CC BY
109
ISSN 2304-3415, Russian Open Medical Journal
2022. Volume 11. Issue 1 (March). Article CID e0106 DOI: 10.15275/rusomj.2022.0106_
Original article
A supportive-educative intervention for tuberculosis patients: Integrated self-care and family-
centered nursing
Nur Melizza 1, Rachmat Hargono 2, Makhfudli 2
1 Muhammadiyah University, Malang, Indonesia 2 Airlangga University, Surabaya, Indonesia
Received 18 September 2020, Revised 2 August 2021, Accepted 21 December 2021
© 2020, Russian Open Medical Journal
Abstract: Aim — This study aims to evaluate the effect of supportive educative system intervention on Tuberculosis (TB) patient's family support.
Material and Methods — This study was a quantitative study with a quasi-experimental design, conducted in the Public Health Center (PHC) of Kedungkandang and Ciptomulyo with 48 respondents. The respondents were divided into the control group with standard PHC intervention (n=24) and the treatment group with standard PHC intervention added with the supportive educative system (n=24). The data were analyzed by paired t-test and independent t-test.
Results — There was a significant difference in family support between treatment and control. The results indicated that a supportive educative system significantly increases family support (p=0.003). Interestingly, PHC standard intervention showed improvement in family support (68.46±73.58) than supportive educative system (74.29±75.83). Supportive educative system interventions were less effective than standard PHC interventions. It could be influenced by sample characteristics, time of the study, control of variables, and other factors. Conclusion — Supportive educative interventions are effective in improving family support but are no better than standard PHC interventions.
Keywords: Family support, intervention, public health center, supportive educative system, tuberculosis.
Cite as Melizza N, Hargono R, Makhfudli. A supportive-educative intervention for tuberculosis patients: Integrated self-care and family-centered nursing. Russian Open Medical Journal 2022; 11: e0106.
Correspondence to Nur Melizza. Address: Department of Nursing, Faculty of Nursing Science Community, Muhammadiyah University of Malang, Bendungan Sutami Street, Malang, East Java 65145, Indonesia. Phone: +62 341 551149. E-mail: [email protected].
Introduction
Tuberculosis (TB) is one of the dominant diseases in Indonesia. According to WHO, Indonesia is placed second in the number of reported TB cases [1]. Indonesian Health Ministry survey showed that TB prevalence in 2013-2014 was 660 per 100.000 population and 1.600.000 people were estimated to have TB in Indonesia [2, 3]. West Java, East Java, and Central Java have the highest TB cases in Indonesia. More specifically in East Java, Surabaya (4.754), Jember (3.128), Sidoarjo (2.292), and Malang (1.932) were the first and fourth regions with the highest number of TB patients [4]. Additionally, based on the Malang City Health Profile report in 2014, Sukun and Kedungkandang Subdistricts were determined as the first and second subdistricts with the highest number of TB patients out of five subdistricts in Malang City, with a total of 84 smear-positive TB patients in Kedungkandang and 101 in Sukun.
Tuberculosis is associated with poverty, population density, alcoholism, stress, drug addiction, and malnutrition. Malnutrition in tuberculosis patients is influenced by several factors, such as 1) economic factors, 2) comorbidities, 4) knowledge, 5) patient behavior on food and health, 6) long-suffering from pulmonary TB, 7) age, 8) sex, 9) marital status, 10) education level, 11) confidence in foods and 12) family support [5-9].
Based on the data from the Public Health Center (PHC) of Kedungkandang and Ciptomulyo in the third quarter of 2017, it was observed that the number of suspected TB patients in both areas was quite high, accounting for 132 cases in Kedungkandang and 220 in Ciptomulyo. One of the main contributors is the number of TB relapse cases. The number of TB patients with positive acid-resistant bacteria in Kedungkandang was 29 people, with 62% experienced decreasing nutritional status, and the increase of TB relapse was 2.03%. In the previous year, there was only 1 person who experienced TB relapse but the number is increased to 7 people this year. Meanwhile, the number of TB patients with positive acid-resistant bacteria in Ciptomulyo was 28 people, with 50% experienced a nutritional status decrease, and the incidence of TB relapse has increased to 3.3%. This happens because of the lack of family support in improving the nutritional status of TB patients.
TB Program holder in the PHC said many programs have been done, such as TB counseling, collaborating with health cadres to make a suspect discovery, and the distribution of 6 cans/person to overcome nutrition problems. However, the program has not run optimally due to the lack of active participation from patients and mainly due to the lack of support from family members.
ISSN 2304-3415, Russian Open Medical Journal
2022. Volume 11. Issue 1 (March). Article CID e0106 DOI: 10.15275/rusomj.2022.0106_
Patients and families are usually focused more on the treatment but the other supporting factors are unnoticed, such as family support. This study is focused to evaluate the supportive educative system intervention, which consists of teaching, guidance, and support, to TB patients' families in increasing family support.
Material and Methods
Ethical consideration
This study was approved by the University Ethics Committee (February 2018), ethical number: 643-KEPK. All of the respondents had agreed with the given informed consent.
Study design
This study is quantitative research with a quasi-experimental design. This study took place in two PHCs in Kedungkandang and Ciptomulyo, Malang City. As many as 48 respondents were divided into 2 groups, control (n=24) in Kedungkandang PHC and treatment (n=24) in Ciptomulyo. The sampling technique was simple random sampling with several inclusion criteria, (1) the family member of the TB patient is in a healthy condition; (2) the TB patient has decreased nutritional status (IMT<18,5 KgM2), and (3) the nuclear, patrilocal or patrilineal family structure from the patient. While the exclusion criteria are family of TB patients with comorbidities, such as diabetes mellitus, HIV/AIDS, and other comorbidities that could affect the patient's nutrition condition.
Data collection
Both groups were given an initial intervention, which was the PHC health programs for TB patients. The program consists of health counseling, inspection schedule, drug administration, and providing milk. Furthermore, the treatment group was given the supportive educative system, which consists of teaching, guidance, and support related to the nutrition of TB, besides the initial intervention, while the control group was not given any additional intervention. The supportive educative system consists of 3 sessions and divided into 3 meetings for 2-3 weeks, and lasted for 45-60 minutes in every meeting. The independent variable in this study was the supportive educative system intervention, while the dependent variable was the family support in improving the nutritional status of TB patients.
At the beginning of the program, the participants were given a pretest, the PHC standard intervention, and the time contract for the next meeting. At the second meeting, the participants were given a supportive educative system, which consists of guidance through introduction, explanation, information about the recommended food for TB patients, and providing positive reinforcement as a form of support. In addition, the participants also got a booklet as reading material at home. In the second week or third meeting, it was a revisit and posttest to evaluate the effect of the intervention by filling out the questionnaire. Meanwhile, the control group's interventions were carried out according to the PHC standard in the form of TB-related education, milk distribution, and scheduling for drug administration and screening. The posttest was done after 2 weeks of intervention.
Table 1. Respondents' characteristics in both groups
Control group Treatment group
Respondents' characteristics Total Total
n (24) % n (24) %
Gender
Female 17 70.8 21 87.5
Male 7 29.2 3 12.5
^45 years Age 15 62.5 9 37.5
> 45 years 9 37.5 15 62.5
Stage of family development
Stage: children reaching adolescence 10 41.7 3 12.5
Stage: children reaching adulthood 14 58.3 21 87.5
Social culture
Abstinence from eating 19 79.2 17 70.8
Do not abstain from eating 5 20.8 7 29.2
Economic level
Economically not capable 7 29.2 9 37.5
Economically capable 17 70.8 15 62.5
Knowledge level
Poor 11 45.8 12 50
Enough 8 33.3 5 20.8
Good 5 20.8 7 20.8
Table 2. Comparison between control and treatment group pre and post-
interview
Group Mean ± S.D Paired t-test (p-value)
Pre Control (n=24) Post 68.46±12.7 73.58±14.4 0
, . Pre Treatment (n=24) * ' Post 74.29±8.6 75.83±8.4 0,003
Data analysis
The collected data were analyzed using SPSS software, version 16.0 (IBM) using the bivariate analysis, the paired t-test, and the independent t-test.
Results
The respondents in the control group were dominated by female respondents (17 or 70.8%) and belong to > 45-years age group (15 or 62.6%). They were in a family with adolescent children (14 families or 58.3%), had a food abstinence culture (19 families or 79.2%), and at a good economic level (17 or 70.8%). The level of family knowledge about TB and TB nutrition was mostly in the "less" category (11 or 45.8%). The respondents in the treatment group were mostly female (21 or 87.5%) and belong to > 45-years age (15 or 62.6%). Most of the respondents had children who were reaching adulthood (14 or 58.3%) and adopting an eating abstinence culture (17 or 70.8%), and the economic level of respondents was capable (15 or 62.5%). Similar to the control, most of the respondents in this group had TB knowledge in the "less" category (12 or 50.0%) (Table 1).
Based on the paired t-test result, there was a difference before and after intervention in both groups (p < 0.05). The independent t-test results showed a significant difference between the control and treatment (p<0.05). The mean value in the treatment group showed a 1-point increase, while the control group had 5-point increase, which means the intervention of supportive educative system influence the family support, but the influence is not as high as the control (Table 2).
"Independent t test p-value =0.005.
ISSN 2304-3415, Russian Open Medical Journal
2022. Volume 11. Issue 1 (March). Article CID e0106 DOI: 10.15275/rusomj.2022.0106_
Discussion
These findings implied that supportive educative system interventions affected increasing the family support in the treatment group. Interestingly, there was a significant difference between the control and treatment groups. The difference indicated that the control group had higher effects on family support than the treatment.
Interventions in the control group were more influential on family support. This finding is following Notoatmodjo in Yuniar, which explains that scheduling the patient's drug administration could improve the drug control and reduce the risk of resistance [10]. Another study by Winetsky et al. also explained that reduced access to supplemental nutrients is one of the factors that influenced the incidence of TB [11]. The provision of information also helps in improving the knowledge and understanding of the patient, which is a pivotal component of self-care [12].
However, this study was not following Mohammadpour et al., who explained that supportive educative interventions can improve the non-hospitalized patient's self-care abilities and positively influence the public health outcomes [12]. Other studies also explain that Orem's Self-Care Model in form of a supportive nursing system can improve the quality of life in all dimensions, including physical function, physical role restriction, body pain, general health, vitality, social function, emotion limitation, and mental health (p<0.05). Furthermore, Orem's nursing care model improved the overall function and quality of life and reduced the cost of migraine and migraine-related disability in individuals and communities [13].
M'imunya in his study also explained that counseling by a nurse over the phone increases the proportion of children completing treatment from 65% to 94% and counseling through home visits further increases it to 95%. Both interventions are superior to counseling by doctors at the tuberculosis clinic. M'imunya also explained that educational or counseling interventions can improve the successful completion of treatment but the number of benefits may vary depending on the nature and the arrangement of the intervention [14].
The results obtained in this study may be caused by the fact that most of the respondents in the intervention group had a lack of knowledge. With sufficient knowledge about nutritious food, the type and amount of food will also be considered by the patients [12]. In addition, the abstinence-eating culture can also influence the support of intervention groups. For instance, a patient knows that the food is not good for consumption culturally but it must be consumed then that patient will ignore the knowledge and vice versa. A person's culture is not easy and takes a long time to change [5, 15].
The concept of nursing by Orem emphasizes the individual's ability to meet his own care needs without depending on others. Most respondents in the treatment group were dominated by the elderly (aged > 45 years). In that condition, instrumental support, such as delivering treatment to patients, providing financial assistance, and information, such as the nutrition care of TB patients, are less provided to the respondents [11]. In addition, Orem's conceptual model is more direct and the patients are included in the systems they are capable for physical movement, so the independence in other than physical movements is less influential.
According to Winetsky et al., the intervention according to Orem's theory is also done to reflect the individual influence on
the environment [11]. The environmental control in this study is rarely done. For instance, the housing conditions that could influence the instrumental support, such as the distance of the patient's house to the shopping center could hinder the respondents to buy the recommended food. Furthermore, some environmental conditions also hinder access to information, such as no television and the difficulty to reach a working signal service. The condition and atmosphere of the respondent's home while performing the system were also less controlled because the arrival of other family members could influence the intervention as well.
Conclusion
This study concluded that the supportive educative interventions are effective in improving family support but worse than the PHC standard interventions.
Acknowledgments
The authors would like to thank the Faculty of Nursing, Universitas Airlangga Surabaya and the Faculty of Health Sciences Muhammadiyah Malang that have facilitated this research. Special thanks go to the Kedungkandang and Ciptomulyo Health Centers for providing respondent data.
Conflict of Interest
The authors declare no conflicts of interest in this study. References
1. WHO. Global tuberculosis report 2015. 20th ed. World Health Organization. 2015; 204 p. https://apps.who.int/iris/bitstream/handle/10665/191102/978924156 5059 eng.pdf;jsessionid=1954D47F7A289F1F7585346A1D2BA1D1?seq uence=1.
2. Indonesian Ministry of Health. National guidelines for tuberculosis control. Jakarta, Indonesia: Kementerian Kesehatan Republik Indonesia. 2011; 99 p. Indonesian. http://rspau.ddns.net:8080/perpustakaan/property/uploads/d8c81b3 affec9ce9d840d2a53d26475a.pdf.
3. Directorate General of Disease Control and Environmental Health. Rencana aksi program pengendalian penyakit dan penyehatan linkungan tahun 2015-2019. Jakarta, Indonesia: Kementerian Kesehatan Republik Indonesia. 2015; 59 p. Indonesian. http://p2p.kemkes.go.id/wp-content/uploads/2017/01/RAP-2015-2019.pdf.
4. Indonesian Ministry of Health. Tuberculosis, data center and information ministry of health. Jakarta, Indonesia: Kementerian Kesehatan Republik Indonesia. 2016; 10 p. Indonesian. https://pusdatin.kemkes.go.id/download.php?file=download/pusdatin /infodatin/Infodatin-TB-2016.pdf.
5. Dodor E. Evaluation of nutritional status of new tuberculosis patients at the Effia-Nkwanta Regional Hospital. Ghana Med J 2008; 42(1): 2228. https://pubmed.ncbi.nlm.nih.gov/18560556.
6. Si ZL, Kang LL, Shen XB, Zhou YZ. Adjuvant efficacy of nutrition support during pulmonary tuberculosis treating course: systematic review and meta-analysis. Chin Med J (Eng) 2015; 128(23): 3219-3230. https://doi.org/10.4103/0366-6999.170255.
7. Lestari ED. Analysis of changes in nutritional status in patients with tuberculosis after 6 months of treatment at Paru Hospital, West Java Province. Bachelor's Thesis. Bogor, Indonesia: Institut Pcrtanian Bogor, 2016. Indonesian.
8. Puspita E, Erwin C, Yovi I. Description of nutritional status in patients with pulmonary tuberculosis (pulmonary TB) who are undergoing
ISSN 2304-3415, Russian Open Medical Journal
2022. Volume 11. Issue 1 (March). Article CID e0106 DOI: 10.15275/rusomj.2022.0106_
outpatient care at Arifin Achmad Hospital Pekanbaru. J Online Mahasiswa Fak Kedokt Univ Riau 2016;3(2): 1-16. Indonesian. https://www.neliti.com/publications/186965/gambaran-status-gizi-pada-pasien-tuberkulosis-paru-tb-paru-yang-menjalani-rawat.
9. Samuel B, Volkmann T, Conelius S, Mukhopadhay S, Mejojose, Mitra K, et al. Relationship between nutritional support and tuberculosis treatment outcomes in West Bengal, India. J Tuberc Res 2016; 4(4): 213-219. https://doi/org/0.4236/jtr.2016.44023.
10. Yuniar I, Sarwono, Astuti S. The influence of PMO and family support on the level of compliance taking pulmonary TB medicine at the Sempor 1 Kebumen health center. In: The 6th University Research Colloquium 2017. Central Java, Indonesia: Universitas Muhammadiyah Magelang, 2017; 357-364. Indonesian. https://journal.unimma.ac.id/index.php/urecol/article/view/1461.
11. Winetsky DE, Almukhamedov O, Pulatov D, Vezhnina N, Dooronbekova A, Zhussupov. Prevalence, risk factors and social context of active pulmonary tuberculosis among prison inmates in Tajikistan. Plos One 2014; 9(1): e86046. https://doi.org/10.1371/journal.pone.0086046.
12. Mohammadpour A, Rahmati SN, Khosravan S, Alami A, Akhomd M. The effect of a supportive educational intervention developed based on the Orem's self-care theory on the self-care ability of patients with myocardial infarction: A randomized controlled trial. J Clin Nurs 2015; 24(11-12): 1686-1692. https://doi.org/10.1111/jocn.12775.
13. Mahmoudzadeh ZF, Raiesifar A, Ebadi A. The effect of orem's self-care model on quality of life in patients with migraine: a randomized clinical trial. Acta Med Iran 2016; 54(3): 159-164. https://pubmed.ncbi.nlm.nih.gov/27107519.
14. M'imunya JM, Kreido T, Volmink J. Patient education and counseling for promoting adherence to treatment for tuberculosis. Cochrane Database Syst Rev 2012; 2012(5): CD006591. https://doi.org/10.1002/14651858.cd006591.pub2.
15. Shivalli S, Majra JP, Akshaya KM, Qadiri GJ. Family centered approach in primary health care: Experience from an Urban Area of Mangalore, India. ScientificWorldJournal 2015; 2015: 419192. https://doi.org/10.1155/2015/419192.
Authors:
Nur Melizza - Lecturer, Department of Nursing, Faculty of Nursing Science Community, Muhammadiyah University, Malang, Indonesia. https://orcid.org/0000-0001-5533-2561.
Rachmat Hargono - Lecturer, Department of Health Promotion and Behavioral Science, Faculty of Public Health, Airlangga University, Surabaya, Indonesia. https://orcid.org/0000-0003-1058-7821. Makhfudli - Lecturer, Department of Community Nursing, Faculty of Nursing, Airlangga University, Surabaya, Indonesia. https://orcid.org/0000-0002-0181-6402.
