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