According to the WHO (2011), pulmonary tuberculosis (TB) is an infectious bacterial disease caused by mycobacterium tuberculosis, which most commonly affects the lungs. It is transmitted from person to person via droplets from the throat and lungs of people with the active respiratory disease. Tuberculosis is still a major public health problem, especially in developing countries. The World Health Organization (2011) there was 8.8 million cases of tuberculosis (TB) and 1.1 million deaths from TB globally. Indonesia carries the fourth highest TB rate in the world. The WHO (2007) reported the number of tuberculosis patients in Indonesia was approximately 528,000 which is the third highest global rate after India and China. The WHO reported in 2009 that Indonesia's rank dropped to fourth position with the number of tuberculosis patients by 429,000 out of 240 millions people of the total population of Indonesia. Four states with the largest number of cases in 2011 were India, China, South Africa, and Indonesia (WHO, 2011).
A WHO Report (2010) on Global TB the data obtained for Indonesia, showed a total of TB cases in 2009 were as follow: 294,731were cases where new smear positive TB cases, 108,616 were smear-negative TB cases and 6,589 were re-treatment cases (retreatment or relapse). The incident of TB in Central of Jawa in 2008 to 2011 still increased from 47.98% to 55.18%. So, it contributed 22,182 point prevalence or 12.5 %of the number of pulmonary tuberculosis in Indonesia although it had been anticipated by DOTS (Directly Observed Treatment Short course strategy) for Tuberculosis control since 1998 (Ministry of Health, 2010). The Case Detection Rate (CDR) in Central Java province in 2008 was 16,748 people or 47.97%.this was less then targetted discovery of new cases of smear positive (+) it's more than 70%. While the case detection rate in Banjarnegara Regency was 33% it is lower rate after Magelang Regency and Boyolali Regency in Central of Jawa Province. The rate was lower Case Detection Rate (CDR) means that there are many cases of pulmonary TB which have not been detected and treated so that it can be a source of infection for people in the environment. Therefore more effort in actively finding the case is truly needed (Ministry of Health RI, 2011).
In fact, the Ministry of Health RI (2010) has a policy to reduce TB with release National Strategy. First, ensure access to diagnosis, effective treatment and cure for every TB patient. Second stop the spread of TB. Third, reduce inequalities in social and economic burden caused by TB. The last develop and implement preventive strategies, diagnosis and treatment efforts in our new stop TB strategy. Control of TB is found on early diagnosis and treatment of active cases and infected contacts. Delays in initiating treatment not only impacts on TB control by increasing the risk of disease transmission and risk of mortality (Yusuf, 2008) Surplus time between diagnosis and initiation of TB treatment provides to ongoing TB transmission (Paul, 2012).
Beside that, the TB control community has recognized that behavior is important. The seeking treatment for pulmonary TB patient's are assumed more effective than self-administration (Silvio W. 2005). In addition Fatiregun (2010) said that "two of the key components of a good TB control programmers are an early diagnosis and prompt institutions of effective treatment". The behavior of people and the seeking of TB treatment, are considered also influence the low coverage of the discovery of the patient, namely the knowledge, perceptions, beliefs, attitudes, economic status, accessibility to the service and quality of the service, (Yulfira, 2011).
Factors of health seeking treatment have become important in addition to contributing to the case finding. It is also to prevent loss of quality of life of patients as reported in a study by Marra (2004) "TB has a major impact on the affected individuals are also namely quality of life through the issues associated with, treatment support the diagnosis, social and behavioral functioning and health." The study by Layogi, 2011; Gemeda, 2010; Hasimah, 2001; Wang, (2008); Qian, 2008; Jian, 2008; Silvio, 2005; Paul, 2010; Jossy, 2011; Weiguo, 2009; Yusuf, 2008 have proved that knowledge, perception, seeking treatment and social economic, can influenced health seeking TB treatment. It is in contrast with research from Kilale, (2008) saying that social economic was associated with health seeking treatment. Then, a study by Nguyen, (2008) described that male had higher rate than female. Patients with TB are not only affected in their physical functioning and emotional or mental well-being, social functioning, but also through isolation, the ability to resume social activities, recreation and treatment of TB is also the impact of the patients life
There is a previous study by Mahendrata, (2010) about seeking treatment behavior was related to quality of service in Yogyakarta Province Indonesia. The study found that socio-demographic factors are not associated with diagnostic delay. According to Haryanto (2006) the implementation of handling and treating pulmonary tuberculosis in Banjarnegara Regency has not been fully implemented well. There is not research about knowledge, perceptions and stigma that is conducted in Indonesia especially in Banjarnegara Regency. Indonesia, as a fourth most number of TB patients in the World, needs more research on health seeking treatment for pulmonary tuberculosis, especially in Banjanegara Regency. The findings of this study do not effect to the patient directly, but it would give understanding about the length of seeking treatment, Tuberculosis knowledge, perception and stigma of pulmonary tuberculosis patients, that will be used to support a policy to stop TB and a strategy on department of health to improve the quality of service properly, the case findings, the health promotion and the prevention of TB disease transmission.
OBJECTIVES
Overall Objective
To examine the relationships among knowledge, perception, stigma and days of seeking treatment for pulmonary tuberculosis patients
Specific Objectives
To examine the knowledge for pulmonary TB patients
To examine the perception for pulmonary TB patients.
To examine the stigma for pulmonary TB patients
To examine the days of seeking treatment for pulmonary TB patients.
Literature Review
Conceptual Frame work
The concept of health beliefe Models is that health behavior considered by personal beliefe or personal perception about the disease and the strategies available to decrease it's occurrence. Personal perception is influenced by the whole range of interpersonal factors affecting health behavior. According to Rossenstock (1997) health beliefe model (HBM), Perception have four main parts, such as Perceived susceptibility is one of the more powerfull perceptions in prompting people to adopt healthier behavior. It is logical that, when people believe they are at risk of disease, they will be more likely to do something to prevent it from hapening. Perceived severity or seriousness is an individual's beliefe about the seriousness or severity of the disease. It is often based on medical information or knowledge. It may also come from beliefes a person has about the dificulties a disease would create or the effect. it would have on them life in general. Perceived benefits is a person's opinion of the value or usefulness of a new behavior in decreasing the risk of developing a disease. The people will tend to adopt healthier behaviors when they are believe of new behavior will decrease their chances of deloping a disease. Perceived benefits play an important role in the adoption of secondary prevention behavior, such as screenings TB disease. Perceived barriers is an individual's own evaluation of the obstacles in the way of him or her adopting a new behavior. however, perceived barrier is the most significant in determining behavior change.
The conceptual framework that is used in this study is based on Health Belief Models (HBM) by Rossentock (1997), The Health Believe Models (HBM). These concepts are proposed for knowing tuberculosis patients in seeking treatment behavior, who got the symptoms until the initiation TB treatment.
Knowledge
The days of seeking treatment for Pulmonary TB
Perception
Stigma
Figure 1 Conceptual frame work.
Source: Roesenstock and Strecher (1997). Health believe Model. San Francisco.
Knowledge.
The tuberculosis (TB) is an infection caused by the mycobacterium tuberculosis, and can affect any part of the body, but most commonly the lungs (pulmonary). This infection is generally transmitted by prolonged and/or frequent contact with an infected person (Oxford, 2006). The symptoms of TB disease are depend on the site of active disease. The most common of TB that are characteristized by chronic cough, hemoptysis, and chest pain. The general symptoms of TB are include, chills, night sweats, malaise, loss of appetite, and weight loss (Crofton 1999).
Household Health Survey shows that TB is the third cause of the death after cardiovascular and respiratory diseases in all age groups. Since 1995, the national TB control programs began to implement the DOTS strategy and applying it to health centers gradually. Almost all clinics have been committed, and implementing the DOTS strategy to integrate the health services, but the burden of TB is still a raise around 75% of TB patients. Based on the household survey Ministry of Health (2010), the reasons or knowledge of TB suspect, that is TB can be cured by itself without treatment amounted to 38.2%. The most of them are productive age (15 -54 years).
Previous studies found that the tuberculosis knowledge were can influence the seeking treatment for pulmonary TB. (Farah (2006) and Mesfin et.al, (2005)). Hussen et.al, (2012) describes some reasons, the lenght seeking treatment for pulmonary tuberculosis are caused of lack of knowledge. In addition, that TB knowledge is hypothesized to be associated with greater willingness to accept treatment, possibly leading to increased rates of treatment completion (Colson, 2010). Different finding in the study from Nigeria, indicated that there was no relationships among prolonged seeking treatment and knowledge (Fatiregun, 2010). A study from Amazon, found that TB patients who had lived with another tuberculosis patient would be expected to be knowledgeable about tuberculosis symptoms, diagnosis, and treatment. They also had more prolonged seeking treatment although patients have knowledge and experience about TB (Ford et.al, 2010). In this study the knowledge is defined as patient ability to correctly recall the memory about TB disease, such as: infectious disease process, transmission, causes, symptoms, diagnosis, prevention and treatment.
Perception.
According to Brown (1999) perception of seriousness is often based on medical information or knowledge. It may also come from beliefs a person has about the difficulties that the disease would create or the effect. Furthermore, Gibson (1996) claimed that perception was an important sense direct. Patient with the poor perception about TB were more likely to be late for their first consultation at public health facilities (Mesfin et.al, 2009). Further, this study explained that the majority of patients believed TB to be a result of exposure to cold, evil spirits and God's will. Traditional beliefs can also influence the perception of people to health. In this case, the traditional belief might contribute to the spread of TB and might affect the human mind not to visit health facilities (Gemeda et.al, 2010). This study perception is defined as a personal belief and way to notice about his or her disease consisting of perceived susceptibility, perceived severity, perceived benefit and barriers.
Stigma.
Stigma is a negative outcome or unwanted effect resulted from any physical attribute, character or behavior which deviates from the norm and is perceived to be undesirable (Wiener et.al, 1998). According to Goffman (1963), stigma is an attribute, behavior, or reputation. Stigma is associated with many problems such as isolation, marginalization, and lack of treatment for those with TB.
In many studies, stigma has been found to be a major compelling reason for people with TB to keep their disease secret. Study from Norway shows that stigma is a major role that influences TB (about 86% of the patients were foreign - born and the majority of them came from countries with high TB prevalence) (Farah et.al, 2006). Similar to the result of Storla et.al (2008) that described that the main determinants of seeking treatment were stigma. Furthermore, improving awareness about TB and treatment, and the stigma attached with TB are crucial to reduce prolonged seeking treatment (Mesfin et.al, 2009). Community in Nepal has a general believe that individual should not meet people who have TB and not visit a home where there is a house member with TB (Gemeda et.al, 2010). In additional, stigma was found significantly associated with TB. One of study described that 64.8% of the highly stigmatized patients were found seeking care for TB (Yusuf, 2008). The stigma is a sense of shame that caused by TB that affects toward behavior to seeking treatment, that is defined in this study.
Research Plan
Health Behavour
If it gets worse i will take the medicationHypothesis.
H0. The knowledge does not have any relationship with days of seeking treatment for pulmonary TB patients.
The perception does not have any relationship with days of seeking treatment for pulmonary TB patients.
The stigma does not have any relationship with days of seeking treatment for pulmonary RB patients.
Ha. The knowledge does have any relationships with days of seeking treatment for pulmonary TB Patients.
The perception does have any relationships with days of seeking treatment for pulmonary TB patients.
The stigma does have any relationships with days of seeking treatment for pulmonary TB patients.
Materials and Equipments
Instrument.
Researcher will use the instrument by Yusuf, (2008) to conduct research in Banjarnegara regency using Indonesian language, so it needs to be translated into Indonesian language by expert, and then the tools will be pre-tested to examine the validity and reliability. This study will be measured with structure questionnaire. The questionnaire consists of knowledge, perception, stigma and seeking treatment TB. It will be adopted from previous study by Yusuf, (2008). Before using the questionnaire, researcher will apply permission to use the questionnaire. The questionnaire consists of 5 (five) section as follows:
Section I: General information and socio-demographic information.
In this section, notification of the name of health center, date of treatment and onset the symptoms based on record and socio-demographic information will be asked to the patients that consists of age, gender, and monthly income.
Section II: Onset of symptoms
This information about when the onset of symptoms started until the patient get the treatment for pulmonary tuberculosis. The specific symptoms of TB disease are such as chronic cough (2-3 weeks), hemoptysis, and chest pain. The general symptoms of TB are include, chills, night sweats, malaise, loss of appetite, and weight loss.
Section III. Knowledge of TB
The variable of knowledge consist of specific question such as cause (6 questions), sign and symptoms (5 questions), transmission of TB (4 questions), Diagnosis (4 Questions), prevention (4 questions), and treatment (5 questions). The correct answer will get one score (1) and incorrect answers will zero score (0), then it will be calculated as the total score of knowledge TB for each patient.
Section IV. Perception of TB.
Perception is rated as score 1(Agree), score 2 (Uncertain), and score 3 (Disagree). The total score will be generated and also categorized as≥80% (good perception), 50% - 79% (average perception), and less than 50% (Less perception). The perception question consist of perceived susceptibility (4 questions), perceived severity (4 questions), perceived benefits (4 questions), and perceived barrier (4 questions).
Section V. Stigma
The information about stigma using closed questions (7 questions) and ordinal scale will be categorized into highly stigmatized (>80%), average stigmatized (50% - 79%), and less stigmatized (<50%).
Validity and reliability.
The validity will use correlation Pearson product moment and reliability will use crombach alpha. It will be carried out in one of health care services selected for the main study. It will use 30 voluntary patients.
Methodology
Study design.
This study will be conducted using descriptive cross sectional design to examine the relationships among knowledge, perception, stigma and days of seeking treatment for pulmonary TB patients.
Sample and Population.
The population in this study is all of patients who have positive smear and X-ray film for pulmonary tuberculosis, who got treatment first within two month (intensive phase) in six primary health care centers under DOTS Program at Banjarnegara Regency. The previous studies used total sample with criteria (Yusuf, 2008; Rojpibulsit, 2005, Solomon. 2005; Faterigun, 2010; Lienhardt, 2000). This study will use purposive sampling in six primary health care services. The sample size is calculated using G power, to obtain the power size 0.95, α=0.05, minimal sample is 115 and the sample will be selected with inclusion and exclusion criteria.
Inclusion criteria.
Pulmonary TB patients who have positive smears or positive X-ray film in the age above 15 years old.
Patients who got treatment in intensive phase (during two months treatment)
Patients with TB who have been treated at six primary health care centers.
Patients who live in Banjarnegara Regency, Indonesia.
Exclusion criteria.
Patients with extra complication disease such as COPD, HIV-AIDS, renal disease.
Patients with mental illness.
Patients defaulted before the data collection.
Patients who relapse and smear negative TB.
Patients who are unwilling to participate in this study.
Data collection plan.
Before collecting the data to the patients, researcher will review the number of patients with positive smear and X-ray film, the starting date of the treatment for each patient will be based on TB register in the Health care services. The data will be used to determine the days of seeking treatment. The samples that can be included in this research are a positive TB smear and positive X-ray film. The patients are over 15 years old based on their record at six primary health care services. With permission of health care worker at the DOTS clinic, patient coming in primary health care service for their treatment under DOTS, and TB patients who gets the treatment under DOTS but does not come to take medicine are possible to get home visit, based on criteria of sample. Before administering the questionnaire to get required information, researcher will explain the procedures, objective of study and get informed consent. The patients who are willing to participate in the study are then given 50 minutes to answer the questions in the questionnaire. After participant finishes answering, a questionnaire will be collected, then the researcher will make sure about the completeness of answers in each section of the questions and the date of the first treatment will be cross-checked between questionnaire, health care service record and the treatment card of the patient, before the data are analyzed.
Data Analysis.
The data analysis will use both bivariate and multivariate statistics. The data analysis will be performed with computer for windows. The measurement to determine the association of each variable on the outcome of variable will be calculating by Pearson correlation and the alpha (α) 0.5 significance level will be used in overall statistical tests. Pearson's correlation is the statistical method to examine the relations between two variables quantified at least ordinal data, Munro (1997).
Ethical consideration.
The research proposal will be submited to the ethical cometee at Kasetsar University, after get the ethical approval by university, then, researchers will continued to apply for government permission in Banjarnegara Regency and Ministry of Health to conduct research.
Time Table.
Activity
2012
2013
Jun
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
Jul
Aug
Identify the problem
Find the relevant literature review
Summarize an analyze the literature
Start writing proposal
Defense proposal
Collecting data
Analyzing data
Write chapter 4 and 5
Thesis defense
Prepare for publication
Places and Duration
The period of this study is between Marchs until April 2013. Banjarnegara Regency has 35 primary health care services that provide TB treatment under DOTS, but this study will be conduct in six primary health care centers mentioned as follows: Primary Health Care Susukan I, Primary Health Care Susukan II, Primary Health Care Mandiraja I, Primary Health Care Bawang II, Primary Health Care Banjarnegara I, and Primary Health Care Pagedongan. That health care center has six bigger number of pulmonary TB than the other primary health care centers in Banjarnegara Regency.
Benefits
The expected outcomes of this study are to understand the length of seeking treatment for pulmonary TB patients and to know the relationships among knowledge, perception, stigma and seeking treatment TB. Furthermore, this finding can be used by Ministry of Health to improve quality of proper service such as active promoting and active case finding for minimizing the transmission of TB disease.
Funding Source
This research funding will be financed by educational foundations "Dwi Puspita". The details of the fund are as follows:
No
Items
Amount/ number
1
Equipments
Photo copy
Printer
CD blank
Flash disk
Papers
Pen
1
10
1
4 rims
10
x
x
x
x
x
5,000
50,000
10,000
500,000
650,000
50,000
120,000
200,000
100,000
2
Transportation using motorcycle or car
5liters
x
90 days
x
4500
3
Small gift for Primary health Public service
7
x
150,000
4
Snack for seminar permission and seminar result in Department of Health
2 times
x
15 Persons
15,000x
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