i

RISK FACTORS FOR TREATMENT DEFAULT AMONG DOTS ENROLLED TB PATIENTS IN BALIWASAN DISTRICT, ZAMBOANGA CITY A RESEARCH PAPER PRESENTED TO THE FACULTY OF THE GRADUATE SCHOOL ATENEO DE ZAMBOANGA UNIVERSITY ZAMBOANGA CITY IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER IN PUBLIC HEALTH BY: DR. REX V. SAMSON APRIL 2007
ii

APPROVAL SHEET
This Research Paper entitled RISK FACTORS FOR TREATMENT DEFAULT AMONG DOTS ENROLLED TB PATIENTS IN BALIWASAN DISTRICT, ZAMBOANGA CITY prepared and submitted by Rex V. Samson, in partial fulfillment of the requirements for the degree Master in Public Health is hereby accepted. Dr. Ricardo N. Angeles Adviser Approved by the Oral Examination Committee with a grade of PASSED. Dr. Rosemarie S. Arciaga Chairman Dr. Fortunato L. Cristobal Dr. Jocelyn D. Partosa Member member Dr. Servando D. Halili Jr. Graduate School Representative ACCEPTED in partial fulfillment of the requirements for the degree Master in Public Health Dr. Servando D. Halili Jr. Dean, Graduate School Ateneo de Zamboanga iii

ACKNOWLEDGEMENT
The researcher would like to thank the following people who in one way or another had been instrumental for the completion of this research endeavor: To Dr. Ricardo Angeles, the researchers research adviser, for the guidance and invaluable insights given since the inception of this study. To Dr. Rodelin Agbulos, for granting the researcher the permission to conduct the study in the four health centers of Baliwasan District. To the Nursing Service Division of the City Health Office, who willingly provided the pertinent records and allowed the researcher access to the files.

To Maam Cory, Maam Elena, Maam Becca and Ate Vivian for the logistic support given through their active BHWs who without reservation accompanied the researcher during the survey. To Maam Rose Page for arranging the schedules for the FGDs. To the respondents of this study, for sharing their experiences and allowing the researcher to delve into their private lives. To the research panel for the positive criticisms and suggestions for the improvement of this paper; To my classmates especially Manang, for the encouragement. To researchers family for the unwavering support and understanding. And most importantly, to the Almighty God for the wisdom, strength, and His faithfulness in the researchers life. To Him is the glory! iv

LIST OF FIGURES Page

Figure 1. CONCEPTUAL FRAMEWORK 8

LIST OF TABLES
Table 1. SOCIO-DEMOGRAPHIC PROFILE OF TB 16 TREATMENT DEFAULTERS AND COMPLIERS IN BALIWASAN DISTRICT Table 2. PERSONAL CHARACTERISTICS OF DEFAULTERS 17 AND COMPLIERS IN BALIWASAN DISTRICT Table 3. COMPARISON OF MEAN KNOWLEDGE 18 SCORES AND PROPORTION OF FAILURES BETWEEN DEFAULTERS AND COMPLIERS IN BALIWASAN DISTRICT Table 4. TREATMENT RELATED CHARACTERISTICS 19 OF DEFAULTERS AND COMPLIERS IN BALIWASAN DISTRICT Table 5. COMMON SIDE EFFECTS EXPERIENCED 20 BY RESPONDENTS IN THIS STUDY Table 6. PREDICTOR VARIABLES WITH 22 CORRESPONDING ODDS RATIO ON UNIVARIATE ANALYSIS Table 7. REGRESSION ANALYSIS USING THE FULL MODEL 24 WHICH INCLUDES ALL IDENTIFIED POTENTIAL RISK FACTORS Table 8. REGRESSION ANALYSIS USING THE FINAL MODEL 25 v

Abstract
This study was conducted to identify risk factors for treatment default among DOTS enrolled TB patients in Baliwasan District, Zamboanga City. Thirty-three (33) treatment defaulters and sixty-six (66) treatment compliers within the last three years were traced and recruited to serve as cases and controls. Data were gathered through a survey using an interviewer administered semi-structured questionnaire and verified through a focus group discussion. Statistical analyses, which involved univariate

analysis and logistic regression, were carried out using SPSS 10 for Windows. Level of statistical significance was set at p-value of 0.05. On univariate analysis, being single (p=0.004), knowledge deficiency (p=0.007), falling below poverty line or being poor (p=0.041), history of travel (p=0.013), experiencing side effects (p= 0.010), and having problem with the tablets (p=0.006) were found to be potentially associated with default. On regression analyses however, only knowledge deficiency (OR= 4.342, 95% CI= 1.415, 13.320), being single (OR=4.246, 95% CI= 1.313, 13.734), and experiencing side effects (OR= 4.031, 95% CI=1.327, 12.244) were found to be strongly predictive of default. It is recommended that health education with special emphasis on treatment duration and side effects be given to all patients upon enrollment in the program and during the course of treatment. It is further recommended that more attention be given to the treatment needs of those who are single who are four times more likely to default from treatment compared to their counterparts. vi

TABLE OF CONTENTS
PAGE APPROVAL SHEET ii ACKNOWLEDGMENT. iii LIST OF FIGURES .. iv LIST OF TABLES.......................................................................................... iv ABSTRACT.... v CHAPTER I THE PROBLEM AND ITS SETTING a.) Background of the Study 1 b.) Related Literature... 2 c.) Statement of the Problem.... 5 d.) Objectives of the Study... 5 e.) Significance of the Study 6 f.) Scope and Delimitation of the study... 6 g.) Definition of Terms.. 7 h.) Conceptual Framework... 8 II METHODOLOGY a.) Research Design 10. b.) Respondents... 10 c.) Sampling Design 11 d.) Data Gathering Procedure.. 11 e.) Research Instrument... 12 f.) Statistical Treatment... 13 III PRESENTATION AND INTERPRETATION OF RESULTS 14 IV DISCUSSION AND IMPLICATION 29 V SUMMARY AND CONCLUSIONS 35 BIBLIOGRAPHY 36 APPENDICES 38 CURRICULUM VITAE 58 1

CHAPTER 1

THE PROBLEM AND ITS SETTING Background of the study

Tuberculosis continues to be a large disease burden in the Philippines. The 2005 WHO global TB report placed the country at number nine in the top ten countries in the world with the highest cases of TB. On that same year, TB ranked 6th in the top 10 leading cause of morbidity and mortality in the country taking a death toll of 78 people per day and afflicting 293 for every 100,000 Filipinos (DOH,2006). To combat the disease, tuberculosis control programs in the world and Philippines had been emphasizing the Directly Observed Therapy Scheme, which was promoted by the WHO and International Union against TB and Lung Disease, in the management of the disease. The current goals are to achieve 85% treatment success rate and 70% case detection among communities. To meet these goals, TB control institutions are faced with the challenge of decreasing treatment non-completion and increasing case detection. In Zamboanga City, the City Health Office had done a good job of bringing the over all default rate down to 3 to 5% and increasing case detection rate from 73 to 92% in the past three years. Certain areas in the city, however, continue to have high defaulting rates and one of these areas is Baliwasan District. Baliwasan District is consistently in the top of the City Health Offices list of areas with the highest treatment default in the last three years, accounting on the average 25% of the citys total defaulters per year. Non-compliance with treatment is strongly associated with poor outcomes such as treatment failure, recurrent TB infections, and most importantly drug resistant TB which 2 is more difficult and costly to treat. In view of this fact and the recent documentation of extremely drug resistant TB in the Philippines, it becomes imperative that all patients undergoing therapy complete their treatment. Defaulting from treatment is a multi-factorial issue that has organizational and socio-economic implications (Chang et al, 2004). The researcher therefore looked into and examined through logistic regression the socio-demographic, treatment related, and personal patient characteristics to find out whether any of these characteristics can be used to predict treatment defaulting under the existing service and social settings in Baliwasan District in the hope of improving the rate of treatment compliance in the said area.

Review of literature
Available literature identified several factors associated with defaulting from DOTS which range from socio-demographic and personal to treatment related factors. The following review summarizes the materials available to the researcher. Knowledge has been cited as one of the major factors contributing to default by most of the studies. The studies in Ethiopia implicated poor awareness about the disease (Belachew et al, 2004) and inadequate knowledge about treatment duration (Ali et al, 2002) as reasons for defaulting. In Zambia, patients were noted to become non-adherent to treatment once they feel better (Kaona et al, 2004) while in Gambia, high rates of defaulting were found among those who were uncertain that their treatment will work (Bah et al, 2005). Uncertainty about treatment success was found to be a very critical factor for defaulting in the first 90 days of treatment. In the Philippines, Blumfeld et al 3 (1999) looked into the correlations between socio-demographic and service factors and

the rate of incomplete treatment and found out that when the infectious nature of the disease and the requisite treatment regimen were explained clearly to the patient, default rates were decreased as much as 50%. Edding (1998) who conducted an interventional study in Sibuco, Zamboanga del Norte likewise found higher compliance in those who received TB education. The study of the PRICOR project of USAID in 1999 also noted that compliers tend to know more about the drug regimen particularly treatment duration compared to defaulters. Another factor implicated with defaulting among DOTS enrolled TB patients is the distance of the residence of the patient from the treatment facility (Belachew et al, 2004). Those who incurred significant time and money costs traveling to receive treatment are most likely to default. Distance of residence from the facility was noted to be critical 90 days after initiation of treatment (Bah et al, 2005). The relevance of social support to defaulting was also tackled in the literature. The lack of family support was found to be strongly predictive of default in the study of Chan et al (2000) in Singapore and Ali et al (2002) in Ethiopia. In Nepal, Bam et al (2006) noted compliance behavior to be closely associated with the social support from family and friends. Social support from health workers however was found to be insignificant. The contribution of treatment side effects to defaulting has been evaluated by studies and there has been conflicting results. Chang et al (2004) in Hong Kong and Ali et al (2000) in Ethiopia find treatment side effects to be associated with default. Soriano (2002) in a qualitative study in Mutia, Zamboanga del Norte likewise stressed that most 4 of those who defaulted did so because of inability to deal with drugs adverse effects. She further stressed that defaulters perceived that the health benefits of undergoing treatment were not worth suffering the negative side effects of the medicine. That long term goals of cure and recovery were disregarded by defaulters for the immediate goal of seeking relief from the discomfort brought about by the side effects of medication. Chan et al (2004) in Singapore and Burman (1997) in Denver USA, however, did not find an association between toxic reactions to drug and default. In Bangalore India, Vijay et al (2003) conducted a retrospective case control study on defaulting among Category 1 and Category 2 patients and found out that male sex and alcoholism are predictive of default. Alcoholism and homelessness were likewise found to be predictive of default in the Denver USA retrospective study by Burman et al (1997) while smoking was found to be significant in Hong Kong. In Nepal, Hansen et al (2005) examined the contribution of socio-economic status to non-adherence to treatment. Results of their study revealed that unemployment, low status occupation, low annual income, and cost of travel to the TB treatment facility are significantly associated with non-adherence to treatment. They concluded that low socioeconomic status and particularly lack of money are important risk factors for nonadherence to treatment in a poor country as Nepal. Chan et al (2004) in Singapore however did not find significant association between employment status and defaulting. In sum, there seems to be a strong support in the literature regarding the predictive value of inadequate knowledge and lack of social support for default. Data on the role of gender, socio-economic status and treatment side effects as predictors of

default were conflicting. Distance of residence from the treatment facility and cost of 5 traveling seem to be important in less developed countries while alcoholism, homelessness and smoking seem to be important in urban areas as predictors of treatment default.

Statement of the Problem

This research will answer the question what are the risk factors for treatment default among DOTS enrolled TB patients in Baliwasan District, Zamboanga City.

General objective
This study aims to identify risk factors for treatment default among DOTS enrolled TB patients in Baliwasan District, Zamboanga City.

Specific objectives
1. To identify socio-demographic characteristics associated with default such as age, gender, civil status, educational attainment, employment status, monthly income, and ethnicity. 2. To identify personal characteristics associated with default such as knowledge about the disease, treatment duration, and side- effects, perceived severity of disease, satisfaction with health center staff/services, experiences of losing hope, stigma, vices such as smoking and drinking and history of travel. 3. To identify treatment related characteristics associated with default such as medication side effects, presence of social support, distance of residence from 6 treatment facility, problem with tablet and not given medicines by the health center, and follow up.

Significance of the study

It takes no more than a single cough or sneeze for an infectious TB patient to infect 10 15 persons in one year who in turn can infect others thereby perpetrating the disease (WHO, 2006). Breaking this vicious cycle therefore entails that every diagnosed TB patient should complete their treatment. It also becomes apparent that identifying persons most likely to default even at the time of enrollment in the DOTS, if feasible, will be a very rewarding endeavor. The result of this study will help health workers identify those patients who are at high risk for treatment default. Once identified, appropriate measures can then be directed to these patients and more attention given to their treatment needs thereby increasing their chances of staying in the program up to treatment completion. The identification of the risk factors for default will also provide health workers and program managers in the area valuable information needed in the development of effective interventions against treatment defaulting, especially in the process of determining those factors that can be changed and those that can only be mitigated, and in the analysis of the pitfalls of the present program in view of the identified risk factors.

Scope and delimitation

This study was limited to the identification of factors specifically sociodemographic factors, personal factors, and treatment related factors that are associated 7 with default among DOTS enrolled patients in Baliwasan District, Zamboanga City. Patients on self administered regimens were excluded from the study. Pediatric patients

were not covered in this research. Lastly, the results of this study may be generalizable only to areas similar to Baliwasan District.

Definition of terms
Baliwasan District a health district in Zamboanga City composed of Barangays Baliwasan, San Jose Gusu, and San Roque Default failure to take anti-TB drugs for at least 2 months under DOTS Drinker any person who consumes at least one bottle of beer or a cup of either liquor or wine per week Follow up pertains to home visitations, text messages, or letters reminding the patient to get medicines from the health center Knowledge deficiency failing in the knowledge quiz Loss hope of being cured disappearance of the conviction that the disease is curable Moslem belonging to either Tausug or Sama ethnic groups Problem with tablet finding the tablets either too big or numerous Received support receiving any of the following from family or friends: encouragement to continue treatment or take medications, reminders to take medicines or continue treatment, financial assistance Risk factor socio-demographic, personal, or treatment related characteristics that is predictive of default 8 Satisfied with health center/staff being contented with the services of the health center or staff Severe disease defined as disease that is life threatening, needs immediate attention, and cannot be ignored Smoker any person who consumes at least 1 stick of cigarette per day Stigma experience of being ashamed, avoided, neglected, or ignored due to having TB Travel going out of Baliwasan District for at least 1 month during treatment Visayan belonging to either Cebuano or Ilonggo ethnic groups

Conceptual framework
The conceptual framework shows that treatment behavior is influenced or shaped by personal, socio-demographic, and treatment related factors. These factors have reciprocal relationships, are interrelated, and may affect behavior positively or negatively. An educated TB patient for example treated under a set up where barriers to service utilization are removed are more likely to comply with treatment than one who have poor knowledge about the disease and is dissatisfied with the services of the health center. The resulting behavior is determined by the ultimate balance of the negative and positive effects of these factors in an individual. Public health interventions therefore are geared towards mitigating the negative effects of these factors in a deliberate effort to promote treatment compliance. These include stringent defaulter recall, extended clinic hours to allow people with work to get medicines, health education, and giving enablers such as food and incentives. (Figure 1) 9

Conceptual framework
Figure 1. Conceptual framework Socio-demographic factors Enablers

Incentives Health Education food Personal factors Treatment related factors Stringent defaulter recall Extended clinic hours Behavior Default/Compliance 10

CHAPTER II METHODOLOGY Research design

A case control design was utilized in this study. This design is the most appropriate for the study considering available time, setting, and purpose of the research.

Respondents
The respondents of this study were TB patients enrolled in DOTS in Baliwasan District, Zamboanga City. Inclusion Criteria: Cases: 1. Must be at least 14 years old 2. A resident of Baliwasan District, Zamboanga City 3. A treatment defaulter within the last 3 years. Controls: 1. Must be at least 14 years old 2. A resident of Baliwasan District, Zamboanga City 3. Completed treatment within the last 3 years. 11

Sampling design
From the TB register, all defaulters for the last three years who can still be located and meet the inclusion criteria were recruited for the study to serve as cases. Patients who completed treatment in the same period who matched the controls with regards to DOTS center and barangay health worker administering the treatment were likewise identified and recruited through convenience sampling to serve as controls. Two compliers were recruited for each defaulter in the case group.

Data gathering procedure

A focus group discussion and individual interviews were conducted among treatment defaulters in one of the DOTS center in the city to find out the reasons for defaulting under the local DOTS set up. A barangay health worker was likewise interviewed to provide a health care provider perspective into the issue and to triangulate data obtained from the defaulters. The results from these FGD and interviews served as the springboard for the formulation of the research instrument which was subsequently processed and made ready for the survey.

The researcher, together with a barangay health worker, traced the respondents of this study to their homes, workplaces, and even the hospital; for one of the respondents who was confined due to hemoptysis; to gather data. The respondents were then interviewed using a semi-structured questionnaire in Filipino specifically constructed to elicit socio-demographic, personal, and treatment related factors that has bearing on treatment defaulting. Each interview approximately lasts for 10 minutes and an average of 7 patients were traced and interviewed in a day. 12 To gain more insight regarding defaulting and to verify the reasons for defaulting stated by the respondents in the individual interview, a focus group discussion was conducted using a guide that specifically ask for reasons for defaulting under the DOTS set-up. The results were then collated and analyzed.

Research instrument
A questionnaire that covers on the socio-demographic, personal, and treatment related factors was formulated in English to serve as research instrument for this study. The questionnaire was formulated based on the results of a focus group discussion and interviews conducted among treatment defaulters and a barangay health worker solely for the purpose of determining the questionnaires content. Factors mentioned in the literature were also considered in the formulation process. The questionnaire was then subsequently submitted to the researchers adviser for editing and face validation. After appropriate corrections were made, the questionnaire was translated to Filipino. To test for clarity, the questionnaire was pretested on six TB patients undergoing treatment at ZCMC DOTS Center and 10 lay people seeking consultation at the OPD section of the same institution. Necessary revisions were then made based on the comments solicited from the respondents of the pretest. To determine the passing score of the knowledge quiz part of the questionnaire, the questionnaire was administered to doctors undergoing residency and in general practice, medical students, nurses and nursing students, criminology and management students, and lay persons to determine the level of difficulty of the exam. After comparing the scores of those respondents with medical (doctors, medical students, nurses and nursing students) and without medical 13 (Criminology, Management students and lay people) background, a 50% passing rate was decided since it is the level of knowledge that is within the fund of knowledge of people without medical background.

Statistical treatment
Univariate analysis was done to identify factors that may have association with defaulting (odds ratio with CI at 95%). Regression analyses were then conducted to look at each factor individually while balancing out all other factors for treatment defaulting. The cut off point was set at p=0.05. Two regression models were constructed for this research. The first is a full model that takes into consideration all the factors regardless of p-value. The second is a condensed model based on the model of regression analysis done by Burman et al (1997) in the US that considers only those factors with p- value of < 0.10 on univariate analysis as covariates. All analyses were carried out using SPSS-10 (SPSS for Windows, SPSS Inc., Chicago, Il, USA). 14

CHAPTER III RESULTS AND INTERPRETATION

There are 372 TB patients registered in Baliwasan District from 2003 to the first quarter of 2006. Forty seven (47) of these patients defaulted from treatment which translates to a default rate of 12.63%. The researcher was able to trace 33 treatment defaulters and 66 compliers for this study.

Socio-demographic profile
Table 1 shows the socio-demographic profile of the respondents in this study. Majority (75.76%) of the respondents belong to the 20 to 39 and 40 to 59 age groups which attests to the fact that TB afflicts people even in their prime years. It can be seen that respondents in the defaulter group tend to fall within the 20 to 39 and >60 age groups while majority of the compliers belong to the 40 to 59 and 20 to 29 age groups. The mean age of the defaulters (45.36 years) however, is not far from the mean age of the compliers (45.77 years). A male predominance was noted in both of the groups. However, there are more married and visayan respondents among the compliers. On the other hand the Zamboangueos were noted to comprise the largest ethnic group among the defaulters. Approximately one third only of the respondents were able to obtain education beyond high school. Almost half (48.48%) of the defaulters and greater than a third (34.85%) of compliers have schooling of up to elementary level only. Overall it can be seen that compliers have higher level of educational attainment compared to defaulters. 15 Majority of the respondents are unemployed, with unemployment slightly more prevalent in the defaulter than the complier group. As a result, the complier group has better earnings than the defaulter group. Average monthly income for defaulters is Php1990.64 and for compliers Php 3400.00. When the poverty line set by NEDA 9 for Zamboanga City (Php 859/person/month) was used to further stratify the respondents as being above or below poverty line, almost one fourth (24.24%) of the defaulters and onetenth (9.09%) of compliers were found to have monthly income that fall below the poverty line. 16 Table 1. Socio demographic profile of TB treatment defaulters and compliers in Baliwasan District Zamboanga City Characteristics Defaulter Complier N=33 (%) N=66 (%) Age Distribution < 20 years 1 (3.03) 0 (0) 20 39 years 14 (42.42) 22 (33.33) 40 59 years 8 (24.24) 31 (46.97) > 60 years 10 (30.30) 13 (19.67) Gender Male 18 (54.55) 42 (63.64) Female 15 (45.45) 24 (36.36) Civil Status Married 18 (54.55) 54 (81.82) Single/widow 15 (45.45) 12 (18.18)

Ethnicity Zamboangueo 13 (39.39) 13 (19.70) Visayan 11 (27.27) 29 (43.94) Moslem 9 (33.33) 24 (36.36) Educational attainment No schooling 0 (0) 5 (7.58) Elementary level 16 (48.48) 23 (34.85) High School level 9 (27.27) 21 (31.18) College level 8 (24.24) 17 (25.76) Employment status Employed 3 (9.09) 9 (13.64) Unemployed 30 (90.91) 57 (86.36) Monthly income < 1 500 Php 20 (60.61) 21 (31.82) 1 501 3000 Php 7 (21.21) 18 (27.27) > 3000 Php 6 (18.18) 27 (40.91) 17

Personal factors
Table 2 shows a comparison of defaulter and complier groups with regards to perceived severity of disease, presence of vices, experience of losing hope of being cured, and history of travel and stigma. It can be seen that there are more smokers, drinkers, and people who experienced losing hope and who traveled during treatment in the defaulter group than in the complier group. There are more compliers, however, who consider their disease severe compared to the defaulters. Table 2. Personal Characteristics of defaulters and compliers in Baliwasan District Personal Characteristic Defaulter n=33 (%) Complier N=66 (%) Perceived disease as severe 5 (15.15) 18 (27.27) Smoker 16 (48.48) 20 (30.30) Alcoholic beverage drinker 13 (39.39) 24 (36.36) Experienced losing hope of being cured 11 (33.33) 17 (25.76) History of travel during treatment 3 (9.09) 0 (0) Stigmatized 10 (30.30) 19 (28.79) 18 Table 3 shows a comparison of the mean knowledge scores and proportion of failures between the two groups. The defaulter group was found to have poor knowledge about the disease and its treatment manifested by a greater proportion of failures and a failed mean score. Noteworthy also of mention was the fact that 66.67% of the defaulters answered yes to an item in the quiz which asks the question If the patient feels well

during treatment, is it okay to stop taking the medications?. On the compliers side, only 30.30% gave the same response. Table 3. Comparison of mean knowledge scores and proportion of failures between defaulters and compliers in Baliwasan District Characteristic Defaulter Complier Mean Knowledge Score 7.76 9.23 Proportion of failures 13 (39.39%) 10 (15.15%)

Treatment related factors

Almost all of the respondents in this study received social support in the form of encouragement, reminders to take drugs, or finances from their family and friends. All of the respondents also did not wait for greater than 1 hour just to get medicine and except for one defaulter, were satisfied with the services of the health center or the staff. There was no great difference between the two groups in the proportion of respondents who were followed up by the BHW when they miss treatment. A great disparity however was noted between the two groups with regards to experience of side effects, problem with tablets, and distance of residence from the health center (Table 4). 19 Table 4. Treatment related characteristics of defaulters and compliers in Baliwasan District Characteristics Defaulter N = 33 (%) Complier N =66 (%) Experienced side effects 14 (42.42) 12 (18.18) Received social support 33 (100) 65 (98.48) Problem with tablets 20 (60.61) 21 (31.82) Lived > 1km from health center 16 (48.48) 16 (24.24) Followed up by BHW 26 (78.79) 57 (86.36) Satisfied with health center services/staff 32 (96.97) 66 (100) Waited greater than 1 hr to get medicines 0 (0) 0 (0) Table 5 shows the side effects experienced by respondents in this study. The most common side effects experienced by both groups is gastrointestinal in nature followed by rashes, feeling weak, dizziness, and other complaints. 20 Table 5. Common side effects experienced by respondents in this study* * Some respondents experienced more than one side effect.

Univariate analysis
To identify those variables that have potential association with treatment defaulting, univariate analysis was done. Of the eight (8) socio-demographic factors evaluated; namely age <40, male gender, being single, belonging to either Zamboangueo, Visayan, or Muslim ethnicities, educational attainment of up to elementary level only, and falling below poverty line; only being single and falling below poverty line were found to be potentially associated with treatment defaulting. Having a history of travel and being knowledge deficient were likewise found to have potential association with treatment defaulting among the personal Side effects Defaulter N = 14 (%) Complier N = 12 (%) Abdominal upset, vomiting, epigastric discomfort 3 (21.43) 6 (50.00) Rashes 2 (14.29) 4 (6.06) Feels weak, sleepy, general body malaise 4 (28.57) 2 (16.67) Dizziness/headache 3 (21.43) 0 (0) Others (chest pain, feels feverish, cramping of hands and legs) 2 (14.29) 1 (8.33) 21 factors examined. Having vices such as being a smoker or a drinker, losing hope of being cured, experiencing stigma, and severe disease perception failed to reached statistical significance on analysis. Lastly, only experiencing drug side effects and having problem with tablets were found to be potential risk factors among the six treatment related factors evaluated. Table 6 shows the predictor variables, the odds ratios, and the corresponding 95% confidence interval of the odds ratios. 22 Table 6. Predictor variables with corresponding odds ratio on univariate analysis Factors p-value Odds ratio 95% CI* Lower Upper Socio-demographic factors Age < 40 0.240 1.667 0.709 3.920 Male 0.383 0.686 0.293 1.063 Single 0.004 3.750 1.483 9.483 Zamboangueo 0.106 2.122 0.844 5.340 Moslem group 0.821 0.813 0.331 1.997 Visayan group 0.248 0.600 0.251 1.434 Up to elementary level 0.774 1.131 0.488 2.623 Below poverty line 0.041 3.200 1.006 10.175 Personal factors Knowledge deficiency 0.007 3.640 1.380 9.599 Perceived disease as severe 0.064 0.341 0.106 1.103 Stigmatized 0.755 0.863 0.341 2.183

Loss hope of being cured 0.752 1.159 0.463 2.906 Satisfied with health center/staff 0.155 0.327 0.246 0.434 History of travel 0.013 3.200 2.378 4.305 Smoker 0.202 1.746 0.739 4.126 Drinker 0.463 1.378 0.585 3.243 Treatment related factors Distance of residence greater 0.879 1.071 0.440 2.609 than 1 km from center Received support 0.477 0.663 0.576 0.764 Experienced drug side effects 0.010 3.316 1.306 8.417 Problem with tablet 0.006 3.297 1.382 7.864 Followed up by BHW 0.122 0.431 0.145 1.277 * Confidence Interval 23

Regression analyses
Two regression models were constructed for this study. The first is a full model while the second is a condensed model based on the regression model of Burman and colleagues (1997) in the US. On model 1, all the 22 variables identified in this study were factored into the analysis regardless of their p-value. Logistic regression identified two sociodemographic and one treatment related risk factors for default. These include being single, a Zamboangueo, and experiencing side effects. No personal factors were found to have predictive value for defaulting. Knowledge deficiency though found to be significant on univariate analysis did not reach statistical significance on unconditional regression. (Table 7) 24 Table 7. Regression analysis using the full model which includes all identified potential risk factors Predictor Variables Odds ratio 95% CI p-value Lower Upper Socio-demographic: Age < 40 1.595 0.381 6.675 0.523 Male 0.847 0.199 3.612 0.823 Single 4.246 1.029 17.516 0.045 Visayan 0.908 0.215 3.830 0.895 Zamboangueo 5.910 1.076 32.480 0.041 Muslim 1.101 0.261 4.646 0.895 Up to Elementary level 1.338 0.346 5.167 0.673 Unemployed 1.349 0.140 13.018 0.796 Poor 0.950 0.415 6.239 0.957 Personal factors: Perceived disease as severe 0.320 0.060 1.696 0.180 Knowledge deficiency 3.509 0.966 12.747 0.056 Stigma 1.959 0.438 8.757 0.379 Received support 657.123 0.000 1.852 0.915 Loss hope 1.085 0.262 4.490 0.911

History of travel* 24323.528 0.000 2.52 x 1028 0.731 Satisfied with health center 0.000 0.000 5.682 0.888 Services/staff Smoker 1.031 0.208 5.109 0.970 Drinker 2.236 0.413 12.098 0.350 Treatment related: Lived >1 km from the 0.722 0.186 3.209 0.722 health center Side effects 4.686 1.301 16.879 0.018 Problem with tablet 3.355 0.798 14.107 0.99 Follow up 0.404 0.081 2.107 0.269 *Only three respondents 25 On model 2, seven variables with p-value < 0.10 were considered as covariates. These include single marital status, being poor/below poverty line, having history of travel, perceiving disease as severe, knowledge deficiency, experiencing side effects, and having problems with the tablets. Three of the seven variables mentioned were found to be associated with four folds risk of treatment defaulting on conditional regression. These are being single, knowledge deficiency, and experiencing side effects. (Table 8) Table 8. Regression analysis using the final model* Predictor variable Odds ratio 95% CI Lower Upper p-value Single 4.246 1.313 13.734 0.016 Poor 0.867 0.175 4.294 0.861 Knowledge deficiency 4.342 1.415 13.320 0.010 Perceived disease as severe 0.416 0.108 1.605 0.203 History of travel# 6833.246 0.000 9.93 x 1020 0.661 Side effects 4.031 1.327 12.244 0.014 Problem with tablet 1.882 0.655 5.411 0.241 *Final model only includes as covariates variables with p-value < 0.01 on univariate analysis # Only three respondents. 26

Focus group discussion

To gain more insight about treatment defaulting under the existing local set up of DOTS and to verify reasons for default given in the individual interviews, a focus group discussion among treatment defaulters was conducted in the area. The patients appear to have adequate knowledge of the procedures involved in the diagnosis of tuberculosis which is evident in their response to the question What do you know about the treatment of TB? Responses collated include: You go to the doctor, have an X-ray taken, give the results to the doctor and then its up to them to determine whether you have the disease or not. I underwent sputum examination and I brought my result to the health center. They also know about the duration of the treatment. I know that it is 6 months that is why I regret that I stopped treatment. In fact, one of the patients alluded to the fact that

they are informed about the duration of the treatment upon enrollment, before we are given medicines, it was explained to us. The reasons for defaulting given by the patients ranged from personal to treatment related. When asked why they stopped taking medicines the following responses were given: I thought I was cured already. I stopped taking medicines because I went to the mountains. I stayed there for three months. When I came back they wont give me medicines because they said that I stopped taking medicines. They gave me a referral to the city health I was told to 27 waitI went back to the health center and I was told to wait for the doctorI went home and did not come back. ... because of our work, we sometimes tend to forget about taking medicines. people will conceal their disease that is why they wont get their medicines. A portion of the patients in the focus group experienced side effects such as dizziness and epigastric discomfort and found the tablets too big. They however believed that side effects and problem with tablet is not a major factor for default. They also believed that perceived severity of the disease doesnt have bearing on defaulting and that social support is important. According to the respondents, Its really good to have support. if there is no support you will forget to take your medicines. If I have no support I wont have something to eat. All the patients were optimistic to be cured. When asked by the researcher if ever they experienced losing hope majority answered no. One added that he did not loss hope because he wanted to get well and the other said that he was optimistic. When asked if they think losing hope can result to default one of the respondents jokingly said, Maybe sir he wants to die that caused the whole group to laugh. When pressed further with the question and if he wants to die he replied, he wont take his medicines. With regards to follow up, the group did not come to a consensus. Some believed that follow up is important while others discounted its role in their defaulting experience. At the end of the discussion, the group was asked to give an advice to people undergoing treatment. The following are the responses given: There should be follow up. The center follow up the patient, the patient follow up at the health center so that they can be given proper attention. 28 Same as his advise (smiles). They should go to the health center everyday. If you want to get well go to the health center to get your medicines and consult the doctor. Consult the doctor if you feel that you have the disease so that your disease will not get severe. Dont be ashamed otherwise you will die without a fight. 29

CHAPTER IV DISCUSSION AND IMPLICATIONS

Defaulting from treatment has been one of the major obstacles to treatment management and an important challenge for TB control. Inability to complete the prescribed regimen is an important cause for treatment failure, relapse, acquired drug resistance and on-going transmission of infection. Over the years there has been

increasing emphasis on DOTS to ensure adherence, wherein each dose of treatment is given under the observation of a health worker. The adoption of DOTS has given impressive results with higher treatment success being reported from developing and industrialized countries. Yet default continues to occur in certain situations and is a matter of concern (Vijay et al, 2003). The default rate in Baliwasan district of 12.65% is substantially higher than the relapse rate after an effective course of treatment which is approximately 1 2 % over a period of 2 years (Chang et al, 2004). This figure, however, is not far from those figures obtained in Hong Kong (8%), Ethiopia (11.6%), and India (15%). This variability in the defaulting rate obtained across communities can be explained by the different implementation strategies utilized by TB program managers in each respective areas and the differing socio-economic context upon which these strategies were carried out. DOTS facilities in Hong Kong, for example, have extended clinic hours to facilitate patient attendance and to allow patient to continue with their employment or other daily activities. Financial incentives and economic support were also provided for those in need and should a patient miss a dose, they are immediately followed up by the staff. In contrast, TB patients in Baliwasan District have to fend for themselves financially and the 30 defaulter recall is not as stringent as in Hong Kong. It is therefore evident why Hong Kong has a lower default rate. Major reasons for stopping treatment given by respondents of this study were feeling well during treatment (52.94%), drug side effects (17.65%), going somewhere (8.82%) and others (20%) such as stigma, busy with work, not given medicines, no more money for transportation, vices and told by quack doctors to stop treatment. This finding is similar to the finding of Kaona et al (2004) in Zambia where TB patients stopped taking their drugs when they started feeling well, feel that TB drugs were too strong, and loss hope to live, run out of drugs and lack of food at home. These findings highlighted the multifactorial nature of treatment defaulting. As pointed by Chang et al (2004), treatment defaulting is a multifactorial issue that has organizational and socio-economic implications. Majority (58.58%) of the respondents in this study fall within the 20 to 59 years age range. This reflects the natural but unexplained high incidence of TB in the late adolescence and early adulthood. The mean age also of the respondents in this study is not far from those obtained by Chang et al (2004) in Hong Kong (49 years). It can be surmised therefore that with respect to age, the respondents in this study are comparable with their foreign counterparts. Compliers tend to have a higher monthly income compared to defaulters. This is consistent with the findings of Hansen et al (2005) who analyzed the contribution of socio-economic status to treatment adherence in Nepal. He found out that low socioeconomic status, particularly lack of money is an important risk factor for non-adherence to treatment. One reason that could account for the defaulting among those who belong 31 to the lower economic strata is the nature of their work. As the respondents in the FGD put it: ...because if you are working you will forget about your medications. You become busy and the nature of our work is heavy. Good if you have a light job and you

just sit. You still have time to think about your medicines. But with us, we are just laborers, its difficult and it will really affect out taking medicines. ...we cannot just leave our job and take medicines. We will be reprimanded. We have to finish our work first thats why we cannot drink our medicines on time. ...because of our work we sometimes tend to forget about taking medicines. Majority (90.09%) of the defaulters are involved in works such as carpentry, vending at the public market, farming, stevedoring, and being hired laborers that involved manual labor keeping them preoccupied and making them forget about treatment. On top of the preoccupation, they have to leave early for work precluding them from getting the tablets from the health center which usually opens at 8 oclock in the morning. They perceived that the treatment program did not fit into their everyday life creating a condition favorable to default. It is perhaps due to this very same circumstance why married respondents in this study fare better than their single counterparts. Spouses can help remind patients to take their medicines or get the medicine for them from the health center. Married respondents therefore have an additional support system that can mitigate the perceived inconvenience of DOTS thereby increasing their chance of completing treatment. A large portion (66.67%) of defaulters believed it is okay to discontinue treatment once they feel better. As verbalized by one of the respondents, I stopped taking 32 medicines because I feel well already. This belief stems from an erroneous assumption of equating cure with disappearance of symptoms and is reflective of their poor knowledge about the disease, its transmission, and treatment. In fact, the mean knowledge score of the group is below the set passing level. Kaona et al (2004), Vijay et al (2003), Bam et al (2006) also came up with the same finding. As pointed by Bam et al (2006), defaulters have insufficient knowledge about the need to take daily treatment especially after they felt better. Noteworthy also of mention is the finding that some of the respondents stopped taking medicines because they were told to do so by quack doctors. Although this finding also reflects poor awareness or knowledge about the disease in the part of the patient, it importantly brings to light the role of culture in shaping the health seeking behavior of an individual. Health programs therefore should be sensitive to the cultural milieu of the place where it is to be implemented in order for such programs to succeed. Adverse reactions to drugs are expected to influence adherence to treatment. In this study 17.65% succumb to the discomfort brought about by the drugs and discontinued treatment. Soriano (2002) aptly put to words how drug reactions contribute to defaulting. Patients perceived that the health benefit of undergoing treatment were not worth suffering the negative side effects of the medicine. Long term goals of cure and recovery were disregarded for the immediate goal of seeking relief from the discomfort brought about by the side effects of medication. Compounded with poor knowledge about the disease, it is not surprising why many patients default. More than half of the defaulters had a problem with the tablets. They either find the tablets too big or too many. As pointed out by a respondent, I can barely swallow it. 33 I feel like choking. Dandona et al (2004) in India also noted these complaints especially among female patients who default in the intensive phase. Though there was a

significant difference in the number of defaulters who had problems with the tablets in this study, no respondent admitted quitting treatment due to the size or number of tablets to be taken. Univariate analysis however finds problem with tablet a potential risk factor for default. A small portion of the defaulters have a history of travel during treatment. All of these defaulters who traveled did not coordinate with the DOTS center before leaving and ran out of drugs. There being no coordination with their DOTS center provider, these people were barred from asking drugs from the health center near the area they visited which led to default. This stresses the need for health providers to constantly remind their patients to coordinate with them should their patients need to go somewhere else. To identify those factors potentially associated with default, univariate analysis was done. Six factors emerged to be potentially associated with three folds risk of default. These include single marital status, falling below poverty line, knowledge deficiency, experiencing side effects, problem with tablet and history of travel. These are the very same attributes where the two groups differ significantly. To look into the abovementioned factors individually while balancing out the other factors for default, logistic regression was done. Results of regression analyses revealed four risk factors for treatment default under the existing service and social settings in Baliwasan District Zamboanga City. These include knowledge deficiency, being single, and experience of side effects. Of these four risk factors, being single and experiencing side effects consistently demonstrated statistical significance both on 34 conditional and unconditional regression. These two factors therefore are the strongest of the four predictors of default identified. 35

CHAPTER V SUMMARY, CONCLUSION, AND RECOMMENDATION

In summary, the study examined under a case control research design factors related to treatment, socio-economics, and the patient to identify risk factors for treatment default among DOTS enrolled TB patients in Baliwasan District, Zamboanga City. Results showed that with respect to the twenty-two (22) variables evaluated in this study, defaulters and compliers differ in the following aspects: civil status; knowledge about the disease, its treatment, and side effects; monthly income; problem with tablet; experience of side effects; and history of travel. Regression analyses however revealed that only knowledge deficiency, being single, and experiencing side effects were strongly associated with default. The researcher therefore recommends that health education with special emphasis on treatment duration and side effects be given to all patients upon enrollment in the program and during the course of treatment. It is further suggested that more attention be given to the treatment needs of single patients who are undergoing treatment for they are four times more likely to default than their counterparts. 36

BIBLIOGRAPHY
Acharya, A. et al. (2003). Non-adherence to tuberculosis treatment in the Eastern Tarai of Nepal. International Journal of Tuberculosis and lung Disease.2003 April; 7(4): 327-35

Ali, A., Mariam, D.H., Tekle, B. (2002). Defaulting from DOTS and its determinants in three districts of Arzi Zone in Ethiopia. International Journal of Tuberculosis and Lung Disease, 6(7), 573-9. Retrieved from Pubmed data base Nov. 2006 Bah, J., Donkor, S.A., Hill, P.C., Hill, S., Jallow, A., Lienhardt, C. (2005). Risk factor for defaulting from tuberculosis treatment: a prospective cohort study of 301 cases in Gambia. International Journal of Tuberculosis and Lung Disease, 9 (12), 13491354. Retrieved from ingentaconnect data base Nov. 2006 Bam, T. et al. (2006). The relationship between social support and patient compliance with DOTS in Kathmandu urban areas, Nepal. International Journal of Tuberculosis and Lung Disease. Vol. 10 (3): 270-276. Belachew, T., Michael, K.W., Jira, C. (2004). Tuberculosis defaulters from the dots regimen in Jimma Zone Southwest Ethiopia. Ethiopian Medical Journal 42(4), 247 53. Retrieved from Pubmed data base. Nov. 2006 Blumenfeld et al. (1999) Application of Systems Analysis to identify Service quality problems in the Philippine National Tuberculosis control program. Reducing treatment default among Tuberculosis patients in the Philippines. USAID data base Burman, J. et al. (1997). Non-compliance with directly observed therapy for TB. Epidemiology and effect on the outcome of treatment. Chest, 111, 1168-1173 Chang, K.C., Leung, C.C., and Tam, C.M. (2000).Factors for defaulting from antituberculosis treatment under directly observed treatment in Hong Kong. International Journal of Tuberculosis and Lung Disease. 8 (12), 1492-98. Retrieved from Ingentaconnect data base.Nov. 2006 CHO Zamboanga City. Nursing Service Division Dandona, R et al. (2004). Gender differentials in the revised national tuberculosis control programme. Center for Public Health Research India DOH (2006). TB Control 2006 2010: Summary. Retrieved from DOH Philippines data base 37 Edding, A. (1998) SCC compliance in TB education. (Unpublished thesis). Ateneo de Zamboanga University School of Medicine. Hansen, E et al. (2005) Socio-economic status and adherence to tuberculosis treatment: a case control study in a district of Nepal. International Journal of Tuberculosis and Lung Disease 2005 Oct; 9(10):1134-9 Kaona, F., Sikaona, L., Siziya, S. (2004). An assessment of factors contributing to treatment adherence and knowledge of TB transmission among patients on TB treatment. BMC Public Health 4: 68. Retrieved from Biomedcentral data base Nov. 2006 Soriano, H. (2002) The perception of NTP-enrolled TB patients and community members on the socio-behavioral issues of PTB. (Unpublished thesis). Ateneo de Zamboanga University School of Medicine. USAID,2006. Philippine TB profile.http//www.usaid.gov/our_work/global_health/id/tuberculosis/countries/ane /Philippines_profile.html Vijay, S., Balangsameswara, V.H., Saroja, V.N., Kumar, P. (2003). Defaults among tuberculosis patients treated under DOTS in Bangalore City: A search for solutions.

Indian journal of Tuberculosis, 50,185. WHO Global TB Report 2006. Retrieved from WHO data base November 2006 38

APPENDIX A English questionnaire

Name: __________________________Age:_______ Gender________________ Civil Status:_________ Religion:______________ Ethnicity/tribe:___________ Occupation:_______________ Highest educational attainment:______________ DOTS center:______________________ Monthly income:______________ Knowledge about TB 1. Can TB be caused by too much heavy work? ( ) yes ( ) no ( ) I dont know 2. If a person is already cured, can he still spread the disease? ( ) yes ( )no ( ) I dont know 3. Can TB spread through overcrowding? ( ) yes ( ) no ( ) I dont know 4. Can TB be acquired from sharing cups with persons who have TB? ( ) yes ( ) no ( ) I dont know 5. Can cigarette smoking cause TB? ( ) yes ( ) no ( ) I dont know 6. Can TB be contracted through drinking unclean water? ( ) yes ( ) no ( ) I dont know 7. If a person has long standing cough but does not cough out blood, should he be suspected of having TB? ( ) yes ( ) no ( ) I dont know 8. Can TB cause weight loss? ( ) yes ( ) no ( ) I dont know 9. Can TB be cured by medication? ( ) yes ( ) no ( ) I dont know Treatment 1. For how long should the drugs for TB be taken? _______________________ 2. If the patient feels well during treatment, is it okay to stop taking the medications? ( ) yes ( ) no ( ) I dont know 3. Will TB recur if required treatment duration is not completed? ( ) yes ( ) no ( ) I dont know Side effects 1. Can we attribute joint pains during treatment to the anti-TB drugs? ( ) yes ( ) no ( ) I dont know 2. Is it possible for patients undergoing treatment to experience orange tears? ( ) yes ( ) no ( ) I dont know 3. Is it possible for patients undergoing treatment to experience eye problems? ( ) yes ( ) no ( ) I dont know 39 4. Is it possible for patients undergoing treatment to experience yellowing of the eye? ( ) yes ( ) no ( ) I dont know Perceived severity 1. When you were undergoing treatment, how do you view the severity of your disease? ____________ Mild: does not need immediate attention : Not life threatening : may be ignored _____________severe: needs immediate attention

: Life threatening : should not be ignored Stigma 1. Were you ashamed because you have TB? ( ) yes ( ) no 2. Have you experienced being neglected because you have TB? ( ) yes ( ) no 3. Have you experienced being ignored because you have TB? ( ) yes ( ) no 4. Have you experienced being avoided by people because you have TB? ( ) yes ( ) no Side effects 1. Did you experience medication side effects? ( ) yes ( ) no 2. If yes, what side effects? ______________________________________________ _____________________________________________________________________ _____________________________________________________________________ ` Losing Hope: 1. Have you experienced losing hope of being cured? ( ) yes ( ) no Social support 1. Were you encouraged by your family to finish the treatment? ( ) yes ( ) no 2. Were you constantly reminded by your family to take your medicine? ( ) yes ( ) no 3. Did you receive financial support from your family? ( ) yes ( ) no 4. Did you receive emotional support from friends? ( ) yes ( ) no 5. Did you feel that you are supported by your family? ( ) yes ( ) no 6. Did you feel that you did not receive enough support during treatment? 40 Distance 1. How far is your house from the health center? ___________< 1 KM __________> 1 KM Service Delivery 1. Were you followed-up by your treatment partner? ( ) yes ( ) no ( ) I dont know 2. On the average, how much time you spent waiting at the health center to get medicine? _______ < 1 hr ________ > 1 hr Satisfaction with the Health center/staff 1. Were you satisfied with the service of your treatment partner? ( ) yes ( ) no 2. Were you satisfied with the service of the health center? ( ) yes ( ) no Size and number of tablets 1. Did you feel that the tablets are just too big? ( ) yes ( ) no 2. Did you feel that the number of tablets you have to take are just too numerous? ( ) yes ( ) no Were you a smoker when you were still undergoing treatment? ( ) yes ( ) no Were you a drinker when you were still undergoing treatment? ( ) yes ( ) no Did you travel outside Baliwasan District for at least a month when you were still under treatment? ( ) yes ( ) no Did you stop taking medications for TB for at least 2 months? ( ) yes ( ) no If yes, Why? ________________________________________________________________________

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 41

APPENDIX D Filipino questionnaire

Pangalan: ________________________________________ Edad:____________ Kasarian: ___________________ Estado sibil:___________Relihiyon: ________ Tribu:_________________________ Natapos:_______________________ Trabaho: _____________________________ Kita sa isang buwan:____________ DOTS CENTER: ____________________ 1. Ang TB ba ay nakukuha dahil sa palagiang mabigat na trabaho? ( ) oo ( ) hindi ( ) di ko alam 2. Kung ang taong may TB ay nakumpleto na ang gamotan at magaling na, pwede pa ba siyang manghawa ng iba? ( ) oo ( ) hindi ( ) di ko alam 3. Ang TB ba ay pwedeng kumalat dahil sa siksikan sa bahay? ( ) oo ( ) hindi ( ) hindi ko alam 4. Ang TB ba ay pwedeng makuha sa pamamagitan ng pag inum mula sa mga basong ginamit ng mga taong may TB? ( ) oo ( ) hindi ( ) hindi ko alam 5. Maaari ka bang magka-TB dahil sa paninigarilyo? ( ) oo ( ) hindi ( ) di ko alam 6. Makukuha ba ang TB mula sa pag-inum ng maruming tubig? ( ) oo ( ) hindi ( ) hindi ko alam 7. Kung may tao na matagal na ang ubo subalit di naman dumudura ng dugo, dapat ba siyang pagsuspetsahan na may TB? ( ) oo ( ) hndi ( ) hindi ko alam 8. Nakakapayat ba ang TB? ( ) oo ( ) hindi ( ) hindi ko alam 9. Gagaling pa ba ang TB pagginamot? ( ) oo ( ) hindi ( ) hindo ko alam Gamotan: 1. Gaano ba katagal ang gamotan ng TB?______________ 2. Kung ang taong may TB ay bumuti na ang pakiramdam habang umininom ng gamot, pwede na bang tigilan ang gamotan kahit di pa nya nakompleto ang anim na buwan? ( ) oo ( ) hindi ( ) hindi ko alam 3. Pwede bang magka TB ulit ang taong ginagamot sa TB kung hindi niya natapos ang naitalagang panahon ng gamotan? ( ) oo ( ) hindi ( ) hindi ko alam Side effects 1. Epekto ba ng gamut sa TB ang panankit ng mga joints? ( ) oo ( ) hindi ( ) hindi ko alam 2. Posible bang makaranas ng pagiging kulay orange ng luha ang mga taong umiinum ng gamot para sa TB? ( ) oo ( ) hindi ( ) hindi ko alam 3. Pwede bang makaranas ng problema sa mata ang mga taong umiinom ng gamot laban sa TB? ( ) oo ( ) hindi ( ) hindi ko alam 4. Pwede bang makaranas ng paninilaw ng mata ang mga taong umiinom ng gamot para sa TB? ( ) oo ( ) hindi ( ) hindi ko alam 42 Severity 1. Noong ginagamot ka pa sa TB, sa iyong paningin, gaano kalala ang inyong sakit?

________hindi grabe: di kailangang bigyan agad ng pansin : di mapanganib : pwedeng pabayaan lang _________grabe: kailagang bigyan agad ng pansin : lubhang mapanganib : di dapat pabayaan Stigma: 1. Nahiya ka ba dahil nagkaroon ka ng TB? ( ) oo ( ) hindi 2. Naranasan mo bang hindi pinansin dahil may TB ka? ( )oo ( ) hindi 3. Naranasan mo bang iniwasan ka ng mga tao dahil sa pagkakaroon mo ng TB? ( ) oo ( ) hindi Side effects: 1. Nakaranas ka ba ng side effects ng mga gamot sa TB? ( ) oo ( ) hindi 2. Kung oo, anong side effect?___________________________________________ _____________________________________________________________________ _____________________________________________________________________ Losing hope 1. Naranasan mo bang mawalan ng pag-asa na gumaling pa habang ikaw ay ginagamot? ( ) oo ( ) hindi Social support 1. Inincourage ka ba ng mga kapamilya mo na tapusin ang gamotan? ( ) oo ( ) hindi 2. Lagi bang pinapaalala ng iyong pamilya ang paginom ng gamot? ( ) oo ( ) hindi 3. Nakatanggap ka ba ng tulong pinansyal mula sa iyong pamilya? ( ) oo ( ) hindi 4. Nakatanggap ka ba ng supporting emosyonal mula sa iyong mga kaibigan habang ginagamot ka sa TB? ( ) oo ( ) hindi 5. Naramdaman mo bang sinuportahan ka ng iyong pamilya habang gingamot ka sa TB? ( ) oo ( ) hindi 6. Naramdaman mo bang hindi sapat ang soporta na natanggap mo habang ikaw ay ginagamot sa TB? ( ) oo ( ) hindi Naninigarilyo ka ba noong ikaw ay ginagamot pa? ( ) oo ( ) hindi Umininom ka ba ng alak noong ikaw ay ginagamot pa? ( ) oo ( ) hindi 43 Bumiyahe ka ba palabas ng Baliwasan District na nagtagal ng di kumulang isang buwan noong ikaw ay ginagamot pa sa TB? ( ) oo ( ) hindi Distance 1. Gaano kalayo ang inyong bahay mula sa health center? _______<1 km _____>1km Service Delivery 1. Finalow- up ka ba ng BHW sa mga pagkakataong hindi ka sumipot upang magpagamot? ( ) oo ( ) hindi 2. Kadalasan, gaano ka katagal naghintay sa health center upang makakuha ng gamot?______________ Satisfaction with health center/staff 1. Kuntento ka nab a sa serbisyo ng kapartner no na Barangay Health Worker? ( ) oo ( ) hindi 2. Kuntento ka na ba sa serbisyo ng center? ( ) oo ( ) hindi Size and number of tablets

1. Sa palagay mo , masyado bang malaki ang mga tableta na ininom mo para sa TB? ( ) oo ( ) hindi 2. Sa palagay mo, masyado bang marami ang mga tabletang iniinom mo para sa TB? ( ) oo ( ) hindi Tumigil ka ba sa pag-inum ng gamot ng pinakamababa 2 buwan? ( ) oo ( ) hindi Bakit? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ 44

APPENDIX C Transcripts of FGDs and interviews

Interview for Questionnaire Formulation Q1. How long have you been a BHW? A1: 24 years. Q2: Here in Tumaga only? A2: Yes. Q3: Base on your experience , who are those people who usually default from PTB treatment? A3: The people who usually default from treatment are those who have no schooling. They default from treatment maybe because it was not properly explained to them because I can see that with proper explanation there is less defaulting. Before, well, you know how numerous the patients that are consulting in the health center. That is probably why it was not properly explained to them. There are also those who are really hard headed. Q4: So those who usually default are those who were less educated? A: those who were less educated. Those who cannot understand. Q5: How about those professionals? A5: The professionals they really comply with treatment. Those who are relatively well off in life. You know TB does not distinguish between rich and poor. Sadly, those who are relatively well off are the ones complying with treatment and those who are poor are lazy. Q6: What do you mean by lazy? A6: Sometimes maybe because of the distance. Q7: Distance of the house from the health center? A7: Yes, the distance of their residence. But I think if they are really interested, they would really get their medicine. In fact, these people at times have neighbors on DOTS who really would come to get their medicine. Q8: So you think that distance really is a factor for default? A8: Yes, I think so because you know, Tumaga is a big area. Q9: What are the other things youve observed? A9: There are those who have pride. They dont want their neighbors to know. Q10: You mean ashamed? 45 A10: Yes, They are ashamed that people will know that they have the disease but it

should be explained to them that they need not be ashamed because it can be prevented and cured. Q11: How about those with permanent jobs? Are they more compliant lets say compared to laborers? A11: Sometimes but not at all times. They have their own varied reasons. Some would let other members of the family come and get their medications maybe because of shame. Q12: How about the age? A12: There are lots of elderly TB patients here but their relatives or family members would get the medicines for them. Q13: I mean compared to older Patients how do the younger ones fare? A13: I have observed that those who are younger would just take their medicines for approximately 2 months and not continue to the maintenance phase because they by then feel well. They have good appetite and sleep so they stop but if you explain it properly, well, I scare them that if they will come back here serious thats why they come back.. Q14: In your experience what are the reasons they gave you why they stop treatment? A14: There are those who say they are allergic to the medicine. They should come even if they are allergic because we will find ways for them to continue treatment. Q15: Allergic you mean they experienced something like side effects perhaps? A15: Yes, there are those who developed red rashes. There are those who feel that they are always hungry. I tell them to eat because its due to the medicine. There are also who are really allergic to the medicines. Q16: How about those side effects such as red urine, numbness, were there people who stopped taking medicine because of these? A16: There are some also. Well, I tell them thats just because of the medicine. Q17: What else? A17: As I have said earlier, those who feel better. When we follow up they dont want to take the medicine because they say that they are feeling better. Thats why they stop. There are also those who dont like because when they come to the health center they will not be entertained immediately because there are lots of patients. They want to be entertained first. They dont want to wait. They go home. Thats why we scheduled Monday solely for them. They complain that they are not given medication immediately that is why Monday is for them. Q18: So you mean there are patients who default because they dont want to wait and feel bad about the service of the health center? A18: Yes, there are some. There are even those who just live near the center. They just took the medicine for 1 week and stopped. 46 Q19: How about the severity of the disease? A19: Not really but I think some stop treatment because we advise them not to smoke and drink. Well they would like to smoke and drink. Some dont come back. Q20: So those with vices? A20: Yes, when we weigh them they either dont gain weight or loss weight. When we ask them if they continue to smoke or drink they tell us yes. We tell them to stop their vices they dont come back. Q21: Do these people know that they have to take the medicine for 6 months? A21: Yes, before they were given medicines it was explained to them that the treatment

lasts for 6 months not 2 not 3. The 6 months should be completed. They know that. It was also explained to them that they should come here everyday to get their medicines because of DOTS. Q22: Have you observed certain tribes to be more of a defaulter example more chavacanos default than visayans? A22: usually muslims. Transients from Basilan, Jolo. Bu there are also compliant muslims. It also depends on their treatment partner to follow up because they have treatment partner. Q23: Do you think these people who default were supported by their family? A23: I think so but I think it is really the patient who really dont cooperate. There are some here whose family member came here to get the drugs but the patient refused to take the drug. Some refuse to take or stopped taking the drug maybe because of the size of the tablets. Q24: the size of the tablets? A24: yes and the number of the tablets. The number of the tablets to be taken depends on the weight. There are some here who need to take 5 tablets and would bargain to take four instead. I tell them its not possible. Q25: What do you think should the health center or the family do so that TB patients will be able to complete treatment? A25: if you have TB patient, you should visit the patient and explain one on one, because if you ask them to come they wont. It should be explained also to the family so that they can help remind the patient to take the medicines. Q26: Is there anything you would like to add? A26: none Ok. Thank you for your time. 47 Focus group discussion for questionnaire formulation Introduction Informed consent Discussion proper Q1: What do you think are the reasons why people stop taking their anti-tb medications? Based on your experience? R1: I stopped taking the treatment drugs because I feel okay after I month of treatment. R2: You know, I am not from here. I just stayed with a relative. I went home to Bongao and after 5 months a cousin went there and brought me back to Zamboanga. I resumed treatment at the health center. R3: In my experience, I was so complacent. I did not know that if you stop treatment the disease will recur. After about two months taking treatment I started to feel lazy. My going to the health center to get medicine become infrequent and I feel that I am better. I dont cough as much so I stopped. Little did I know that the disease recurs if you stop taking the drugs. R4: I did not voluntarily stop. The health center did not give me medicines. Q2: why were you not given medicines? R1; I dont know. Q3: Do you think the distance of the residence from the health center is one of the reasons why people stop going to the health center to take medications?

R1.Sometimes Dr, there are people who are lazy. They are lazy thats why they dont get their medicines. Q4: Before what do you know about TB treatment? R1: consult the doctor, have your sputum checked, have an x-ray, then take medicines. Q5: How about duration of treatment? Do you know something about it? R1; 6 months dok. Q6: What else in your experience you think prompted you /others to stop taking TB meds? R1: others after taking meds for 1 month they started to feel better. They stop taking the drugs thinking they were cured already. Q6: How about treatment side effects? Have you experienced treatment side effects? R1: I experienced dizziness especially during the first month . after 1 month you eventually get used to it. R2: you cant hear clearly the conversation. 48 Q7: you mean deafness? R1; yes Q8: You think education has something to do with default? R1: I think so. Q9: How about perceived severity of the disease? R1; At first, I lost hope to be cured. I was so depressed. I was told by my doctor I cant be cured. He said that Ive lost one of my lungs thats why I neglected treatment. I cant be cured. I stopped treatment. Q11: Do you think family support is important to complete treatment/ R1: thats one Q12: In what way/ R1: encourage. Remind you to take your medicines. Encourage you to continue treatment. R2: It is important. They give you help. As you know you cough a lot when you have TB. You have chest pain. They massage your back. R3: They see to it that you are treated and see you have MEDS. Q13: Satisfaction of health center or staff? R1: the attitude of the midwife. Their approach to the patient that the patient would like. They should be good. Q14: Did you have bad experiences with the health center? R1: None, I was just told at the health center that the medications have no effect on my body. I was worried. I thought that If I will be admitted I will receive help. Q15: Do you have something to add? R1.: None Q16: Does educational attainment have bearing on defaulting? R1: depends on the person. If the patient wants to get well. He must be interested. He should make a sacrifice and get his medication. Q17: How about side effects? R1: none R2: none R3:none

R4: none Q18: If residence is far? R1: Still depends on the patient if she wants to get well. Q19: How about permanent or temporary job? 49 R1: thats one also. They have problem. Example the husband does not have work he will just be preoccupied and his health would suffer. Q20: What else? How about perceived severity of the disease/ R1: None R2: None R3: none still depends on the person R4: none Q21: What do you know about TB before? R1: the patient should have knowledge about TB Q22: Was it not explained properly to you? R1: It was well explained to us. Q23: How about stigma? R1: thats also a factor. The patient feels ashamed. He becomes hesitant to enter the health center and just go home especially if there are so many people around. Q24: Why if there are many people? R1: they dont want people to know they have the disease. R2: Not all people. I am not ashamed of my disease. I trust in the Lord. I am not the only one with this disease. This is from God. Thats why I am not ashamed. R3: I am not ashamed also. Q25: But you believed that being ashamed is a factor for defaulting? R1: depends on the patient R2: Of course you need to be treated. Q26: Have you experienced stigma? R1: There are lots of people who dont go near us but for me, I took care of my self. I dont go near them, cough when they are near. I really took care not to spread my disease. I underwent treatment. Its better to be cured through medications than pass the disease to others. Q27: What should midwives do to encourage compliance? R1: They should give advice. Our health center in Rio Hondo doesnt give advice. But here even if I live from a far, I just bear the brunt of the traveling expense because I want to be treated here. R2: Upon enrollment, the center should remind the patient. Once enrolled, the treatment should be continued so that the disease will not recur, so that treatment will not be wasted and time as well will not be wasted. R3: They should not stop treatment so that they will get well. R4: They should take care of themselves. 50 R5: You know Doc, the midwife here; they were the ones who were more worried about us compared to the midwife in our old center. They ask for our celphone number to remind us to take our medicine. If we are unable to come they visit us. R6: In the health center, whether you get your medications or not they dont care. Here,

they help us and visit us and have sympathy for us. R&: Yes, I agree. Q28: In the center where you once were enrolled, how were the Meds given/ R1: weekly Q29: Were you followed up by them? R1: yes R2: yes R3; No. they dont ask for our cellophane numbers R4: No. You know dock, in our center, even if it is not Saturday or Sunday it is closed. Thats why we miss treatment. Q30: So far the common reasons for default we have identified include the following: 1. perceived well being after initial taking of meds 2. transient in the area 3. Complacent. Does not know that disease4 will recur if treatment is stopped 4. not given medication by HC 5. Lazy, does not go to the health center. 6. 6. lost hope, depressed 7. not encouraged by family 8. No follow up by midwife, bad approach. Q31: Anything you can add? Silence Q32: You have knowledge about the treatment duration and side effects? R1: Yes, I know R2: I took the medications for 3 months. I did not know that it is six months. Q33; What else? Silence. Well then thank you for your time. 51 Focus Group Discussion Research Proper Introduction Informed Consent Discussion Proper Moderator: What do you know about the treatment of TB? R1: You go to the doctor, have an X-ray taken, give the result to the doctor and then its up to them to determine if you have the disease or not. You ask the doctor if you have the disease. As for me, I read my result. I ask the doctor what is PTB minimal because if I have TB, I want to be treated. I further asked the doctor Since I have PTB minimal and why is it that you are only giving me prescriptions. Prior to my check up, I went to the center and Mrs. Francisco gave me Bract am tablets which afforded relief. Moderator: How about you Mr. S, What can you say about what Mrs. R said? R2: In my case, I underwent sputum examination and I brought the result to the health center. They told me I have TB. You now Doc, I was not able to complete treatment. I stopped taking Medicines. Time came when my disease became severe. I went back to the health center and Mrs. Francisco told me to have sputum exam again. This time I was able to complete treatment and I am okay now.

Moderator: I want to ask further about your stopping medication, why did you stop taking medicines? R2: I dont know. Well I thought I was cured already. Moderator: You thought you were cured already? R2: yes Moderator: Why did you think that you were cured already? R2: Because I feel well already. Moderator: were there other reasons why you stopped? R2: none (shakes head) Moderator: Mr. M, what can you say about what Mr. S said? He said that he stopped treatment because he thought he was cured already. 52 Silence R1: Dont be shy! (Laughs) R4: Yes, dont be shy. (Laughs) R3: Sir, I stopped taking medicines because I went to the mountains. I stayed there for 3 months. When I came back and asked for medicines, they wont give me because they said that I stopped taking medicines. They gave me a referral to the city health. I was told there to wait and I waited for so long I went back to the health center. I was again told to wait for the doctor to arrive because the doctor was busy at that time. I went home and did not come back. R1: He became yellow Doc. When he went to the mountains he contracted another disease. His eyes and skin become yellow. R3: My skin became pale and I had bouts of dizziness. Moderator: When you developed this yellowing, are you still on medication? R3: I was not on medication at that time. Moderator: So you were unable to continue treatment because you went to the mountains and not because you developed yellowing? R3: yes. Moderator: So Lola J, what can you say about what they said? Mr. S said he stopped treatment because he thought that he is already cured when he felt better and Mr. M here said he stopped taking medicines because he went to the mountains? R4: Thats the problem. Both of them stopped taking medicines that is why their disease become severe. Moderator: As far as you know, what are the reasons why people with TB stop taking their medicines? R4: I dont know. (Laughs) R1: Sometimes because of the food. Moderator: What do you mean food? R3: (interrupts) In as much as I would like to take my medicines, I was in the mountains for quite a time. I cannot get my medicines. R4: Yes you were far from the center. R1: well if you really want, anywhere, there is always a center. Even in the mountains there is a health center. We cannot say theres no center. We should go to the center and request for medicines. R3: they wont give us without records.

R1: But you have records here! They can say you have records here so that they can tell the other center to give you medicines. 53 Moderator: So you think the distance of the residence from the health center can be a reason why people stop taking medicines? R1: yes, it can be especially if the center is far. R3: if I had not left, I think I could have completed my treatment for 6months. My cousin brought me there to look after their land. Thats why. I asked them to get my medicines from the health center here but the center wont give them because they really wanted me to be the one to get the medicines. R4: yes its the patient that should get the medicines not just anybody else. Moderator: What can you say about this going to the mountains and its being far? R2: Maybe he has to go to the mountains to look for a living. You know doc, he dont have parents anymore that is why he has to look for a living. He forgot about his medicine in the process. The problem he did not request the health center here so that he can take his medicines. He forgot about his medicines and stopped taking it. Moderator: So you think that the kind of job a person has can be a factor why people stop taking medicines? R1: No because all you need to do is drink the medicines. You dont have to work for your medicines. Drinking your medicines and earning a living are different stories. R2: of course, because if you are working you will forget about your medications. You become busy and the nature of our work is heavy. Good if you have a light job and you just sit. You still have time to think about your medicines. But with us, we are just laborers, its difficult and it will really affect out taking medicines. Moderator: In what way it is difficult? R2: Of course, we cannot just leave our job and take medicines. We will be reprimanded. We have to finish our work first thats why we cannot drink our medicines on time. Moderator: Lola J, what can you say about it? R4: Yes, because of our work we sometimes tend to forget about taking medicines. R1: it has no effect. You know the anti-tb medicines you take it at 6 am., after 30 minutes you take another one. I think it is up to us to really take the medicines. You take rifampicin, and then you have breakfast, after 30 minutes you take another. Where is the difficulty there? Moderator: So you dont agree that because of the nature of work people forget to take their medicines? R1: yes, I dont agree. 54 Moderator: So what do you think are the other reasons why people stop medications? R1: Sometimes, you know, they think; because they fell better; they are already cured. They should see a doctor and ask the doctor if it is okay for them to stop treatment. Of course, the doctor will tell them if they can stop. That should be the way of stooping treatment. R4: What she said is true. If they feel well they should consult the doctor and ask the doctor if they still need to take the medicines because if they still have the disease the doctor can give them medicine.

Moderator: You think know ledge about treatment duration has bearing on people stopping treatment? R1: They are knowledgeable about treatment duration because before we are given medicines, it was explained to us. R2: I know that it is 6 months that is why I regret that I stopped treatment. Moderator: You stopped treatment because? R2: I was really feeling better. Moderator: You did not know that you still need to continue treatment even if you feel better. R2: yes doc. You know, my disease recurred and I visited the health center. Mrs. Francisco scolded me. She told me that if I will not complete treatment this time, she will not give me medicines again. Thats why I am thankful to her. R1: You know doc, when I was coughing out blood. I had my sputum checked and it was negative. I underwent lots of evaluation. I quarreled with Mrs. Francisco. (Laughs) Moderator: Talking about quarreling with midwives, you think its a possible reason why people stop taking medicines? R1: I dont think so. The midwife would not mind. It is her job. In my case I was just asking why so many sputum exam and x-rays and then the result PTB minimal. I was coughing out blood. I told them No, this is not PTB minimal this is really full blown TB. (Laughs) R3: No, its really the fault of the person because he did not take the medicines. (Laughs) R2: (laughs) I agree. It doesnt matter. Moderator: How about shame? R1: yes because people will conceal their disease thats why they wont get their medicines. 55 R3: Sooner or later, the signs of the disease will become evident no matter how you hide it. That is why it is better that you tell people you have the disease so that you will get help. R2: (nods in agreement) So that you will be given medicines. R4: I was never ashamed I had the disease. Its given by god, why be ashamed. Moderator: Did any of you experience something while taking the medicines? R3: Ive experienced dizziness Moderator: Was it contributory to your stopping treatment? R3: No, In fact I want to take medicines. Its just that I went somewhere. R1: I had epigastric discomfort but it does not bother me much. Moderator: So are we in agreement that its not a contributing factor for treatment default? R1: yes R2; nods in agreement R3: yes R4: yes Moderator: Do you think the way you perceived the severity of your disease have some bearing on your decision to stop treatment? R2: No its not a reason. R3: No, I really wanted to get meds.

R4: because of stopping treatment thats why peoples disease becomes severe. Moderator: We have identified the following reasons why people stop treatment, feeling well, went somewhere, nature of work, shame, how about the size of the tablets? R1: its only the rifampicin that is large. The others are okay. R2: Its difficult to swallow the medicines sometimes but doesnt bother me much R3: As for me I wanted to continue but have no choice. R4: I did not feel they are big at all. Moderator: How about family support? R3: Maybe it has no effect. As far as I am concerned all you have to do is take the medicines R2: Of course its necessary. Because if there is no support, you will forget to take your medicines. R4: It is really good to have support. R1. just like me, I cant work now. If I have no support I wont have something to eat. 56 Moderator: Did any of you loss hope of being cured? R1: No I wanted to get well R2: I was optimistic R3: no R4: No Moderator: Do you think losing hope is a factor why people with Tb stop treatment? R2; Maybe sir he wants to die. (Everybody laughs) Moderator: If he wants to die? R2: he wont take his medicines. R1: Mr. S doesnt want to die. (Laughs) he is still young. Moderator: Were you followed up by the BHW at time s you did not get your medicines? R2: I was not followed up. Does it have some bearing on your stopping treatment? R2: I think none. R3: It has some bearing because you wont be able to take your medicines if you were not followed up. R4: For me it has no bearing. If they dont follow up, you go to the health center. Moderator: Anything you want to add? Silence R3: We dont have IQ anymore! (Laughs) Everybody laughs Moderator: Before we end what advice can you give to people on medications or the health center staff so that the people will really complete their treatment? R2: There should be follow up. The center follow-up the patient, the patient follows up in the center so that they can be given proper attention. R3: the same with his advice (smiles). They should go to the center everyday. Moderator: anything to add? R3: none 57 R4: If you want to get well go to the health center to get medicines and consult the

doctor. R1: Consult the doctor if you feel you have the disease so that youre disease will not become severe. Dont be ashamed. Otherwise you will die without a fight. Moderator: Is there something more you want to say Silence Moderator: Thank you so much for your time. Stay for the refreshments. 58

CURRICULUM VITAE
PERSONAL INFORMATION Name: Rex Villadarez Samson Age: 28 years old Sex: Male Civil Status: Single Date of Birth: May 29, 1978 Address: Sia Subd. Sindangan, Zamboanga Del Norte Religious Affiliation: Roman Catholic Father: Rodolfo Esteban Samson Mother: Exoferia Teope Villadarez EDUCATIONAL BACKGROUND GRADUATE Degree: Doctor of Medicine School: Ateneo de Zamboanga University Place: La Purisima St, Zamboanga City Year of Grad: 2006 COLLEGE Degree: Bachelor of Science in Physical Therapy School: Silliman University Place: Dumaguete City Year of Grad: 2000 HIGH SCHOOL: Sindangan National Agricultural School ELEMENTARY: Sindangan Pilot Demonstration School 59 60