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Effect of staff concordance based communications on tb management at

Public Health Clinic Kota Medan

Arlinda Sari Wahyuni1, Noni Novisari Soeroso2, Ivana Alona1


1
Medical Faculty Of University Of North Sumatera Public Health Department/Public Prevention
Department.
2
Medical Faculty Of University Of North Sumatera Pulmonology and Respiratology
Department.
Email: dr_arlinda_123@yahoo.com

Background : Concordance behaviour of TB management is a form of cooperation between


doctor, staff, and TB patient in doing TB management. Agreement between patient, doctor and
staff can be achieved after there is a respect and wisdom in communication between patient,
doctor and staff by the partnership principle.
Objective : This study intent to analyze the effect of concordance behaviour principle by the TB
staff to patient obedience at public health clinic kota Medan.
Method : The study type is quasi experimental on intervention public health clinic. The target of
this study is the TB staff that applied concordance behaviour principle with non-intervention
health clinic. The population is all TB patients with age more than 18 years old, TB category 1
with positive BTA test, and also a doing the TB medication regiment in public health clinic Kota
Medan. Total subject population is 74 patients. Patients had been interviewed by staff
communication instrument which based on concordance principle, knowledge, attitude and
medication that already been validated. The result then analyzed statistically using chi square, t
test and logistic regression.
Result : Score of knowledge, attitude, and management of TB patient to the treatment is higher
on intervention health clinic rather than non intervention health clinic
Conclusion : Management behaviour model based on concordancy could completed today TB
program which based on DOTS (Directly Observerd Treatment Shortcourse chemotherapy)
Keyword : concordance, medication, TB patient, Medan
Foreword
WHO (Global Reports, 2014) stated that in 2013, TB incidency in whole wide world is 9
million people and 1.5 million people died of it. Most of the TB population (85%) lived in
developing country such as Asia and Africa, and around 75% of TB patients is at productive age
category which is 15-50 years old. Right now, Indonesia is ranked 4 th for the most TB patients,
behind India, China and South Africa.
TB Management in public health clinic began to get noticed by the goverment. Every
Public health clinic in Indonesia especially public health clinic in Kota Medan already got a
special staff to service a TB patient (Health Department of North Sumatera Province, 2013) But
the fact showed that the effect of this TB staff in Public health clinic was not optimum. A lot of
TB patients in Public health clinic are not getting a clear explanation from the staff about their
disease and medication in some Public health clinic, addition to that, the staff does not
continually giving explanation to TB patient especially to patients that already been in the further
stage of medication. Patients usually only came to get the drugs without further explanation
about the medication. This could increase the occurence of Multi Drug Resistance (MDR) if the
medication are not properly consumed.
The appropriate treatment is consist of adequate dosage, duration and the step by step
treatment is depend on management behaviour by TB patients and also doctor and the staff who
treat them. Good theraupetic behaviour is when there is a concordance between doctor, patient
and staff. Concordance is a form of cooperation between doctor, patient and staff in doing the
management. Agreement between doctor and patient could be achieve if there is a respect and
wisdom between doctor and patient when communicating. Concordance focused on consultation
which doctor, patient and staff could achieve a mutual consent about the treatment process that
based on partnership principle ( Cushing and Metcalf , 2007, NCCSDO, 2005, Benson, 2005).
This condition could cause an adherence patient behaviour that could increase the commitment
on doing the management.
Right now, the study of concordance in TB management still limited. The previous study
(Arlinda, 2017) showed a relationship between communication based on concordance behaviour
with attitude and management of TB patients. But the fact that education and counseling time
provided by the TB staff in Public health clinic Kota Medan in Indonesia still limited. Another
fact also showed that the quality of interaction between doctor/staff-patient concordance still not
optimal, doctor tend to be hurried when dealing with chronic disease, especially TB. Limited
consultation and education and the communication that dominated mostly by doctor and staff and
uncooperated doctor (Patriani, 2013). This study aim to analyze the effect of concordance
behaviour of the staff and the level of knowledge, attitude and action of TB patient to their
treatment.

Method
This study using a quasi experimental study type. This study will be held at some public
health clinic in Medan. Seven Public health clinic has been selected purposively as an
intervention public health clinic which using concordance based communication and compared
to non intervention public health clinic which running their service as usual. The staff of
intervention public health clinic has been trained to communicate based on concordance
principle using a communication based on concordance guideline which has been designed by
the earlier study (Arlinda, 2016). The ongoing study has been approved by Medical Faculty of
University of North Sumatera/Haji Adam Malik General Hospital Health Research Ethical
Committe.
Subject in this study is category 1 TB patient, older than 18 years old. Subject are the
population who fulfilled the inclusion criteria which is category 1 TB patient with a positive
BTA, older than 18 years old, agree to sign the informed consent. The exclusion criteria
including TB patient with chronic disease such as cancer, HIV, Diabetes Melitus or in an ongoing
steroid medication.
Minimal total subject calculated using a 2 population hypothesis test method. α equal to
5% and β equal to 20% for the phase 1. The respondent interviewed using a structured
questionnaire that has been validaten consist of knowledge, attitude, management and staff
intrapersonal concordance communication questionnaire. Total subject are 39 patients from
intervention Public health clinic and 34 patients from non intervention public health clinic.
Data from this study analyzed using a computer program. The frequency distribution
method used for the descriptive analysis and chi square test and t test for the bivariate analysis.
Result
This study was started on July until October 2016 on 7 intervention Public health clinic in
Medan, which are : Public health clinic Belawan, Amplas, Teladan, Helvet, Johor, Padang Bulan,
and Denai, and non intervention Public health clinic, which are : public health clinic Medan Deli,
Selayang, Pasar Merah, Sentosa.
Characteristics of the respondents consist of : gender, age , education , income , job , tribe , and
marital status.

Intervention Public Non Intervention


Health Clinic n=35
Characteristic
n=39
Total Percentage Total Percentage
Gender
Male 24 61.5 25 71.4
Female 15 38.5 10 28.6

Age
Young (18-40 years) 21 53.8 17 48.6
Young Adult (40-59) 13 33.3 11 31.4
Older (> 60 years) 5 12.8 7 20.0

Education
Low (SD, SMP) 10 25.7 16 45.7
high (SMA, D-III, S1) 29 64.3 19 54.3

Family Income
Low ( < 2 million) 27 69.2 24 68.6
Moderate (2-5 million) 11 28.2 10 28.5
High (>5juta) 1 2.6 1 2.9
Job
Unemployed 8 20.5 8 22.9
Employed 31 79.5 27 77.1
Race
Bataknesse 13 33.3 21 60.0
Javanesse 10 25.6 10 28.6
Minang 10 25.6 0 0
Malay 5 12.9 2 5.6
Aceh 1 2.6 1 2.9
Etc 0 0 1 2.9
Marital Status
Married 25 64.1 21 60.0
Not married 14 35.9 14 40.0
Household
1-2
3-4 1 2.6 3 8.6
>4 12 30.8 15 42.9
26 66.6 17 48.5

Result of the study showed most of the respondents are man, either on the intervention
group (61,5%) or the non intervention group (71,4%), mostly are young either on the
intervention group (53.8%) or non intervention group (48,6%). A small part of it are the elderly,
12,8% on the intervention group and 20% on the non intervention group. Based on the
educational background, it was known that 64,3% of the intervention group and 54,3% of the
non intervention group had higher education. Generally, the respondent that had their income <2
million is 69.2% on the intervention group, and 22,9% on the non intervention group. Most tribe
on both group is Batak which is 33.3% on the intervention group and 60% on the non
intervention group. Respondent’s whom occupational status is working 79,5% on the
intervention group and 77,1% on the non intervention group. For marital status, most of the
respondent are married 64,1% on the intervention group and 60% on the non intervention group.
Based on the amount of people in the family, mostly for both intervention group (66,6%) and non
intervention group (48,5%) had >4 family members.

Table 2. Comparison of knowledge, attitude, and action of management score between


intervention Public Health clinic and non intervention Public Health Clinic.

Public Health Clinic


Intervention Non
p-value*
Intervention
Mean SD mean SD
Knowledge
Good 32 59.3 19 41.3 0.954
Poor 22 40.7 27 58.7
Behaviour
Good 34 63 19 41.3 0.031
Poor 20 37 27 58.7
T independent

Discussion
The results showed 54% has a good concordance on TB management in Public health
clinic Kota Medan. In contrast to the study by Patriani (2013) that showed 35.1% of patient
concordance in RSUD Mataram. In this study, concordance includes developing effective
communication based on partnership principle, openness, empathy and support between staff and
TB patient. It could build the trust that patient will be honest on how they feel and will cooperate
with TB staff in treating his illness. The requirements that must be fulfilled in a concordance are
power sharing consulting, opening discussion by any chance, adequate information, fair and
equitable discussion, and adequate timing (Benson, 2005). Patient handled the trust of their
health problem to the staff, the staff will build the concordance with partnership communication,
facilitating patient to take part with clear intention (Wahl, 2004).
In this study, a good concordance is related to the attitude and action of TB patient on
their ongoing medication, but not related to the patient knowledge. Most (51%) of patient
knowledge is good, which is caused by the information received by the patient from many
sources, not only from the staff. In accordance with study by Patriani (2013) stating the
connection between concordance and patient’s management attitude and behaviour. Addition to
that, Rugun etc. (2014) stated the connection between staff and medication staff (PMO) with
the obedience in taking the medication of TB patient in Public health clinic Kota Medan (P <
0.05). A good concordance will increase patient’s medication obedience 3,4 times better. This
will cause higher adherence or patient’s obedience compared to a less concordance, that patient
will have commitment, motivation, and responsibility on the illness and its treatment. This is
really needed in treating chronic illness medication like TB. They must understand and be
responsible with the illness. Both being responsible and higher commitment will also prevent
their environment from TB and MDR which treatment is complicated and take a really long time
(2 years).
The result of this study could be a base for government to increase the management
quality on TB patient by developing concordance behaviour from TB management staff in Public
health clinic, for they are the first line who has important influence in treating management
behaviour of TB patient (Health Department, 2011).

Conclusion and Sugestion


Most of the concordance behaviour, knowledge, attitude and management from the
subject are include in good performance group. There is a connection between concordance with
attitude and management in TB medication, but there is no relation between the concordance and
the knowledge of TB patien about their disease and medication. There is a need to increase the
communication based on concordance capability of TB staff in Public health clinic since they are
the first line of TB management which had an important effect in maintain TB management
behaviour (Department of Health, 2011).

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