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ORIGINAL ARTICLE

Cigarette smoking and health-promoting behaviours among
tuberculosis patients in rural areas
Shu-Lan Tsai, Chun-Liang Lai, Miao-Ching Chi and Mei-Yen Chen

Aims and objectives. To explore cigarette smoking and health-promoting beha-
viours among disadvantaged adults before their tuberculosis diagnosis and after What does this paper contribute
their tuberculosis treatment. to the wider global clinical
Background. Although tuberculosis infection is associated with impaired immune community?
function, healthy lifestyle habits can play a role in improving the immune system.  Malnutrition, cigarette smoking,
However, limited research has explored the health-promoting behaviours and and unhealthy habits were
cigarette smoking habits among tuberculosis patients in Taiwan. prevalent among tuberculosis
patients before their diagnosis.
Design. A cross-sectional retrospective study with a convenience sample.
 Body mass index and health-pro-
Methods. This study was conducted between May 2013–June 2014 with 123 moting behaviours improved sig-
patients at a rural district hospital in Chiayi County, Taiwan. Statistical analyses nificantly after treatment for
included descriptive statistics, univariate analysis and stepwise regression analysis. tuberculosis.
Results. Tuberculosis tended to be associated with less education, male sex, mal-  Cigarette smoking cessation and
nutrition, cigarette smoking and unhealthy lifestyle habits before the tuberculosis lifestyle modification pro-
grammes should be initiated for
diagnosis. The percentage of smoking decreased from 469% before to 302%
tuberculosis patients during their
after the tuberculosis diagnosis. Body mass index and health-promoting beha- treatment.
viours also significantly improved after tuberculosis treatment. After controlling
for potential confounding factors, multivariate analysis identified chronic disease
and completed treatment as significant factors that were associated with current
health-promoting behaviours.
Conclusions. A high prevalence of cigarette smoking and low levels of health-pro-
moting behaviours were observed before the diagnosis and during or after com-
pleting tuberculosis treatment.
Relevance to clinical practice. This study’s findings indicate the importance of
promoting healthy lifestyle changes among tuberculosis patients; aggressive mea-
sures should be implemented immediately after the first diagnosis of tuberculosis.
Furthermore, health promotion and smoking cessation programmes should be ini-
tiated in the general population to prevent activation of latent tuberculosis infec-
tion, and these programmes should specifically target men and rural residents.

Key words: cigarette smoking, health-promoting behaviours, rural, tuberculosis

Accepted for publication: 28 February 2016

Authors: Shu-Lan Tsai, RN, MSN, TB Case Manager, Dalin Tzu of Nursing, Chang Gung University of Science and Technology,
Chi Hospital, Chiayi; Chun-Liang Lai, MD, Division of Pul- Chiayi County, Taiwan
monary and Critical Care, Dalin Tzu Chi Hospital, Chiayi; Correspondence: Mei-Yen Chen, Professor, No. 2, Chiapu Road
Miao-Ching Chi, PhD, Assistant Professor, Department of Respi- West Sec., Putz City, Chiayi County 61363, Taiwan. Telephone:
ratory Care, Chang Gung University of Science and Technology, +886 (5) 3628800 ext. 2201.
Chiayi; Mei-Yen Chen, RN, PhD, Professor, Graduate Institute E-mail: meiyen@gw.cgust.edu.tw

© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, doi: 10.1111/jocn.13289 1

Host defenses may be strengthened by individ. Savicevic et al. 2012). recent in vitro study from South Africa. consisting tion. (4) adherence to treatment. which respectively (WHO 2015). In 2014. In Taiwan. the presence of a ing behaviours reported before and after TB diagnosis sufficient amount of M. 2014. Prevention strategies that address all three of Expert consensus indicates that ideal TB control involves these factors are critical for reducing infections in all health the following measures: (1) Bacillus Calmette-Guerin vacci- care settings.000 children were infected with or died from 2012). 2013). and many studies have demonstrated that health. nation in all eligible newborns. and few patients. These behaviours are often the result of pub. Compared to nonsmokers. and an adequate among adults in a disadvantaged region. 2012. including smoking ces- improve the society’s collective health status. most studies have focused on the side effects of have examined health-promoting behaviours among TB anti-TB drugs and adherence to TB treatments. In a (Yunlin) and 627/105 (Chiayi) (CDC 2014). Therefore. modern medicine has rendered TB curable and preventable. Patients who have previously reported risk factors associated with TB infec- latent TB infection have a 10% lifetime risk of developing tion. Therefore. However. level requires an understanding of the gaps in the adoption promoting behaviours are positively correlated with health of healthy behaviours at the different disease stages. 2008. Narasimhan 105) was higher than that in Singapore (44/105). maintaining a healthy immune system is TB respectively (WHO 2015). spread disease in many developing and developed countries. Unfor- status (Chen et al. many people critical for safeguarding against TB infection. enhancing immunity at the individual patients. based on the value of promoting healthy behaviours active TB. 2012. 2012. personal hygiene and regular exercise of regular chest radiography and directly observed treat- (WHO 2010). Li et al. WHO 2014). In addition. This study used transmission environment (CDC 2014). (2) early diagnosis.S-L Tsai et al. ment programmes with a six to nine month course of 3–4 lic health promotion strategies that motivate individuals to antimicrobial drugs and (5) enhanced individual immunity take increased control over their health. van Zyl-Smit et al. prompt treatment. it remains a source of wide. In particular. Clinicians sation and adequate nutrition (Li et al. and host. this study aimed to evaluate and The risk of developing TB depends on three interrelated compare changes in cigarette smoking and health-promot- factors: a weakened host immune system. immunisation. environment ment of Mycobacteria in infected individuals. below normal weight (Cegielski et al. Approximately one-third people worldwide were infected with or died from TB of the world’s population is infected with latent TB. such as diabetes and HIV coinfec- in Asia (WHO 2014). Furthermore. develop latent TB infection. few studies tunately. 2006. cigarette smoking (Shang et al. unhealthy lifestyle. 96 million and 15 million (Horne et al. even after completing treat- increasingly ageing populations with TB rates of 703/105 ment (d’Arc Lyra et al. 2013. 2012). Thankfully. malnutrition. the incidence rate (545/ tion (Mupere et al. still die from multidrug-resistant TB. and compromised immune systems and In 2012. lion and 140. and endogenous reactivation is one of the top-ranking infectious diseases globally in may occur when the individual’s health condition weakens terms of mortality. (2014) found that cigarette smoke moderated effector cyto- Three important interrelated factors are generally associ. 2013). smokers have a 2– 105) and the USA (48/105) (CDC 2014). which is a contagious. many people Tuberculosis (TB). kine response and compromised the macrophage contain- ated with infectious diseases: the pathogen. During the incubation period. airborne disease. is both noncommunicable and asymptomatic (Horne et al. despite a 47% Epidemiological studies have indicated that certain char- decrease in the TB-related mortality rate and a treatment acteristics are associated with higher risks of acquiring TB success rate of 86% for newly diagnosed individuals (WHO infection: older age. male sex. Hsu et al. However. 2014. Although Mycobacterium tuberculosis is a pathogen that 2012. an estimated 1 mil. Dogar et al. Ladefoged et al. which may through healthy lifestyle strategies. 2011). (3) ual health-promoting behaviours that are related to nutri. 2015). © 2016 John Wiley & Sons Ltd 2 Journal of Clinical Nursing . the 3-fold higher risk of acquiring TB infection and progressing rural regions of Yunlin and Chiayi Counties contain from latent to active disease. 2011. 2011. Jurcev- has existed since ancient times. approximately 60% of all new TB cases occurred specific chronic diseases. Japan (27/ et al. tuberculosis. WHO play an important role in lifestyle modification for TB 2014). in TB patients. studies have investigated whether TB patients actually adopt health-promoting behaviours and how these beha- viours change between the pre-diagnosis and post-treat- Background ment stages. ble for protecting the other 90% does not activate (Horne Introduction et al. poverty. Ladefoged et al. while the immune defense mechanism responsi.

Body mass index was fully capable of living independently. age. Three measures were used to assess the treatment status ‘Did you smoke before you were diagnosed with TB and practice of health-related behaviours during daily life infection?’ and ‘Have you smoked recently. (five items with scores ranging from 5–20. community participation emphasised that the responses would be kept confidential. such as ‘I brush my teeth three times per day’). healthy diet (three completed) TB treatment within the last six months. confidentiality was maintained ticipate in a community program’). (093. 12–16 g/dl). two nursing Methods supervisors and one member of a pulmonary nursing fac- ulty) were invited to evaluate the questionnaire. the content tient clinic in a local district hospital. including foods from five food by a senior case manager working at the TB outpatient groups’).Original article Smoking and health promoting behaviours five experts (including two chest physicians. such as ‘I patients who had received greater than two weeks of (or know the level of my blood pressure’). each item. The GHPs contains six behaviour dimensions: pose and procedures of this study had been explained. we allowed one to from 2–8. Participants established to rate the clarity. this study was approved by the insti. occupation. The GHPs is a exclusion criteria were: (1) severe disease (e. TB treatment status. albumin level (35– within the last six months. Three three-point Likert scales were implemented between May 2013–June 2014. via interview. relevance.g. The participant was asked. been diagnosed with TB and receiving treatment?’ © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing 3 . marital status. haemoglobin level (normal: men. viours. This 22-item dementia) and (3) an uncertain TB diagnosis. including Study design and setting the questions regarding participant characteristics and Retrospective and cross-sectional research designs were cigarette smoking. 3 Cigarette smoking information was obtained using a stan- Measures dardised personal interview. 2 Health-promoting behaviours were measured using the tal and (7) provided their written informed consent. such as ‘I par- During the data analysis. (4) was at least 20 years old and 55 mg/dl) and comorbid diseases. and oral health (two items with scores ranging from information. sion criteria were: (1) the first TB diagnosis was made by a 1 Participant characteristics were obtained through medical pulmonary physician using positive chest radiographs and records and structured questions for sex. which answer the questionnaire in Mandarin or Taiwanese dialects were measured during the interview. 135– greater than two weeks of (or completed) TB treatment 175 g/dl. and health habits (seven items with scores ranging from 7–28.g. To minimise any recall bias. (2) infection was present either on the inside level. Informed more frequent practice of the health promoting beha- consent was obtained from all participants after the pur. and importance of were selected using convenience sampling from a TB outpa. (2) concurrent mental health condition (e. women. scale was developed by Wang et al. We ference between individual periods. TB or outside of the lung. such as ‘I eat a bal- participant interviews and data recording were performed anced diet every day. Responses were scored as ‘never’ (1). and the patient (3) had received contact history. The Geriatric Health Promotion scale (GHPs). 2013). Participants (2). ‘sometimes’ tutional review board of Tzu Chi Hospital. such as ‘I exercise for at least 30 minutes each two minutes for the participants to recall and confirm their day’). All items with scores ranging from 3–12. The interview was conducted with TB (three items with scores ranging from 3–12. regular exercise (two items with scores ranging clinic. The inclu. The reliability coefficient for the total scale was with TB’ or ‘Were you a smoker six months ago?’ 087. diabetes with multidimensional instrument that attempts to evaluate the leg amputation). A four-point rating scale was used to score the frequency Procedures and ethical considerations of a behaviour. education sputum smears. After each expert rated the items. with the total possible scores ranging from Before data collection. All participants lived validity index was used to calculate the content validity near disadvantaged rural areas of central Taiwan. our questions emphasised the dif. and the alpha coefficients for the subscales ranged from 064–094 and explained 68% of the total variance. 081–094). Before conducting the investigation. such as ‘Now. 22–88. range. the covering letter that accompanied the questionnaire such as ‘I eat breakfast daily’). Higher scores indicate were invited to participate by the case manager. after having among TB patients. In addition. (5) was able to (BMI) was calculated using weight and height. let’s talk found that this scale had acceptable content and construct about the habits you practiced before you were diagnosed validity. (2015) and can be administered in less than 10 minutes (Chang et al. health responsibility using data coding. 2–8. (6) was able to walk to the community hospi. lifestyle patterns of elderly Taiwanese people. ‘usually’ (3) or ‘always’ (4).

and more than half of the partici- pants were currently working (n = 65. The the reported 469% (n = 45) before TB diagnosis to 302% Table 1 Demographic characteristics and reported cigarette smoking behaviour changed before and after diagnosis of tuberculosis (n = 123) Nonsmokers Stopped smoking Variables before diagnosis after diagnosis Still smoking v2 p Gender 1996 <0001 Male 51 (531) 16 (167) 29 (302) Female 27 (1000) 0 (00) 0 (00) Age 1297 0002 <65 35 (556) 5 (79) 23 (365) ≧65 43 (717) 11 (183) 6 (100) Education 753 0023 ≦Primary 50 (725) 9 (130) 10 (145) ≧Secondary 28 (519) 7 (130) 19 (352) Occupation 1851 <0001 Unemployment 48 (828) 5 (86) 5 (86) Employment 30 (462) 11 (169) 24 (369) Marital status 893 0012 Married 60 (659) 15 (165) 16 (176) Others 18 (562) 1 (31) 13 (406) Chronic Disease 743 0024 Yes 57 (679) 13 (155) 14 (167) No 21 (538) 3 (77) 15 (385) Treatment status 088 0644 Incomplete 30 (588) 7 (137) 14 (275) Complete 48 (667) 9 (125) 15 (208) © 2016 John Wiley & Sons Ltd 4 Journal of Clinical Nursing . USA) (n = 72. and treatment.. colleagues with TB was observed among 207% (n = 31) of The paired t-test. 165 years. smoking habit and treatment status.0. and the mean age was 614 years (standard TB treatment or as ‘have smoked at some time’ if they deviation. relatives or p-values of <005 were considered statistically significant. The majority of participants were married (n = 91. (118%). and chi-square test the participants. and hypertension sion analysis was conducted using variables that were sig. behaviours. Participants were classified as ‘never smoked’ if they had majority of the remaining 123 participants were men never smoked cigarettes before their TB diagnosis or after (n = 96. More than half were a smoker before their TB diagnosis or had smoked (n = 69. SPSS Inc. Chicago. and 415% (n = 51) were still undergoing was used for data analyses. Statistical analysis Over half of the participants had completed TB treatment SPSS software (version 17. To investigate the factors that were associated The most common concurrent chronic diseases were dia- with health-promoting behaviours. 74%). 561%) of the participants completed primary during or after completing TB treatment. Approx- in the pre-diagnosis and post-treatment comparison of per. betes (275%). 21–89 years). 13% (n = 16) of the nificant (p < 005) in the univariate analyses of occupation. All tests were two-sided. 683%) of the participants sonal factors. Results Demographic characteristics Cigarette smoking among participants with TB Among the 134 candidates who were invited to participate The percentage of participants who smoked decreased from in this study. 11 failed to complete the assessment. kg/m2). 585%). and 793% (n = 92) of the participants were used for evaluating rates and equality of proportions stated that they had a negative TB contact history. school or less (≤6 years). Before their TB diagnosis. 78%). health-related factors and health-promoting reported having one or more concurrent chronic diseases. independent t-test. stepwise linear regres. Hospital medical records revealed that more than half of the participants with available records had below- average haemoglobin (57/105) and albumin (31/49) levels. Positive contact history with family. range. imately two-thirds (n = 84. hepatitis (213%). participants were classified as underweight (BMI < 185 chronic disease.S-L Tsai et al. 528%) (Table 1). IL.

Participate health education 124 (071) 122 (071) 063 0529 11. Participants who had never smoked or who had stopped smoking for Factors associated with health-promoting behaviours greater than one year had significantly higher scores. com- Table 2 shows that the three dimensions of the GHPs and pared to current smokers. Current smokers were significantly younger p < 0001). p < 0001). healthy diet (p < 001) and total nificantly from reported behaviours before TB diagnosis to GHPs score (p < 005). 14 items of the health-promoting (v2 = 1297. health responsibility (p < 001). Interact with friends 332 (097) 315 (102) 281 0006 Community participation 827 (305) 799 (294) 258 0011 8. in the dimensions of health 11 items of the health-promoting behaviours changed sig. (t = –301. p = 0003). Knowing blood sugar level 240 (146) 254 (147) 222 0028 Healthy diet 829 (217) 867 (217) 348 0001 16. and had no concurrent chronic diseases ship or religious activities). Two fist-sized fruits/day 240 (091) 241 (092) 053 0595 Regular exercise 419 (257) 450 (268) 223 0028 19. Table 2 also shows that a significant cantly associated with cigarette smoking habits (v2 = 1996. regular exercise (p < 005) p = 0003).g. Participants with chronic diseases after receiving or completing TB treatment. sions (e. p = 0028) and the total GHPs score (Table 1). Participate community programme 114 (056) 114 (056) 000 1000 10. p = 0001). Knowing my cholesterol level 222 (143) 229 (144) 132 0190 14. (v2 = 743.’ especially for the community participation dimen- (v2 = 1851. GHPs dimensions included health responsibility (t = –303. Brush teeth before sleep 269 (146) 270 (147) 100 0319 22. Good fitted shoes 378 (059) 378 (059) 000 1000 5. had a secondary school or greater behaviours occurred at frequencies of ‘sometimes’ or education (v2 = 753. p = 0002). Significant had significantly higher scores in health habits (p < 005). Familiar with village head 356 (104) 357 (103) 038 0707 7. 1. Table 3 shows the findings of the univariate analysis regarding current health-promoting behaviours. male sex was signifi. p = 0023). Exercise three times/day 211 (129) 226 (134) 223 0028 Oral Health 412 (198) 415 (202) 114 0259 21. Participate township activities 176 (113) 172 (110) 104 0299 12. Participants who were Table 2 Reported health promoting behaviours and BMI changed before diagnosis and during or completing TB treatment (n = 123) Before diagnosis During/completing Variables Mean (SD) Paired t p Health habits 2368 (295) 2391 (275) 150 0136 1. healthy diet (t = –348. I eat breakfast daily 370 (078) 386 (053) 298 0004 2. Furthermore.5 bowls of vegetable/day 259 (106) 275 (108) 307 0003 18. Wear slipper resistant shoes 245 (137) 247 (138) 114 0259 6. participation in community programmes. Regular diet schedule 340 (089) 358 (075) 323 0002 3. Participate in exercise 132 (084) 127 (080) 118 0241 9. Knowing blood pressure level 302 (132) 335 (116) 387 <0001 15. were unmarried (v2 = 893.Original article Smoking and health promoting behaviours (n = 29) after receiving or completing TB treatment exercise (t = –223. town- p = 0012). Feel sleep enough 348 (088) 350 (092) 040 0693 4. Among the participants. A balanced diet (five groups) 330 (091) 351 (078) 351 0001 17. responsibility (p < 005). Participate religious activities 281 (126) 264 (126) 351 0001 Health responsibility 763 (373) 819 (348) 303 0003 13. increase in BMI occurred after TB treatment (t = –613. Brush teeth three times/day 143 (102) 145 (104) 082 0416 Total score 5619 (968) 5741 (983) 301 0003 Body mass index (BMI) 2244 (341) 2335 (318) 613 <0001 © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing 5 . Exercise 30 minutes/day 208 (128) 224 (134) 223 0028 20. regular and total GHPs score (p < 001). p = 0024). p < 0001). were currently employed ‘never.

Similar to previous studies of TB (Olson et al. lower socioeconomic Participants who had completed TB treatment scored signif. Notably. health responsibility. OH. regular exercise. HD. for uptake of Mycobacteria via monocyte-derived or alveolar health habits (p < 005). oral health. smoking and a low rate of health-promoting behaviours Previous studies revealed that malnutrition is a risk factor among the participants. Independent t-test.S-L Tsai et al. latent TB infection (Dogar et al. One mathematical mod- stepwise linear regression analysis (Table 4) revealed that elling analysis by Basu et al. smoking cessation should be aggres- between reported behaviours before TB diagnosis and dur. men). ing or after TB treatment. **p < 001. p = 0005) and completion cases and deaths worldwide in the coming years. both before TB diagnosis and dur. status and smoking habits were important characteristics icantly higher in health-promoting behaviours. After adjusting for potential confounding variables. we found that male sex. related public health goals include reducing TB relapse and moting behaviours and smoking habits among adults multidrug-resistant TB. WHO 2014). (2011) predicted that tobacco the determinants for current health-promoting behaviours smoking could substantially increase the number of TB were chronic disease (b = –025. no one started to smoke after the diagnosis. Although the prevalence of cigarette smoking decreased from 469% before to 302% after the diagnosis of TB. Discussion smoking remains a significant problem. Nicotine has the ability to impair the participants who had not completed TB treatment. *p < 005. CP. © 2016 John Wiley & Sons Ltd 6 Journal of Clinical Nursing . 2010. compared to working participants. of TB treatment (b = 023. Lonnroth et al. our Louwagie & Ayo-Yusuf 2013). healthy diet. 2012. for TB infection and relapse after treatment (Karyadi et al. Choi et al. Pakasi et al. Horne et al. currently not working had significantly higher scores in reg. health habits. 2009. There was a high prevalence of cigarette more likely to smoke (e. ular exercise (p < 001). especially for individuals who are geographical area. 2000. p = 0007). and this macrophage impairment may (p < 005). health responsibility (p < 005) and total GHPs weaken the host immune response and increase the risk of score (p < 001). Table 3 Factors associated with present health promoting behaviours (n = 123) HH CP HR HD Exercise OH Total score Variables Mean (SD) Gender Male 239 (24) 81 (29) 84 (34) 85 (21) 47 (26) 40 (21) 576 (88) Female 238 (36) 78 (29) 73 (38) 92 (23) 39 (28) 47 (18) 567 (129) Age (years) <65 239 (29) 77 (28) 78 (37) 90 (22) 42 (26) 43 (19) 569 (94) ≧65 239 (25) 83 (31) 86 (33) 83 (21) 48 (28) 39 (21) 579 (103) Education ≦Primary 239 (25) 80 (28) 86 (34) 84 (21) 45 (28) 39 (21) 573 (94) ≧Secondary 239 (31) 79 (31) 77 936) 90 (22) 45 (25) 44 (19) 575 (104) Occupation Unemployment 241 (27) 85 (35) 81 (34) 87 (23) 53 (27)** 41 (19) 586 (109) Employment 238 (28) 76 (22) 83 (36) 87 (21) 38 (25) 42 (21) 563 (860 Chronic disease Yes 243 (26)* 83 (32) 89 (32)** 88 (22) 49 (27)* 40 (20) 592 (99)** No 232 (30) 73 (21) 67 (37) 84 (19) 37 (25) 45 (19) 536 (86) Smoking Never/cessation 239 (27) 80 (31) 85 (35)* 89 (22)** 46 (27) 42 (20) 581 (100)* Current user 237 (29) 78 (21) 63 (32) 73 (13) 39 (28) 39 (19) 527 (67) Treatment status Incomplete 233 (31) 72 (24) 73 (32) 86 (23) 41 (26) 41 (22) 545 (89) Complete 244 (24)* 85 (32)* 89 (35)* 88 (21) 48 (27) 42 (19) 595 (99)** HH. in this study. if TB- This study aimed to investigate the changes in health-pro. community participation. exercise. Therefore. 2012. compared to among TB patients. HR.g. 2012. community participation macrophages. sively addressed in TB treatment protocols and in coun- ing or after completing TB treatment in a disadvantaged selling environments.

For example. concern. although significant to cause TB (Jurcev-Savicevic et al. Taiwanese TB programmes and treatment) and motivate these patients to continue their future research should utilise strategies that incorporate health-promotion behaviours. R2 = 012. recall bias may have occurred. Second.g. Fourth. completing TB treatment were associated with health. Therefore. poor health con- improvements were identified in these patients. tuberculosis is necessary. but not sufficient. and albumin levels. concurrent chronic diseases and unhealthy lifestyle habits were practiced at a frequency below “usually” dur. such as a prospective study of health beha- providers. National data from the US (Cegielski et al. According to the present There are several limitations in this study. this strategy could potentially significantly improve exhibited low levels of health-promoting behaviours.Original article Smoking and health promoting behaviours Table 4 Determinant factors associated with present health promoting behaviours (n = 123) Variables Unstandardised B SE b t value p 95% CI Constant 5634 145 3895 <0001 5345 to 5921 Chronic disease (1 = no) 520 180 025 288 0005 876 to 163 Treatment status (1 = complete) 463 170 023 272 0007 126 to 800 Model summary F = 840 (p < 0001). Therefore. smoking. First. Nevertheless. we conclude that healthy lifestyle promotion to eliminate TB. healthy ditions. recency. recall bias is of during the identification and treatment of TB. before their TB diagnosis. such as primacy. associations and do not indicate causal relationships. future research should use more general health promotion messages from their health care robust methods. Therefore. both the physical condition of patients who complete TB before their TB diagnosis and during or after completing treatment (e. Although the participants who completed TB treatment had improved presence of M. mation of certain health-related behaviours. ate these nutritional elements before a TB diagnosis or after self-reporting may have caused underestimation or overesti- TB treatment. Although emphasising lifestyle improvements during TB treatment is not a health promotion strategy in Our findings revealed that the majority of participants Taiwan. the participants were underweight. future treatment plans should consider pants was 61 years. Moreover. would lead to the biases in memory. Our study also revealed similar findings. which are produced current chronic disease (especially type 2 diabetes) and by factors outside consciousness. Nurses are expected to provide evidence-based care. and demand characteristics of the experiment. occupation. care in Taiwan encourage patients to adopt better exercise habits and a balanced diet that includes food from the five Conclusion food groups. health behaviours. to continue building up the host play roles in susceptibility to TB. the GHPs was used. treatment status. by reducing unwanted side effects after TB TB treatment. 2014). Therefore. 2013). Independent variables – Chronic disease. 2014) indicate that amount and frequency of cigarette use or personal dietary individuals who are underweight (BMI < 185 kg/m2) and habits. choices are also important host immunity factors that can ing daily life. because the findings. Dependent variables – total score of health promoting behaviour. with abnormal haemoglobin generalisability of these findings may be limited. and nursing leaders have an obligation to support and enable Limitations nurses to meet that expectation. immune system and avoid activation of latent TB. it is nec- essary to establish standardised counselling that encourages Relevance to clinical practice TB patients to adopt healthier behaviours. Fifth. The potential inaccuracy of the recall measure The present findings also demonstrate that having a con. To achieve promoting behaviours. protocols for standardised diabetes viours from the time of diagnosis. cigarette smoking and unhealthy participants were recruited using a convenient sample from habits were prevalent among TB patients. Our findings the cross-sectional and retrospective data only reflect appear to indicate that not all health care providers evalu. These patients might have received more conclusive results. as many a rural hospital with relatively uneducated patients. which might have nutritional assessment and provide nutritional counselling resulted in measurement error. as current have low serum albumin levels are at an increased risk of smoking status was not determined using a carbon monox- developing TB infection and having poor TB treatment out. ide monitor. it is © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing 7 . malnutrition. Therefore. Third. such as the 2012) and South Korea (Choi et al. although the mean age of the partici- comes.

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