

5. Conclusion
Author contribution
Compliance with pulmonary TB patients in taking TB medi-
Erindyah Retno wikantyasning
cine needs to be improved by Since counseling give a positive
✓Entry data and analysis.
impact on enhancing patient's compliance to take TB medi-
✓Read and approved the manuscript.
cine, it presents an opportunity for pharmacists to provide
clinical services that utilize pharmacist strength and ensure
positive therapeutic outcomes for patients. One of the phar-
macist services is providing counseling about TB medicine. Acknowledgement
Additional media such as leaflets to improve patient compli-
ance in taking medicine can be considered. Leaflets help pa- This project was financially supported by LPPM Universitas
tients to be obedient because they can be read by patients Muhammadiyah Surakarta through the scheme of PID-772.
wherever and whenever. Leaflets significantly improve pa- The authors also would like to thank to the staffs of TB
tient knowledge. Increased knowledge of patients can in- department at Lung hospitals who assisted and supported
crease patient awareness about the disease and the risk of the authors during the study, the Director of the Lung hos-
complications so that patients become obedient in taking TB pitals, and the staff in the Education and Training for the
 i n d i a n j o u r n a l o f t u b e r c u l o s i s 6 6 ( 2 0 1 9 ) 3 6 4 e3 6 9 369

research permit, panel expert to review the question- 12. Volino LR, Das RP, Mansukhani RP, Cosler LE. Evaluating the
naire and research, and all respondent participated in this potential impact of pharmacist counseling on medication
research. adherence using a simulation activity. Am J Pharmaceut Educ.
2014;78.
13. Taitel M, Jiang J, Rudkin K, Ewing S, Duncan I. The impact of
pharmacist face-to-face counseling to improve medication
Appendix A. Supplementary data adherence among patients initiating statin therapy. Patient
Prefer Adherence. 2012;6:323e329.
Supplementary data to this article can be found online at 14. Shareef J, Fernandes J. Evaluating the effect of pharmacist's
https://doi.org/10.1016/j.ijtb.2019.02.015. delivered counseling on medication adherence and glycemic
control in patients with diabetes mellitus. bJ Diabetes Meta.
2016;07.
references 15. Lim T, Kowalski S, Tan K. Impact of asthma counseling by
pharmacist on asthma control and medication adherence in
Asia. J Allergy Clin Immunol. 2012;129:AB125.
16. M'Imunya JM, Kredo T, Volmink J. Patient education and
1. WHO. Tuberculosis. World health Org; 2018. Available at: counselling for promoting adherence to treatment for
http://www.who.int/news-room/fact-sheets/detail/ tuberculosis. Cochrane Database Syst Rev. 2012. https://doi.org/
tuberculosis. Accessed October 9, 2018. 10.1002/14651858.CD006591.pub2.
2. Tb J. The joint external TB monitoring mission. Kementeri 17. Riwidikdo H. Belajar Mudah Teknik Analisis Data Dalam
Repub Indones. 2017;100. Penelitian Kesehatan (Plus Aplikasi Software SPSS). Mitra
3. Kementerian Kesehatan Republik Indonesia. Pedoman Nasional Cendikia Press; 2007.
Pengendalian Tuberkulosis : Indonesia Bebas Tuberkulosis. 18. Karuniawati H, Wahyuni AS, Mirawati H, Suryani,
(Kementerian Kesehatan Republik Indonesia. Direktorat Jenderal Sulistyarini. Pengetahuan dan perilaku pasien tuberkulosis
Pengendalian penyakit dan Penyehatan Lingkungan; 2014. terhadap penyakit dan pengobatannya. Pros Semin Nas Int.
4. WHO. WHO j Guidelines for Treatment of Tuberculosis; 2010. 2015;0.
Available at: http://www.who.int/tb/publications/2010/ 19. Rao S. Tuberculosis and patient gender: an analysis and its
9789241547833/en/. Accessed October 19, 2018. implications in tuberculosis control. Lung India off. Organ
5. Karuniawati H, Sudjono TA, Utami HN, Pangastuti RA. Risk Indian Chest Soc. 2009;26:46.
Factors for Multidrug Resistant (MDR) in Tuberculosis Patients at 20. Nhamoyebonde S, Leslie A. Biological differences between the
Public Hospitals in Indonesia. 2017 https://doi.org/10.1166/ sexes and susceptibility to tuberculosis. J Infect Dis.
asl.2017.10794. 2014;209:S100eS106.
6. Karuniawati H, Rahmadi GI. Influencing factors of non-adherence 21. Gupta D, Das K. Role of socio-economic factors in tuberculosis
of tuberculosis medication in pulmonary tuberculosis patients at the prevalence. Indian J Tuberc. 2003;6.
Lung Health Center Surakarta. Thesis. Faculty of Pharmacy 22. Mondal MNI, Nazrul HM, Chowdhury MRK, Howard J. Socio-
Universitas Muhammadiyah Surakarta; 2017. demographic factors affecting knowledge level of
7. Khan MA, Mehreen S, Basit A, et al. Characteristics and Tuberculosis patients in Rajshahi City, Bangladesh. Afr Health
treatment outcomes of patients with multi-drug resistant Sci. 2014;14:855e865.
tuberculosis at a tertiary care hospital in Peshawar, Pakistan. 23. Sanii Y, Torkamandi H, Gholami K, Hadavand N, Javadi M.
Saudi Med J. 2015;36:1463e1471. Role of pharmacist counseling in pharmacotherapy quality
8. Morris MD, Quezada L, Bhat P, et al. Social, economic, and improvement. J Res Pharm Pract. 2016;5:132e137.
psychological impacts of MDR-TB treatment in Tijuana, 24. Departemen Kesehatan RI. Pedoman Konseling Pelayanan
Mexico: a patient's perspective. Int J Tuberc Lung Dis Off J Int Kefarmasian di Sarana Kesehatan. direktorat Bina Farmasi dan
Union Tuberc Lung Dis. 2013;17:954e960. Klinik Direktorat Jenderal Bina Kefarmasian dan Alat
9. van den Hof S, Collins D, Hafidz F, Beyene D, Tursynbayeya A, Kesehatan; 2007.
Tiemersma E. The socioeconomic impact of multidrug 25. Fleissner D, Schmitz D, Tran T. A systematic review: the
resistant tuberculosis on patients: results from Ethiopia, impact of pharmacist-delivered patient education on
Indonesia and Kazakhstan. BMC Infect Dis. 2016;16. tuberculosis drug therapy adherence. Adv Pharm J Stud Solut
10. Gebreweld FH, Gebremicheal FE, Simel LL, et al. Factors Pharm Chall. 2017;1.
influencing adherence to tuberculosis treatment in Asmara, 26. Kayyali R. Patients perceptions of medication counselling
Eritrea: a qualitative study. J Health Popul Nutr. 2018;37. from community pharmacies. Pharm Pharmacol Int J. 2016;4.
11. Bhardwaj A, Kumar R, Dabas V, Alam N. Assessment and
Enhancing Adherence to Treatment Regimen in Tuberculosis Out
Patients. vol. 4. 2012:6.