TUBERCULOSIS HEALTH EDUCATION PROGRAM: A CRITICAL REVIEW
By: Neti Juniarti, S.Kp., M.Kes., MNurs
Faculty of Nursing
Universitas Padjadjaran
TUBERCULOSIS HEALTH EDUCATION PROGRAM: A CRITICAL REVIEW
By: Neti Juniarti, S.Kp., M.Kes., MNurs
Faculty of Nursing Universitas Padjadjaran
2008
Acknowledge by:
Dean,
TUBERCULOSIS HEALTH EDUCATION PROGRAM: A CRITICAL REVIEW
Introduction
The following essay seeks to critically review the research evidence about the best possible Tuberculosis health education program for mothers/families and nurses to increase adherence of Tuberculosis treatment among children, and to discuss the application of this evidence to practice in Indonesia.
The essay has been broken into two distinct sections. Section one is a concise critical review of existing research evidence on a topic of choice including protocol (research plan) for investigation. Section two discusses the research basis for professional knowledge in community health area.
It is important to distinguish that for the purpose of this essay, the focus of this essay is a brief critical review of the online research evidence from six most important studies (systematic review and primary research studies) that relevant with tuberculosis health education program in community health centre in Indonesia, particularly West Java.
Section one: A concise critical review of existing research evidence
1. Identification of a topic of high priority to Community Health Centre in West Java, Indonesia
Tuberculosis (TB) is a communicable disease that is still a public health problem in developing countries including Indonesia. TB is a major health problem in the world because it can affect the physical, economic, social, and mental health condition of the patient (Weiss, et al. 2006).
(DOTS). Its key components include: government commitment; case detection by predominantly passive case findings; standardized short course chemotherapy at least to all confirmed sputum smear-positive cases, provided under proper case management conditions; a system of regular drug supply where anti-TB medicine is given free to poor patients to reduce defaulted ratesresulting from a lack of funding; and, a monitoring system for program supervision and evaluation (Depkes RI, 2002; WHO, 2006b). In 1999, the Department of Health launched new program called Gerdunas (National Integrated Movement) which catalysed the wide acceptance of DOTS with a treatment success rate of over 85%, a case detection rate of 54%, and 24% of large hospitals having implemented the DOTS strategy (WHO, 2005).
Despite the success of these initiatives, the incidence of TB is still high. Of the high-burden TB countries, in 2004 Indonesia was ranked third after India and China. Specific Indonesia data relating to TB is shown in Table 1.
Table 1 TB statistics in Indonesia in 2004 Incidence of TB
2. Protocol (search plan) for investigation of Tuberculosis health education approach
Background
Table 2 Numbers of Patients with TB in District Sumedang from 2001 - 2004
Year Categories
2001 2002 2003 2004
Adults 763 717 846 707
Children with TB 24 57 132 392
Source: Subdin P2P Dinkes Kabupaten Sumedang, 2004
Table 2 shows that overall the number of adults with TB in Sumedang, West Java Indonesia is slightly decreased, however, of all patients the number of children with TB has increased rapidly. The ratio of increase for children with TB has been more than 15 times from 2001 to 2004. Such increases in the number of TB patients are costly to both patients and the society including paying for visits to clinics, tests, transportation to and from clinics, provision of additional nourishing foods, absenteeism from school, and adverse impacts on health and education of children (WHO, 2002; The Global Fund, 2005).
Two major obstacles to the success of Tuberculosis control in the world are patients delaying to seek treatment and ignoring or leaving the treatment before it was really effective because misunderstanding early symptoms like coughs or weight loss which they related to other factors (Helman, 2000). According to the Indonesian Household Survey in 2004, the knowledge of Indonesian people about TB was still low for instance:
o Knowledge about TB, the cause and methods of transmission of TB: 77% did not know about free medication for TB; 38.8% did not know about the way of TB transmission; 23.1% did not know sign and symptoms of TB; and, 22.7% never heard about TB.
Based on these data, health education is one of important aspect to help reducing the spread and incidence of TB in Indonesia. Moreover, TB care for children is depending on their mother so that a good approach and health education for mothers is very important. Therefore, evidence based of the best approach for TB health education program for mother whose children have TB is important to recognize.
The topic or question
What is the best possible approach for TB health education program for mothers whose children have TB?
Objectives
The aim of this protocol (search plan) is to investigate the level of existing research evidence related to the best approach of health education for mother whose children have tuberculosis.
Inclusion Criteria
A list of participants that meet inclusion criteria: o Mothers/families
o Community volunteer/lay health worker o Nurses
A description of the intervention (s) that meets inclusion criteria: o Direct observer of TB treatment
o Strategy or intervention to increase adherence for TB treatment o Health education strategy for community
A list of the outcomes that meet inclusion criteria: o Decrease of TB incidence
o Increase of TB cure rate
o Decrease of unfavourable treatmentoutcomes
Search Planning
a. List of databases that will be search: - Cochrane library
- Turning Research Into Practice (TRIP) - Medline
- CINAHL
- Academic search elite from EbscoHost
b. The search term that will be used: - Tuberculosis
- Health education
3. Result of the online research evidence
Database searches for article on tuberculosis health education were conducted from 23rd April 2007 to 16th May 2007 which includes five databases: Cochrane library, Turning Research Into Practice (TRIP), Medline, CINAHL, and academic search elite from EbscoHost. The searches of five databases retrieved a total of 39 citations (including 15 critical reviews). Of the all citations, six articles were chosen as the most relevant article to answer the question from protocol for investigation. The following is a brief summary of systematic review article as the result from online research evidence:
1) A systematic review article by Volmink and Garner (2006) which had objective to compare directly observed therapy (DOT) with self administration of treatment in people requiring treatment for clinically active tuberculosis or prevention of active disease– stated that no strong evidence that DOT strategy would increase cure rate or treatment completion in people receiving treatment for tuberculosis. However, home-based DOT showed a significant improvement in cure compared to clinic-based DOT, but the difference was small.
a. More instruction for patient e.g. verbal, written material, visual material, and programmed learning.
b. Counselling about the patients’ target disease, the importance of therapy and compliance with therapy, and, the possible side effects.
c. Various ways to increase the convenience of cure, e.g. provision at home. d. Involving patients more in their case through self-monitoring of respiratory
function
e. Direct observation or treatment by health worker or family member f. Lay health mentoring
3) A systematic review article by Briggs and Garner (2006) which aims to assess the effect of strategies to integrate primary care services on producing a more coherent product and improving health care delivery and health status. The result of this systematic review stated that there is no clear evidence that integrating primary care services is better than specialized one to increase adherence to primary care. The way of primary care services should remain the choice made by government and non-government organization based on rational and availability of resources.
4) A systematic review article by Lewin, et al. (2006) which had objective to assess the effect of lay health worker intervention in primary and community health care on health care behaviour, patients’ health and well-being, and patients’ satisfaction with care. This article showed strong evidence that lay health worker program might provide promising benefits in promoting immunization uptake and improving outcomes of acute respiratory infection and malaria. However, there is no strong evidence about the effectiveness of lay health worker program for mothers with sick children.
practitioner for skin test reading could improve adherence, but for adherence for medication regimen, the contract did not improve adherence.
6) A systematic review article by Woolacott, et al. (2006) which aims to investigate the clinical effectiveness of self care support networks in health and social care. This article stated that the evidence of benefit of self care support networks is very weak due to low quality of trials even though one study about TB club in Ethiopia showed that it can improved treatment adherence amongst people with TB in Northern Ethiopia.
4. Discussion
The relative strength of the evidence I have located in terms of level of research ranking is high because fifteen of thirty nine articles found are systematic review, but in terms of relevance to practice is at medium level because from six articles that most relevant to topic or question for investigation only half that showed significant effect.
All systematic review articles measures clearly defined outcomes measures, but only four articles have similar outcomes measures which are adherence to treatment. The research studies I located sufficiently consistent to allow comparison. Discussion of how the research evidence located can be applied in the context of my workplace could be found in section two.
Section two: Discussion of the research basis for professional knowledge
Section two of this assignment will discuss the overview of research evidence found in section one, application of the research evidence to practice in Indonesia, recommendation for further research, limitation of the approach that have been used, and conclusion.
Overview of research evidence
six systematic review articles that are most relevant evidence about the best approach for TB health education for mothers whose children have TB.
In terms of place for implementation of directly observed therapy (DOT), home-based DOT is better approach compared to clinic-based DOT (Volmink and Garner, 2006; Haynes, et al. 2005). Therefore mother as a direct observer at home– play important role to make sure their children take the anti-tuberculosis medication properly.
Interventions or approach to increase adherence with prescribe medication include: more instruction for patient as part of health education e.g. verbal, written material, visual material, and programmed learning; counselling about the patients’ target disease, the importance of therapy and compliance with therapy, and, the possible side effects; family intervention; various ways to increase the convenience of cure, e.g. provision at the worksite or at home; simplified dosing; involving patients more in their case through self-monitoring of respiratory function; reminder, e.g. tailoring regiment to daily habits; special ‘reminder’ pill packaging; using dose-dispensing units of medication and medication charts; using appointment and prescription refill reminders; using reinforcement or rewards for both improved adherence and treatment response; and, using different medication formulation, such as tablet versus syrup (Haynes, et al. 2005).
Other approach that can be used for health education to mother in order to increase children’s adherence with their medication include: using self care support networks in health and social care for example ‘TB club’ in Ethiopia (Woolacott, et al. 2006); and using contract between patients and healthcare practitioners to increase adherence for further TB test (Bosch-Capblanch, et al. 2006). Even though there is no strong evidence about the effectiveness of lay health worker program for mothers with sick children (Lewin, et al. 2006), there is strong evidence that approach by using lay health mentoring could change adherence with prescribe medication (Haynes, et al. 2005).
Health education program as part of primary care services can be conducted integrated or separated from primary care program for children since there is no clear evidence that integrating primary care services is better than specialized one to increase adherence to primary care
(Briggs and Garner, 2006).
Application of research to practice
In Indonesia, health education for tuberculosis patient in community health centre conducted in traditional way, healthcare practitioner just tell the patient that he/she has TB and need to take anti-TB medication for six to eight months. Beside that, the patients often express that they did not satisfied with the health education provided because of lack of privacy, lack of involvement in decision making for their health, longer waiting period, and inability to choose healthcare facility and healthcare practitioner (Badan Penelitian dan Pengembangan Indonesia, 2005).
In order to improve health education for patients, evidence-based practice about best approach to provide health education is important. The finding of evidence from online searching could be applied to mothers whose children have TB in west Java, Indonesia because:
1. Considering Indonesian geographical condition which make transport to and from community health centre difficult then home-based DOT is an appropriate approach to apply (Volmink and Garner, 2006; Haynes, et al. 2005). More over, health education will be more effective because mother feel that they have privacy and can discuss their concern about TB more freely. Some people in Indonesia feel ashamed if they or their family have TB because of stigma associated with TB. Provision of health education at home is one way to increase the convenience of cure (Haynes, et al. 2005).
interest the integrating home-based health education program with ‘POSYANDU’ could save more patient’s money and time. It is also can reduce waiting time, increase mothers’ and family’s participation, built trust between mother, family, and healthcare practitioner, and also as opportunity to involve lay health worker or self care support network in the community to help motivating and strengthening mothers’ positive behaviour towards their children therapy (Woolacott, et al. 2006; Lewin, et al. 2006). However, before conducting home visit, healthcare practitioner should make a clear contract about time, purpose and content of each home visit activity, as describe by Bosch-Capblanch, et al. (2006) that using contract between patients and healthcare practitioners could increase adherence for further TB test and therapy.
3. Health education with more instruction for patient e.g. verbal, written material, visual material combined with counselling about the patients’ target disease, the importance of therapy and compliance with therapy, and, the possible side effects. More over, involving mothers more through self monitoring of the children’s respiratory function could help increase mothers’ ability to take care their children (Haynes, et al. 2005).
In order to implement integrated health education program with ‘POSYANDU’ for mothers whose children have TB, multidisciplinary collaboration need to establish. First, Health practitioners in community health centre should prepare material for TB health education that involving doctor, nurse, environmental health expert, and nutritionist that suitable with local condition. Second, socialization about new approach and coordination with community volunteer or lay health worker in ‘POSYANDU’ should be done. Third, a pilot project is conducted to find out the effectiveness of this approach. Finally, evaluation, revision, and implementation of new approach are conducted.
Recommendations for further research
Limitations
There are some limitations of the approach I have been use in this investigation. Even though I have located some high quality systematic review articles, only a few article that showed significant result of the best approach for TB health education.
Conclusion
In conclusion, the best possible approach for TB health education program for mothers whose children have TB is home-based DOT with integrating health education program with ‘POSYANDU’ program in the village and involving lay health worker or self care support network in the community so that cost for home visit can be minimized. Health education content more instruction for patient e.g. verbal, written material, visual material combined with counselling about the patients’ target disease, the importance of therapy and compliance with therapy, and, the possible side effects; and self monitoring of the children’s respiratory function could help increase mothers’ ability to take care their children. In order to implement this approach, it is recommended to conduct further action research to find out the best possible of TB health education program for mothers.
Reference List
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Briggs CJ, Garner P 2007, Strategies for integrating primary health services in middle and low income countries at the point of delivery, Cochrane Database of Systematic Review 2006, Issue 2, Art. No.: CD003318. DOI: 10.1002/14651858. CD003318.pub 2, viewed 15 May 2007, <http://www.thecochranelibrary.com>.
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