Kekkaku Vol. 83, No. 12 : 765-772, 2008 765
Original Article
ANALYSIS OF FACTORS OF TREATMENT COMPLETION
IN DOTS HEALTH FACILITIES IN METRO MANILA, PHILIPPINES :
A CASE-CONTROL STUDY
1 Leizel P.LAGRADA, 2Naruo UEHARA, and 1Kazuo KAWAHARA
Abstract [Study Background and Objectives] The Philippines is one of the 22 countries with high TB burden.
DOTS was adopted not only by purely public providers (PP) but also by public-private mix (PPM) facilities.
This study aims to identify the patient and facility factors that promote completion of TB treatment in DOTS
facilities in an urban setting. The study also explores the difference between the PP and PPM DOTS facilities in
terms of case management and treatment outcomes. [Methods] A case control study was done by interviewing
394 patients sampled from TB cohort report between 2003 and 2005 of 14 DOTS facilities in Metro Manila.
Statistical analyses used include chi-square test and logistic regression analysis. [Results] Being female and aged 30-44 (OR =7.04 ; 95 %CI 1.12-44.35), unemployed (OR =2.73 ; 95 %CI 1.18-6.33), being above per
capita poverty threshold (OR =2.03 ; 95% CI 1.03-3.99), having experienced at least one of the signs and
symptoms of TB (OR = 4.64 ; 95 % CI 1.29 -16.67), taking the medication at health facility (OR =3.87 ; 95%
CI 1.48-10.16) and patient's understanding of DOT (OR = 2.67 ; 95 %CI 1.37-5.23) predict TB treatment completion. Public-private mix type of DOTS facility was also significantly associated with completing
treatment (X2 (1)=54.76, p= 0.000). [Conclusion] Patient factors like middle-aged female compared to female
aged more than 60, being above per capita poverty threshold, unemployment and having experienced at least
one signs and symptoms of TB and facility factors like providing treatment at the facility and explaining the DOT to patient increase the likelihood of completing treatment. Thus, encouraging patients to take their
medication at the facility and helping the patients understand the importance of DOT can increase TB treatment
completion. The seemingly better DOTS implementation and treatment outcomes by the PPM must be evaluated
further through cost effectiveness and efficiency studies. Key words : Treatment outcome, DOTS, Public-private mix, Case control, Philippines
Introduction
Tuberculosis ranks 6th as the leading cause of morbidity
and mortality in the Philippines in 2003'). Despite four decades
of implementing the National Tuberculosis Control Program
nationwide, the prevalence of active pulmonary TB has not
significantly changed between 1983 and 19972) 3). Although
the rates of detection and treatment success have improved
from 48% to 74% and 88% to 89% between 2000 and 2005,
respectively4), variations in TB control outcomes exist across
regions with defaulter rates ranging between 2% and 9% and treatment success rates between 83 % to 93 %5)• Major
constraints to the achievement of TB control targets include
under-utilization of DOTS services because of inappropriate
health seeking behavior6) 7), non-adoption of Department of Health (DOH)-recommended DOTS protocol by private
practitioners, and until recently, low case detection rate6)-9) The Philippine health sector has a large private component.
Estimates of individuals with TB symptoms who consult
private providers range from 11.8%7) to 23 %1°)• Private
1 Department of Health Policy Science, Graduate School of Tokyo
Medical and Dental University, 2Department of International Health,
Graduate School of Tohoku University1東京医科歯科大学大学院医歯学総合研究科環境社会医歯学系
専攻医療政策学講座政策科学分野,2東北大学大学院医学系研究科社会医学講座国際保健学分野
Correspondence to : Leizel P. Lagrada, Department of Health Policy Science, Graduate School of Tokyo Medical and Dental University,
1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519 Japan. (E-mail : lei-hcm®tmd.ac.jp)連 絡先:ラ グラダ ・リーゼル ・パ ーラン,東 京医科歯科 大学大
学 院医歯学総合研究科環境社 会医歯学系専攻医療政策学講座政
策科学分野,〒113-8519東 京都文京区湯 島1-5-45
(Received26May20081AcceptedgSep.2008)
766 結核 第83巻 第12号2008年12月
Table1 Treatmentsuccessanddefau葺trates・f脚icipatingDOTS血ci1itics,2003-2005
Treatmentsuc。essra重 。(%) 一Defaultrate(%)
TypoofDOTS 2003 2004 2005* 2003 2004 2005*
PPTotal
PPMDTotal
{J
qJ
く》
07
07
ΩU
{U
OO
-轟2
00
0ノ
2
轟」
2 10
内∠
1 2
AU
1
*Only2qua∫tcrsofcoho貫2005wereavailab!eduringsampli轟g,
PP:p鵬lypublicPPMD:p揃bliひprivatemixDOTS
doctorsseeanaverageof16TBpatientsamonthoran
averageofl4%ofthe廿patientload3).Recognizingthese
cond隻tions,thegovernmentencouragedtheinvolvementof
P】rivateprovidersinnationaltuberculosiscontrolef負)rts
throughtheimplementationofpublic-privatemixstrategyin
2003,Moreover,morerecentpoliciesonaccredltingprivate
faci皇it藍esasTBDOTSclinicsandprovidinginsurancecover-
ageforTBtrea1mentt㎞oughPhilippineHealthInsurance
の のProgramaredesignedtoimprovethehealthsystem'spr◎v1-
sionofqua蓋ity加berculosiscarebyincre訊singtheTBcase
丘ndingand㎞provi盤gthecaseholdinginbothpub1董ca血d
privatesector.Withthesedevelopments,TBpatientsca盤be
managedbyeitherpublicorprivateprovidersinhealth
cen重ers,privateclinicsorhospitaloutpatientdepartment
foBowingdhesameDOTSprotoco1.
Asbothpublicandp盛vatehealthfac鍍itiespmvideDOTS
services,severalquestionsadse.Giventhatal韮hea1血facilities
provideDOTSservicestoTBpatients,aretreatmentoutcomes
fbrDOTSthesamebetweenpurelypublicfacilitiesand
publ孟c-privatemixDOTS?DoesthetypeofDOTSfacility
(i.e.pule藍ypublicorprivate-publicmix)affectadherenceto
treatment?V鴨atarethepatientandfacilityfactorsthataffect
adherencetoTBtreatment?IfTBDOTSclinicisthereco!孤 一
mendedmodelfbrprovidingTBcareinthecountry,whether
managedbypublicorprivatesectoτ,undeτstandinghowthe
patients'respondtoandaccessTBseτvicesinthesefacUities
areimportant.Thisstudyidentまfiesthepadentan(葦facility
factorsthatpromotecomplctionofTBtreatmentinDOTS
魚cilitiesinanurbansetting。Moreover,thispaperexplores
theeffectoftypeofDOTSfacilityon舵atmentcomplαio無.
Me伽do夏ogy
s伽 の 伽ign伽4P砂 郡纏oπ
,FacilityselectionHealthfacllitiesthatprovideDOTS
servicesarede負nedinthisstudyaseitherpuτelypublic
(he舳ce航ersmanagedbyLocalG。vemmentUnits)or
public-privatemixDOTS(eitherprivateoτpublichealth
facilitiesthatarecerti戴edbytheDOHaspublic-privatemix
DOTS,orPPMD).BasedontheDOTSregistryofDOHin
2006,LocalGovemmentUnits(LGUs)thathavecertified
PPMDfbradeast2yearswe∫eidenti丘ed.Outof16citiesand
lmunicipalityintheNationalCapitalRegion,onlysixcities
havePPMDfacilitiesintheirjurisdiction.Requestlettefsto
conductresearchweresenttothesesixcitiesandfburofthem
agreedtoparticipateinthestudy.PurelypublicDOTScenters
fr。meac肌GUthathave・ ・tPatien幡i鵬 ・fa琶 圓30幽y・
andwithavailableDOTScoho雌repOrtfbrtheb513yea錫
(2003-2005)wereidenti蘇ed,Tw・s纏chDOTSfaciliti¢8w。 爬
rand。mlych・senin螂hpa鍾icipatl且gc垂ty・A曲esametime
lettersweresentd薫rectlyωma駐agersofPPMD血cilitie6and
sixoutofllPPMDfacilitiesparticipatedilth垂55働dy。Tねblc
笠showsthe甜mmary鵬atmentsロ ㏄cessanddefaultrate60f
participati総gDOTSfacilities.
PatientselectわnConsideringthatPPM韮)fac鰍 鮭釦e8w㏄
certifiedbytheDOH,diagnoβtic,舵 伽 ¢nt翻repOrting
procedu顧esintぬese血cilitiesareassumedtObeconsisten重w仙
theDOTSprotocolandl鵬s㎞ila【 ωP縫 鷲ly帥1icDOTS・A
listofpatientswhocompleted舵atment(bOthcllredand◎om-
pleted)andalistofthosewhodidnot◎omp塾e魯e(defanltu◎d
orlost)wereconstnlcted貨omtheTB◎oho質of14DOTS
塩cilitiesbetw㏄nlst〔111arterof2003鵡d2ndq馴 働of
2005.0証lynewpulmonaryTBcases,regardlessofs㎜
result,wereincludedi轟the正ist.Thetetalnurnberofpatients
includedinthesamplingframewas2265,55%w瓠e㎞
purelypublicDOTSfaci豆ities.Asthisisacaseoon廿o猛s加dy,
caseswerepatientswhocompletedthe畑lcourseofTB
treatmentwhilecontrolswerethosewho面dnoI㎞ 臨h
treatment.Asamplesizeof385wasn㏄dedωachieve80%
poweratO.05sig無ificanceleveltodetectanOdds1atioof2、0,
U㎜atchedsa即lingwasdonewi伽 蘭oof5:1L¢.㎞
every5cases,lco鷹01wassdec塾ed.Patientswererand(mily
chosenfromthelistofthosewhocomplete(ltreatmentandthe
listofthosewhodidnoしThetotalsamp貰cinthisstudyis394,
3290fwhichwerecases.
EthicalconsiderationThisstudywaspresentedtoand
approved『bytheDOHResearchEi血icsCommi腫ee.Patient's
consentwassecuredbeforetheinterviewwasconducted.
1)碗co〃eetionandanalysts
Sur》eyofselectedpa雌eRtswasdonebαweenNovember
2006toFebmary2007usingaq秘estionnairethatwasdesign-
ed,pre-testeda臓dtran、slatedtoF弧ipinolanguagc,whichin-
dudedsocio・demographiccharacteristics,patient㎞owledge
ofTB,accessibilityofTBcare,TBmanagement,andpatient
satisfa」ction.Thepatienゼsconsentwassecuredbefore吐 鳩
垂nterviewwasconducted.
DatawereprocessedandanalyzedusingSPSSlL5.
Chi-squaretestswereusedtotesttheassociationbetween
demographicandsocio-economiccharacteristicsalldadher-
encetoTBlreatment、Logisticregressionanalysiswasdone
toidentifシtheeffectofvariousfactorsrelatedtopatient
Tre血entCemple樋on加DOTSlLP.Lagradaetal . 767
Tabfie2 Socie・economiccharacteristicsofpatien重sassociatedwithtreatmentcomp豆etien
Classificationofpatient
Vadables T鵜a重me蹴
co鳳pleted
ロ=329
T,eatme廊 臨 α
compIeted
戯業65
Gender
Age
Educationlevel
Workstatus
Percapitapoverty
threshold
Male
Female
〈30
30-44
45-60
>60*
Pdmaどylevelorless
Secondarylevel
Tertiarylevelandvocational
Nooccupation*
Employed
Self-employed**
Equa呈orabovepercapitapoverty
thresholdinMetroMallila(2003)
210(64%)119(36)
86(26)
107(32)
88(27)48(15)
86(26)
172(52)
71(22)
104(32)
96(29)
129(39)
179(55)
47(72%)
18(28
18(2818(28
12(18
17(26
24(37
32(499(14
11(17
16(25
38(58
)
)
)
)
)
)
)
〉
)
)
)
27(42)
Statisticallysignificantatp〈0.05*and〆0.01**
chamcteristicsandDOTSfacility圭nachiev董ngtreatme籔t
completion.Oddsr窺tiowascomputedtomeasuretheeffects
ofthedifferentvariablestotheoutcome、Percapitaincome
wasestimatedfromthereportedhouseholdincomeincash
anddividedbythehouseholdsize.Patient'spercapitaincome
isthencα 叩aredwiththepefcapitapovertythresholdto
classifソpatientsasaboveorbelowthepercapitapoverty
thresholdinyea■2003fbrMetroManilall).Knowledgeof
tuberculosiswasbasedon4itemsl㎞ ◎wledgeofatleast3
co∬ectsignsandsymp重oms,cause,transmission,andcurabil-
ityofTB.ExcellentTBknowledgemeans4correctanswers;
averageTBknowledgemeans2-3correctanswefsandpoor
TB㎞owledgemeansnoorlco癬ectanswer.Othervariables
wererecordedasdummyvariables,wherel・yesandO=
otherwise.
inthefirstregressionmodel(Mode11),socio-demographic
variablessuchasage-and-gendαcombination,educational
level,woでkingsta加sa繊dbeingequalorabovepercapita
povertythresholdwereenteredasindependentpredictorsof
纐ealmentcompledo鷺.inModel2,vadablesτelatedtorespon-
dent為 ㎞owledgeofTB,healthconditionandTBmanagement
wereadded.Thesepredictorsincludepoorpatientknowledge
ofTB,havingexperiencedTBsignsa馳dsymptoms,having
treatmentparmer,patientexpe】dencingsideeffectandgetting
explanationforitandplacewheτetreatmenttookplaceand
patien霊 ㎞owledgeofDOT.
Results
P飢io髄tfactors
Atotalof394patientswereinterviewedfbrthestudy,
majoritywassa鵬p丑edfrompurelypublicDOTSfacilities
(54%).AboutlO(2.6%)p飢ientsfromtheo】rig血alsampleof
385werereplacedbecausepatientmovedaway,theaddress
givenwasnotcorrect,thepatientrcf睦sedtobeinterviewed
aロ(至2patientsdiedaiready、Thesepatientswererep董acedby
thesucceedingpatientonthesamplelistNinepat量ents
面tiallyrefUsedtobeinterviewedbutlateronagreed,
resultingto394insteadof385samp藍esize.Mostofthe
patientsinterviewedweremale(65%),an虚hemeanagewas
41.6yearswithagerangeofl5to81years.Amongsocio-
economiccharacteristicsofpatients,onlyage>60years〔X2
(1)==5.27,P=0.022],havi擁gnooccupation【X2(1)=5.66,
p=O.01刀andbeingselfempIoyed【Z2(1)=8.24,ρ ・=0.004】
aresignificantlyassociatedwithtreatmentcomp監etion(Table
2).Althoughsomepatientswhohadnosignsandsymptoms
wereidentifiedthro臓ghroutineexami㎞ationhlschooland
priortoemployment,patient'sexperienceofatleastoneof
thesignsandsymptomsofTBissignificantlyassociatedwith
treatmentcompletion【Z2(1)=19.13,p=0.000}.Generally,
patientswhocompletedtreatmenthaveaverageknowledgeof
sig臓sandsymptoms,causality,transmissionandcurabilityof
TB(Table3).However,poor㎞owledgeofTBisnegative韮y
associatedwithtreatmentcompletion【X2(1)=7.03,p=
0.008].Patienゼsunderstandingofdiτectlyobservedtreat-
mentalsosigni戴cantlyaffectstreatmentcompletion【X2(1)
=30,6,p=0.000}.
1)OTSfacdityfactors
Severalvariableswereusedtotesttheassociationbetween
treatmentcompletionandfacilityfactors(Table3).Twoof
丘vecomponentsofDOTSweretestedfbrassociationwith
treatmelltcompletio歴:sputummicroscopytodiagnoseTBand
assigningtreatmentpartner.AlthoughDOTSguidelinesstate
thatsputumsmearisthestandardfbrdiagnosingTBcases,
77%ofthepatientsreporthavingbothsputumsmearand
768 緒核 第S3巻 錦12号2008年12月
x-raywhentheyconsultedfbrTB.T罫eatmentpartneralso
mngesfbmheakhprovid釘s(nurse,midwife,vo1岨teerhealth
worker)tofarnilymembers(parent,sibling,childrenand
in-1aws).Havingtreatmentpartneτissignific烈ntlyassociated
with¢eatmentcompletion【Z2(1)繍5、01,P#O、032】,bu馨
healt}】providerispositivelycoπel烈tod【 二ど2(1):25,95,P
皿0 .000】whileafamilymemberisnegativelyco鵬latedwith
treatmentcompletion[X2(1)竺2759,ρ 篇0,000】,Despite
cerdficationofallhealthfacilitiesasDOTS,notallpatients
haddi,rectlyobservedtreatment、Treatmentifdoneatthe
healthfacilitysigni行cantlyaffectstreatmentcompletion[㌶2
(1)==19.20,p罵0.000】.
SomeDOTSfacilitiesgaveincentivestopatientstoencour一
ag飢hemt。c・mpl鵬 鵬atment伽 蜘ccntiv。sweremain韮y
n・n・m・netaryranging伽ce醜 鵬8・f甑mentc・ 卿 遷e儒
ti・nt・Chri就maspartyforthepatientsandgrcNpery伽8釦 「
thepatie轟ts、Altho職 」ghロsロal1ygiv¢ 礁attheond・of¢het『 ◎atの
me籍tpedbd,inco轟live三sass㏄iatedwiεhadhereneeto
はrcatment£1と2(1)==4。15,ρ 騙0・049】 ・
PPMDisp。sitivelyc・rrelatedwithtre伽entc・mp且 αion
【κ2(1)欝54、76,ρ=0.000}.Public・prlv鵬mixDOTS伽i1・
itiesaresignificantlydifferentfr・mp鵬Iypub1三cin伽8・f
ass孟gning鵬a臨ntpa比n。r伽pati。nt[Z2ω 雪61・02〃 屑
0.000LgivingTBmedicali・natthchca蓋th伽i撫yIκ2(1)
篇100 ,8,ρ 雷0、㎜L。xp豆ainingthe8id。 ¢撫tS・fTBdmgβ
whenpatientsexperienced山emIZ2ω 謬17・ 餌 ・ρ爆0・000L
丁翁Me3P飢ient鋤d飴ci蓋ityfactorsassociatedwithtreatmentcomple重io麩
C』 脇5i箆caIionofpatien重
Variab韮esT鵬atme飢
comp藍eted
血=329
セ
伽響購
●
Knowledgeoftuberculosisa
VerygoodTB㎞owledge
AverageTB㎞owledge
PoorTBknowledge**
Exposure,hea玉thconditionandhealthseekingbehavior
OtherhouseholdmembershavingsignsandsymptomsofTB
Presenceofatleastonesignsandsymp沁msofTB***
Delayedconsultationofmorethan30days
Typeofhealthfacility
Purelypublic***
Public-privatemixDOTS***
TBmanage鶏entandpa£ienteducation
Sputummicroscopydo轟e
Treatmentpartnerwasassigned*
A翁ti-TBmedicationtake無atthehealthfac孟1ity***
Presenceofsideeffectandsideeffectexplainedbyhealthworkerb
Presenceofsideeffectsandsideeffectnotexp垂ai薙edbyhwb
Patientτeceivedincentivec*
Patientu轟dαs伽dsthereasonfbrDOT"'*
36(ll%)
216(66)
75(23)
77(23)
322(98)104(32)
149(45)
180(55)
302(92
264(80
122(37
120(37
34(10
57(18
242(74
¥ノ
)
)
)
)
)
)
2(3%)
38(58)
25(38}
12(18)
56(86)
26(40)
62(95)
3(5)
58(89)
44(68)
6(9)
17(27)
11(17)4(7)
25(38)
Stadsticallysigni菰cantatp<0,05*,ρ<0.001**andpく0.001***
aFouritemsrelated沁Tuberculosisknowlcdgeworeasked:a象 嚢east3correctsignsandsym幽msofTB,ca"蜘vcagcnち
transmissienandcurability.ExcellentTBknowledgemeans4correctanswers;AverageTBknowiedgemeans2-300n℃ α
answers;PooτTBk無owledgemeansnooτ1correctanswcr.
bNo爬sponse實om3patie謙s .n=391
cPatients曲eanswcreddon'tknoworcannotTememberiftheyreceivedincentivewerenotincludedinthe姻ysis .n=
380
Table4FactorsassociatedwithtypeofDOTSfacilities
CharacteristicsofDOTSfacility(%)PP
n=211
PPMD
n=183
SputUmmicroscopydone
TBpartnerassigned***
Anti-TBdrugsgivenatthefacility***
Experiencedsideeffectandsideeffectexplainedbyhealthworker***
GaveincentivetopatieRts***
PatientunderstoodDOT***
191
133(63
22(10
53(26
10(5
102(48
(90%))
)
)
)
¥ノ
169(92%)
175(96
106(58
84(46
51(28
165(90
)
)
ヘノ
)
¥重■
***Statisticallysignificantatp<0.001
TreatmentCompletioninDOTS/LP,Lagr呂daeta1 , 769
providing血cen盤ve{X2(1)=臨38.86,ρ 踏0.000】andheIping
thepatユentunderstandDOTstrategy[X2(1)零78.48,p=
0.000】(Tabie4).
Faotorsthatprediotoompletio皿ofTBtroatment凹nder
DOTS
Sixfactorsthatp爬dictTBtreatmentcompletionwe1'e
identified(Table5)・Femaleaged30to44yearsaremo,etha轟
seventimesmorelikelytocompletetreatmentcomparedwith
femaleolderthan60years.Unemployedpatientsarealmost
threetimesaslikelyastheself-employedpatientstocomplete
treatment・Patientswhoaleabovethepercapitapoverty
血resholdarealittlemorethantwiceas1盤 くelyasthoseunder
perc統pitapovertythresholdtocompletetreatment.Th◎se
pat三entswhoexper蚤encedatleastonesignorsymptomofTB
aremo爬 傾1anfbunimesmorelikelytocompleteTBtreat-
ment。Anlongthefacilityfactors,takingthemedicationatthe
血cilityincreasesdleoddsofpatientcompletingtreatmentby
almostfou㎡bldwhilepatient'sunderstandingofDOTincreas-
estreatmentcomplet藍onbyalmost象hr巳efbld.
Discussion
ThePhilipPinesisthesecondhighburdencountryto
achievethegoalsof70%casedetectionand85%treatment
successforTBcontrolforcohorts2003and2004i2),but
nationalimprovementsinTBcontmlindicatorsconceal8an
underlyingdisparitiesacrossreg孟on85,.Understandingwhy
pation匡sdonotcompletetreatme厩is匡hereforeimportantsince
TBtreatmentisalongdynamicprocessaffectedbyinter・
actionsamongs蜘c鋤ra1,porsona1,sociem盈andhea正thselvice
factors匡3}.Thiss重udyshowsthatw1緊enpalicntundersIand8hi81
herillnessandtreatmentandthefacility'smamg¢mentofTB
casesandhealtheducationstrategiesa,epatie醜t轍c¢ntered,then
treatmentcompletionissignificantlyenhanced.Moreover,this
s蝕dyprovidesevidencethatalthoughDOTSaresuppo8edly
be量ngadoptedbyal登facilitiesstロdied,Ihedifferencein
impleme漁tio鍛betweenpurelypublicandPPMDOTS
facilitiesseemstoresulttodifferenttreatmentoutcomes.
However,thereareseveralcaveatsthatshouldbeconsidered
i臓 血isstudy.Firstly,theresロltofincreased1弧 【e髄hoodi鰍
comple血 監gtreatmentamongthosewhotookIheir飢ti齢TB
medication厩th¢heakhfacilityshould.notbetakenasan
evidencetodiscouragecommunityDOTSespeciallyfbf
patientswhoareunabletogotothehealthfacilitybecauseof
oldageorin丘n皿ities、Sign童ficantassociationbetweenhaving
atreatmentpartnerandcompletionoftreatmentisapositive
sign由atshouldbeemphasizedincomrnunity-basedDOTS.
Secondly,althoughTBmanagementinPPMDfacilitiesshow
highcorrelationwithtreatmentcompletion,血isresultshould
TablesDeterminantsofadherencetoTBtreatmentinDOTSfacilitiesinMetroManila
ExplanatoryVariablesModell
OR[95%CI1
Mode12
0R【95%C珂
Ageandgendercombinationl
Maleagedunder30yrs
Fe皿ialeagedund釘30yrs
Maleaged30-44yrs
Femaleaged30-44yrs
Maleaged45-59yτs
Femaleaged45-59yrs
Maleagedover60yrs
Educationallevel2
P1imaπylevelandbelow
Secondarylevel
Wo曲gs蜘s3
Noemployment
EmpIoyed
Equal/abovepeTcapitapovertythresholdinMetroMa【 オ1a(2003)
PoorTB㎞owledge
Presenceofatleastlsignlsympto憩
Expe]riencedsideeffectofdrug4
Havingsideeffectandexplanationprovidedbyhealthworker
Havingsideeffectbutnoexplanationprovidedbyhealthworker
Havingtreatmentpa血er
Treatmenttakenatthehealthfacility
Patie皿ts'㎞owledgeofDOT
1.42【0.42-4.74】
3。40【0.82-14.06]
1.47【0.46-4.73】
1④.71【1.87-61.38】"★
3.14【0.93-10.641
6.9511。22-39。47】*
1.80【0.54-6.04]
0.63[0。25-1、591
0.87【0.38-2.oe]
2.90【1.33-6.32雇 費嚢
L64【0.81-3。34]
157[0、85・-2.88]
1.26【0.33-4.85】
2、30【0.48一 韮0.94】
0,98[0.28-352】
7。04【Ll2-44。351t
l。84[0.47-7.19】
5.14【0.82-32.25】
1.19【030-4.31】
0.68【0.24-L93】
0.80【0.32-2.00】
2.73【L18-6.331脅
1.57【0.72-3.42】
2.0311。03-3.99】 ☆
0.68【0.34-1.37]
4・64【1.29-16.671★
0.97【0.45-2.07】
0.81[0.31-2.Ol】
1.45[0.68-3.07】
3.87【1.48--10.16]"*
2.6711.37-5.23】 伽彫
一2Loglikelihood
Prob>X2
R2
309.76
0.003
0.127
266.16
0.000
0.296
AIIvaluesinboldfbntarestatisticallysigni員cantaψ<0.05*andρ<0.01**.
Refbrencevaliablesarefema韮eagedoveτ60yrs1,tertiaryandvocaticnal工eve12,selfLemployme擁t3,andexperiencednosideeffect4.
770
bet鉦kenwithcautionasmorestudiesmustbedonetooval.
uatetheeffect量venessa礁def行ciencyofPPMoverpu回y
publicfacilities.Thiss加dywasalsolimitedbythcsample
sizeanddlefindingsofth量sstudycou葦dbestrongerwith
largersamplesizebuttracingpatientswasdif行cult,particu醐
larlyfoTpatientswhodidnotcompletetre飢mont.Tho鵠amplo
sizecouldhavebeenlargerifallqualifiedPPMinMetro
Manilapa1ticipatedlnthest"dy、Thep飢ientsweresampled
from象heTBregistryfrom2003t◎20050fstudyfacilities,
thusfindingsmaybeaffectedbyrecallbias.
Findi鶏gs出atpersonalfactoτs甕ikebeingfbmale,middle
age,employmentstatusandhigherincomearei鵬po1tant
鉱ctorsincompletiRgtreatmentl4)15).Thesefactorsareknown
toaffectpatienゼsmotivati◎n飢dmotivatedpat圭entsaremore
likdytofinishtre飢ment、Moreover,P飢ientswho舳shed
treatmentaremα ℃ ㎞owledgeableabouttuberculosisthan
thosewhodidnotcompletetre8tment、Thesignificanteffect
ofunderst毫mdingthesideeffectsofdrugsandDOTprocesson
completingtre飢mentisco轟sistentwithearlierstudiesi6)韮7).
Thesefindingsundαsco罫etheimportanceof圭ncreasing
patient'sknowledgeabouttheirhealthandtreatmenti8).
Previousstudiespresentedconnictingevidenceonthe
effectofDOTstrategyinpromotingtreatmentcomplet壼on.
Somestud藍eslaudedtheimportanceofdirectlyobser》ingthe
patientwhiletheytaketheirmedicati◎n19)20)whileotheT
studiesdemonstratedtheopposite21)22}。 ㎞thePh簸ippin、es
wheretreatmentpa血eτmaybeanyofthefbllowing,midwifb
ornurseinthehealthcenteτ,volunteerhealthworker,local
governmentofficial,fbmerTBpatient,ofmemberofthe
patient'sfamily23),thisstudycon血rmstheimportanceof
treatmentpartneτmpromot磁9Posユhvetreatmentoutcome・
Moreover,thisstudyalsoidenti最esDOTtreatmentinaheal重h
facility(measuredasmedicatio獄takenathealthfacility)and
patien{'shea藍theducationfbrTBt罫eatment(measuredas
patienガsund釘standingofDOT)aspredictorsoftreatment
completion.These負ndingssuppoτttheideathatdirectly
observedtreatme飢shouldbesuppoτtedbyotherfactorsthat
promoteadherencelikeimprovedpatienteducation,good
qualityofcommunic劉tionbetweenpatientsandhealthpro-
vidersandotherinterventionsthats甘engthenhealthservice
delivery24)。These負ndingsalsosupPo!tthestrategiesidentified
inthePhilippineNationalTuberculosisControlProgram
ManualofProcedures25)wherehealtheducationanddh・ectly
observedtreatmentaτeemphasizedtoimpτovetτeatment
adherence.
Theprivatesectorhascontributedanadditional3%in-
creaseincasedetectionratethroughtheestablishedPPMD
nationwide3).Theres蝋softhisstudyshowsthatthereare
signi且cantdifferencesbetweenpurelypublicandPPMDOTS
飴cilitiesintemlsofmanagingTBcasesandsuchdifferences
seemtoleadtodifferencesintreatmentcompletion.However,
cautionmustbeexeτcisedindτawingconclusionfromthese
results.ThedifferencesbetweenPPandPPMintemlsof
patientload,theextentatwhichDOTSfacilitiestrackand
納核 第8蜷 鋤2帰2008年12月
舵atdefaultersand。therstrロcturali轟p鵬w。mn・t餌aly痂
in血issmdy.H・wevcゆascd・ 撫 伽 孟膨 曲w8・fDOTS
pr・vid鵬 ・ne・fthePPMD血ciliIie8w・ 嘱d・ 傭a・rdinary
measurest。t燃1・stp鋤ti。nts鵬n5鵬 臨 血 触 蟹㈱will
bekeptat翻 伽 臨Asexample,伽sfaciliryw・u且d匪 ・曲ゆ の ゆ
1ivingaccommodationsfbτatra鳳sio離tpa纏 ¢癬も1・e・apaε 鴻nt
whoo翁1ycametoMe伽oManilafor'TB鵬atm棚 ・Co面d・
ering幅PPMDwoロ 霊dgoω 甜chleng伽a8鱒p鵬v㎝I
pat量ent飾omdefaロlting,costeffectivenes爵 飢 己efficiCncy
studiesmustbedonecomparing伽e8etwomajorp幽ovidα80f
DOTS,Meanwbi豆e,theresロ1tssロ99鰍 重hats鵬ng伽ning由 ㊤
PPfaci蓋ities三ntermsofconsi舘 診憾韮ya58igning鵬a㎞ 疇nε
pa1tners,exp監a垂ni轟gthesid¢effectsofTiB{㎞g6a期 ゆth㊤
imp・ 舳c・ ・fDOTt・patien伽denc・ ほ鶉agi卿aε もen働 幽
theirmedicationsatthehealthfaei骸tywhen¢verpOs8ibl¢may
leadtobetter戯reatmen£outeomesinPPfac藍 盤t丘¢s,タ ゆ
Thepositiveeffectofinc¢ 鰍tivesonl臨P璽 ゆvmg釦 ℃伽o皿
c・mpleti・nisc・nsistentwith醐 ・uss臨sM'鋤b轍m・ 鵜
studiesneedtobedonebefb郵 ¢thisstrategycanbeinc1綱a5
anintegralpartofDOTSm鋤ageme轟ti擁 艦hePhi1ippines.Asゆ ゆ の の
Be隻oandcoHeaguesshowedthaロhema鵬Mcenuve沁m-
pr・vetreatmentadherenceinRiod¢Jan伽i5』eal重hservice
support,re負ecti血gthepatie貌 ゴspreferencefbrbeI髄rrb¢ ぎ岨重h
services,itisalsoimporIanttodefinewhichamong血e㎞ ㏄n-
tivescuπentlybeingprovided㎞DOTS伽 皿ilieshavea
signi血cantimpacton舵aImentcompletio臓 ・
Co顧c匪 凹s藍o轟
Thisstロdyshowspatientandfaci駈 重yfactors血ata罰e
associatedwithcolmpletingTBtreatment.Patientfacta喧shke
middle-agedfemalecomparedtofema互eagedmore由an60,
beingabovepercapitapt)ve盛yほ 鵬shold,unemp監oym㎝ 象md
havingexpe】riencedatleasIonesignsandsymptomsofTBam
predicωrsofcomple血9treatmentwhi豆efacilityfactOrsl掴se
providingtreatmentatthefacilityandexp韮a㎞gtheDOT電o
patientincreasethelikelihoodofcomp蓋e血gtreatment.A1-
thoughhavingtreatmentpa血eris血otasignficantP鳳 鰻ctor
oftreatmentco磁pletio総,鮭iss孟9織i丘can"ycorrelatedwith
サのpos血vet祀atmentoutcome.Thus,ens面ngthatDOTS
facilitiesassigntreatmentpa血ers,encouragingthepaticntSto
taketheirmedicationat廿Iefaci航tyandhelpi轟gほ 鳩patients
unders伽dtheimportanceofDOTmayincreaseTBtreatment
completion.Thesee田inglybet塾erDOTSimplcmentationby
thePPMmustbeevaluatedf㎞hert㎞oughcoste飾 ㏄tiveness
andef丘dencystudies,
Acknowledgement
Wesincerelythanktherespondentsfbrallowingusto
interviewthem、Wearegra{efUltotheLocalGovernrnent
Units,theirhealthof五cersandvolmteerhealthworkersfbr
assist血gusinidentifyingandtrackingrespondentsforthis
stロdy.LikewisewehighlyapPr㏄iatethePPMDunitsfbr
pa並icipatinginandassistingusinthisstudy.Wetha血kMs.
MaricelGallardoforhelpingus圭nterviewpatients,Mr.
Treatment Completion in DOTS /L.P.Lagrada et al.
Hamano of H-stat for statistical advice and Dr. Tewarit
Somkotra for assisting us in our analysis. We are also grateful
for the support of Health Policy Development and Planning
Bureau and the Infectious Disease Office under the National
Center for Disease Prevention and Control of the Department
of Health. The financial support through a research grant from
Japan Ministry of Health Labor and Welfare is gratefully
acknowledged.
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PH1 -5.
772 緒核 第83巻 第12号2008年 ・且2月
フィリピン,マ ニラ首都圏に存するDOTS施 設での治療完了に影響する
因子に関する調査研究
ラ グ ラ ダ ・リー ゼ ル ・パ ー ラ ン,上 原 鳴夫,河 原 和 夫
要旨:〔目的〕マニラ首都圏 でのDOTSの 成否に関連する患者 と医療機関双方の要因を調べた。〔対象〕
2003年 か ら2005年 にかけて14カ 所のDOTS施 設の登録結核患者394人 に対 してインタビュー し,治
療完了群 と非完了群について症例対照研究を実施 した。解析はX2検 定 とロジスティック回帰分析 を
用いた。〔結果〕患者側因子は中年女性,貧因 ラインを越えている者,結 核症状自覚者,医 療従事者
の治療パー トナーを有する者等が,結 核治療を終了する割合が有意に高かった。医療機関側因子とし
ては,政 府が運営 しDOTSを 提供している公的医療機関(PurelypublicDOTSfacilities)よ り政府が民
間医療機関と協力してDOTSを 行っている施設(Public-privatemixDOTSfacilities)で,DOTSに つい
て患者に十分に説明している施設で治療完了者が多かった。〔考察〕社会経済因子に加えて結核治療
の完遂には患者および医療側の結核に関する正 しい知識の理解や普及の程度が関係 し,個 人および施
設問格差を招来すると考える。〔まとめ〕今後,こ れらの因子を考慮 しなが ら,医 療施設の特性に応
じた結核対策を推進する必要がある。
キ ー ワ ー ズ:治 療 成 績,DOTS,Public-privatemix,症 例 対 照 研 究,フ ィ リ ピ ン