DETERMINANTS OF CLIENTS’ ADHERENCE TO PUBLIC-

PRIVATE MIX (PPMD)TREATMENT

John Carlo L. Divina, MSN, RNCebu Philippines

INTRODUCTION

One-third of the world’s population is infected withMycobacterium tuberculosis, mostly in developing countries,where 95% of the cases occur (Dye et al., 1999).

In 2012, the Philippines has recorded 93, 586 sputum positivepatients which could infect at least 10 – 20 persons a year, ifleft untreated (National Tuberculosis Control Program Manualof Procedure, 2004). Therefore, this major public healthconcern has been set as part of the target of the 6th

Millennium Development Goal which is to reduce theprevalence and mortality of Tuberculosis by half in 2015.

RATIONALE

Non-adherence to treatment may

reduce treatment efficacy and cause drug

resistance, resulting in increased

morbidity and mortality and further

infections (Raviglione et al., as cited by

the ISTC, 2006), hence, the need to

address this challenge.

PROBLEM

1. What are the characteristics of the

respondents categorized as adherent and

non-adherent in terms of the following

variables?

2. Which variables influence adherence toPPMD treatment?

3. Is there a significant relationship between

the selected predictors and the clients’adherence to PPMD treatment?

THEORETICAL FRAMEWORK

NOLA J. PENDER’S HEALTH PROMOTION MODEL

ADHERENCE TO PPMD TREATMENT

METHODOLOGY

Design: Descriptive Correlational

Locale: Mandaue City Health OfficePPMD South District

Respondents: 70 adherent and non-adherent PTB patients

Instrument: PPMD Treatment Adherence Index

RESULTSPercentage of Demographic Profile

60%

91%

94%

77%

69%

46%

66%

57%

83%

91%

63%

46%

31%

60%

0% 20% 40% 60% 80% 100%

Perceived Self-Efficacy: VeryEffective

Without Co-Morbidity

Accessible TB DOTS Unit

Sputum Smear Status :Negative

Income: Php 5,001 - 20,000

Educational Attainment: HSGraduate

Age: Young Adult

V

A

R

I

A

B

L

E

S

Non-Adherent

Adherent

RESULTSMean Scores of the Intrapersonal Variables

3.31 3.26

2.2

3.64

3.09

3.6

2.49

3.69

Perceived Quality ofHealth Services

Perceived SocialSupport

Perceived SocialStigma

Motivation toTreatmentAdherence

VARIABLES

Adherent Non-Adherent

RESULTSPercentage of Side Effects to Treatment

0%

20%

40%

60%

80%

100%

Adherent

Non-Adherent

RESULTSPercentage of Adverse Reactions to Treatment

0%

5%

10%

15%

20%

25%

30%

35%

Adherent

Non-Adherent

RESULTSVariables that Influence and Its Relationship to Adherence

DISCUSSIONQuality of Health Services

Quality of health services with coefficient of 0.476directly influences adherence.

Health care service factors, such as long waitingtimes and inconvenient opening times in clinics,add to economic discomfort and social disruption forpatients and negatively influence adherence (Klink,1969, as cited by Munro, 2007).

DISCUSSIONIncome

Income at coefficient -0.381 inversely influences adherence.

Non-adherence related to high income levels maybe attributed to the increased capacity of thepatient to purchase medications and may notsignificantly rely on the free anti-tuberculosismedications provided by the PPMD unit.

DISCUSSIONPerceived Social Stigma

Perceived social stigma with coefficient of -0.376 likewise indirectly influences adherence.

Stigma makes patients reluctant to attendingtreatment in clinics located in their neighborhoodswhich may lead to non-disclosure of illness, hence,is considered a potential barrier to treatment(Gebremariam et al., 2010).

DISCUSSIONDiscriminant Analysis Coefficient Function

Discriminant analysis coefficient function (D) = income + (2.139 x quality of health services) +

(-0.242 x perceived social stigma)) + -0.388.****

This equation can help discriminate whether apatient with tuberculosis will be adherent or not.However, the model can only explain 33.29% of thetime as reflected in the over-all Wilk’s Lambdascore.

DISCUSSIONOver-all Wilk’s Lambda_Score

66.70 % of the variation cannot be explained by the model at significant p value of 0.024.

The percentage is quite high noting that majority ofthe independent variables does not have a significantrelationship across groups of the dependent variable.Other cofounding variables not evaluated by thisstudy may have bearing on adherence.

DISCUSSIONClassification Results

Classification results which revealed that 72. 94% ofthe respondents were classified correctly intoadherent and non-adherent groups.

Adherent respondents were classified with slightlybetter accuracy (80%) than non-adherent (65.7%).However, cross-validation indicated that 61.4% ofthe group cases were correctly classified, thus, thisdata provided a more reliable function than theoriginal group classification.

CONCLUSION

Income and perceived social stigma

are good screening parameters in

assessing clients’ adherence. Quality of

health services should be considered

when providing treatment since it is a

good determinant of clients’ likelihood oftreatment adherence.

RECOMMENDATIONS

Evaluation Tool – be developed by National

TB Program Managers in Assessing provision

on Quality of Health Services

Frequent Counselling and Assistance – be

readily available to all clients

Future Research – be conducted in a larger

population with more detailed items in the

significant variables and considering other co-

founding variables.

REFERENCES

1. Department of Health. (2004). National tuberculosis control program manual of procedure. Philippines: Department of Health

2. Dye C., Scheele S., Dolin P., Pathania V., RaviglioneM.C.(1999). Consensus statement. Global burden of tuberculosis: estimated incidence, prevalence, and mortality by country. WHO Global Surveillance and Monitoring Project. Journal of American Medical Association,282(7):677-86.

3. Klink, W.B. (1969). Problems of regimen compliance in tuberculosis treatment. New York (NY): Columbia University

REFERENCES

4. Gebremariam, M., Bjune, G., Frich, J. (2010). Barriers and facilitators of adherence to TB treatment in patients on concomitant TB and HIV treatment: a qualitative study. Retrieved from http://www.biomedcentral.com/1471-2458/10/651

5. Munro, Salla et al, (2007). Patient adherence to Tuberculosis treatment: a systematic review of qualitative research. Retrieved from http://www.plosmedicine.org/article/info%3Adoi%2F

10.1371%2Fjournal.pmed.00402386. Pender, N. J. (2006). Health promotion in nursing practice

(5th edition). Singapore: Pearson Education South Asia

REFERENCES

7. Raviglione M, Snider D, Kochi A. (1995). Global epidemiology of tuberculosis : Morbidity and mortality of a worldwide epidemic. Journal of American Medical Association, 273:220-226. Publisher Full Text.

8. Tuberculosis Coalition for Technical Assistance. (2006). International standards for Tuberculosis care (ISTC).The Hague: Tuberculosis Coalition for Technical Assistance

9. World Health Organization. (2003) Adherence to long-term therapies. Evidence for action. Geneva: World Health Organization.

ACKNOWLEDGEMENT

My heartfelt gratitude goes to the

research respondents for their trust and

time, the barangay health workers who

have volunteered their services in

accompanying me to locate the

respondents, the PPMD Nurses who

have assisted me in many ways.

To my colleagues , family and

friends, a million thanks for inspiring me

to reach my dreams.

ABOUT THE RESEARCHER

JOHN CARLO L. DIVINA, MSN, RNResearcher & PPMD Nurse, South General Hospital PPMD Unit

Contact Information:South General Hospital PPMD UnitNational Highway, Tuyan, City of Naga, Cebu, Philippines 6037Cellular Number: +63933 325 2888Email: dvynejc2000@yahoo.com