The influence of TB care community cadre’s roles onthe treatment adherence of tuberculosis (TB)sufferers

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www.elsevier.es/enfermeriaclinica

The inﬂuence of TB care community cadre’s roles on the treatment adherence of tuberculosis (TB)

sufferers ^夽

Sapar

^a^,∗

, Salju

^a

, M. Risal

^b

, Samsinar

^a

, M. Zainal S

^c

, Muhammad Akbar

^d

aFacultyofEconomicandBusiness,UniversitasMuhammadiyahPalopo,SouthSulawesi,Indonesia

bMasterofManagement,UniversitasMuhammadiyahPalopo,SouthSulawesi,Indonesia

cFacultyofHealth,AgricultureandMarine,UniversitasMuhammadiyahPalopo,SouthSulawesi,Indonesia

dCommunicationDepartment,SocialandPoliticalSciencesFaculty,HasanuddinUniversity,Indonesia

Received8November2019;accepted2June2020

KEYWORDS Earlydetection;

Advocate;

Motivation;

Makassar

Abstract

Objective:ThisresearchwasconductedtoanalyzetheeffectofTBcareAisyiyahcommunity cadre’srolesontreatmentadherenceoftuberculosissufferers.

Method: Thisstudyusedaquantitativeapproachwithacross-sectionalsurveymethod,which isstrengthenedbyqualitativedatawithanin-depthinterviewwith4peopleofTBcareAisyiyah communitycadres.SampledeterminationusingthecensustechniquetoallTBpatientstotaling 128,whichwascarriedoutinMakassarCityfromFebruarytoMay2018.

Result: TheresultsshowedthattheroleofTBcareAisyiyahcommunitycadreswasrelatively low,whilethemedicationadherenceisrelativelyhigh.TherolesofAisyiyah’sTBcarecom- munitycadrereﬂectedbyseveralindicators,namelyearlydetectionofTBsuspects,abilityto advocate,abilitytomobilize,abilitytomotivate,andtheabilitytoeliminatethestigmaofTB sufferers,didnotsigniﬁcantlyaffectTBmedicationadherence.

Conclusion:In general,therole ofAisyiyah’sTBcarecommunitycadrewaslowanddidnot signiﬁcantlyaffectthetreatmentcomplianceofTBsufferers.

夽 Peer-reviewunderresponsibilityofthescientiﬁccommitteeof the4thInternationalConferenceHospitalAdministration(ICHA4).

Full-textandthecontentofitisunderresponsibilityofauthorsof thearticle.

∗Correspondingauthor.

E-mailaddress:sapar@umpalopo.ac.id(Sapar).

Introduction

Tuberculosis(TB)isaninfectiousdiseasecausedbythebac- terium Mycobacterium tuberculosis,which usually infects thelungsandaffectsotherpartsofthebody.TBcanspread into theair throughcoughing causes it is easy tospread.

Over thepast 5years,tuberculosis(TB) evenhas become

https://doi.org/10.1016/j.enfcli.2020.06.056

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a leading cause of death witha ranking above HIV/AIDS.

It happens even though with timely diagnosis and proper treatment,themajorityofTBsuffererscanbecured.

TB cases arestill a threatin South Sulawesi Province.

SouthSulawesi HealthProﬁle Datain 2016notedthat the number of pulmonary TB sufferers in SouthSulawesi was 8470cases,andspeciﬁcallyinMakassarCitywas1884cases, the largest compared to all districts and cities in South Sulawesi.¹ TBcasesarenotonlyeconomicallydetrimental butalsohave negativesocial impacts,suchasstigmaand evenostracizedbythecommunity.

TB control is notonly theresponsibility of thegovern- ment,butitalsoneedsthesupportandinvolvementofall elementsofthecommunity,includingcommunityorganiza- tions.AsstatedinIndonesianLawNumber36theYear2009 concerninghealtharticle152paragraphs1and3concerning infectiousdiseases,whichstatesthatthegovernment(local government)andthecommunityareresponsibleformaking effortstoprevent,controlanderadicateinfectiousdiseases andtheirconsequences.²

Treatment adherence is inﬂuenced simultaneously by socio-economicfactors,healthcaresystems,diseasecharacteristics, patient-related factors, and treatment of the disease.Improved medication adherence can beachieved by solving problems related to each of these factors.³ A research literature study examining TB treatment adher- encefoundthatfourmaininterrelatedfactorsaffectingTB treatmentadherenceincludingstructuralfactors(including povertyandgenderdiscrimination), socialcontext,health servicefactors,andpersonalfactors.⁴

Study offactorsthat inﬂuenceindividualsto(including families) seek health care and be compliant for treat- mentincludesocialfactors,familysupport,economy,health care system (including good communication), peer group support,diseasecharacteristics,patientpersonalities,and treatmentofdisease.^5---14

Methods

This study uses a quantitative approach with a cross- sectionalsurveymethodthatisstrengthenedbyqualitative analysis.Determinationofthesampleusingacensustech- nique to 128 TB patients as researchsamples. The study was conducted in Makassar City from February to May 2018. Data collection was carried out through question- naires, direct observation, and an in-depth interviews at the study site. Data processing and analysis using quantitative statistical analysis (descriptive and inferential).

Descriptiveanalysis is usedtodescribe informationabout thedata or phenomenon understudy. Inferential analysis using Smart Partial Least Squares (Smart PLS2.0) soft- waretotesttheresearchhypothesesanddrawconclusions based on the analysis results. Qualitative data obtained throughin-depth interviews with 4 representatives of TB care Aisyiyah community cadres in Makassar. Qualitative data analysis was carried out to deepen quantitative ﬁndings.

Results and discussion

Therolesofcadres

The roles of Aisyiyah’s TB care community cadres which werethefocusof thisresearchstudynamely (a)theabil- itytodetectTBsuspects early,(b)theabilitytoadvocate TBsufferers, (c)the abilityofsocial mobilization,(d)the abilityof TB cadrestomotivate TBsufferers, and (e)the abilitytominimizestigmaforTBsufferers.Ingeneral,the roleof cadres in thisstudy is in the low category caused by thelack of meetingsand visits of cadres to sufferers.

Adetaileddescriptionoftheroleofcadresispresentedin Table1.

Table1 Thefrequencyandpercentageofrespondents’assessmentsofthecadre’srole.

Indicator Category Frequency Percentage(%)

EarlydetectionabilityinsuspectedTB Low 78 61.0

Medium 30 23.4

High 20 15.6

TheabilitytoadvocateTBsufferers Low 77 60.1

Medium 47 36.8

High 4 3.1

Theabilityofsocialmobilization Low 101 78.9

Medium 21 16.4

High 6 4.7

TheabilityofTBcadrestomotivateTBsufferers Low 76 59.4

Medium 11 8.6

High 41 32.0

AbilitytominimizestigmaforTBsufferers Low 81 63.2

Medium 36 28.1

High 11 8.6

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Table2 Thefrequencyandpercentageofrespondents’assessmentsofmedicationadherence.

Indicator Category Frequency Percentage(%)

Thefrequencyoftakingdrugs High 118 92.2

Low 10 7.8

Dosagecompliance High 124 96.9

Low 4 3.1

Check-upschedule High 109 85.2

Low 19 14.8

Treatmentadherence

Treatmentadherencethatisthefocusofthisstudyincludes thefrequencyoftakingdrugsinTBpatients,dosagecompliance,andcheck-upschedule.Ingeneral,Table2showsthat thelevelofpatientmedicationadherenceinallindicators is in the high category. It means that the majority of TB sufferersadheretotreatment.Adescriptionofthesample distributionbasedontreatmentcompliancewithTBpatients canbeseeninTable2.

The frequency of taking medication is in thehigh category (92.2 percent). Most sufferers take medicine as recommended by health workers (every day in the ini- tial phase of treatment and three times a week in the nextphase),neverforgettingtotakemedication,andnot deliberatelynottakingmedication.However,wefoundsev- eral cases of patients stop taking medicines before the allotted time. The reason to that was because they feel thattheirhealthconditionhasimproved (usuallythe next phase of treatment, which is the 3rd month of treatment).Itisalsobecausetheyforgetnottotakemedicine for days (for example: due to working outside the area, like a driver). Beside it is also caused by feeling bored taking medication and because of side effects of the drug.

Dosagesuitabilityisinthehighcategory(96.6percent), whichmeans thatmost sufferers take medicineaccording tothedosagehealthworkersrecommended.Thehighper- centageof dose compliance is due to the fact that most TBsufferersneverreduce orincrease thenumberofanti- TBdrugsthathavebeen recommendedbyhealthworkers, never replace anti-TB drugs with other drugs or herbal medicines,andneverthrowawayanti-TBdrugs.However, wefoundseveralcasesofpatientsstoppingtakinganti-TB drugsandpreferringtraditionalor herbalmedicines,stop- pingtakingmedication becauseit wasdifﬁcult toswallow thedrugduetoitslargesizeandalargenumberofdrugs(3 drugsinonedrink)whichisusuallyexperiencedbysufferers oftheelderlycategory.

Thecheck-upscheduleisrelativelyhigh(85.5percent), whichmeansthatthepatientfollowsthecheck-upschedule regularlyandcorrectlyaccordingtotheadviceofthehealth worker.Based on observationsof research locations, it is knownthat sufferers routinely visithealth services (Com- munityHealthCenter(Puskesmas)orhospitals)forsputum check,lung check,andfortakinganti-TBdrugs. However, for taking medicines, the patient is usually accompanied bya closerelativeandsometimes representedby a close relative.

TheeffectoftheroleofTBcareAisyiyah

communitycadresonthetreatmentadherenceof TBpatients

The results of statistical analysis (Fig. 1) show that the roleofAisyiyah’sTBcarecommunitycadrereﬂectedinthe several indicators, including the ability to detect the TB suspect early,advocacy ability, socialmobilizationability, motivation ability, and ability to eliminate the stigma of TBsufferers,didnotsigniﬁcantlyaffecttreatmentcompli- ancebyTBsufferers.Itiscausedbythelackofmeetingsor interactionsofcadreswithTBsufferers.

The result found in this research is different from researchﬁndingsinseveralliteratures.Dudleyetal.(2003) concludedthat in NorthAfrica, communityhealth worker support contributedtobetter TB controlprogram perfor- mancethanapproaches basedsolelyonhealthfacilities.¹⁵ Besides,itwasalsoreportedintheliteraturethatleaders, speciallytrainedleaders,canhelpTBcontrol.Pirkanietal.

(2009)foundthatreligiousleaderswhohadreceivedtrain- ingwereeffectiveinﬁndingindividualssuspectedofTBas well as inadvising them tovisit TB clinics,resulting in a noticeable increase in case detection rates.¹⁶ These reli- giousleadersconveymessagestothepublicinaneffective waysothatpatients attendTB clinicsasreligiousleaders suggest. Sutisna et al. (2017) stated that the leadership role of community leaders in ﬁnding TB sufferers was to provide motivation, a place to ask questions and consul- tations, hold regularmeetings, andmanageactivities and raisedonations.¹⁷

Also,United Nations Children’s Fund (UNICEF), in col- laboration with non-governmental organizations in India, createsaSocialMobilizationNetwork(SMNet),whichaims toincreaseaccessandreducefamilyandcommunityresis- tanceto poliovaccination. Variousinnovationshave been carriedout,includingtheformationofalocalsocialmobi- lizationcoordinator,theinvolvementofcommunityleaders, the use of child motivators and child parades, the intro- ductionofhealthcamps,andthesupportofrelatedhealth interventions such as sanitation, hygiene, and maternal health education.¹⁸ Zainal et al. (2019) found that the patient’s personal factors (self-efficacy) had a significant effectonthetreatmentofTBsufferers.¹⁹Itisalsofoundby Zainaletal.(2018)thattheroleofcadresandadministra- torsoftheAisyiyahTBcarecommunityprograminMakassar greatlyinfluencesTBsufferersthroughadvocacy,communication,andsocialmobilizationactivities.²⁰

AshwellandBarclay(2009)oncommunity-basedhealth programs in Papua New Guinea found that sustainable

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Cadre’s roles

Treatment Adherence Early detection ability

0.140 Ability to advocate

The ability of social mobilization

Ability to motivate

Ability to minimize stigma

Figure1 TheeffectofCommunityTBCareAisyiyahcadre’srolestotreatmentadherenceofTBsufferer.

independenceinthehealthsectorcanbeachievedthrough the leadership of community leaders and maintaining health-relatedactivities.²¹ Kamineniet al.(2011) pointed out that the involvement of Non-Government Organiza- tions(NGOs)asalink,coupledwithincreasedtrainingand involvementofhealthworkersandcommunitygroups,and the distribution of community-based resources can con- tributetoraisingawarenessandknowledgeaboutTB.²²

Overall,theﬁndingsofthelowroleofcadresinthisstudy werestrengthenedbytheresultsofinterviewswithcadresin thestudylocation.Forexample,cadresinPanakukangSub- districtadmit thatit isdifﬁcult todividetheirtimesince beingacceptedasahealthworkerinoneofthehealthser- vices in Makassar City. Sincebeing appointed asa health workerin2013,thefrequencyofmeetingswithTBsuffer- ersismorefrequentinhealthservices.Buthecontinuedto monitorthedevelopmentofpatientsor suspectedthrough cadres,‘‘satellite’’thatherecruitedineachworkingarea.

The‘‘satellite’’cadreisinchargeofdeliveringinformation aboutTB.

‘‘Since2013,CadreLYhasbeenlessactiveinlookingfor suspectedTB becausehe hasbeen accepted at Makas- sarCity’s Lung Centerasan employee. ButI recruited satellitecadrestohelpconveyinformationaboutTBand suspects.’’

Likewise, a cadre working in the Makassarsub-district admitted that from 2015 to 2017, there was very little searchingforTBsuspectsorTBpatientassistancebecause ofcosts,especiallytransportationandlogisticscosts.How- ever, the cadresaid that at the beginningof joining as a cadre(from2008to2014),heactivelysought TBsuspects andprovidedassistancespecificallytohelpTBsufferersget drugsinhealthservices(puskesmas).Inaddition,thereare alsocadres whoalsowork asadministrators of theRukun Tetangga(RT), villageofficials, sothat ithasimplications forthelessoptimalinfindingandassistingTBpatients.

‘‘CadreNBsaidthatheactivelysoughtsuspectsandTB patientsaround2008---2014.From2015,2016to2017,he isnolongeractivelyseekingsuspectsandpreferstowait at the Puskesmas due totransportation funds.Besides that,gatheringpeopleneedsconsumptionforpeople.’’

However,itwasfoundthattherewerestillactivecadres assisting TBsufferers. Oneofthem isa cadreintheTallo District of Makassar City. The cadres have relatively free

timetoﬁndandhelpTBpatientsandhavegoodfriendships withlocalhealth workers. Accordingto him, the purpose of being a cadre was only to accompany her husband in ordertorecoverfromTB.But overtime,cadresbegan to becomeactive ascadres for socialcare, also tohelp the householdeconomybecausebecomingcadresgetsalaries, ifthey ﬁndsuspects and TB positive patients. Sometimes theyalsoreceiveanadditionalhonorariumforattendingTB trainingheldbytheAisyiyahTBcarecommunitycommittee.

‘‘Cadre STHeexplainedthatmyinitial motivationwas tojoin becausemyhusbandhadsufferedfromTB, soI hadtoaccompanyhimduringtreatmentuntilhealed.In additiontotheeconomicboost,ithappenedthatmyhus- bandwasonlyaprivateemployee,andIstillhadseveral familymembers(children)whowereattendingschool.’’

Cadres hope to get the attention of the government becausetheyaredirectlyinvolved inhelpingalleviatethe government’sresponsibility(in thehealth sector)toover- comeTB.

Conclusion

Ingeneral,theroleofAisyiyah’sTBcarecommunitycadres wasrelativelylow. The influence ofthe roleof Aisyiyah’s TB care community cadre reflected by indicators of TB suspected early detection ability, advocacy ability, social mobilizationability,motivationability,andabilitytoelim- inatethestigmaofTBsufferersdidnotsignificantlyaffect TBpatienttreatmentcomplianceduetothelowmeetingsor interactionsofcadreswithTBsufferers.Effortstoimprove thecompetencyofcadresareneededsothattheirroleas the‘‘spearhead’’in the fieldcan have amore significant influenceonthetreatmentcomplianceofTBsufferers.

Conﬂict of interest

Theauthorsdeclarenoconﬂictofinterest.

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