GPH 2014

1. DETERMINANTS OF CLIENTS’
ADHERENCE TO PUBLIC-
PRIVATE MIX
(PPMD)TREATMENT
John Carlo L. Divina, MSN, RN
Cebu Philippines

2. INTRODUCTION
One-third of the world’s population is infected with
Mycobacterium tuberculosis, mostly in developing countries,
where 95% of the cases occur (Dye et al., 1999).
In 2012, the Philippines has recorded 93, 586 sputum positive
patients which could infect at least 10 – 20 persons a year, if
left untreated (National Tuberculosis Control Program Manual
of Procedure, 2004). Therefore, this major public health
concern has been set as part of the target of the 6th
Millennium Development Goal which is to reduce the
prevalence and mortality of Tuberculosis by half in 2015.

3. RATIONALE
Non-adherence to treatment may
reduce treatment efficacy and cause drug
resistance, resulting in increased
morbidity and mortality and further
infections (Raviglione et al., as cited by
the ISTC, 2006), hence, the need to
address this challenge.

4. PROBLEM
1. What are the characteristics of the
respondents categorized as adherent and
non-adherent in terms of the following
variables?
2. Which variables influence adherence to
PPMD treatment?
3. Is there a significant relationship between
the selected predictors and the clients’
adherence to PPMD treatment?

5. THEORETICAL FRAMEWORK
NOLA J. PENDER’S HEALTH PROMOTION MODEL
ADHERENCE TO PPMD TREATMENT

6. METHODOLOGY
Design: Descriptive Correlational
Locale: Mandaue City Health Office
PPMD South District
Respondents: 70 adherent and non-
adherent PTB patients
Instrument: PPMD Treatment Adherence
Index

7. RESULTS
Percentage of Demographic Profile
60%
91%
94%
77%
69%
46%
66%
57%
83%
91%
63%
46%
31%
60%
0% 20% 40% 60% 80% 100%
Perceived Self-Efficacy: Very
Effective
Without Co-Morbidity
Accessible TB DOTS Unit
Sputum Smear Status :
Negative
Income: Php 5,001 - 20,000
Educational Attainment: HS
Graduate
Age: Young Adult
V
A
R
I
A
B
L
E
S
Non-Adherent
Adherent

8. RESULTS
Mean Scores of the Intrapersonal Variables
3.31 3.26
2.2
3.64
3.09
3.6
2.49
3.69
Perceived Quality of
Health Services
Perceived Social
Support
Perceived Social
Stigma
Motivation to
Treatment
Adherence
VARIABLES
Adherent Non-Adherent

9. RESULTS
Percentage of Side Effects to Treatment
0%
20%
40%
60%
80%
100%
Adherent
Non-Adherent

10. RESULTS
Percentage of Adverse Reactions to Treatment
0%
5%
10%
15%
20%
25%
30%
35%
Adherent
Non-Adherent

11. RESULTS
Variables that Influence and Its Relationship to Adherence

12. DISCUSSION
Quality of Health Services
Quality of health services with coefficient of 0.476
directly influences adherence.
Health care service factors, such as long waiting
times and inconvenient opening times in clinics,
add to economic discomfort and social disruption for
patients and negatively influence adherence (Klink,
1969, as cited by Munro, 2007).

13. DISCUSSION
Income
Income at coefficient -0.381 inversely influences
adherence.
Non-adherence related to high income levels may
be attributed to the increased capacity of the
patient to purchase medications and may not
significantly rely on the free anti-tuberculosis
medications provided by the PPMD unit.

14. DISCUSSION
Perceived Social Stigma
Perceived social stigma with coefficient of -0.376
likewise indirectly influences adherence.
Stigma makes patients reluctant to attending
treatment in clinics located in their neighborhoods
which may lead to non-disclosure of illness, hence,
is considered a potential barrier to treatment
(Gebremariam et al., 2010).

15. DISCUSSION
Discriminant Analysis Coefficient Function
Discriminant analysis coefficient function (D) =
income + (2.139 x quality of health services) +
(-0.242 x perceived social stigma)) + -0.388.
****
This equation can help discriminate whether a
patient with tuberculosis will be adherent or not.
However, the model can only explain 33.29% of the
time as reflected in the over-all Wilk’s Lambda
score.

16. DISCUSSION
Over-all Wilk’s Lambda_Score
66.70 % of the variation cannot be explained by the
model at significant p value of 0.024.
The percentage is quite high noting that majority of
the independent variables does not have a significant
relationship across groups of the dependent variable.
Other cofounding variables not evaluated by this
study may have bearing on adherence.

17. DISCUSSION
Classification Results
Classification results which revealed that 72. 94% of
the respondents were classified correctly into
adherent and non-adherent groups.
Adherent respondents were classified with slightly
better accuracy (80%) than non-adherent (65.7%).
However, cross-validation indicated that 61.4% of
the group cases were correctly classified, thus, this
data provided a more reliable function than the
original group classification.

18. CONCLUSION
Income and perceived social stigma
are good screening parameters in
assessing clients’ adherence. Quality of
health services should be considered
when providing treatment since it is a
good determinant of clients’ likelihood of
treatment adherence.

19. RECOMMENDATIONS
Evaluation Tool – be developed by National
TB Program Managers in Assessing provision
on Quality of Health Services
Frequent Counselling and Assistance – be
readily available to all clients
Future Research – be conducted in a larger
population with more detailed items in the
significant variables and considering other co-
founding variables.

20. REFERENCES
1. Department of Health. (2004). National tuberculosis
control program manual of procedure. Philippines:
Department of Health
2. Dye C., Scheele S., Dolin P., Pathania V., Raviglione
M.C.(1999). Consensus statement. Global burden of
tuberculosis: estimated incidence, prevalence, and
mortality by country. WHO Global Surveillance and
Monitoring Project. Journal of American Medical
Association,282(7):677-86.
3. Klink, W.B. (1969). Problems of regimen compliance in
tuberculosis treatment. New York (NY): Columbia
University

21. REFERENCES
4. Gebremariam, M., Bjune, G., Frich, J. (2010). Barriers and
facilitators of adherence to TB treatment in patients
on concomitant TB and HIV treatment: a qualitative
study. Retrieved from
http://www.biomedcentral.com/1471-2458/10/651
5. Munro, Salla et al, (2007). Patient adherence to
Tuberculosis treatment: a systematic review of
qualitative research. Retrieved from
http://www.plosmedicine.org/article/info%3Adoi%2F
10.1371%2Fjournal.pmed.0040238
6. Pender, N. J. (2006). Health promotion in nursing practice
(5th edition). Singapore: Pearson Education South Asia

22. REFERENCES
7. Raviglione M, Snider D, Kochi A. (1995). Global
epidemiology of tuberculosis : Morbidity and
mortality of a worldwide epidemic. Journal of
American Medical Association, 273:220-226.
Publisher Full Text.
8. Tuberculosis Coalition for Technical Assistance. (2006).
International standards for Tuberculosis care (ISTC).
The Hague: Tuberculosis Coalition for Technical
Assistance
9. World Health Organization. (2003) Adherence to long-
term therapies. Evidence for action. Geneva: World
Health Organization.

23. ACKNOWLEDGEMENT
My heartfelt gratitude goes to the
research respondents for their trust and
time, the barangay health workers who
have volunteered their services in
accompanying me to locate the
respondents, the PPMD Nurses who
have assisted me in many ways.
To my colleagues , family and
friends, a million thanks for inspiring me
to reach my dreams.

24. ABOUT THE RESEARCHER
JOHN CARLO L. DIVINA, MSN, RN
Researcher & PPMD Nurse, South
General Hospital PPMD Unit
Contact Information:
South General Hospital PPMD Unit
National Highway, Tuyan, City of
Naga, Cebu, Philippines 6037
Cellular Number: +63933 325 2888
Email: dvynejc2000@yahoo.com