Family Support, Self-efficacy, Motivation, and Treatment Adherence

in Multidrug-resistant Tuberculosis Patients

Tintin Sukartini, Ika Minarni and Candra Panji Asmoro

Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Keywords: Family Support, Self-efficacy, Motivation, Treatment Adherence.

Abstract: Multidrug resistance (MDR) is caused by treatment inadherence. Inadherence is known to increase the risk

of MDR tuberculosis (TB) by 2.3 times. Inadherence is prompted by a knowledge deficit, low self-efficacy,

and poor motivation. Family support could be a solution to adherence problems. This study aimed to

analyze the correlation of family support with self-efficacy, motivation, and treatment adherence in MDR

TB patients. A cross-sectional study involved 55 respondents who were selected using consecutive

sampling. The independent variable was family support. The dependent variables were self-efficacy,

motivation, and treatment adherence. Data were retrieved through the completion of a questionnaire then

analyzed statistically using the Spearman rank rho and Chi-square with α ≤ 0.05. Family support did not

significantly correlate with self-efficacy with p-value = 0.429 or (p ≥ 0.05). Family support significantly

correlated with motivation p-value = 0.043 r = 0.275 (p ≤ 0.05), and treatment adherence p-value = 0.037 or

(p ≤ 0.05). TB MDR treatment should optimize family involvement to increase motivation and adherence.

Further research suggests using counseling to improve family involvement in supporting MDR TB patients.

1 BACKGROUND

Multidrug-resistant tuberculosis (MDR TB) is the

tuberculosis (TB) disease that has resistance to

isoniazid (INH), rifampicin, and one or more anti-

tuberculosis drugs based on standardized laboratory

tests and occurs due to treatment failure, stopping

treatment, or improper treatment, resulting in the

occurrence of primary resistance (WHO, 2015). The

results showed that non-adherence of patients during

treatment increased the risk of developing MDR TB

by 2.3 times compared with patients who were

adhered to treatment (Farmani, 2015).

By 2015 it is estimated that 3.9% of new cases

and 21% of old cases will have MDR TB,

accounting for 580,000 cases. Indonesia ranks 4th in

MDR TB cases with an estimated 32,000 cases with

2.8% of new cases and 16% of old cases (WHO,

2016). Based on data from Infodatin Ministry of

Health Republic of Indonesia (2016) the number of

new cases of Pulmonary TB AFB (acid fast bacilli)

+ + in East Java, in 2016, Indonesia ranks second,

with 21,606 new cases. Data of preliminary study

results at the TB MDR clinic, Dr. Soetomo Hospital,

Surabaya indicated 64 MDR TB patients, a total of

40 adherent patients and 24 inadherent patients, who

refused to undergo intensive phase treatment.

Drug supervisors have a role in preventing the

occurrence of non-compliance medication. The

family of the patient can take that role. Glick et al. in

Maulidia (2014) explains that medication adherence

increases when patients receive support from the

family. Muhtar (2013) discusses the influence of

family empowerment in improving self-efficacy.

Patients with supportive families who promote

family empowerment interventions, including self-

care, had a higher self-efficacy than the control

group. Sukartini (2015) showed that social support

from family and officers, who had knowledge and

perceptions regarding TB, had a positive effect on

motivation for the adherence of treatment.

Deskhmund et. al (2017) state that one of the factors

that can improve treatment compliance is social

support.

Positive family support is needed in the

treatment of TB disease that requires long-term

medication. Support comprises of providing

information verbally or non-verbally, and real

assistance or action is given via social intimacy or is

gained through the presence of the family, who can

have an emotional or behavioral benefit to the

178

Sukartini, T., Minarni, I. and Asmoro, C.

Family Support, Self-efﬁcacy, Motivation, and Treatment Adherence in Multidrug-resistant Tuberculosis Patients.

DOI: 10.5220/0008322301780182

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 178-182

ISBN: 978-989-758-336-0

recipient (Royce, S. et al., 2014). Problems found at

the TB clinic in the government hospital were

related to forms of non-adherence to treatment,

which tends to occur in patients with low family

support. The researcher intends to further examine

the relationship between family support and

compliance, motivation, and self-efficacy during the

treatment of multidrug-resistant tuberculosis (MDR

TB).

The purpose of this study is to analyze the

correlation of family support with self-efficacy,

motivation, and treatment adherence in MDR TB

patients.

2 METHODS

2.1 Design

This study used a cross-sectional design.

2.2 Sample

The population in this study are MDR TB patients

undergoing treatment at the MDR TB clinic during

November 2017. A consecutive sampling technique

was used in this study. The sample size was 55

respondents.

Table 1: Characteristics of multidrug-resistant patients.

Characteristic

Indicators

f (x)

Age

15–25 y.o.

26–45 y.o.

46–70 y.o.

Total

100

Education

Primary school

Junior high school

Senior high school

Bachelor

Total

100

Gender

Male

Female

Total

100

Profession

Housewife

Entrepreneur

Civil servant

Security

Total

100

The inclusion criteria for the sample in this study

are: MDR TB patients accompanied by family, aged

15–70 years, cooperative, able to communicate

verbally, and able to read and write.

2.3 Instrument

The instrument used was a questionnaire regarding

family support using the Source of Social Support

Scale (SSSS), a self-efficacy questionnaire, a

motivational questionnaire, and a compliance

observation sheet.

2.4 Data Collection

Data were collected using the questionnaire. Test

statistics in the study were analyzed using the

Spearman rank and Chi-square tests. The Spearman

rank test was used to analyze family support data

regarding self-efficacy and motivation. The Chi-

Square test was used to analyze family support

regarding adherence.

2.5 Ethical Clearance

This study obtained ethical clearance from the

Research Ethics Committee at Faculty of Medicine,

Universitas Airlangga: No. 418/EC/KEPK/FKUA/

2016.

3 RESULTS

Table 1 indicates that more than half of the

respondents in the study (70%) were between 26 and

45 years old; more than half (51%) of the

respondents have a high-school education

background; more than half (64%) of respondents

are male; and more than half (54%) of respondents

have background jobs with other categories such as

security guards and drivers.

Table 1 demonstrates that most patients are 46–

70 years old, graduates from senior high school,

male, and work in security.

3.1 Correlation of Family Support with

Self-efficacy in Multidrug-resistant

Tuberculosis Patients

Table 2 shows the results of the Spearman rho

statistics test, which determined that family support

does not significantly correlate with self-efficacy.

Family Support, Self-efﬁcacy, Motivation, and Treatment Adherence in Multidrug-resistant Tuberculosis Patients

179

Table 2: Correlation of family support with self-efficacy.

Variable

Family support

Low

Moderate

High

Total

Self-efficacy

Low

Moderate

High

Total

Spearman rho p-value = 0.429

Table 3: Correlation of family support with motivation in

multidrug-resistant tuberculosis patients.

Variable

Family support

Total

Low

Moderate

High

Motivation

Low

Moderate

High

Total

Spearman rho p-value = 0.043 or (p ≤ 0.05)

Table 4: The correlation of family support with treatment

adherence in multidrug-resistant patients.

Variable

Family Support

Total

Low

Moderate

High

Adherence

Non-adherence

Total

Chi square p-value = 0.037

3.2 Correlation of Family Support with

the Motivation of Multidrug-

resistant Tuberculosis Patients

Table 3 shows the results of the Spearman rho test

statistical test regarding the correlation of family

support with patient motivation.

3.3 The Correlation of Family Support

with Treatment Adherence in

Multidrug-resistant Tuberculosis

Patients

Table 4 shows the results of the Chi-square test,

which indicated a significance of p = 0.037. These

results showed a significant correlation between

family support and treatment adherence.

4 DISCUSSION

A small percentage of respondents demonstrated

moderate self-efficacy but low family support. The

results of the statistical tests indicated no significant

correlation between family support and self-efficacy

in MDR TB patients.

The results of this study are not consistent with

work by Hendiani, Sakti and Widayanti (2012),

which suggests that family members supporting as

drug supervisors do have a correlation with self-

efficacy in pulmonary TB patients. The results

showed that patients who had positive perceptions of

family support in supervising drug had a higher self-

efficacy. Self-efficacy is not only formed by family

support, but also by knowledge, attitude, high self-

esteem, feelings of sufficient ability, confidence to

act, and trust their ability to change situations

(Notoatmodjo, 2010).

The Spearmen rho statistical test results found a

significant relationship between family support and

motivation in patients with MDR TB. According to

John Elder (Notoatmodjo, 2007), motivation is an

interaction between behavior and environment, so

can increase, decrease, or maintain behavior. This

result is consistent with a study by Sutarno and

Utama (2012), which indicates that social support

from family and health workers, and sufficient

knowledge and perceptions about TB, has a positive

effect on motivation for treatment. According to

Mohammadi (2009) motivation is needed to

encourage patients to be actively involved in the

control of the disease.

The correlation between family support and

motivation in MDR TB patients indicates that

families can encourage MDR TB patients to

consistently adhere to treatment programs. Family

support has a positive effect on respondents'

motivation to seek treatment.

Most respondents who demonstrated non-

adherence to treatment of MDR TB, had insufficient

family support. The results of the Chi-square

statistics test indicated that there was a significant

correlation between family support and MDR TB

patient compliance. The results of the study are

consistent with Maulidia (2014), who showed a

significant correlation between family support and

treatment adherence for tuberculosis patients.

The results of the study are consistent with

Hutapea (2009), who studied the effect of family

support on treatment adherence. The results

indicated that there is an influence of family support

on the regularity of taking medication. More than

half of respondents take medication once daily. The

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

180

statistics of these two studies equally emphasize the

impact of family support on patient treatment

adherence.

The results are consistent with Wilson et al.

(2016) who suggest that video-based education

regarding TB for families be successfully

implemented in busy and resource-limited outpatient

settings, and can provide a potentially efficient and

low-cost effective strategy towards optimizing

patient understanding, acceptance, and compliance

with TB treatment recommendations

This study is consistent with work by

Castelnuovo (2013) who conducted a review of

compliance in anti-tuberculosis treatment. The risk

factors for defaulting treatment were: distance from

the hospital, not being on the first course of TB

medication, lack of repeated smears, unit transfer

after the intensive phase, experiencing side effects,

having no family support, poor knowledge about TB

treatment, being more than 25 years old, and the use

of public transport.

Sagbakken, Frich and Bjune (2008) investigated

barrier and enablers in the management of

tuberculosis treatment, through a qualitative study.

Their result showed that patients with limited access

to financial or practical help from relatives or friends

experienced barriers to adherence during the early

stages of treatment.

Akshata and Chakrabarthy (2016) studied the

management of multidrug-resistant tuberculosis

(MDR TB). They discovered that monitoring is the

key to successful outcomes. Their results indicated

that early diagnosis of MDR TB, and adequate

clinical monitoring during treatment, is essential.

Identifying adverse drug reactions, other co-

morbidities, and their optimal management are keys

to success.

Adherence is a behavior that can be planned for.

Treatment adherence is the result of interaction

planning for internal and external factors of MDR

TB patients. Family support is an external

reinforcing factor as well as an enabling source of

support when MDR patients become less motivated

to seek treatment. Constant family support will form

consistent patient compliance behavior.

5 CONCLUSIONS

Family support has no significant correlation with

self-efficacy but has a significant correlation with

motivation and adherence to the treatment of

multidrug-resistant tuberculosis (MDR TB).

REFERENCES

Akshata, J. S., Chakrabarthy, A. (2016). Management of

multidrug resistant tuberculosis (MDR-TB) -

Monitoring is the key to successful outcome. Egyptian

Journal of Chest Diseases and Tuberculosis. Volume

65, Issue 2, 1 April 2016, Pages 447-450

Aisyah (2013). Hubungan persepsi, pengetahuan TB

paru dan PMO dengan kepatuhan berobat pasien TB

paru di puskesmas kecamatan Jatinegara Jakarta

Timur. Tesis, FKM-UI

Bildenhann, A. (2015). Assesment of Knowledge and

Attitudes on Latent Tuberculosis Treatment

Acceptance in a South West. Dayton, Ohio:Wright

State Univerity.

Castelnuovo B (2013). A review of compliance to anti

tuberculosis treatment and risk factors for defaulting

treatment in Sub Saharan Africa. African Health

Sciences 2010; 10(4): 320 - 324

Darmadi (2010). Analisis kualitatif perilaku kepatuhan

menelan obat pasien tuberkulosis Paru di 4

Puskesmas Wilayah Kabupaten Ketapang tahun 2000

(http://www.lontar.ui.ac.id//opa

c/themes/libri2/detail.jsp? id=70978 &lokasi=lokal)

akses 30 Juli 2017

Departemen Kesehatan Republik Indonesia. (2008).

Pedoman Nasional Penanggulangan TBC. Jakarta:

Bhakti Husada.

Dhewi, G. I., Armiyati, Y., & Supriyono, M. (2011).

Hubungan Antara Pengetahuan, SIkap Pasien dan

Dukungan Keluarga dengan Kepatuhan Minum Obat

Pada Pasien TB Paru di BKPM Pati. Semarang:

Program Studi S1 Ilmu Keperawatan Stikes

Telogorejo.

Deskhmund, RD, Caroline, MD. & Nutherford, LS.

(2017). Social support a key factor for adherence to

multidrug-resistant Tuberculosis treatment.

http://dx.doi.org /10.1016./j.itjb.2017.05.03

Farmani, P. (2015). Prediktor Ketidakpatuhan Minum

Obat Tuberkulosis (TB) pada Pasien dengan

Pengobatan Kategori 1 di Puskesmas Kota Denpasar

pada Tahun 2011-2012. Denpasar: FK Unud

Hendiani, N., Sakti, H. & Widayanti, C. G. (2012). The

relationship between perceived family support as drug

consumption controller/ pengawas minum obat

(PMO)’s and self-efficacy of tuberculosis patients in

BPKM Semarang region. Jurnal Psikologi, Vol. 1 (1)

94-105

Hidayati, L. (2012). Pengaruh hypertension self-

management program terhadap perubahan self-

efficacy, self-care behaviour dan tekanan darah

penderita hipertensi di puskesmas Mojo. Tesis.

Universitas Airlangga.

Hutapea. (2009). Pengaruh dukungan keluarga terhadap

kepatuhan minum OAT. Jurnal Respirologi Indonesia.

29 (2).

Kementerian Kesehatan RI. (2016). Petunjuk Teknis

Manajemen Dan Tatalaksana TB Anak.Jakarta:

Kementerian Kesehatan RI.

Family Support, Self-efﬁcacy, Motivation, and Treatment Adherence in Multidrug-resistant Tuberculosis Patients

181

Kholifah, S.N. (2014). Self-management intervention

sebagai upaya peningkatan kepatuhan pada

penderita DM. Jurnal Ners, Vol. 9 (1) 143-150.

Maulidia, DF. (2014). Hubungan Antara Dukungan

Keluarga dan Kepatuhan Minum Obat Pada Pasien

Tuberkulosis di Ciputat (Skripsi). Jakarta: UIN

Mohammadi, E., Abedi, H.A., Gofranipour, E., Jalali, F &

Kazemnejad, A. (2009). Evaluation of 'partnership

care model' in the control of hypertension.

International Journal of Nursing Practice, 12, 153-

159.

Muhtar (2013). Pengaruh pemberdayaan keluarga dalam

meningkatkan self-efficacy dan self-care activity

keluarga dan penderita tuberkulosis paru di kota Bima,

Nusa Tenggara Barat. Tesis, FKp-UNAIR.

Notoatmodjo, S. (2010). Ilmu Perilaku Kesehatan. Jakarta:

Rineka Cipta.

Nursalam. (2013). Metodologi penelitian: Pendekatan

praktis (edisi 3). Jakarta: Salemba Medika

Rekam Medik RSUD Dr. Soetomo. (2017).

Data kejadian TB MDR bulan Juli-September 2016.

Surabaya: RSDS

Royce, S. Carls, F. Bare, T. & Gates, G. (2014)

Identification of Multidrug Resistance in Previously

Treated Tuberculosis Patients: a Mixed Methods

Study in Cambodia. NIH Public Access: Inj.

Tuberculosis Lugn Disease. November; 18(11): 1299–

1306.doi:10.5588/ijtld.14.0116

Sukartini, T. (2015). Pengembangan model peningkatan

kepatuhan. Jakarta: Disertasi. Universitas Indonesia.

Sutarno, S., & Utama, G.A., (2012). Faktor-faktor yang

mempengaruhi motivasi berobat penderita tuberculosis

paru di Pekalongan tahun 2012. Jurnal

Ilmiah Widya, Vol. 1 (1) 2012

Sagbakken, M., Frich, J.C., and Bjune, G (2008). Barrier

and enablers in the management of tuberculosis

treatment in Addis Ababa, Ethiopia: a qualitative

study. BMC Public Health.

(https://bmcpublichealth.biomedcentral.com/articles/1

0.1186/1471-2458-8-11)

WHO. (2016). World statistics of Tuberculose Prevalence.

New York: World Health Organization

Wilson, J.W., Ramos, J.G., Castillo, F., Catellanos, E.F.,

Escalante, P. (2016). Tuberculosis patient and family

education through videography in El Salvador.

Journal of Clinical Tuberculosis and Other

Mycobacterial Diseases. Volume 4, 1 August 2016,

Pages 14-20

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

182