Qual Life Res (2014) 23:15231533

DOI 10.1007/s11136-013-0571-x

Factors associated with health-related quality of life

among pulmonary tuberculosis patients in Manila, the Philippines
Shoichi Masumoto Taro Yamamoto
Akihiro Ohkado Shoji Yoshimatsu
Aurora G. Querri Yasuhiko Kamiya

Accepted: 1 November 2013 / Published online: 22 November 2013

Springer Science+Business Media Dordrecht 2013

Abstract
Purpose Health-related quality of life (HRQOL) among
pulmonary tuberculosis (PTB) patients has not been
investigated in the Philippines. This study aimed to
describe HRQOL among PTB patients and to determine
factors that are associated with HRQOL.
Methods A cross-sectional survey was conducted at 10
public health centers and 2 non-government organization
clinics in District I, Tondo, Manila. Face-to-face interviews
using a structured questionnaire including Short Form-8,
Duke-UNC Functional Social Support Questionnaire, and
Medical Research Council (MRC) dyspnea scale were
performed with 561 PTB patients from September to
November 2012.
Results HRQOL among PTB patients was generally
impaired. Factors associated with lower physical component summary were exposure to secondhand smoke (SHS)
(P = 0.038), positive sputum smear result (P = 0.027),
not working (P = 0.038), lower education level
(P \ 0.01), number of symptoms (P \ 0.01), number of
adverse drug reactions (ADRs) (P \ 0.01), higher score on
the MRC dyspnea scale (P \ 0.01), and low perceived
social support (P = 0.027). Lower body mass index
S. Masumoto (&)
T. Yamamoto
Y. Kamiya
Graduate School of International Health Development, Nagasaki
University, 1-12-4 Sakamoto, Nagasaki, Nagasaki 852-8523,
Japan
e-mail: smash422@hotmail.co.jp
A. Ohkado
S. Yoshimatsu
A. G. Querri
Research Institute of Tuberculosis/Japan Anti-Tuberculosis
Association Philippines, Manila, The Philippines
A. Ohkado
S. Yoshimatsu
Research Institute of Tuberculosis, Japan Anti-Tuberculosis
Association, Kiyose, Japan

(P = 0.016), non-SHS exposure (P = 0.033), number of

symptoms (P \ 0.01), number of ADRs (P \ 0.01), low
perceived social support (P \ 0.01), and negative perception for waiting time in the clinic (P = 0.026) were identified to be factors significantly associated with lower
mental component summary.
Conclusion Socioeconomic status including SHS exposure and low perceived social support, in addition to clinical factors, may be associated with poor HRQOL. Further
study would be needed to assess our findings.
Keywords Tuberculosis
Health-related quality of
life
Secondhand smoke exposure
Social support

Introduction
Tuberculosis (TB) continues to be a global public health
problem, with approximately 8.7 million incident cases and
1.4 million deaths in 2011 [1]. TB is the fifth highest cause
of morbidity and mortality in the Philippines, which is one
of 22 high-burden countries in the world [2]. Although the
case detection rate and treatment success rate have
exceeded the global target since 2005 after the initiation of
directly observed treatment, short-course (DOTS) [3], the
prevalence, and incidence of TB are still high. According
to the Global Tuberculosis Report 2012, the estimated
prevalence is 484/100,000 and the estimated annual incidence is 270/100,000 as of 2011 in the Philippines [1].
Health-related quality of life (HRQOL) has recently
been evaluated as an outcome for many medical conditions
and refers to patient-reported physical, social, and mental
functioning. Although clinical and biological outcomes
such as case detection rate or treatment success rate have
been used as an indicator of TB control program, patient-

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reported outcomes such as HRQOL have not been well

investigated [4] and have been neglected when evaluating
outcomes of TB patients [5]. According to a systematic
review, Short Form-36 (SF-36) has been used most commonly to measure HRQOL in TB patients in past studies,
but the disease-specific instrument is not well established
[6]. Recent studies have shown that TB has a negative and
prolonged effect on HRQOL [710]. In addition, the
positive effect of treatment on HRQOL among TB patients
has been reported [11, 12].
Factors associated with HRQOL among TB patients
have already been analyzed in several studies. Demographic characteristics: age, socioeconomic status: income,
education, housing condition, social security, diseaserelated factors: white blood cell count, the number of
symptoms, and adverse drug reactions (ADRs) caused by
anti-TB drugs were indicated to be associated with
HRQOL among TB patients [7, 1315].
Tobacco smoking is well known as a risk factor for poor
treatment outcomes such as death [16], default [17], and
relapse after treatment [18]. It was reported that integrating
a smoking cessation program with DOTS had a positive
effect on the HRQOL of TB patients [19]. However, the
relationship between tobacco smoking and HRQOL has not
been evident. Therefore, scientific assessment of the relationship between tobacco smoking and HRQOL among TB
patients needs to be conducted.
Secondhand smoke (SHS) exposure is also a risk factor
for TB [20] and has been demonstrated to be related to
lower HRQOL among the general population [21] and
patients with heart failure [22]. However, the relationship
between HRQOL and SHS exposure among TB patients
has not been well documented. Because sidestream smoke
contains similar toxic substances as active smoking, SHS
exposure can have a negative effect on HRQOL among TB
patients.
Social support is assumed to be associated with HRQOL
among TB patients during treatment and is usually defined
as existence or availability on whom we can rely, people
who let us know that they care about, value, and love us
[23]. The relationship between social support and HRQOL
among TB patients has not been evaluated sufficiently.
Social support is expected to be a factor related to HRQOL
among TB patients because support from others, including
family members, is essential in completing long-term
treatment for TB.
HRQOL has not been well surveyed in TB patients in
the Philippines thus far. The objective of this study was to
investigate HRQOL among pulmonary TB (PTB) patients
and to determine factors that are associated with HRQOL
in Manila, the Philippines. The effect of tobacco smoking,
SHS exposure, and social support on HRQOL among PTB
patients was also analyzed.

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Methods
Study design
A cross-sectional survey was conducted to describe
socioeconomic status, smoking status, HRQOL, and other
social factors among PTB patients, including both sputum
smear-positive and smear-negative patients, treated under
DOTS.
Study area
The survey was conducted at 10 public health centers and 2
non-government organization (NGO) clinics providing
DOTS in District I, Tondo, Manila, where many socioeconomically deprived people live in a congested area. The
population is estimated to be approximately 410,000 in an
area of 5.64 km2 and 195,980 (47.8 %) accounts for the
underprivileged population.
Study population
Study participants were recruited from PTB patients who
were newly diagnosed or undergoing retreatment under
DOTS in District I, Tondo, Manila, between September
and November 2012. Patients with drug-resistant cases,
with extrapulmonary TB, with human immunodeficiency
virus, younger than 18 years of age, who were pregnant,
who were critically ill, or who had communication problems or severe complications such as cancer were excluded. All cases of PTB were diagnosed according to the
National Tuberculosis Control Program (NTP) guideline in
the Philippines [24].
Data collection
Recruitment was conducted by consecutive sampling of
PTB patients confirmed by the TB register except those
who were not eligible at each health facility. All patients
who were identified as having PTB and undergoing treatment under DOTS were then recruited. Height and weight
were measured after completion of the interview, and body
mass index (BMI) was calculated. Patient interview using a
structured questionnaire was performed by 3 data collectors. The structured questionnaire was designed to assess
the socio-demographic factors: working status, marital
status, monthly income, education level, alcohol drinking
habit, smoking habit, secondhand smoking exposure,
symptoms, and adverse drug reactions. On top of that, 3
instruments were included in the questionnaire to evaluate
HRQOL, social support, and severity of dyspnea. The
questionnaire was translated into Tagalog from the English
version using the forwardbackward translation method.

Qual Life Res (2014) 23:15231533

Patients information about treatment was collected from

the TB register and NTP Treatment Card at the health
facilities.
Data collectors were recruited from local people and
trained for 2 days to conduct standardized interviews. A
pretest was conducted at one NGO clinic, which provides
TB Care Services to the urban poor in Payatas, Quezon
City, to confirm the feasibility, relevance, and validity of
the questionnaire before full implementation of the study.
Instruments
Generic HRQOL (Short Form-8)
Short Form-8 (SF-8), a short version of SF-36, was used as
an indicator of HRQOL because of its brevity. Although no
study using SF-8 has been done to assess HRQOL of TB
patients, feasibility and reliability of SF-36 have been
validated in TB patients [25]. SF-8 uses one question to
estimate each of the 8 domains of SF-36 (GH: General
Health, PF: Physical Function, RP: Role Physical, BP:
Bodily Pain, VT: Vitality, SF: Social Function, RE: Role
Emotional, and MH: Mental Health), which describe different aspects of HRQOL. The Physical Component
Summary (PCS) and Mental Component Summary (MCS)
are calculated by weighting each health domain scale score
and computing aggregate scores for each measure. Use of
the Tagalog version of the questionnaire was permitted by
Quality Metric Inc. Scores of each domain, PCS, and MCS
were calculated using scoring software provided by Quality
Metric Inc., into mean scores of 50 and standard deviation
(SD) of less than 10 in the 1998 U.S. general population.
The internal consistency of SF-8 was confirmed to be
sufficient by calculating Cronbachs alpha [26], which was
0.764.
Social support (Duke-UNC Functional Social Support
Questionnaire)
The Duke-UNC Functional Social Support Questionnaire
(FSSQ) was used to assess social support and has been
widely used to assess 2 areas: confidant support and
affective support [27]. The questionnaire consists of 8
items with a 5-point scale ranging from 1 (much less than I
would like) to 5 (as much as I would like). FSSQ scores can
range from 1 to 5, and higher scores reflect higher perceived social support. In this study, scores were dichotomized into low and high perceived social support group,
taking the 10th centile of the score as the cutoff point. To
the best of our knowledge, there is no definite cutoff score
in FSSQ. In the present study, the distribution of FSSQ
score was skewed to high score, so that FSSQ score of 3.5

1525

(10 percentile in this study) seemed to be reasonable to

dichotomize into two groups. Cronbachs alpha of FSSQ
was 0.803, which shows high internal consistency.
Medical Research Council dyspnea scale
The Medical Research Council (MRC) dyspnea scale was
used to assess the severity of lung disease [28]. The MRC
dyspnea scale consists of five statements about perceived
breathlessness. Patients are classified into 5 groups
according to how they perceived their disability. Grade 1
indicates the lowest, and Grade 5 shows the severest degree
of breathlessness.
Statistical analysis
Data were double entered into a Microsoft Access 2010
database and validated for any discordance. All statistical
analysis was conducted using STATA 12.1 (Stata Corp LP,
College Station, TX, USA). Scores of PCS and MCS were
dealt as dependent variables. On the other hand, demographic factors: age, sex, BMI; information of treatment:
type of treatment, sputum smear result, treatment phase;
socioeconomic status: working status, marital status,
monthly income, number of people living together, education level, alcohol drinking habit, smoking habit, secondhand smoking exposure; disease-related factors: the
number of symptoms, the number of ADRs; perception of
social support; severity of breathlessness; quality of services: type of the clinic, time required to come to the health
center, waiting time, respect from health workers, cleanliness of the facility, were dealt as independent variables. On
univariable analysis, each domain of SF-8 was analyzed
using Wilcoxon rank-sum test. PCS and MCS were analyzed using Students t test or analysis of variance. Differences between groups were analyzed by chi-square tests
and Cochrane-Armitage tests. Multiple linear regression
models were constructed to determine factors associated
with PCS and MCS. Independent variables that were
related to dependent variables on univariable analysis
(P \ 0.20) were chosen to be analyzed in the multivariable
models. In addition, age, sex, treatment phase were also
included in multivariable analysis for adjustment. In multiple linear regression models, a backwardforward stepwise selection procedure with a probability of 0.10 for
removal and a probability of 0.05 for entry was used to
identify associated variables. Variance inflation factor
(VIF) was calculated to assess multicollinearity in multivariable models [29]. Significance tests are 2 sided, with
P values of \0.05 considered statistically significant.
Results of multiple linear regression models are reported as
regression coefficients.

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Table 1 Demographic characteristics of study participants
Characteristics

Mean
(SD)

Age (years)

41.87
(15.6)

1830

166 (29.6)

3150
5180

205 (36.5)
190 (33.9)

Sex (male/female)
Body mass index (BMI) (kg/m2)

Fig. 1 Flowchart of the study participants. TB tuberculosis, PTB

pulmonary tuberculosis, DOTS directly observed treatment, shortcourse, MDR multidrug-resistant. Treatment partner = A person who
gets medicine and conduct directly observed treatment

Ethical considerations

n (%)

367 (65.4)/194
(34.6)
19.65
(3.28)

\18.5

228 (40.6)

18.525

294 (52.4)

C25

39 (7.0)

Type of treatment, new/retreatment

421 (75.0)/140
(25.0)

Sputum smear, positive/negative

273 (48.7)/288
(51.3)

Treatment phase, intensive/

continuation

230 (41.0)/331
(59.0)

Occupation, working/not working

266 (47.4)/295
(52.6)

Monthly income (pesos)

\5,000

203 (36.2)

5,00010,000

220 (39.2)

[10,000

98 (17.5)

Missing

40 (7.1)

Marital status

The research proposal was reviewed by the Department of

Health Research Ethics Committee in the Philippines and
the Institutional Review Board of the Graduate School of
International Health Development, Nagasaki University,
and ethical approval was obtained from both institutions. In
addition, research permission was obtained from the
Manila City Health Department and each health center,
including 2 NGO clinics.
The study participants were informed of the overview
and the significance of the study as well as the risks and
benefits. Written informed consent was then obtained in
advance from each participant. Data obtained from the
study were maintained in the locked database and will be
kept for 1 year after the completion of the study.

Results
General
In total, 703 patients were identified by the TB register as
having PTB treated under DOTS. Forty-four of these
patients were excluded for shown reasons (Fig. 1). In total,
561 of the 659 eligible patients were interviewed, with a

123

Married

204 (36.4)

Single

157 (28.0)

Cohabitating

106 (18.9)

Widowed/separated
Family member
Education level

94 (16.7)
5.87

None

5 (0.9)

Elementary

180 (32.1)

High school

256 (45.6)

Vocational/college
Total years of education

120 (21.4)
8.35

Alcohol drinking
Never drinker

151 (26.9)

Former drinker

357 (63.6)

Current drinker

53 (9.5)

Smoking
Never smoker

236 (42.1)

Former smoker

274 (48.8)

Current smoker

51 (9.1)

Secondhand smoke exposure

Not exposed
Exposed
Symptoms C4

242 (43.1)
319 (56.9)
133 (23.7)

Qual Life Res (2014) 23:15231533

1527

Table 1 continued
Characteristics

Mean
(SD)

n (%)

Adverse drug reactions C4

188 (33.5)

Medical Research Council dyspnea

grade C3

98 (17.5)

Functional Social Support

Questionnaire score B3.5

68 (12.1)

SD standard deviation

response rate of 85.1 %. Ninety-eight patients could not be

recruited because they did not come to the health facilities
at the scheduled time for the following reasons: 1 patient
refused, 27 were working, 10 had treatment partners;
alternative person to get medicine for patients, 5 were
students, and 55 had unknown or other reasons (Fig. 1).
Comparisons of the subjects who were interviewed
(n = 561) and those who were not interviewed showed that
the participants were older than the non-participants (41.9
vs. 36.7 years, P = 0.002), but no difference was seen in
sex distribution.
The demographic characteristics of the study participants (n = 561) are shown in Table 1. The mean age of the
participants was 41.9 years, and 65.4 % were male. The
BMI of 40.6 % of participants was less than 18.5 kg/m2,
which implies that underweight patients were prevalent at
the study site. In total, 25.0 % of the study participants
were undergoing retreatment. A total of 51.8 % of patients
with newly diagnosed PTB and 39.3 % of patients undergoing retreatment had positive sputum smears.
More than half of participants were not currently
working, and 36.2 % had income of less than 5,000 pesos
(%125USD) per month. Fifty-one patients (9.1 %) were
current smokers despite undergoing treatment for TB,
whereas 274 patients (48.8 %) were former smokers. With
regard to SHS exposure, 56.9 % of participants answered
that they were exposed to smoking in the household.
Similarly, 9.4 % kept drinking alcohol during treatment,
although 63.6 % were former alcohol drinkers.
The average scores of PCS and MCS were 44.5 7.7
and 46.0 8.0, respectively (Fig. 2). Distribution of both
PCS and MCS was not skewed. Patients whose PCS and
MCS are less than 40, which indicate impaired function in
each dimension [30], accounted of 27.8 and 21.0 % of total
respondents, respectively.

Fig. 2 Distribution of Physical Component Summary (PCS) and

Mental Component Summary (MCS) in Short Form-8. The average
scores of PCS and MCS were 44.5 7.7 and 46.0 8.0,
respectively

(P = 0.023), not working (P = 0.018), monthly household

income less than 5,000 pesos (P \ 0.01), lower education
level (P \ 0.001), SHS exposure (P = 0.03), number of
symptoms (P \ 0.001), number of ADRs (P \ 0.001),
higher grade on the MRC dyspnea scale (P \ 0.001), and
low perceived social support (P = 0.035) were associated
with lower PCS. On the other hand, BMI less than 18.5 kg/
m2 (P = 0.014), monthly household income less than
5,000 pesos (P = 0.018), marital status of cohabitation
compared with single (P = 0.039), no SHS exposure
(P = 0.03), number of symptoms (P \ 0.001), number of
ADRs (P \ 0.001), higher grade on the MRC dyspnea
scale (P \ 0.001), low perceived social support
(P = 0.004), and negative perception to health workers
attitude (P = 0.04) were significantly associated with
lower MCS.
SHS exposure and SF-8

Factors associated with HRQOL

Comparisons of component summary scores were conducted for each independent variable, and the results are
shown in Table 2. On univariable analysis, BMI less than
18.5 kg/m2 (P = 0.045), positive sputum smear result

The younger population and female patients were more

frequently exposed to SHS on univariable analysis (mean
age was 43.4 years old in SHS non-exposed group versus
40.7 years old in SHS-exposed group, P = 0.02; 65.0 % of
female patients were exposed to SHS versus 52.6 % of

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Table 2 Comparisons of Short Form-8 component summaries by each independent variable

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Qual Life Res (2014) 23:15231533

1529

Table 2 continued

PCS Physical Component Summary, MCS Mental Component Summary, SD standard deviation
a

Students t test

Analysis of variance

Tukeys HSD test

male patients were exposed to SHS, P = 0.005). Table 3

demonstrates the relationship between SHS exposure and
scale of each SF-8 domain, which shows that SHS-exposed
patients scored lower in the PF domain (P \ 0.001), and
reveals that SHS-exposed patients scored lower PCS
(P = 0.03). On the other hand, SHS exposure was significantly associated with a higher score on the MCS
(P = 0.03).
Social support and SF-8
On univariable analysis, younger patients (P = 0.12), male
patients (P = 0.076), and smoker (P = 0.047) tended to
have social support score of B3.5. Low perceived social
support was significantly related to worse VT (P \ 0.001),
MH (P = 0.026), and RE (P = 0.047). Table 4 shows that
low perceived social support was associated with lower
HRQOL, both on the PCS (P = 0.035) and MCS
(P = 0.004).
Multivariable analysis for HRQOL
Multiple linear regression models for PCS and MCS were
constructed. Forty-one questionnaires (7.3 %) had 1 or more
missing answers and were excluded from multivariable
analysis. On multivariable analysis, SHS exposure remained
significantly associated with lower PCS (P = 0.035). Positive sputum smear result (P = 0.025), not working
(P = 0.041), lower education level (P \ 0.01), number of
symptoms (P \ 0.01), number of ADRs (P \ 0.01), grade

on the MRC dyspnea scale (P \ 0.01), and low perceived

social support (P = 0.029) were significantly related to
lower PCS (Table 5). Low perceived social support also
remained significantly associated with lower MCS
(P \ 0.01). Low BMI (P = 0.02), number of symptoms
(P \ 0.01), number of ADRs (P \ 0.01), and negative
perception to waiting time in the clinic (P = 0.037) were
also identified as factors significantly associated with lower
MCS (Table 5). In addition, SHS exposure remained associated with higher MCS (P = 0.045). VIF was below 5 in all
independent variables in the models.

Discussion
The present study showed that the average scores of the
PCS and MCS of SF-8 were 44.5 and 46.0, respectively,
which demonstrated that HRQOL among PTB patients in a
socioeconomically depressed area is impaired compared
with the general population in the United States [30]. The
impaired HRQOL of PTB patients in this study is attributable to the effect of TB disease and socioeconomic factors. Factors that reflect the severity of TB disease, such as
number of symptoms and breathlessness, were strongly
associated with HRQOL both in physical and mental
aspects. These disease-related factors could be improved
along with the TB treatment. On the other hand, number of
ADRs was associated with lower HRQOL both in physical
and mental aspects. Compared with other disease-related
factors, ADRs can be managed by medical intervention to

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Table 3 Secondhand smoke exposure and Short Form-8 domains

Secondhand smoke

Scale of answer in Short Form-8c

1

General Health
Physical Function

P value

Not exposed

28 (11.6)

52 (21.5)

103 (42.6)

48 (19.8)

11 (4.5)

Exposed

46 (14.4)

69 (21.6)

143 (44.8)

46 (14.4)

13 (4.1)

Not exposed

45 (18.6)

61 (25.2)

118 (48.8)

15 (6.2)

3 (1.2)

Exposed

32 (10.0)

63 (19.7)

190 (59.6)

27 (8.5)

7 (2.2)

Role Physical

Not exposed

48 (19.8)

85 (35.1)

75 (31.0)

20 (8.3)

14 (5.8)

Exposed

71 (22.3)

90 (28.2)

78 (24.5)

60 (18.8)

20 (6.3)

Bodily Pain

Not exposed
Exposed

69 (28.5)
81 (25.4)

25 (10.3)
34 (10.7)

67 (27.7)
90 (28.2)

63 (26.0)
95 (29.8)

17 (7.0)
18 (5.6)

Vitality

Not exposed

38 (15.7)

100 (41.3)

93 (38.4)

7 (2.9)

4 (1.7)

Exposed

44 (13.8)

173 (54.2)

93 (29.2)

5 (1.6)

4 (1.3)

Social Function

Not exposed

37 (15.3)

60 (24.8)

126 (52.1)

14 (5.8)

5 (2.1)

Exposed

43 (13.5)

69 (21.6)

178 (55.8)

22 (6.9)

7 (2.2)

Mental Health

Not exposed

36 (14.9)

79 (32.6)

96 (39.7)

29 (12.0)

2 (0.8)

Exposed

57 (17.9)

110 (34.5)

119 (37.3)

30 (9.4)

3 (0.9)

Not exposed

43 (17.8)

56 (23.1)

110 (45.5)

23 (9.5)

10 (4.1)

50 (15.7)

78 (24.5)

151 (47.3)

35 (11.0)

5 (1.6)

Role Emotional

Exposed
Physical Component Summary

Not exposed

Mental Component Summary

Not exposed

45.16 (8.06)

Exposed

46.62 (7.89)

Exposed

0.19a

2 (0.6)
\0.001a
0.21a
1 (0.4)
1 (0.3)

0.53a
0.06a
0.24a
0.19a
0.92a
0.03b

45.32 (7.60)
43.9 (7.72)

0.03b

Wilcoxon rank-sum test

Students t test

1 is the best condition, and 5 or 6 are the worst condition in each domain

improve the patients HRQOL, and better management of

ADRs may have positive influence on treatment outcomes
through the improvement of adherence. Levels of education and monthly income had a substantial correlation with
HRQOL in the present study, which indicated that patients
with low socioeconomic status have a low perception of
HRQOL. These findings concur with the results of the
earlier studies [7, 8, 14], although these factors would be
difficult to modify. Having low BMI was also strongly
associated with low MCS, which suggests nutrition state is
associated with mental health of TB patients. In addition,
avoidable factors such as SHS exposure and lack of social
support were suggested to be associated with decreased
HRQOL. These findings suggest that HRQOL of TB
patients can be improved by intervention to such kinds of
social factors on an opportunity of getting TB.
Smoking has been reported to be a factor related to
worse HRQOL in the general population [3133], although
the relationship between smoking and HRQOL has not
been well documented in TB patients. In the present study,
no difference was detected in summary scores among
current smokers, former smokers, and never smokers. This
can be partly explained as a healthy smokers effect,

123

which means that those who have a good health status keep
smoking [9].
SHS exposure in TB patients has not been well discussed compared with active smoking. Surprisingly, more
than half of the TB patients were exposed to SHS in the
household in the present study. Moreover, a negative effect
of SHS exposure on physical aspect of HRQOL was suggested. The PF domain was affected significantly among
the 8 domains of SF-8, which implies that a direct negative
physical effect played a role in deteriorating PCS. In
contrast, a higher MCS was observed among the SHS
exposure group in the present study. An earlier study
reported that SHS exposure in the general population had a
negative effect on the mental aspect of HRQOL [21]. The
reason why this paradoxical result was obtained may be
explained by the influence of the MH domain, in which
there was a tendency for SHS-exposed patients to answer
positively. However, a causal relationship remains
unknown, and potential factors that were not measured in
this study might confound the association between SHS
exposure and the MH domain.
Women and the younger generation were likely exposed
to SHS exposure. Their family members should be

Qual Life Res (2014) 23:15231533

1531

Table 4 Social support and Short Form-8 domains

Functional social support
Questionnaire
General Health
Physical Function
Role Physical

Scale of answer in Short Form-8c

1

P value
4

B3.5

7 (10.3)

14 (20.6)

28 (41.2)

17 (25.0)

1 (1.5)

1 (1.5)

[3.5

67 (13.6)

107 (21.7)

218 (44.3)

76 (15.4)

23 (4.7)

1 (0.2)

B3.5

8 (11.8)

10 (14.7)

42 (61.8)

6 (8.8)

2 (2.9)

[3.5

69 (14.0)

114 (23.2)

266 (54.1)

35 (7.1)

8 (1.6)

B3.5

9 (13.2)

23 (33.8)

18 (26.5)

13 (19.1)

5 (7.4)

[3.5

110 (22.4)

151 (30.7)

135 (27.4)

67 (13.6)

29 (5.9)

Bodily Pain

B3.5
[3.5

14 (20.6)
136 (27.6)

7 (10.3)
52 (10.6)

17 (25.0)
139 (28.3)

24 (35.3)
134 (27.2)

5 (7.4)
30 (6.1)

Vitality

B3.5

4 (5.9)

25 (36.8)

33 (48.5)

4 (5.9)

2 (2.9)

[3.5

78 (15.9)

247 (50.2)

153 (31.1)

8 (1.6)

6 (1.2)

B3.5

8 (11.8)

16 (23.5)

35 (51.5)

6 (8.8)

3 (4.4)

[3.5

72 (14.6)

112 (22.8)

269 (54.7)

30 (6.1)

9 (1.8)

B3.5

8 (11.8)

19 (27.9)

28 (41.2)

12 (17.6)

1 (1.5)

[3.5

85 (17.3)

170 (34.6)

186 (37.8)

47 (9.6)

4 (0.8)

B3.5

8 (11.8)

16 (23.5)

27 (39.7)

16 (23.5)

1 (1.5)

[3.5

85 (17.3)

118 (24.0)

233 (47.4)

42 (8.5)

14 (2.8)

B3.5

42.67 (7.44)

[3.5

44.77 (7.70)

B3.5

43.38 (8.19)

[3.5

46.35 (7.90)

Social Function
Mental Health
Role Emotional
Physical Component
Summary
Mental Component
Summary
a

0.25a
0.11a
0.11a

1 (1.5)
1 (0.2)

0.09a
\0.001a
0.36a
0.026a
0.047a
0.035b
0.004b

Wilcoxon rank-sum test

Students t test

1 is the best condition, and 5 or 6 are the worst condition in each domain

encouraged not to expose patients in the household to

smoke. As indicated in the recommendation from the
International Union Against Tuberculosis and Lung Disease [34], it would be effective and efficient to integrate
smoking cessation counseling for patients and their family
members with usual health education for TB patients. Such
approach may contribute to improve ones HRQOL even
after treatment.
Social support was associated with the physical and
mental aspect of HRQOL among PTB patients in the
present study. This result is consistent with an earlier
finding that closer relationship with family members and
friends is correlated with better HRQOL [14]. Patients with
low perceived social support tended to be younger and
were negatively affected especially in VT, MH, and RE,
which may suggest that they lost motivation to join social
activities. In addition, impaired mental health might lead to
decreased perception for physical aspect of HRQOL as a
consequence. For such patients, it can be helpful to
encourage them to join peer groups or community groups.
Moreover, social workers, whom patients can consult about
mental problems including economic matters, are desirable
in health centers.

The present study has several limitations. First, SF-8 has

not been sufficiently evaluated in the general population in
the Philippines; hence, the results of SF-8 have to be
interpreted carefully. Because cultural differences may
threaten the validity of the questionnaire, normative data
for the Filipino population will need to be assessed. Second, this was a cross-sectional study, so it is difficult to
determine the causal relationship. Third, the study was
conducted in an economically deprived urban area in
Manila, and it would be difficult to generalize the results
because this area has special circumstances. Fourth, comparisons of the subjects who were interviewed and those
who were not interviewed showed that the participants
were older than the non-participants. This difference might
lead to selection bias, but might not influence the result.
Finally, the present study was conducted through face-toface interviews, which may result in misclassification of
smoking status, alcohol drinking habit, and SHS exposure
due to social desirability bias. It is well known that patientoriented data about smoking status tend to be underestimated [35]. In this study, we were not able to measure
biomarkers such as serum cotinine or exhaled carbon
monoxide concentration for validating smoking status of

123

1532

Qual Life Res (2014) 23:15231533

Table 5 Multiple linear regression model for physical component

summary and mental component summary
Scale

Variable
estimate (SE)

P value

0.02 (0.02)

0.41

Physical Component Summary

Age
Sex, female (reference = male)
Type of treatment, retreatment
(reference = new case)

0.20 (0.67)
-1.27 (0.62)

0.77
0.093

Sputum smear positive

-1.35 (0.60)

0.025

Working

1.28 (0.62)

0.041

Total years of education

0.29 (0.11)

Exposure to secondhand smoke

-1.28 (0.61)

No. of symptoms

-1.08 (0.20)

\0.01
0.035
\0.01

No. of adverse drug reactions

-0.51 (0.14)

\0.01

Medical Research Council dyspnea

scale

-0.89 (0.31)

\0.01

Social support (FSSQ [ 3.5)

2.02 (0.92)

0.029

Mental Component Summary

Age

-0.02 (0.02)

Sex, female (reference = male)

0.48

-0.13 (0.68)

0.85

Type of treatment, retreatment

(reference = new case)

0.13 (0.67)

0.84

Body mass index

0.24 (0.10)

0.02

Exposure to secondhand smoke

1.31 (0.65)

Acknowledgments We appreciate the support of the technical and

administrative staff of RJPI and cooperation from staff in each health
center and NGOs. In addition, we wish to thank Dr. Pasquala Agujo,
Chief of Division of TB Control; Dr. Romeo Cando, District Health
Officer; and Ms. Gloria Inocencio, District Supervisor/NTP Nurse
Coordinator; Dr. Armie Vianzon, NTP Medical Coordinator, for
arranging and helping in the implementation of data collection. We
also wish to thank all patients who participated in the study, and
research assistants who conducted interview. This study was conducted as a research for master thesis of first author and funded by
Graduated School of International Health Development, Nagasaki
University.
Conflict of interest

None declared.

0.045

No. of symptoms

-0.90 (0.20)

\0.01

No. of adverse drug reactions

-0.81 (0.15)

\0.01

Social support (FSSQ [ 3.5)

Positive perception for waiting time in
the clinics

3.34 (0.99)
2.19 (1.05)

\0.01
0.037

Positive perception for attitude of

health workers

2.54 (1.38)

0.067

SE standard error, FSSQ Functional Social Support Questionnaire

participants. SHS exposure can be misclassified as well,

though a linear correlation was shown between selfreported SHS exposure and biomarkers such as salivary or
serum cotinine [36, 37].
To overcome these limitations, SF-8 needs to be validated in the general Filipino population. Subsequently, a
well-designed study such as a cohort study is needed to
confirm the causal relationship between each factor and
HRQOL.

Conclusions
A cross-sectional survey was conducted to describe
HRQOL among PTB patients in Manila, the Philippines.
This study provided basic information about HRQOL
among PTB patients and identified the factors associated
with HRQOL in an economically depressed area in the

123

Philippines, which could be a relevant reference for possible policy change in the National Tuberculosis Control
Program. In addition to clinical factors, socioeconomic
status such as working status and education level was
associated with physical aspect of HRQOL. On the other
hand, clinical factors, BMI, and waiting time in the clinic
were related to mental aspect of HRQOL. Especially, SHS
exposure and social support seemed to be significant and
modifiable factors associated with both physical and
mental aspects of HRQOL.

References
1. WHO. (2012). Global tuberculosis report 2012. World Health
Organization. http://apps.who.int/iris/bitstream/10665/75938/1/
9789241564502_eng.pdf. Accessed January 30, 2013.
2. National Statistics Office (NSO) [Philippines], and ICF Macro.
(2009). National Demographic and Health Survey 2008. Calverton, MD: National Statistics Office and ICF Macro.
3. Tupasi, T. E., Radhakrishna, S., Chua, J. A., Mangubat, N. V.,
Guilatco, R., Galipot, M., et al. (2009). Significant decline in the
tuberculosis burden in the Philippines ten years after initiating
DOTS. The International Journal of Tuberculosis and Lung
Disease, 13(10), 12241230.
4. Chang, B., Wu, A. W., Hansel, N. N., & Diette, G. B. (2004).
Quality of life in tuberculosis: A review of the English language
literature. Quality of Life Research, 13(10), 16331642.
5. Aggarwal, A. N. (2010). Editorial: Health-related quality of life:
A neglected aspect of pulmonary tuberculosis. Lung India, 27(1),
13.
6. Guo, N., Marra, F., & Marra, C. A. (2009). Measuring healthrelated quality of life in tuberculosis: A systematic review. Health
and Quality of Life Outcomes, 7, 14. doi:10.1186/1477-7525-714.
7. Chamla, D. (2004). The assessment of patients health-related
quality of life during tuberculosis treatment in Wuhan, China.
The International Journal of Tuberculosis and Lung Disease,
8(9), 11001106.
8. Muniyandi, M., Rajeswari, R., Balasubramanian, R., Nirupa, C.,
Gopi, P. G., Jaggarajamma, K., et al. (2007). Evaluation of posttreatment health-related quality of life (HRQoL) among tuberculosis patients. The International Journal of Tuberculosis and
Lung Disease, 11(8), 887892.
9. Maguire, G. P., Anstey, N. M., Ardian, M., Waramori, G., Tjitra,
E., Kenangalem, E., et al. (2009). Pulmonary tuberculosis,

Qual Life Res (2014) 23:15231533

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

impaired lung function, disability and quality of life in a highburden setting. The International Journal of Tuberculosis and
Lung Disease, 13(12), 15001506.
Bauer, M., Leavens, A., & Schwartzman, K. (2012). A systematic
review and meta-analysis of the impact of tuberculosis on healthrelated quality of life. Quality of Life Research,. doi:10.1007/
s11136-012-0329-x.
Marra, C. A., Marra, F., Colley, L., Moadebi, S., Elwood, R. K.,
& Fitzgerald, J. M. (2008). Health-related quality of life trajectories among adults with tuberculosis: Differences between latent
and active infection. Chest, 133(2), 396403.
Kruijshaar, M. E., Lipman, M., Essink-Bot, M. L., Lozewicz, S.,
Creer, D., Dart, S., et al. (2010). Health status of UK patients with
active tuberculosis. The International Journal of Tuberculosis
and Lung Disease, 14(3), 296302.
Guo, N., Marra, C. A., Marra, F., Moadebi, S., Elwood, R. K., &
Gitzgerald, J. M. (2008). Health state utilities in latent and active
tuberculosis. Value in Health, 11(7), 11541161.
Duyan, V., Kurt, B., Aktas, Z., Duyan, G. C., & Kulkul, D. O.
(2005). Relationship between quality of life and characteristics of
patients hospitalised with tuberculosis. The International Journal
of Tuberculosis and Lung Disease, 9(12), 13611366.
Guo, N., Marra, F., Fitzgerald, J. M., Elwood, R. K., & Marra, C.
A. (2010). Impact of adverse drug reaction and predictivity of
quality of life status in tuberculosis. European Respiratory
Journal, 36(1), 206208.
Gajalakshmi, V., Peto, R., Kanaka, T. S., & Jha, P. (2003).
Smoking and mortality from tuberculosis and other diseases in
India: Retrospective study of 43000 adult male deaths and 35000
controls. Lancet, 362(9383), 507515.
Chang, K. C., Leung, C. C., & Tam, C. M. (2004). Risk factors
for defaulting from anti-tuberculosis treatment under directly
observed treatment in Hong Kong. International Journal of
Tuberculosis and Lung Disease, 8(12), 14921498.
Thomas, A., Gopi, P. G., Santha, T., Chandrasekaran, V., Subramani, R., Selvakumar, N., et al. (2005). Predictors of relapse
among pulmonary tuberculosis patients treated in a DOTS programme in South India. International Journal of Tuberculosis
and Lung Disease, 9(5), 556561.
Awaisu, A., Haniki Nik Mohamed, M., Noordin, N., Muttalif, A.,
Aziz, N., Syed Sulaiman, S., et al. (2012). Impact of connecting
tuberculosis directly observed therapy short-course with smoking
cessation on health-related quality of life. Tobacco Induced
Diseases,
10(1).
http://www.tobaccoinduceddiseases.com/
content/10/1/2. Accessed January 30, 2013.
Leung, C. C., Lam, T. H., Ho, K. S., Yew, W. W., Tam, C. M.,
Chan, W. M., et al. (2010). Passive smoking and tuberculosis.
Archives of Internal Medicine, 170(3), 287292.
Bridevaux, P. O., Cornuz, J., Gaspoz, J. M., Burnand, B., Ackermann-Liebrich, U., Schindler, C., et al. (2007). Secondhand
smoke and health-related quality of life in never smokers: Results
from the SAPALDIA cohort study 2. Archives of Internal Medicine, 167(22), 25162523.
Weeks, S. G., Glantz, S. A., De Marco, T., Rosen, A. B., &
Fleischmann, K. E. (2011). Secondhand smoke exposure and
quality of life in patients with heart failure. Archives of Internal
Medicine, 171(21), 18871893.

1533
23. Sarason, I. G., Levine, H. M., Basham, R. B., & Sarason, B. R.
(1983). Assessing social support: The Social Support Questionnaire. Journal of Personality and Social Psychology, 44(1),
127139.
24. Department of Health. (2005). Manual of Procedures for the
National Tuberculosis Control Program, Philippines (4th ed.).
Manila, The Philippines: Department of health.
25. Dion, M. J., Tousignant, P., Bourbeau, J., Menzies, D., & Schwartzman, K. (2004). Feasibility and reliability of health-related
quality of life measurements among tuberculosis patients. Quality
of Life Research, 13(3), 653665.
26. Bland, J. M., & Altman, D. G. (1997). Cronbachs alpha. British
Medical Journal, 314, 572.
27. Broadhead, W. E., Gehlbach, S. H., de Gruy, F. V., & Kaplan, B.
H. (1988). The Duke-UNC Functional Social Support Questionnaire. Measurement of social support in family medicine patients.
Medical Care, 26(7), 709723.
28. Bestall, J. C., Paul, E. A., Garrod, R., Garnham, R., Jones, P., &
Wedzicha, J. (1999). Usefulness of the Medical Research Council
(MRC) dyspnoea scale as a measure of disability in patients with
chronic obstructive pulmonary disease. Thorax, 54(7), 581586.
29. Obrien, R. M. (2007). A caution regarding rules of thumb for
variance inflation factors. Quality & Quantity, 41, 673690.
30. Ware, J. E., Kosinski, M., Dewey, J. E., & Gandek, B. (2001).
How to Score and Interpret Single-Item Health Status Measures:
A Manual For Users of the SF-8 Health Survey. Lincoln (RI):
Quality Metric Incorporated.
31. Mody, R. R., & Smith, M. J. (2006). Smoking status and healthrelated quality of life: Findings from the 2001 Behavioral Risk
Factor Surveillance System Data. American Journal of Health
Promotion, 20(4), 251258.
32. Heikkinen, H., Jallinoja, P., Saarni, S., & Patja, K. (2008). The
impact of smoking on health-related and overall quality of life: A
general population survey in Finland. Nicotine & Tobacco
Research, 10(7), 11991207.
33. McClave, A. K., Dube, S. R., Strine, T. W., & Mokdad, A. H.
(2009). Associations between health-related quality of life and
smoking status among a large sample of U.S. adults. Preventive
Medicine, 48(2), 173179.
34. Bissell, K., Fraser, T., Chiang, C. Y., & Enarson, D. A. (2010).
Smoking cessation and smokefree environments for tuberculosis
patients. Paris, France: International Union Against Tuberculosis
and Lung Disease.
35. Gorber, S. C., Schofield-Hurwitz, S., Hardt, J., Levasseur, G., &
Tremblay, M. (2009). The accuracy of self-reported smoking: A
systematic review of the relationship between self-reported and
cotinine-assessed smoking status. Nicotine & Tobacco Research,
11(1), 1224.
36. Emmons, K. M., Abrams, D. B., Marshall, R., Marcus, B. H.,
Kane, M., Novotny, T. E., et al. (1994). An evaluation of the
relationship between self-report and biochemical measures of
environmental tobacco smoke exposure. Preventive Medicine,
23(1), 3539.
37. Nondahl, D. M., Cruickshanks, K. J., & Schubert, C. R. (2005). A
questionnaire for assessing environmental tobacco smoke exposure. Environmental Research, 97(1), 7682.

123

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