One-third of the world's population estimated to be infected with the Mycobacterium tuberculosis bacillus. In 2011, "#$ estimates there are 260 000 incident cases in the country and 24 000 die in a year 'he pre+alence of ') is hi%h amon% the hi%h ris5 %roups such as the elderly, urban poor, smo5ers and those with compromised immune systems.
One-third of the world's population estimated to be infected with the Mycobacterium tuberculosis bacillus. In 2011, "#$ estimates there are 260 000 incident cases in the country and 24 000 die in a year 'he pre+alence of ') is hi%h amon% the hi%h ris5 %roups such as the elderly, urban poor, smo5ers and those with compromised immune systems.
One-third of the world's population estimated to be infected with the Mycobacterium tuberculosis bacillus. In 2011, "#$ estimates there are 260 000 incident cases in the country and 24 000 die in a year 'he pre+alence of ') is hi%h amon% the hi%h ris5 %roups such as the elderly, urban poor, smo5ers and those with compromised immune systems.
Introduction In 2006, with approximately one-third of the worlds population estimated to be infected with the Mycobacterium tuberculosis bacillus, and more than 9 million new cases and 1! million deaths annually, the "orld #ealth $r%ani&ation declared that 'uberculosis (')* remains one of the most important infectious diseases worldwide #owe+er, because one-third of the ,2 million people li+in% with #I-./I01 worldwide are co-infected with Mycobacterium tuberculosis, the #I-./I01 pandemic has %reatly hindered %lobal efforts to control tuberculosis ("#$, 2006* ') is a ma2or health problem in the 3hilippines It is the sixth leadin% cause of death and illness In 2011, "#$ estimates there are 260 000 incident cases in the country and 24 000 die in a year 'he pre+alence of ') is hi%h amon% the hi%h ris5 %roups such as the elderly, urban poor, smo5ers and those with compromised immune systems such as people li+in% with #I-, malnutrition and diabetes It is estimated that 10 600 patients ha+e multi-dru% resistant ') (M06-')* in 2011 'his situation leads to substantial socio-economic losses to the country 7ocally, 1urallah, a 1st class, a%ri-industrial municipality in the pro+ince of 1outh 8otabato, 3hilippines, achie+ed a of 99 :detection rate on ') 'he municipality of 1urallah has a population of !4,424, and from this, 6,; patients were examined throu%h microscopy (1outh 8otabato /ccomplishment 6eport, 2012* 1 #owe+er, the number of patients treated with ') in 1urallah 1outh 8otabato is not decreasin% "orst, the number of Multi-0ru% 6esistant ') (M06-')* cases is also increasin% 'o address this issue, the "#$ recommended the ') 0$'1 (0irectly $bser+ed 'reatment 1hort-8ourse* in aim of controllin% the disease Moreo+er, 0$'1 is recommended because of its %oal of detectin% !0: of all new smear positi+e cases and its 49: success rate when implemented 1trate%ies which comprise set of actions li5e sputum smear microscopy amon% symptomatic patients, directly obser+ed treatment (0$'*, monitored and standardi&ed, re%ular pro+ision of dru%s, information and re%istration system, and e+en the %o+ernments commitment to prioriti&e ') amon% health policies are part of the pro%ram to achie+e its %oals ("#$,2010* #owe+er, despite bein% curable, tuberculosis is still a sti%mati&ed disease <ot only are ') patients sufferin% due to its clinical manifestations, but also because of societys pre2udice, embarrassin% situations, and e+en self-discrimination /ccordin% to 3orto (200!*, professionals such as psycholo%ists, anthropolo%ists, sociolo%ists, and ') analysts ha+e repeatedly indicated that tal5in% about the disease still causes discomfort and unease in the population, especially within the poorer communities /ccordin% to "#$ (2006*, In addition to the focus on treatment and cure rates, a more comprehensi+e approach towards disease control is now ad+ocated, in order to address po+erty and other social ris5 factors, of which sti%ma is one component =nderstandin% what ') mean to patients and to all people surroundin% them enables health wor5ers to deli+er comprehensi+e health mana%ement beyond clinical 2 and con+entional care 3atients lifestyles and thin5in% modes ha+e an effect on how they respond to healthcare wor5ers inter+entions and actions (>on&ale& et al, 1999* 'he researcher would li5e to elicit data from the experiences of ') patients from dia%nosis to completion of treatment ?urthermore, this research is rele+ant to better understand possible health care mana%ement in increasin% their adherence to treatment, minimi&in% undesirable results, facilitatin% the resumption of their daily li+es, and promotin% a shared lan%ua%e amon%st health professionals and patients "ith this, a holistic approach in impro+in% the @uality of life will be achie+ed 'his study aimed to in+esti%ate psychosocial experiences reported by patients who had successfully under%one 'uberculosis treatment in 1urallah, 1outh 8otabato Statement of the Probem 'he proposed study is primarily focused in determinin% the life experiences of patients who ha+e completed 'uberculosis treatment in 1urallah, 1outh 8otabato 1pecifically, it sou%ht answers to the followin% sub problemsA 1 "hat is the profile of patients in terms ofA a 1exB b /%eB c Cducational /ttainmentB d Marital 1tatus e 8linical ?orm of ')B f $ccupationB % ?inancial 1tatusB and h 6eli%ionD 2 "hat is the life experiences of ') patients in terms of the followin% cate%oriesA a 1ufferin% caused by the diseaseB b Impact to familial and social settin%sB c 1upport from %o+ernment health ser+icesB 3 d 0eficient cultural 5nowled%eB and e Implication to post-treatment lifeD ; )ased on the life experiences of patients, what health education pro%ram for health wor5ers can be de+eloped to impro+e the @uality of life of ') patientsD Sco!e and Deimitation" of the Stud# 'his research study is limited to the 19 pre-identified patients who ha+e already completed the 'uberculosis treatment 1urallah, 1outh 8otabato 'he +ariables of the study are delimited on patients sex, a%e, educational attainment, marital status, clinical form of '), occupation, financial status and reli%ion ?urthermore, to obtain rele+ant data on the life experiences of the patients, +ariables such as sufferin% caused by the disease, impact to familial and social settin%s, support from %o+ernment health ser+ices, deficient cultural 5nowled%e and implication to post-treatment life are included 'he result of this study will be utili&ed for the de+elopment of health education pro%ram for health wor5ers to pro+ide them with enou%h s5ills in addressin% psychosocial issues with patients with ') 'o %ather rich information, the research will utili&e a @ualitati+e study amon% the respondents / semi-structured @uestionnaire will aid in collectin% salient themes in the life experiences of the patients specifically on a* 1ufferin% caused by the diseaseB b* c* Impact to familial and social settin%sB d* 1upport from %o+ernment health ser+icesB d* 0eficient cultural 5nowled%eB and e* Implication to post-treatment life $nly participants who a%reed and si%ned the consent can participate in the study 1ince the study will be conducted on a municipal le+el, the participants will be in+ited for a %eneral assembly with the coordination with the municipal health office Si$nificance of the Stud# 8onsiderin% the increasin% number of ') cases in 1outh 8otabato, this study is important to impro+e the mana%ement of this disease from detection to treatment 4 ?urthermore, the result of this study can benefit the Patients with Tuberculosis, because they are considered the primary recipients of care 'he result of this study will ha+e a positi+e impact on the de+elopment of patient care mana%ements anchored on the patients psychosocial aspect 'he Public Health Nurses, throu%h this study, public health nurses will be 5nowled%eable of the appropriate nursin% care which promotes @uality of life amon% ') patients 'he Municipal Health Office of Surallah, because of the +ast information that can be ac@uired in this study, there will be opportunities for %rowth and impro+ement in the deli+ery of health ser+ices pro%rams particularly in the mana%ement of ') ?inally, the result of the study will add to the existin% literature pertainin% to sti%ma and 5nowled%e of baran%ay health wor5ers on ') and #I-, which may be beneficial as reference material for future related studies Definition of Term" 'he followin% are some of the terms used in the study as defined in their operational context Life E%!erience"& 'his refers to the obser+ations, personal encounters, or under%oin% of thin%s %enerally as they occur in the course of treatment period of 'uberculosis Mode of Tran"mi""ion& 'his refers to the mo+ement or the transmission of patho%ens from a reser+oir to a susceptible host 5 Sti$ma& 'his pertains to <e%ati+e beliefs that a society or %roup of people ha+e about ') and #I- Patient Care Mana$ement& 'his refers to %eneratin%, plannin%, or%ani&in%, and administerin% medical and nursin% care and ser+ices for patients Treatment Protoco& 'his pertains to the customs and re%ulations dealin% with diplomatic formality for carryin% out patients treatment re%imen CHAPTER II RE'IE( O) RELATED LITERAT*RE AND ST*DIES 'his chapter presents the conceptual framewor5 of the study It also contains articles, readin%s, and studies related to the study of sti%ma and 5nowled%e amon% the )aran%ay #ealth "or5ers of 1urallah, 1outh 8otabato on ') and #I- as basis for the de+elopment of <ursin% #ealth Cducation 3ro%ram Conce!tua )rame+or, 'his study will be conducted in order to explore the life experiences of patients who ha+e completed the treatment re%imen of ') $ne of the ma2or assumptions of this study is that the demo%raphic profile of patients plays a ma2or role in their life experiences =sin% @ualitati+e data collection strate%ies, assumptions will be re+ealed ?urthermore, results of this study will be a basis for the de+elopment of <ursin% #ealth Cducation 3ro%rams on ') 'his study is therefore aimed to contribute in the eradication of ') throu%h impro+ement of health ser+ices deli+ery pro%rams of the local %o+ernment of 1urallah, 1outh 8otabato 6 ?i%ure 1 presents the schematic dia%ram of the conceptual framewor5 of the study
)i$ure - Conce!tua )rame+or, Re.ie+ of Literature 'uberculosis in the 3hilippines is still considered a burden not only to the %o+ernment but as well as to the population, especially to those belon% to the mar%inali&ed sector /ccordin% to $n% (2011*, ') is the number six leadin% cause of death, with !; ?ilipinos dyin% e+ery day of ') /n estimated 200,000 to 600,000 7 3rofile of 3atients in terms ofA 1exB /%eB Cducation /ttainment Marital 1tatus 8linical ?orm of ') $ccupation ?inancial 1tatus 6eli%ion 7ife Cxperiences a1ufferin% caused by the diseaseB bImpact to familial and social settin%sB c1upport from %o+ernment health ser+icesB d0eficient cultural 5nowled%eB and eImplication to post- treatment lifeD 7ife Cxperiences CO*NSELING S/ILLS ENHANCEMENT PROGRAM ?ilipinos ha+e acti+e ') in which this condition ma5es the person sic5 and conta%ious to others "ith most of us 5nowled%eable to the uni+ersal si%ns and symptoms of acti+e ') which include cou%h, phle%m (sometimes with blood*, unexplained wei%ht loss, fati%ue, afternoon fe+er, ni%ht sweats, chills, and loss of appetite, data re+ealed that still in 2011, 4! million people were fell with ') and 1, million died from ') (Montoya, 201;* Moreo+er, $+er 99: of ') deaths occur in low and middle income countries, and it is amon% the top three causes of death for women a%ed 19 to ,9 ("#$, 201;* 'his scenario included the 3hilippines in the top 22 hi%h-burden tuberculosis countries in the world, which ran5s the 3hilippines at number nine worldwide ("#$, 2012* /t the same time, ') in the country still remains the sixth %reatest cause of morbidity and mortality in the country /t least !9 ?ilipino dies of ') e+ery day (0i&on, 200!* 'his may be caused by so many factors includin% bud%et allocation by the %o+ernment >o+ernment offices by and lar%e are seen to ha+e the mandated policies and structures to these infections #owe+er, resource limitations remain one ma2or hindrance to maximi&e these policies and pro%rams ?or example, out of 32,6 )illion bud%et of 2009, 6!: of it was earmar5ed for pro-poor pro%rams mainly feedin% and medicines 'he ma2or chun5 of the balance is already earmar5ed for administrati+e costs, plus the standard allocations to health units and their on%oin% wor5, of which ') is a new but additional concern (/lfonso, 2010* 7ocated in 1$81E1/6>C< or 6e%ion FII of the Mindanao Island, the municipality of 1urallah is seated about 20 5m south-west of pro+ince capital city of Eoronadal and about 1,002 5m south-south-east of 3hilippine main capital, Manila It is also the fastest %rowin% municipality of 1outh 8otabato (8$MC7C8, 201;* 8 /s economic acti+ities flourished in the area, more people especially businessmen settled into the place, which contributed to a faster pace of de+elopment Its functional role is an /lternate 3ro+incial /%ro-industrial 8enter "hile bein% a ma2or producer of corn and rice, 1urallah has explored its +ast potential for pro%ress #owe+er, this urbani&ation put its toll on the health of the people /ccordin% to Mutat5ar (1999*, communicable diseases amon% the urban poor coexist with non- communicable diseases amon% the comparati+ely affluent, thus, public health and social problems ha+e arisen lowerin% the @uality of life 'his is e+ident in the increase of number of ') in children in 1urallah, 1outh 8otabato It consisted the 12 : of the total number of ') in 8hildren in 1outh 8otabato (1outh 8otabato /ccomplishment 6eport, 2012* $n the other hand, one of the %oals of this research is to determine the demo%raphic data of selected patients who already completed the treatment re%imen of ') ?ortunately, se+eral literatures were identified lin5in% socio-demo%raphic and personal experiences with the default and treatment failure, thus resultin% not only to the increase in ') cases but as well as in cases of Multi 0ru% 6esistance ') ?or instance, 5nowled%e has been cited as one of the ma2or factors contributin% to default by most of the studies /ccordin% to )elachew (200,* in his study in Cthiopia, poor awareness about the disease and inade@uate 5nowled%e about treatment duration are amon% ma2or reasons for defaultin% In addition, Eaona (200,* noted that patients in Gambia stop their medication once they feel better Meanwhile in >ambia, hi%h rates of defaultin% were found amon% those who were uncertain that their treatment will wor5 ()ah et al, 2009* =ncertainty about treatment success was found to be a +ery critical factor for defaultin% in the first 90 days of treatment 9 In <epal, #ansen et al (2009* examined the contribution of socio-economic status to non-adherence to treatment 6esults of their study re+ealed that unemployment, low status occupation, low annual income, and cost of tra+el to the ') treatment facility are si%nificantly associated with non-adherence to treatment 'hey concluded that low socio-economic status and particularly lac5 of money are important ris5 factors for non-adherence to treatment in a poor country as <epal 8han et al (200,* in 1in%apore howe+er did not find si%nificant association between employment status and defaultin% In sum, there seems to be a stron% support in the literature re%ardin% the predicti+e +alue of inade@uate 5nowled%e and lac5 of social support for default In the 3hilippines, )lumfeld et al (1999* loo5ed into the correlations between socio-demo%raphic and ser+ice factors and the rate of incomplete treatment and found out that when the infectious nature of the disease and the re@uisite treatment re%imen were explained clearly to the patient, default rates were decreased as much as 90: Cddin% (1994* who conducted an inter+entional study in 1ibuco, Gamboan%a del <orte li5ewise found hi%her compliance in those who recei+ed ') education 'he study of the 36I8$6 pro2ect of =1/I0 in 1999 also noted that compliers tend to 5now more about the dru% re%imen particularly treatment duration compared to defaulters /nother factor implicated with defaultin% amon% 0$'1 enrolled ') patients is the distance of the residence of the patient from the treatment facility ()elachew et al, 200,* 'hose who incurred si%nificant time and money costs tra+elin% to recei+e treatment are most li5ely to default 0istance of residence from the facility was noted to be critical 90 days after initiation of treatment ()ah et al, 2009* 'he rele+ance of social support to defaultin% was also tac5led in the literature 'he lac5 of family support was found to be stron%ly predicti+e of default in the study of 10 8han et al (2000* in 1in%apore and /li et al (2002* in Cthiopia In <epal, )am (2006* noted compliance beha+ior to be closely associated with the social support from family and friends 1ocial support from health wor5ers howe+er was found to be insi%nificant In <epal, #ansen et al (2009* examined the contribution of socio-economic status to non-adherence to treatment 6esults of their study re+ealed that unemployment, low status occupation, low annual income, and cost of tra+el to the ') treatment facility are si%nificantly associated with non-adherence to treatment 'hey concluded that low socio-economic status and particularly lac5 of money are important ris5 factors for non-adherence to treatment in a poor country as <epal 8han et al (200,* in 1in%apore howe+er did not find si%nificant association between employment status and defaultin% #owe+er, it was pro+ed that the onset of ') is si%nificantly hi%her in children In a study conducted by Marias (200,*, he stated that disease ris5 after primary infection with Mycobacterium tuberculosis is %reatest in infants and declines slowly to a lowest point at a%e 9-10 years 0urin% adolescence, there is a rapid increase in ris5 with a second pea5 between a%es 20-;0 =nderstandin% the mechanisms that cause this sudden transition are fundamentally important because lun% ca+itations promotes disease transmission and on%oin% transmission sustains the epidemicHthe primary e+olutionary bottlenec5 that must be o+ercome for the patho%en to thri+e in a human population 7ittle is 5nown about either bacterial or host features that allow transmission / prominent sex-related difference is the early predominance of adult-type ca+itary lun% disease in women, which can persist until a%e ;9 years 'he a%e of transition to predominance +aries, but tends to become earlier as the incidence of tuberculosis declines (0annenber%, 2009* 11 Meanwhile, "#$ (201,* stated that in most of the world, more men than women are dia%nosed with ') and die from it ') is ne+ertheless a leadin% infectious cause of death amon% women /nnually, about !00 000 women die of '), and o+er three million contract the disease, accountin% for about 1! million 0isability /d2usted 7ife Iears (0/7I* /s tuberculosis affects women mainly in their economically and reproducti+ely acti+e years, the impact of the disease is also stron%ly felt by their children and families /ccordin% to >lan& (2009*, @ualitati+e and @uantitati+e analyses indicate that patient and dia%nostic delays in ') dia%nosis and care are mediated by a constellation of indi+idual patient factors which include demo%raphics, 5nowled%e, attitudes beha+iors, beliefs, percei+ed barriers, s5ills, %ender, le+el of education, socioeconomic status and so on $lufemi (201;* in his article entitled, Awareness of the Warning Signs, Risk Factors, and Treatment for Tuberculosis among Urban Nigerians, he stated that the si%nificant predictors of awareness of ') warnin% si%n were increasin% a%e, bein% a 8hristian, hi%her family income, and education 'he association of increasin% a%e with awareness of ') si%n may be attributed to increasin% 5nowled%e of ') and lifetime experiences of close relati+e who had the disease 'he researcher also disco+ered that those who belon% to 8hristian faith were more li5ely to be aware of ') si%n than others after ad2ustin% for confoundin% +ariable li5e a%e, sex, income, and le+el of education ?urther sub analysis by stratification of the reli%ion, was suffice to explain the reli%ious predisposition as 04: of the 8hristians were uneducated compared with the Muslims that had 204: uneducated sub2ects in this study 12 $n the other hand, bein% married to a ') positi+e patient put partners into hi%h ris5 of de+elopin% an infection In an article of 'rop Med (2011* entitled, Married to M Tuberculosis! risk of infection and disease in s"ouses of smear "ositi#e tuberculosis "atients, describe an extremely hi%h ris5 %roup J spouses of smear positi+e pulmonary ') patients 'hey ha+e a hi%h pre+alence of #I-, many are already immunocompromised and they ha+e intense contact with infectious '), sharin% sleepin% rooms and fre@uently also nursin% the patient 'his intense exposure and susceptibility is hi%hli%hted by the hi%h rate of initial '1' positi+ity at baseline compared to a control %roup, the subse@uent additional '1' con+ersions, the pre+alence of acti+e ') on screenin% and subse@uent ris5 of ') 'here is a +ast and numerous factors which exacerbate the increasin% cases of ') in a %lobal perspecti+e #owe+er, the most crucial and misloo5ed area is the life experiences of patients who considered to be the 5ey players of the uni+ersal mana%ement of ') /ccordin% to 7on% (1999*, personal experiences, percei+ed etiolo%y of the disease, sti%ma, beliefs and attitudes associated with ') are important in health-see5in% beha+ior In a similar study in -ietnam re+ealed perceptions of '), each contributin% to dia%nosis delays, to sti%ma and isolation of patients and their families 8hoice of treatment could depend on the a+ailability of money, and +arious health care pro+iders 0ecisions are often inKuenced by Lsi%niMcant othersL or lay referral 13 %roups 3roblems arise when health wor5ers and pro%ramme mana%ers fail to consider social and beha+ioral factors in pro%ramme desi%n "hen these factors are not addressed, social sufferin% from the disease can be experienced by the patients 1ti%ma associated with tuberculosis (')* is often re%arded as a barrier to health see5in% and a cause of social sufferin% 1ti%ma studies are typically patient-centered, and less is 5nown about the +iews of communities where patients reside In a study of /tre (2011*, hestudy clarified features of ')-related sti%ma 8oncealment of disease was explained as fear of losin% social status, marital problems and hurtful beha+ior by the community ?or the female +i%nette, heredity was percei+ed as a cause for sti%mati&in% beha+ior Marital problems were anticipated more for the male +i%nette /nticipation of spouse support, howe+er, was more definite for men and conditional for women, indicatin% the +ulnerability of women 8ommunity +iews ac5nowled%ed that both men and women with ') share a psycholo%ical burden of unfulfilled social responsibilities 'he distinction between public health ris5s of infection and un2ustified social isolation (sti%ma* was ambi%uous 1uch a distinction is important for effecti+e community-based inter+entions for early dia%nosis of ') and successful treatment 'uberculosis is lin5ed with po+erty, because of its relation with wea5ened immune system due to poor nutrition as well as tendency of li+in% in crowded homes ') mar%inali&es people both from a social and an economic point of +iew, experiencin% 14 social isolation both within their own family and outside of it In addition, sufferers encounter sti%ma and discrimination, leadin% to a delayed dia%nosis and treatment 'he sti%ma of disease and the resultant discrimination impacts ') control pro%rammes, because a patient afraid of bein% identified as a sic5 person is li5ely to delay proper treatments ()aral N Ear5i, 200!* 'he sti%ma attached to ') has e+en more hostile conse@uences for women, which may influence the pre+alence and pro%nosis of ') and its social implications (7on%, Oohansson, 0iwan, N "ind5+ist, 2001* 1ic5 women face the ris5 of di+orce, or they ha+e to accept their husbands ta5in% a second wife More fre@uently they are literally ostraci&ed from their families until the end of the treatment )y contrast, men sufferin% from the same disease are usually pampered by and recei+e care from their wi+es (#udelson, 1996* ') impacts the economic producti+ity of women as it mainly affects youn% adults between the a%es of 19-,9 1ocial, economic and cultural factors seem to influence %ender differentials in the infection rate 'hese factors are related to tradition and also based on sexual di+ision of labor 8ausin% them to ne%lect their household chores and parental duties, women sic5ness may impact household routines 1ic5 men mainly worry about a loss of wa%e, while women are concerned about re2ection and di+orce, and unmarried women worry about their opportunities of marria%e bein% reduced (#udelson, 1996* / study in 'hailand disco+ers how disease-related costs ha+e an impact on ') dia%nosis and treatment, especially in low-income households (Eamul-ratana5ul, 1awert, Eon%sil, N 7ertmaharit, 1999* 'he authors stron%ly recommend the 15 implementation of free care policies and decentrali&ation of ser+ices in order to reduce costs for these patients ?loyd, in his article, mentions that impro+in% health care in %eneral, and controllin% ') in particular, can lead to a positi+e impact on the economic %rowth and, with a domino effect, conse@uently contribute to increasin% in+estments in the health sector (?loyd, 200;* CHAPTER III RESEARCH DESIGN AND METHODOLOG0 'his chapter presents the +ariables of the study and the procedures that will be underta5en in %atherin% the rele+ant data and information Re"earch De"i$n 'he main focus of the study is to explore the life experiences of ') patients in 1urallah, 1outh 8otabato 'o %ather rich source of information, a @ualitati+e research desi%n will be utili&ed Re"earch Locae 'his study will be conducted at 1urallah Municipal $ffice in 1urallah, 1outh 8otabato 'his municipality is chosen because of the recommendable detection and cure rate of the municipality when it comes to ') detection and treatment 16 17 Life E%!erience" of TB Patient" in Suraah1 South Cotabato 3rofile of the 6espondents /%e 1ex Cducational attainment Marital 1tatus 8linical ?orm of ') $ccupation ?inancial 1tatus 6eli%ion 7ife Cxperiences 1ufferin% caused by the disease Impact on familial and 1ocial 1ettin%s 1upport from %o+ernment health ser+ices 0efiecient 8ultural Enowled%e Implication to post- treatment life Research Locale 1urallah Municipal #ealth 8enter Respondents of the Study 19 patients who completed 'b treatment re%imen Research Instrument 1emi-1tructured inter+iew ?>0 0ata 'reatment 8odin% #ierarchy method <etwor5s Method Identification of 'hemes HeathEducation Pro$ram on TB )i$ure 2& Re"earch De"i$n Re"earch Partici!ant" 'he respondents of the study are the 19 (6* patients who ha+e completed the 6 months treatment re%imen of ') 'he number represents the total population of the tar%et respondents, and hence, will pro+ide the complete and reliable data Sam!in$ Method 1ince %enerali&ation in a statistical sense is not a %oal of @ualitati+e research, purposi+e samplin% method in selectin% the informants will be utili&ed 3urposeful samplin% is based on the assumption that the in+esti%ator wants to disco+er, understand, and %ain insi%ht and therefore must select a sample from which the most can be learned (Merriam, 2009* 'he lo%ic and power of purposeful samplin% lie in selectin% information-rich cases for study in-depth Information-rich cases are those from which one can learn a %reat deal about issues of central importance to the purpose of the in@uiry, thus the term "ur"oseful sam"ling 3olit and )ec5 (2004* explained that in @ualitati+e studies, sample si&e should be determined based on informational needs #ence, a %uidin% principle in samplin% is data saturation that is samplin% to the point at which no new information is obtained and redundancy is achie+ed 0ata @uality can also affect sample si&e If participants are %ood informants, who are able to reflect on their experiences and communicate effecti+ely, saturation can be achie+ed with a relati+ely small sample 18 Ethica Con"ideration Cthical considerations raised by the present research are concerned with obtainin% informed consent and maintainin% participants confidentiality Informed consent is defined as Pthe +oluntary and re+ocable a%reement of a competent indi+idual to participate in a therapeutic or research procedure, based on an ade@uate understandin% of its nature, purpose, and implicationsQ (/22awi, and #i%%s, 200!* Informed consent may be bro5en down into four constituent elementsA disclosure (pro+idin% ade@uate information*, comprehension (understandin% of information*, and competence (ability of participants to ma5e a rational decision*, and +oluntariness (no coercion* /ll participants will be pro+ided with information sheets detailin% the aims of the research and the research process 'hese information sheets will be pro+ided to the participants directly /ll participants shall be %i+en the opportunity to as5 @uestions about the research, and shall be aware that they could withdraw from this research at any time without ne%ati+e conse@uences "ritten consent will be obtained from each +olunteer prior to commencement of data collection 'here shall be no existin% power relations between the researchers and the participants that could be percei+ed as coercion 8onfidentiality will maintained throu%h the use of pseudonyms in the research reportin% and by chan%in% specific contextual details that could re+eal the identity of the participants 19 Re"earch Too / semi-structured sur+ey %uide constructed for this study will be utili&ed to facilitate the data %atherin% 'he semi-structured sur+ey %uide will consist of close- and open-ended @uestions to encoura%e elaborati+e discussion #owe+er, more open- ended @uestions will be reflected $pen-ended @uestions are @uestions that in+ite free ran%in% responses, sometimes called +erbatim responses 1uch responses are extremely useful for obtainin% a deep understandin% of the participants +iews and beha+ior but they are difficult to capture precisely (the respondent may %i+e a lon% winded answer that is shortened by the inter+iewer* and are time consumin% to analy&e 'hey are only suited to @ualitati+e and small @uantitati+e sur+eys 0urin% the construction of the semi-structured sur+ey @uestionnaire, the researcher will constantly and critically immerse the main purpose and the pre-defined research @uestions of the present study 'his will ensure that the semi-structured sur+ey %uide co+ers all the necessary points and it will %enerate a rou%h topic list which will e+entually be con+erted into more explicit @uestions 'aidation of the Re"earch Too 8ontent +alidation of the prepared semi-structured sur+ey @uestionnaire will be done by submittin% it to the research ad+iser for any su%%estion ?ace +alidation will also be done by as5in% by as5in% fi+e eli%ible informants whether they can clearly understand what each @uestion is tryin% to assess 'he su%%estions and the recommendations of the +alidators will be incorporated in the re+ision of the said 20 @uestionnaire / trial inter+iew will be conducted after the face +alidation has been accomplished Data Gatherin$ Procedure" / co+er letter explainin% the research purpose will be pro+ided amon% prospecti+e and eli%ible participants 'his will enable them to ma5e informed choices whether to participate or not in the actual data %atherin% Informed consents will also be pro+ided upon acceptance of intent to participate /n inter+iew utili&in% the semi-structured inter+iew %uide will be conducted to initiate the %atherin% of information Ea2ornboon (2006* explained that the researcher or the inter+iewer often uses open @uestions durin% in-depth inter+iews 0ata is collected from the inter+iewee 'he researcher needs to remember the inter+iewers +iews about the topic are not of importance 'he inter+iewee or informant is the primary source of data for the study 0urin% the in-depth inter+iews, data will be transcribed in audio tapes to facilitate re+iewin% of participants experiences durin% the analysis and discussion )ailey (2004* elaborates that many @ualitati+e studies collect audio or +ideo data (e% recordin%s of inter+iews, focus %roups or tal5 in consultation*, and these are usually transcribed into written form for closer study 'ranscribin% appears to be a strai%htforward technical tas5, but in fact in+ol+es 2ud%ments about what le+el of detail to choose (e% omittin% non- +erbal dimensions of interaction*, data interpretation (e% distin%uishin% RI donLt, no from RI donLt 5now* and data representation (e% representin% the +erbali&ation Rhwarryuhh as R#ow are youD* 21 Data Ana#"i" In 5eepin% with the methodolo%y adopted in this research, data analysis methods will be de+eloped from phenomenolo%ical and hermeneutic principles and from %uidelines in the literature about systematic, useful ways of interpretin% research data 'hrou%hout all sta%es of the data analysis there shall be on%oin% interpretation of the research text and the phenomenon of learnin% to communicate clinical reasonin% More specifically, thematic analysis will be implemented in obtainin% and interpretin% the %athered data 'he first step is to prepare the data for analysis 'he researcher will ensure that e+ery in-depth inter+iew will be transcribed in audio recordin% media and then into text and format so that the mar%in could be used for identifyin% indi+idual bits of data 'his can be done by assi%nin% line numbers as identifiers for cross referencin% 1econd step is to read the text and notin% items of interest /n inducti+e approach to thematic analysis allows themes to emer%e from the data, rather than searchin% for pre-defined themes 0urin% the first readin% the researcher will ma5e note of ma2or issues as they come to mind in order to ac@uire a sense of the +arious topics embedded in the data 'he third step is to sort items of interest into proto-themes 'his is where themes be%in to emer%e by or%ani&in% items relatin% to similar topics into cate%ories 8omputers are %reat for pastin% the line references to%ether 'his should be a fluid process so cate%ories can be modified, de+eloped and new ones allowed to emer%e freely /t this sta%e 5eepin% the themes as simple as possible assists flexibility in the cate%ori&ation process whereby any re-orderin% of the clusters of cate%ories can help create and re-define the initial themes 22 'he fourth step is to examine the proto-themes and attempt initial definitions 'his phase of trawlin% bac5 throu%h the data examines how information was assi%ned to each proto-theme in order to e+aluate its current meanin% / pro+isional name and flexible definition should then be created for each emer%in% theme 'he fifth step is to re-examine the text carefully for rele+ant incidents of data for each proto-theme 'a5in% each theme separately and re-examinin% the ori%inal data for information relatin% to that theme is a +ital sta%e in the analytic process because human perception is selecti+e and the rele+ance of data can be easily o+erloo5ed ?urthermore, pieces of data pre+iously assi%ned to a theme may in fact be contradictory 'he sixth step is to construct the final form of each theme 'his sta%e of re- contextuali&ation focuses more closely upon the underlyin% meanin% of each theme 'he last step that the researcher will underta5e is the reportin% of each theme 'he researcher will finali&e the name of each theme, write its description and illustrate it with a few @uotations from the ori%inal text to help communicate its meanin% to the reader 23 A!!endi% A SEMI3STR*CT*RED S*R'E0 4*ESTIONNAIRE Date5 666666666666666666666666666666666666666666666666666666 Time5 666666666666666666666666666666666666666666666666666666 'enue5 66666666666666666666666666666666666666666666666666666 Inter.ie+er5 6666666666666666666666666666666666666666666666666 Orientation Obecti!e" 'o find explore the counselin% experiences of <otre 0ame of 0adian%as =ni+ersity >uidance 8ounselor Acti.it# Pro!er Note! This should not be less than forty$fi#e %&'( minutes but not more than ninety %)*( minutes This is to ensure the +uality of the information gathered Demo$ra!hic Profie of Patient 24 /%eASSSSSSSSSSSSSS 1exASSSSSSSSSSSSSS Cducational /ttainmentASSSSSSSSSSSSSSSSSSSSSSSSSSSSS Marital 1tatusASSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS 8linical ?orm of ')ASSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS $ccupationASSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS ?inancial 1tatusASSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS 6eli%ionASSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS Guide 4ue"tion" 7In"truction"8 1 0id you experience sufferin% durin% the entire treatment re%imenD "hat are some of these sufferin%sD 2 "hat is the impact of ') in your relationship with your family and societyD 3articularly, how does it affect your a 1ocial obli%ationB b ?amily obli%ationB c OobB d 1ense of fulfillmentB e $thersD ; 0id you recei+e any support from the %o+ernment especially durin% the period of your treatmentD , 0id you experience bein% sti%mati&ed because of deficient cultural 5nowled%e towards ')D 5. "hat is the implication of ') to your post-treatment lifeD Summar# of Di"cu""ion Point" Co"in$ Remar," 25 Co"in$ Pra#er BIBLIOGRAPH0 1 >offman C 1ti%maA notes on the mana%ement of spoiled identity >arden 8ity (<I*A /nchor )oo5sB 196; 2 #ei2nders M, -an 0er Mei2 1 'he fi%ht a%ainst sti%maA an o+er+iew of sti%ma- reduction strate%ies and inter+entions 3sychol #ealth Med 2006B11A;9;-6; ; 7in5 ), 3helan O 8onceptuali&in% sti%ma /nnu 6e+ 1ociol 2001B2!A;6;-49 26 , 1mith 6, 6ossetto E, 3eterson )7 / meta-analysis of disclosure of ones #I-- positi+e status, sti%ma and social support /I01 8are 2004B20A1266-!9 9 Mutat5ar 6E1oc 1ci Med 1999 $ctB,1(!*A9!!-41 6 1teen '" N Ma&onde >< (1999* <%a5a ya setswana, n%a5a ya se5%oa or bothD #ealth see5in% beha+iour in )atswana with pulmonary tuberculosis Social Science and Medicine ,4, 16;J1!2 ! 'homas )C, 6ehman ?, 1uryanarayanan 0 et al (2009* #ow sti%mati&in% is sti%ma in the life of people li+in% with #I-A a study on #I- positi+e indi+iduals from 8hennai, 1outh India A,-S .are 1!, !99J401 4 -an )ra5el "# (2006* Measurin% health-related sti%maJa literature re+iew /sychology, 0ealth 1 Medicine 11, ;0!J;;, 9 "#$ (200,* ,nterim /olicy on .ollaborati#e T230,4 Acti#ities "orld #ealth $r%ani&ation, >ene+a 10 "#$ (2006* 5lobal Tuberculosis .ontrol! Sur#eillance, /lanning, Financing "orld #ealth $r%ani&ation, >ene+a 11 "orld #ealth $r%ani&ation, 8ommission on 1ocial 0eterminants of #ealth 8losin% the %ap in a %enerationA health e@uity throu%h action on the social determinants of health ?inal report of the 8ommission on 1ocial 0eterminants of #ealth >ene+aA "#$B 2004 12 Marais )O, >ie 63, 1chaaf #1, et al The natural history of childhood intrathoracic tuberculosis6a critical re#iew of the "re$chemothera"y literature Int O 'uberc 7un% 0is 200,B 4A ;92J,02 1; Marais )O, 0onald 36, >ie 63, 1chaaf #1, )eyers < -i#ersity of disease manifestations in childhood "ulmonary tuberculosis /nn 'rop 3aed 2009B 29A !9J46 1, 0annenber% /M 7i+uefaction and ca#ity formation in "ulmonary T2! a simple method in rabbit s5in to test inhibitors 'uberculosis 2009B 49A 2,;J,! 27 19 >lan& E, 6imer )E, -iswanath E (Cds*A 0ealth 2eha#iour and 0ealth 8ducation Theory, Research and /ractice ,th edition 1an ?rancisco, =1/A Oohn "iley and 1onsB 2004A,64J,69 16 $lufemi $ 0esalu, /de5unle $ /deoti, /bayomi ?adeyi, /la5i2a E 1alami, /demola C ?awibe, and $lanrewa2u $ $yedepo, P/wareness of the "arnin% 1i%ns, 6is5 ?actors, and 'reatment for 'uberculosis amon% =rban <i%erians,Q 'uberculosis 6esearch and 'reatment, +ol 201;, /rticle I0 ;69!1!, 9 pa%es, 201; doiA101199.201;.;69!1! 1! 'rop Med Int #ealth Oul 2011B 16(!*A 411J4143ublished online Mar 29, 2011doiA 101111.21;69-;196201102!6;x 14 7on%, <, Oohansson, C, 0iwan, -E N "in5wist, / (1999* 0ifferent tuberculosis in men and womenA beliefs from focus %roups in -ietnam 1ocial 1cience N Medicine ,9, 419-22 28