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ORIGINAL ARTICLE
Year : 2016  |  Volume : 60  |  Issue : 1  |  Page : 10-16  

Identification and exploration of the needs for health care in tuberculosis patients dropping out from therapy in Malang city: A qualitative phenomenological study


Faculty of Medicine, Community Health Nursing Specialist, Department of Public Health Nursing, Brawijaya University, Malang, Indonesia

Date of Web Publication23-Feb-2016

Correspondence Address:
Nrs. Kumboyono
Faculty of Medicine, Community Health Nursing Specialist of Department of Public Health Nursing, Brawijaya University, Malang
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.177260

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   Abstract 

Background: Tuberculosis (TB) is a chronic infectious disease that remains a major public health issue in the world, including Indonesia. Various efforts have been made by governments to cope with increase of TB. However, various obstacles are found that hinder the goal of the treatment program, such as patients dropping out from treatment. Phenomenological study on TB patients dropping out from treatment in Malang City was greatly required and could be achieved through exploration of perceptions and experiences of TB patients dropping out from treatment. Objective: The purpose of this study is to identify requirements for health care among TB patients dropping out from treatment, based on the perspective of TB patients in Malang City. Materials and Methods: The study is of a qualitative phenomenological design in which samples were drawn using convenience sampling technique. In-depth interviews were used for collection of data by asking semistructured open-ended questions during 6 months from March to August 2014. Results: Problems that induce the failure of TB therapy are delay of treatment, inability to complete sufficient therapy, and various internal and external factors that affects patients' compliance. Conclusion: It was concluded that there were themes in the requirements of health care to prevent and deal with dropping out from therapy: More attention from health workers, accurate examination, clinic opening hours and availability of health workers at working hours, anti-TB drugs of branded patent granted for free, and other drugs in addition to those already known.

Keywords: Drop out from treatment, phenomenology, tuberculosis (TB), the need for health care


How to cite this article:
Nrs. Kumboyono. Identification and exploration of the needs for health care in tuberculosis patients dropping out from therapy in Malang city: A qualitative phenomenological study. Indian J Public Health 2016;60:10-6

How to cite this URL:
Nrs. Kumboyono. Identification and exploration of the needs for health care in tuberculosis patients dropping out from therapy in Malang city: A qualitative phenomenological study. Indian J Public Health [serial online] 2016 [cited 2020 Aug 11];60:10-6. Available from: http://www.ijph.in/text.asp?2016/60/1/10/177260


   Introduction Top


Tuberculosis (TB) is a chronic infectious disease that remains a major public health issue in the world. There were 22 countries classified as high-burden countries for TB in 2003, among which Indonesia has the third-highest number of TB patients after India and China. [1],[2] Seventy-five percent of people suffering from TB range 15-50 years in age; this interferes with work productivity and also causes complex health problems. [3],[4],[5]

The Indonesian government implemented a TB eradication program using direct observed treatment, short course (DOTS) strategy with a target cure rate of 85%. [6] However, DOTS coverage is only 14%, with a high number of dropouts as the obstacle. [7],[8],[9],[10],[11] The underlying background of dropping out needs to be examined from patients' experiences. [7] Phenomenological study on dropped-out TB patients in Malang City was required and could be achieved through exploration of perceptions and the meaning of experiences of dropping out.

Experiences could be revealed using a qualitative phenomenological study that has the ability to explore the meaning and significance of them. [12] Descriptive phenomenological study was aimed at describing life experiences about a concept or phenomenon. [13] It is expected that health care requirements for patients dropped out in Malang City can be identified to reconstruct a holistic picture of their experiences.


   Materials and Methods Top


This phenomological descriptive study was held as obligated by the Helsinki Declaration of 1975 and ethical clearance from the Ethical, Health, and Research Commission of Faculty of Medicine, Brawijaya University of the number: 261/EC/KEPK/04/2014. It was held for a period of 6 months, from March to August 2014. The phenomenological design was used to understand the experiences of patients dropping out and to explore related phenomena in an intuitive, analytic, and descriptive manner. [14] This study was held by a community health nursing specialist who is a registered practitioner and a lecturer at Brawijaya University. There were no researcher/participant relationships prior to the study and interviews were held after a confidential relationship was built in the tenth to fifteenth meetings, which was proven by the patients' willingness to sign informed consent forms and answer questions. The purpose and the procedures of the study were explained at the beginning of the study. The instrument to collect data (questions for interview) and the interviewer had been tested through pilot testing with two dropped-out participants. Participants were all open, honest, and direct in answering questions. There were no ethical issues regarding legality of the study as major ethical principles (autonomy of participants, confidentiality, and protection from discomfort) were upheld throughout the interviews.

Participants were selected by convenience according to inclusion criteria that required TB patients who had been in treatment from Malang City's primary health care facility for at least 2 months and dropped out before it was completed. Participants were approached face to face and asked to be involved, and no correspondents refused to be participants. Data were collected at the participants' home through private interviews and there were no repeat interviews. Data were recorded in the form of audio files (MP3), and the duration of interviews ranged 24-41 min. Field notes were made manually and data saturation was achieved by the seventh participant. Data analysis was done by triangulation of data sources (identifying key words of themes and subthemes from the results of interviews). Transcripts were later shown to the participants for confirmation, to give them the opportunity of checking the accordance of original statements with the ones mentioned in the transcript, and all participants gave consent to data collection.


   Results Top


Seven participants (two females and five males) ranged 20-65 years old and with the educational background of junior and senior high school were involved. There were seven major themes among the experiences of participants that contain subthemes and supporting statements: Reasons to seek medical help, perceptions regarding the advantages and disadvantages of taking part in treatment, responses to treatment, reasons to drop out, impacts after dropping out, significance and meaning in undergoing treatment, and requirements of a primary health care facility in providing treatment [Table 1].
Table 1: Themes, subthemes, and supporting statements of experiences of tuberculosis (TB) participants

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Reasons of TB participants to search treatment

The reasons of TB participants to look for treatment are complaints of cough, rapid weight loss, and demands of the family to look for treatment.

The question was: "What are your reasons for looking for TB treatment?" The statements in reply have been shown in [Table 1].

Cough was indicated by the statements P1 and P5. Rapid weight loss was shown by the statement P4. Demands of families to get involved in treatment are indicated by the statement P2 [Table 1].

Perceptions of TB participants about advantages and disadvantages of TB treatment

The results of the interviews demonstrated perceptions about the advantages and disadvantages of undergoing treatment.

The question was: "What are the advantages and disadvantages of undergoing TB treatment?"

An advantageous perception of being cured was revealed by comment P2. The disadvantages of undergoing treatment (nausea, weakness, weight loss, dizziness, and insomnia) can be inferred from statements P1, P4, and P5 [Table 1].

Response of participants to TB treatment

Responses to treatment included uncertainty about information given by health officers, requirements for serious treatment, and noncompliance with treatment despite it being given for free.

The question was: "What are your responses to treatment?"

Uncertainty about information given by health practitioners was revealed by specific comments of P1. Requirements for serious treatment were shown by the statement P5. Noncompliance with treatment, despite it being given for free, was shown by the statements P3 and P4 [Table 1].

Reasons of TB participants dropping out from treatment

The reasons behind participants dropping out centered around several subthemes: Absence of solutions to drug side effects, feeling healthy in the middle of treatment, boredom with the lengthy treatment period, forgetting to take medicines, and moving to another place.

The question was: "What are your reasons for dropping out from treatment?"

The absence of solutions to drug side effects was shown by the P1 statement. Feeling healthy in the middle of treatment was shown by the P2 comment. Boredom due to the lengthy treatment period of consuming drugs was revealed by the P3 comment. Boredom due to the long periods of the whole treatment was explained by the P5 statement. Moving to another place was indicated by the P6 statement [Table 1].

Impacts experienced by participants after dropping out

Physical changes expressed subjectively as the results of dropping out were: feeling healthy, and weight gain.

The question was: "What are the impacts after dropping out?"

Feeling healthy was reflected by the P2 statement. Gaining weight was stated by the P4 comment [Table 1].

Significances of undergoing TB treatment

The significances of undergoing treatment as revealed by the patients were: Desire for recovery, precious values of health, and fear of death.

The question was: "What are the significances of undergoing treatment?"

Desire of recovery was indicated by the P1 statement. Precious values of health were shown by the P2 and P3 statements. Fear of death was expressed by the P4, P5, and P6 comments [Table 1].

Requirements of primary health care facility in providing TB treatment

Requirements of health care were categorized into several subthemes: More attention from health workers, thorough examination, fixed clinic opening hours and availability of health workers at office hours, TB drugs of branded patent for free, and drugs other than those already well known.

The question was: "What are your suggestions for ideal primary health care?"

Getting more attention from health workers was stated by P1, P2, and P5. The suggestion of more thorough examinations was stated by P3. The problem of clinic opening hours and the availability of health workers at office hours was expressed by the P5 statement. The requirement for TB drugs of branded patent for free was revealed by the P4 comment. Hope for drugs other than those already well known was indicated by the P4 comment [Table 1].


   Discussion Top


Reasons of TB participants to search treatment

The reasons to seek treatment indicate that the participants experienced typical and additional symptoms of TB. [15],[16] These symptoms were ignored so that it was too late to seek medical help in early stages of TB. [16],[17] Low motivation for getting treatment was reflected in participants' need to be motivated in getting a checkup after prolonged symptoms. History of illness implied that dropped-out patients need to increase their knowledge and awareness about TB signs and symptoms so that they can seek medical help immediately. [18],[19] Health promotion, screening, and socialization of elementary service of initial phases of TB should be done for individual and public primary health care to increase mass awareness. [19],[20] Psychological counseling and emotional support is important in motivating completion of treatment. [20],[21]

Perceptions of TB participants about advantages and disadvantages of TB Treatment

Perceptions of participants show wrong assumptions about the TB process. Recovery within 1 or 2 months did not mean completion of treatment, as first-line treatment should last for 6 to 9 months. [15],[17],[22] Perceived disadvantages (weakness and weight loss) reflect pathological processes that are not adverse effects of treatment. [16],[23] The wrong perception about treatment reflects poor knowledge about TB management and this situation needs to be improved through education about the duration and reactions to treatment. [23] The main effects and side effects of drugs should be explained at the beginning of treatment along with appropriate measures. [15],[19] Strict follow-up should be maintained to ensure symptomatic drug administration and no side effects or allergic reactions. [16],[23]

Response of participants to TB treatment

Initial responses to treatment can vary from confusion about health informations, more serious treatment and evaluations for participants, to feelings of dislike about the treatment provided by health practitioners. [20],[22] This suggests that health practitioners should employ special methods to get personally acquainted with and satisfy their patients' specific needs. Clear explanations should be adjusted to psychosocial backgrounds to avoid providing false information. [17],[19] Seriousness of working according to standards of operational procedures should be guaranteed by periodic monitoring and evaluation. [15],[16] Persuasive methods involving patients and their families should be followed to provide health service according to the patients' subjectivity. [20]

Reasons of TB participants dropping out from treatment

Dropping out can be no solution to adverse effects of drugs, feeling healthy in the middle of treatment, boredom due to lengthy periods of treatment and drug consumption, and moving to another place, and this needs to be immediately rectified. [24],[25] Solutions for adverse reactions to drugs and continuous motivation are of great importance in every treatment. [23],[26] Better communication and referral systems are required to anticipate the possibility of patients' mobility to other areas. [20],[25] Positive results in preventing the dropout phenomenon can be obtained through a good approach in case management. [16],[19],[20]

Impacts experienced by participants after dropping out

The positive physical changes experienced by participants were expressed as impacts of dropping out from treatment and can be included among the wrong perceptions of TB treatment. The subjectivity of perceptions that were experienced is temporary and can change over a longer period of time. [25],[27] These conditions can be comprehended pathologically as impacts of health improvement from TB treatment that was accomplished in 2 months. [16],[19] A wrong perception implicates that health promotion is highly needed to increase awareness about changes in bodies during treatments. [15],[16],[17] Health education and identification of multidrug-resistant TB (MDR-TB) cases should be done early in primary health services to avoid noncompliance with drug consumption. [19],[25],[27],[28]

Significances of undergoing TB treatment

Dropped out participants expressed that they obtained positive significance and meaning by undergoing treatment. These positive perceptions about advantages of TB treatment were found to not affect participants' compliance to TB treatment. The perception of significance of experiences in getting treatment cannot guarantee compliance in completing it and this condition requires a psychosocial approach to stabilize motivations to complete treatment in 6-9 months. [15],[16],[17] Various such approaches include counseling, consultations, home visits, and positive feedback. [19],[20],[21],[22]

Requirements of primary health care facility in providing TB treatment

More attention given by health workers together with thorough examinations and health evaluations will create the impression of higher acknowledgement of TB patients. [19],[20],[21],[22] Consistency of service hours and availability of health workers during office hours guarantee satisfaction and confidence until treatment is complete. [15],[16],[17],[19] Participants also need TB drugs of patented brands that can be distributed free and other, more effective drugs than those used today as solutions to reduce boredom due to long periods of treatment. [27]


   Conclusion Top


The reasons TB patients seek treatment are the complaints of their symptoms of TB and the demands of their families to do so. Various factors induce patients to drop out from treatment; dropping out is greatly influence by internal and external factors, such as a strong intention or motivation for recovery, location of affordable health care, and support from family and close friends. It is very important to raise public awareness about TB by practicing primary prevention, giving health education about treatment programs, and improving health staff and the referral system between institutions to ensure the compliance of patients.

Acknowledgment

We are grateful for the support of the Directorate General of Higher Education, Ministry of Culture and Education, Republic of Indonesia in funding this public health research.

Financial support and sponsorship

Directorate General of Higher Education, Ministry of Culture and Education, Republic of Indonesia.

Conflicts of interest

There are no conflicts of interest.

 
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