UNIVERSITY OF HEALTH AND ALLIED SCIENCES

SCHOOL OF NURSING AND MIDWIFERY

ADHERENCE TO TREATMENT REGIMEN BY TUBERCULOSIS

PATIENTS: A STUDY AT THE TUBERCULOSIS CLINIC OF THE TEMA

GENERAL HOSPITAL

BY

NANCY MENSAH

NAOMI ASAFUABA YAAFO

MARY DARKOA ASAMOAH

BEATRICE BOATENG

GENEVIEVE NEEQUAYE

A PROJECT WORK SUBMITTED TO THE UNIVERSITY OF HEALTH

AND ALLIED SCIENCES IN PARTIAL FULFILMENT OF THE
REQUIREMENTS FOR THE AWARD OF BACHELOR OF NURSING
DEGREE

APRIL, 2023
UNIVERSITY OF HEALTH AND ALLIED SCIENCES
 SCHOOL OF NURSING AND MIDWIFERY

ADHERENCE TO TREATMENT REGIMEN BY TUBERCULOSIS

PATIENTS: A STUDY AT THE TUBERCULOSIS CLINIC OF THE TEMA
GENERAL HOSPITAL

BY

NAME INDEX NUMBER SIGNATURE

NANCY MENSAH UHAS20200169 ………………….…….

NAOMI ASAFUABA YAAFO UHAS20200484 ………………….…….

MARY DARKOA ASAMOAH UHAS20200372 ………………….…….

BEATRICE BOATENG UHAS20200539 ………………….…….

GENEVIEVE NEEQUAYE UHAS20200588 ………………….…….

A PROJECT WORK SUBMITTED TO THE UNIVERSITY OF HEALTH

AND ALLIED SCIENCES IN PARTIAL FULFILMENT OF THE
REQUIREMENTS FOR THE AWARD OF BACHELOR OF NURSING
DEGREE

APRIL, 2023
 DECLARATION

With the exception of references and quotations from other sources which have all been credited,

we the undersigned, hereby declare that this piece of work is the original research work of mine

and that no part of it has been presented elsewhere. Also, we would like to say that any errors of

judgment, facts, omissions and style remain our liability.

NAME OF STUDENT SIGNATURE OF STUDENT DATE

NANCY MENSAH ………………….……. ………………….

NAOMI ASAFUABA YAAFO ………………….……. ………………….

MARY DARKOA ASAMOAH ………………….……. ………………….

BEATRICE BOATENG ………………….……. ………………….

GENEVIEVE NEEQUAYE ………………….……. ………………….

NAME OF SUPERVISOR SIGNATURE DATE

Felix K. Nyande (PhD) ………………… …………………

i
 DEDICATION
This work is dedicated to God almighty and our lovely parents.

ii
 ACKNOWLEDGEMENT

We are thankful to God Almighty for His guidance and protection throughout this programme.

We want to express our profound gratitude to our supervisor Dr. Felix K. Nyande for his

guidance, tolerance and hospitality.

We also want to thank the staff of the Tema General Hospital (TB clinic) for without their

support this project would not have come into fruition.

We also express our profound gratitude to the respondents who took their time to respond to the

questionnaire towards this study for without them, there is no research.

iii
 TABLE OF CONTENTS

DECLARATION............................................................................................................................i
DEDICATION...............................................................................................................................ii
ACKNOWLEDGEMENT...........................................................................................................iii
TABLE OF CONTENTS.............................................................................................................iv
LIST OF TABLES.......................................................................................................................vii
LIST ABBREVIATIONS AND ACRONYMS........................................................................viii
ABSTRACT..................................................................................................................................ix
CHAPTER ONE............................................................................................................................1
INTRODUCTION.........................................................................................................................1
1.1 Background.......................................................................................................................1
1.2 Problem Statement............................................................................................................4
1.3 Purpose of the study..........................................................................................................6
1.4 Specific Objectives...........................................................................................................6
1.5 Research Questions...........................................................................................................7
1.6 Justification of the study...................................................................................................7
1.7 Significance of the Study..................................................................................................8
1.8 Operational Definitions.....................................................................................................8
1.9 Organization of the Study.................................................................................................8
CHAPTER TWO.........................................................................................................................10
LITERATURE REVIEW...........................................................................................................10
2.1 Introduction.....................................................................................................................10
2.2 Knowledge of patients on TB.........................................................................................11
2.3 Adherence level of TB medication among the TB patients............................................13
2.4 Relationship between knowledge and adherence to TB medication...............................15
2.5 Factors influencing adherence to TB treatment among patients attending the TB clinic
16
2.6 Summary of literature review.........................................................................................18
CHAPTER THREE.....................................................................................................................20
METHODOLOGY......................................................................................................................20
3.0 Introduction.....................................................................................................................20

iv
 3.1 Research Design..............................................................................................................20
3.2 Study setting....................................................................................................................20
3.3 Study Population.............................................................................................................21
3.4 Sampling.........................................................................................................................21
3.4.1 sample size...............................................................................................................21
3.4.2 sample size determination........................................................................................21
3.4.3 sampling procedure..................................................................................................21
3.4.4 Inclusion criteria......................................................................................................22
3.4.5 Exclusion criteria.....................................................................................................22
3.5 Data collection................................................................................................................22
3.5.1 Data collection instrument.......................................................................................22
3.5.2 Data Collection Method...........................................................................................22
3.5.3 Validity and reliability.............................................................................................23
3.5.4 Pre-test/pilot study...................................................................................................23
3.6 Data handling..................................................................................................................23
3.6.1 Statistical Analysis...................................................................................................24
3.7 Limitations of the study..................................................................................................24
3.8 Ethical considerations..........................................................................................................24
CHAPTER FOUR.......................................................................................................................26
DATA ANALYSIS AND PRESENTATION OF FINDINGS.................................................26
4.1 Introduction.....................................................................................................................26
4.2 Demographic Characteristics of respondents..................................................................26
4.3 Knowledge of respondents attending the TB clinic on TB.............................................27
4.4 Adherence level of TB medication among the TB patients............................................29
4.5 Relationship between knowledge, demographic variables and adherence to TB
medication..................................................................................................................................31
4.6 Factors Influencing Adherence to TB Treatment...........................................................33
CHAPTER FIVE.........................................................................................................................35
DISCUSSION OF FINDINGS, SUMMARY AND CONCLUSION.......................................35
5.1 Introduction.....................................................................................................................35
5.2 Discussion of findings.....................................................................................................35
5.2.1 Knowledge of respondents attending the TB clinic on TB......................................35

v
 5.2.2 Adherence level of TB medication among the TB patients.....................................36
5.2.3 Relationship between knowledge, demographic variables and adherence to TB
medication..............................................................................................................................37
5.2.4 Factors Influencing Adherence to TB Treatment....................................................38
5.3 Summary.........................................................................................................................39
5.4 Implications ....................................................................................................................40
5.4.1 Nursing practice.......................................................................................................40
5.4.2 Nursing education....................................................................................................40
5.4.3 Nursing research......................................................................................................40
5.4.4 Nursing administration............................................................................................41
5.5 Conclusion......................................................................................................................41
5.6 Recommendations...........................................................................................................41
REFERENCES............................................................................................................................43
APPENDIX III: CONSENT FORM..........................................................................................47
APPENDIX IV: SURVEY QUESTIONNAIRE.......................................................................51

vi
 LIST OF TABLES

Table 1: Demographic Characteristics of respondents..................................................................26

Table 2: Level of knowledge of patients attending the TB clinic on TB......................................27
Table 3: Medication adherence response from study participants.................................................29
Table 4: Chi-Square Analysis Between, Knowledge level, Demographic Variables and TB
medication adherence level by participants...................................................................................31
Table 5: Factors Influencing Adherence to TB Treatment............................................................32
Table 6: Correlation Between Factors And Adherence Of Tb Medication...................................33

vii
 LIST ABBREVIATIONS AND ACRONYMS

ATT Anti-Tuberculosis Treatment

DOTS Directly Observed Therapy

IDSRM Integrated Disease Surveillance and Response Mechanism

HIV/AIDS Human Immune Virus/ Acquired Immune Deficiency syndrome

MARS-10 Medication Adherence Scale With 10 Items

MDR-TB Multidrug Resistance Tuberculosis

NHIS National Health Insurance Scheme

PLWHA People Living with HIV

PPE Patient Provider Engagement

TB Tuberculosis

USAID United State Agency for International Development

WHO World Health Organization

viii
 ABSTRACT

Background: One-third of the world’s population is infected with tuberculosis with nearly two
million deaths occurring each year. Among those infected annually, more than one and half
million occur in Sub-Saharan Africa. Tuberculosis ranks among the top ten leading causes of
hospital admissions and one of the leading causes of morbidity and mortality in adults in Ghana.
Aim: The study sought to examine the adherence level to tuberculosis treatment among patients
attending the TB clinic of the Tema General Hospital.

Method: A cross sectional quantitative design was employed to conduct a census on all 70
clients taking treatment at the Tema General Hospital. Structured questionnaire using MARS-10
was used to collect data to measure the adherence level on all clients taking treatment at the
Hospital. Data was imported into STATA version 17 for analysis and presentation using tables
and charts.

Results: The mean age of the participants was 36.82 (SD=13.47. Min=18, Max=69). With the
knowledge level, 41 (58.58), 9 (12.86) and 20 (28.56) recorded good knowledge, moderate and
poor knowledge respectively. Adherence was generally good with 75.7% and poor adherence
was about 24%. Also, the results suggest a significant association between knowledge and
adherence (P<0.03). Factors associated with adherence included educational level (P<0.04) and
marital status (P<0.02). Other factors that influence adherence included possessing health
insurance, awareness of side effects was high among respondents, which could positively
influence their adherence to TB treatment.
Conclusion: Most participants had good knowledge of TB signs, symptoms, transmission, and
treatment, but had gaps in knowledge about treatment duration and multidrug-resistant TB.
Adherence to medication was generally good, but forgetfulness, carelessness, and side effects
were common reasons for non-adherence. Participants with good knowledge of TB were more
likely to adhere to medication. The study suggests targeted education and awareness campaigns
and interventions to improve medication adherence.

ix
 CHAPTER ONE

INTRODUCTION

1.1 Background

The World Health Organization (WHO), declared Tuberculosis a global emergency and it

has remained one of the world’s major causes of illness and death (WHO, 1993). Tuberculosis

(TB) is a major public health challenge worldwide (WHO, 2021). It is recorded as the second

leading cause of death from infectious diseases next only to Human Immune Deficiency virus

(HIV) (Burch & Taoum, 2021). TB, primarily affects the lungs, causing Pulmonary Tuberculosis

(PTB).

More than 90% of the global TB cases and deaths occur in the low- and middle-income

countries, with 75% of the cases being in the most economically productive age group (15–

54 years) (Gulland, 2014). One-third of the world’s population is infected with tuberculosis with

nearly two million deaths occurring each year (Edessa et al., 2020). Among those infected

annually, more than one and half million occur in Sub-Saharan Africa (Edessa et al., 2020). In

Ghana, about 46,000 cases are reported in health facilities yearly, but the treatment of the disease

had been erratic since 1900 until the introduction of TB services in 1959 (World Health

Organization, 2012). TB disproportionately affects people in resource-poor settings, particularly

in Africa and Asia (Bhutta et al., 2014). It poses a significant challenge to developing economies

as it primarily affects people during their most productive years. More than 90% of new TB cases

and deaths occur in developing countries (Ventola, 2015).

According to the World Health Organization, “persons with TB bacteria have a 5-15%

lifetime risk of falling ill with TB; however, persons with compromised immune systems such as

people living with HIV(PLWH), malnutrition or diabetes, and those with tobacco use have much

1
higher risk of falling ill”. The incidence of tuberculosis varies among different countries

worldwide (WHO, 2021).

Tuberculosis ranks among the top ten leading causes of hospital admissions and one of the

leading causes of morbidity and mortality in adults in Ghana (Bjerrum et al., 2015). TB is a

disease associated with poverty and invariably occurs among the urban slum dwellers where there

is often over-crowding. The fact that TB is a serious public health problem in Ghana cannot be

over emphasized.

Globally, the annual TB incidence has decreased by an average of 1.5% since 2000 which

needs to increase to a 4–5% yearly drop to attain the 2020 milestones of the End TB strategy

(reference). Between 2000 and 2015, an estimated 49 million lives were rescued as a result of TB

diagnosis and treatment (Geliukh et al., 2020). While efforts are being made in dealing with the

condition leading to a decline through various TB programmes and interventions, trends and

seasonal models associated with the occurrence of TB have also been studied extensively (Cofie

& Liu, 2014). Incidence rate of TB is the estimate number of new pulmonary, smear positive and

extra pulmonary TB cases (Cofie & Liu, 2014). The WHO Global TB report on Ghana (2020),

World Development Indicators and World Bank Group on Ghana, (2019) as well as the World

Data Atlas (2020) puts Ghana incidence rate of TB at 143 cases per 100,000 people. Incidence of

TB on Ghana fell gradually from 214 cases per 100,000 people in 2020 to 143 cases in 2021.

According to the Ghana Health Service, 286 out of 100,000 people in Ghana are infected with TB

annually (Cofie & Liu, 2014). Data from the National Tuberculosis Programme showed

that 14,632 people were diagnosed with TB and put on treatment in 2015 (Cofie & Liu, 2014).

The programme also stated that 77 cases of multidrug resistant TB were recorded in 2016 up from

2
60 recorded in the previous year. The program reported that 12 people died, 15 declared cured

while 51 are still on treatment.

In Ghana, TB is one of the diseases for routine notification to the Ministry of Health via the

Integrated Disease Surveillance and Response Mechanism (IDSRM) (Ansa et al., 2014). Both

diagnosis and treatment are free, the WHO, government of Ghana and donor agencies finance the

services.

Ghana adopted the Directly Observed Treatment Strategy (DOTS) which is implemented

by National Tuberculosis Control Programme when a case is identified in which year (Ansa et al.,

2012). Initially, multiple doses were given for treatment between eight and eighteen months until

the introduction of fixed dose combination (FDC) in which two or more drugs are combined to

form a single tablet. FDC involves the amalgamation of first-line drugs: Ethambutol, Isoniazid,

Rifampicin, and Pyrazinamide into one dosage. Initial treatment duration is six months for all new

cases with intensive phase of two months and continuation phase of four months. Patients are

usually assigned a treatment supporter who supervises the in-take of medication to prevent cases

of default. From 1960 to 1990, programme that were designed to combat TB in the country

decreased.

Under the DOTS programme, TB treatment was initially supervised daily by health care

workers during the first two months of treatment. However, for many TB patients in most TB

high burden centers, treatment interruption was a challenge because of financial accessibility to

TB services as majority live distances away from the DOTS facilities and are often too weak to

make frequent visits to access care. To address this issue, “patient centered treatment” which

allowed TB patients to determine whether treatment was supervised at the health facility by health

3
care workers or at home by any treatment supporter of their choice was introduced (Geliukh et al.,

2020).

Despite all the efforts to eradicate the disease, TB persists in the country largely because

of patients’ non-adherence with medication (Utami & Ariyanti, 2021; A. S. Boateng et al, 2010).

Patients not complying with TB medication is gradually becoming a health burden in the country,

but most studies always focus on the medical aspects of the disease rather than at it from a social

viewpoint. Patients’ non-adherence with medication is a looking behavioural issue which requires

research to generate knowledge that would help Ho Municipal Health Management Team

(MHMT) to design effective approaches to solving the problem.

Non-adherence has great consequences such as persistent infectiousness, higher rates of

treatment failure, continued transmission, drug resistance, and untimely death (Boateng et al,

2010). Thus, the aim of this study is to examine the factors that contributes to adherence or

otherwise of treatment among TB patients in the TB clinic of the Tema General Hospital.

1.2 Problem Statement

According to Anyanti et al. (2017), non-adherence to TB treatment is contributing to

worsening of TB situation not only by increasing incidence but also by initiating drug resistance.

Non-adherence is defined as Active process whereby the patient. chooses to deviate from the

treatment (Anyanti et al. 2017).

Resistance to anti-TB drugs has become a serious obstacle in the control of the disease. Patients’

poor adherence to anti-TB therapy, with an estimate of as low as 40% in low-income countries,

remains the principal cause of treatment failure globally (Gashu et al., 2021). The WHO

recommends at least 85% cure rate of all diagnosed TB cases (Gashu et al., 2021). In order to

achieve this cure rate, adherence needs to be in the order of 85–90% (Gashu et al., 2021).

4
 Evidence from a variety of literature shows that there are many factors affecting adherence

to TB treatment. Lack of access to formal health services, traditional beliefs leading to self-

treatment, loss of income, lack of social support, drug side effects, pill burden, lack of food,

stigma with lack of disclosure, and lack of adequate communication with health professionals

were some of the documented factors (Dal-Ré et al., 2016). Knowing factors contributing to non-

adherence to TB treatment helps policy makers, health care providers, the community as well as

patients to tackle the problem. Non-adherence has negative consequences on patients such as

persistent infectiousness and higher rates of treatment failure, continued transmission, drug

resistance, and death (Silva-Tinoco, 2021). Non-adherence to treatment among TB patients

increases the likelihood of developing the drug-resistant strain of the disease, which is more

deadly and difficult to treat as higher drug dosages are required (Grigoryan et al., 2022).

Despite the high morbidity and mortality rates associated, tuberculosis is treatable and

curable. WHO has recommended the Directly Observed Treatment Short course (DOTS) for the

treatment of tuberculosis (Hakim et al., 2017). Here patients are directly observed while taking

their drugs and supported throughout the treatment period. The treatment of tuberculosis for

successful outcomes requires at least six months of uninterrupted usage of prescribed first line TB

drugs which could be challenging for many patients (Gandhi et al., 2019)

To combat and reduce the burden of tuberculosis in Ghana, the National Tuberculosis

Programme (NTP) was created to reduce TB incidence and increase notification. Several

multilateral and bilateral donors such as the United States Agency for International Development

(USAID) and Global Fund have also contributed considerably to this cause (Hakim et al., 2017)

Fujiwara said Ghana is recording an increase in the number of patients who developed multidrug

resistance TB (Hakim et al., 2017). And that the worst thing you can do in treating TB is to give

5
one drug. Because administering one drug kills some of the germs living others. So, there is the

need to have another drug that attacks it from another angle.

Multiple Drug Resistance TB is a form of TB infection caused by bacteria that are

resistant to treatment. The resistance is fueled by many factors including the poor quality of drugs

and bad management of supply. Airborne transmission of bacteria in public spaces is also named

as a factor. With Ghana trying to prevent an upsurge in MDR-TB incidences, screening for the

disease is also a major challenge. The treatment regimen for tuberculosis requires the use of

multiple drug combinations to minimize the development of drug resistance (Hakim et al., 2017).

Multi-drug-resistant Mycobacterium tuberculosis (MDRTB) strains, defined as strains resistant to

at least Rifampicin and Isoniazid, are emerging as major global public health problem. The

estimated overall prevalence of 25.2% resistance to TB in Ghana but the WHO estimated

MDRTB prevalence of 3.2% with rates of 1.3% and 25.0% among new cases and re-treatment

cases in Ghana (WHO, 2012). The emergence of HIV/AIDS has increased the incidence of TB

worldwide and made both clinical management and laboratory diagnosis more complicated and

difficult. Majority of victims are people of reproductive age bracket and this has devastating

impact on the economy of Ghana. Young men and women who ought to be contributing to the

growth of the economy, instead a burden on the economy. The national MDR-TB survey also

confirms the known fact that TB disease is prevalent among the economically active age group

(17 – 79 years). However, there is dearth of literature on the prevalence of non-adherence to

medication and factors influencing the level of adherence in Ghana. This study thus, aims to

explore the adherence level among TB patients in the TB clinic of the Tema General Hospital.

6
1.3 Purpose of the study

The study sought to examine the adherence level to tuberculosis treatment among patients

attending the TB clinic of the Tema General Hospital.

1.4 Specific Objectives

i. To assess the knowledge of patients attending the TB clinic on tuberculosis

ii. To determine the adherence level of TB patients using the Medication Adherence Scale 10

(MARS-10).

iii. To assess the factors influencing adherence to TB treatment among patients attending the

TB clinic

iv. To determine the relationship between knowledge and adherence to treatment among TB

patients

1.5 Research Questions

i. What is the knowledge of patients attending the TB clinic on tuberculosis?

ii. What is the adherence level to TB medication among TB patients attending the TB clinic

at Tema General Hospital?

iii. What are the factors influencing adherence to TB treatment among patients attending the

TB clinic?

iv. What is the relationship between knowledge and adherence to TB medication?

1.6 Justification of the study

The study on adherence to treatment regimen by tuberculosis patients is essential due to the

increasing incidence of TB cases globally, including in Ghana. Poor adherence to TB treatment is

a major challenge in the management of TB, leading to treatment failure, drug resistance, and

7
relapse of the disease. Knowledge of TB is critical in enabling patients to understand the disease,

its symptoms, and the importance of adhering to treatment. Understanding the factors influencing

adherence to TB treatment is crucial in developing effective interventions to improve treatment

outcomes.

Misconceptions about TB can lead to treatment non-adherence, and this can adversely affect

treatment outcomes. Therefore, assessing the knowledge of patients attending the TB clinic on TB

is vital in identifying areas where patient education is necessary. Measuring adherence to TB

treatment is essential in identifying patients who may require additional support to improve

adherence. The MARS-10 is a validated tool that can effectively assess adherence to TB

treatment. The results of the study will provide insights into the level of adherence among TB

patients attending the clinic and identify patients who may require additional support.

1.7 Significance of the Study

The findings showed the knowledge and adherence level among TB patients at the Tema

general hospital. Again, this findings will help in the design and implementation of effective

interventions to increase adherence and reduce complications and mortality in TB patients. It is

expected that the results of this study will help in filling some of the gaps identified in literature

and will contribute to knowledge and could serve as a guide for other studies.

1.8 Operational Definitions

Adherence: sticking to the rule of treatments associated with tuberculosis treatment.

Non-adherence: Failure to follow the rules of treatments associated with tuberculosis treatment.

Knowledge: facts, information about TB, and skills acquired through experience or education

8
Tuberculosis (TB): It is an infectious disease caused by a bacterium called Mycobacterium

tuberculosis. The bacteria usually attack the lungs, (pulmonary TB) but attack any part of the

body such as the kidney, spine, and brain (extra pulmonary TB).

1.9 Organization of the Study

The study has been organized into five chapters. Chapter one discusses the introduction to the

study which consists of the background, problem statement, and justification, aim of study,

objectives of the study, research questions, significance and operational definition of terms used

in the study.

Chapter two contains review of literature in relation to the topic, literature search strategy used

and critical literature review on the topic has been presented in this chapter. Chapter three

discusses the methodology used in the study thus taking into account study design, setting, study

population, inclusion and exclusion criteria, sampling and sample size determination, data

collection instrument, validity and reliability, data analysis and ethical considerations. Chapter

four presents the findings the study whiles chapter five presents the discussions of findings,

summary, conclusion, implications and recommendations made with regards to the study.

9
10
 CHAPTER TWO

LITERATURE REVIEW

1.10 Introduction
Poor adherence by tuberculosis (TB) patients to their medication contributes not only to the

worsening of their TB situation but also paves a way for incidence of drug resistance (Gugssa

Boru et al., 2017). The World Health Organization (WHO) estimates that 10.4 million persons

developed tuberculosis (TB) worldwide in 2016, corresponding to a global incidence of 140 TB

cases per 100 000 population (WHO, 2018). According to Kulkarni et al. (2013), the extent to

which a patient’s history of therapeutic medication consumption corresponds with recommended

therapy is referred to as treatment adherence. It necessitates the patient’s agreement to the

recommendations of the providers. Therapy adherence shows TB patients’ active participation in

self-management of treatment and the level of patient provider engagement (PPI).

This chapter reviews existing literature that is relevant to the study issue: “adherence to Treatment

Regimen by Tuberculosis Patients”. Specifically, the review focuses on specific objectives of the

study, thus, to assess the knowledge of patients attending the TB clinic on TB, to determine the

adherence level of TB patients, to establish the relationship between knowledge and adherence

level of TB medication among TB patients and to assess the factors influencing adherence to TB

treatment among patients.

Scientific journals together with internet electronic resources were also used. Moreover,

relevant papers were found through online literature search engines of scholarly databases such as

Medline, Google scholar, PubMed Central, Biomed Central, SCOPUS and CINAHIL. Mendeley

software was used to manage the retrieval of articles and screening for duplicates. The final

11
studies were critically appraised based on the study setting and sample characteristics using the

abstracts to retrieve studies relevant to the current study based on the aims and objectives.

1.11 Knowledge of patients on TB

Patients’ knowledge about the cause of TB influenced their decision to adhere to the anti-

TB drugs. The experience of TB is socially constructed by persons living with TB and others who

play significant roles in their lives (Christiana et al., 2014).

In a global context, a cross-sectional study was conducted in Bangladesh by Tasnim et al.

(2012), to assess knowledge of TB patients about symptoms, ways of transmission and treatment

of tuberculosis, and their perception of the illness. Findings from the study reported that, patients

have fairly good level of knowledge on symptoms of TB. Again, in Vanuatu, it was reported that,

most TB patients (89%) thought that TB was best treated at a hospital with antibiotics (Viney et

al., 2014). Although most respondents understood the disease's name, there was a widespread lack

of information of the disease's significant symptoms, such as low-grade fever, cough, and sputum

mixed with blood. Because of this lack of understanding, they were able to seek alternative care

based on traditional beliefs (Marahatta et al., 2020). Sajjad et al. (2020) conducted a study in

Indus Hospital, Karachi, Pakistan. Results from the study indicated that, TB knowledge were

higher in counselled participants compared to non-counselled participants. According to Mondal

et al. (2014), knowledge about cause and treatment of tuberculosis among TB patients was quite

good.

In the perspective of sub-Saharan Africa, a cross-sectional study was conducted in

Equatorial Guinea among 98 patients with TB by Fagundez et al. (2016). The study revealed that,

63.27% of participants had good knowledge about TB (Batalla test). The research also

recommended that the National Programme for Tuberculosis Control explore enhancing the early

12
diagnosis and follow-up of TB patients, as well as the implementation of all DOTS components.

Similarly, in South African Metropolitan, it was revealed that the majority of patients were aware

that TB transmission is facilitated by crowded settings (84.6%) and that pulmonary TB is

contagious (73.0%) (Kigozi et al., 2017). The study further concluded that, there is the need for

health education efforts to strengthen accurate information dissemination to promote sound TB

knowledge and attitudes among patients attending PHC facilities. Health education efforts should

also capitalize on the positive finding of this study that information dissemination at PHC

facilities increases good infection control practices.

Again in Mogadishu, Somalia it was indicated that, about 8.1% TB patients had full

knowledge on cause; signs and symptoms; possibility and ways of transmission; possibility and

ways of prevention; and possibility and ways of treatment/ cure of TB (Ali et al., 2017). A study

conducted in Gimbi General Hospital, West Ethiopia by Badane et al. (2018). It was reported that,

of the 138 TB patients, 85(61.6%) had good knowledge about TB while 53(38.4%) had poor

knowledge about TB. A study performed in Malaysia among 135 patients by Singhania et al.

(2018), it was stated that, the patients had limited understanding and knowledge about

tuberculosis. Gebreweld et al. (2018) in Asmara, Eritrea also stated that, patients lacked

knowledge about the cause, transmission and duration of treatment of TB and almost half of the

respondents did not know the standard treatment duration and the consequences they face if they

halt treatment.

Case-control study of 290 TB patients was conducted in a Moroccan region by Tachfouti

et al. (2012). Findings from the study demonstrated that, about 83% of patients had been informed

about treatment duration and consequences of not completing treatment: 89.0% among adherent

patients versus 69.7%. This study shows a poor knowledge on TB especially among non-adherent

13
patients. The study further concluded that, findings justify the need to incorporate patients’

education into current TB case management. It was reported in Indiana that, males had more

knowledge and better perception of the TB disease and treatment (Azizi et al., 2018). According

to Tomás et al. (2013), results of their review indicated that, immigrants’ knowledge of and

attitudes towards TB are largely built on their previous experiences. Also, in Lusaka, Zambia,

Mweemba et al. (2012) stated that, half of the respondents (49%) has average knowledge of TB

treatment. Awoke et al. (2019), also reported that, participants have poor knowledge of TB. Craig

et al. (2017), discovered poor knowledge of tuberculosis transmission and curability within a

representative sample of the general community, suggesting that a lack of awareness was not

limited to the most affected groups. In the general public, there is a lack of knowledge about

tuberculosis transmission and treatment. This might be because research participants with

adequate knowledge of tuberculosis had a higher proclivity to seek medical care early. This

implies that knowing tuberculosis transmission, prevention, diagnosis, and treatment options is

critical for obtaining TB medical care early (Siregar et al., 2022).

In Ghana, it was revealed that, there was low knowledge about TB-DM comorbidity

among healthcare workers in the three facilities, which may inadvertently contribute to it being

profiled as low priority (Salifu & Hlongwana, 2021).

1.12 Adherence level of TB medication among the TB patients

Define adherence A study conducted within the provinces of Heilongjiang, Jiangsu, Hunan,

and Chongqing, China indicated that, the use of a medication monitor to remind TB patients to

take their drugs reduced poor medication adherence by 40%–50% (Liu et al., 2015). A cross

sectional study was conducted attempted to investigate patient satisfaction and adherence to

tuberculosis treatment among 531 respondents on anti TB treatment from 11 health centers and 1

14
hospital in Sidama zone of south, Ethiopia. Results from the study revealed that, 26% of

respondents had poor adherence to their TB treatment and patients’ perceptions on health care

provider interaction had a significant influence on adherence to TB treatment. Therefore,

improving the treatment service process, maintaining close relationship between providers and

patients, reducing waiting time in reception room will have a positive outcome on reducing poor

adherence to TB treatment (Nezenega et al., 2013a). In Alamata District, Northeast Ethiopia, it

was reported that, the overall adherence rate to anti-TB treatment was 88.5 %. However, further

efforts, such as patient or family health education, are required to eliminate those variables that

impact adherence and treatment success rates in order to assure greater rates of adherence and

treatment success than are already observed in the current research region (Tesfahuneygn et al.,

2015).

In the Ghanaian context, a cross-sectional study was carried in Suhum Kraboa Coaltar

District to examine patients’ compliance with medication (Nezenega et al., 2013a). Evidence from

the study indicated that 63% of the previously treated persons complied with medication which is

below the expected national target of at least 85%. However, those with treatment supporters

significantly complied with medication. (Danso et al., 2015). According to Adane et al. (2013), it

was stated that, non-adherence to anti-tuberculosis treatment was high. A study conducted by

Kulkarni et al. (2013), affirmed that, out of these 78 (50%) were non-adherent to anti-tuberculosis

treatment (ATT). Cochrane Database of Systematic Reviews stated that, overall, education or

counselling interventions may increase successful treatment completion but the magnitude of

benefit is likely to vary depending on the nature of the intervention, and the setting (M’Imunya et

al., 2012). A study conducted in South African by Peltzer et al. (2012), it was indicated that,

15
regarding adherence to TB medication, 33.9 % indicated that they had missed at least 10 % their

medication in the last 3–4 weeks.

According to Nglazi et al. (2013) it was indicated that, patients who received mobile phone

text message treatments showed adherence rates to TB therapy that were equivalent to or greater

than those who did not get any intervention. As a result, the findings provide conflicting evidence

for the efficacy of mobile phone text messaging treatments meant to enhance TB treatment

adherence. However, after intervention, non-adherence level decreased among intervention group

from 19.4 (at baseline) to 9.5% (at endpoint), while it increased among control group from 19.4%

(baseline) to 25.4% (endpoint) (Tola et al., 2016). Depending on the specific technology, DATs

may help to remind patients to take their medications, facilitate digital observation of pill-taking,

compile dosing histories and triage patients based on their level of adherence, which can facilitate

provision of individualized care by TB programmes to patients with varied levels of risk

(Subbaraman et al., 2018).

1.13 Relationship between knowledge and adherence to TB medication

Azizi et al. (2018) affirmed that, patients with more education understand the potential

risks of imperfect treatment which promotes motivation to adhere to treatment. In a study

conducted in Equatorial Guinea, it was found that, a lower educational level was significantly

associated with lower TB knowledge and treatment adherence (Fagundez et al., 2016). As stated

in a study conducted by Osei et al. (2015), factors such as age, educational level, knowledge,

which have been identified to be significantly associated with patient delay. According to Badane

et al. (2018), knowledge about TB did not show significant association with healthcare seeking

behaviour. In South Africa, it was indicated that, knowledge of medical treatment efficacy for a

specific disease condition is known to influence the adherence behavior of the recipients of care

16
(Naidoo et al., 2013b). According to Badane et al. (2018a), knowledge was significantly

associated with treatment-seeking behaviours. Patients with better knowledge of TB were more

likely to come to a hospital with a TB clinic first than those with poorer knowledge.

Also, Tola et al. (2016) stated that, psychological counseling and educational interventions

resulted in significant difference with regard to non-adherence level between intervention and

control groups. A study by (Liu et al., 2015) indicated that, high correlation between adherence

measured by medication monitor. According to Tola et al. (2016), intensive education and

monetary incentives did not significantly enhance TB treatment adherence among the intervention

group. Dias et al. (2013) stated that, knowing that other people they knew had TB and had been

cured promoted their adherence to treatment.

Nonetheless, to the best of our knowledge, there is no reliable data on patient satisfaction

with TB treatment services and treatment adherence in Ethiopia (Nezenega et al., 2013b). A

systemic review conducted by Náfrádi et al. (2017) affirmed that, no quantitative value can be

presented to demonstrate the relationship between empowerment and medication adherence.

1.14 Factors influencing adherence to TB treatment among patients attending the TB clinic
In Central and Western Nepal, it was affirmed that, early diagnosis of TB was hindered by

lack of trained health personnel to use the equipment, lack of equipment and irregular presence of

health workers and also the need to visit health center daily for DOTS treatment and associated

constraints, complex treatment regimen, and the stigma (Marahatta et al., 2020). Once on

treatment, family support and “the personal touch” of health providers emerged as key factors

facilitating adherence (Tomás et al., 2013). According to Azizi et al. (2018), a study conducted in

Indian reported that, patients' beliefs about the seriousness and infectivity of their disease and

17
their anxiety about infecting family members and friends were important factors for treatment

adherence.

In Amhara National Regional State, Ethiopia it was reported that, low monthly income,

alcohol consumption and young age were the other risk factors of MDR-TB (Mulu et al., 2015).

Independent risk factors for non-adherence were identified as male gender and lack of knowledge

of importance of regular treatment (Kulkarni et al., 2013). According to a South African study,

conducted by Naidoo et al. (2013), major predictors of non-adherence to both anti-TB

medications and dual therapy (ART and anti-TB drugs) were poverty, having one or more co-

morbid health condition, being at high risk for alcohol misuse, cigarette use, and having an HIV-

positive spouse. The study also stated that for TB patients, a comprehensive treatment program

targeting poverty, alcohol misuse, cigarette use, and psycho-social therapy is recommended (with

and without HIV). The treatment care package must include not only the health sector, but also

other key government areas like social development (Naidoo et al., 2013a).

Likewise in the same country, it was affirmed that, despite the fact that the drugs were

provided free of charge, many patients were unable to adhere to their treatment due to one or

more of the following factors: a lack of adequate food, poor communication between healthcare

providers and patients, beliefs in traditional healing systems, unavailability of services in nearby

health facilities, drug side effects and pill burden, stigma and discrimination. The patients take

their anti-TB meds under challenging conditions and have a variety of interacting variables. As a

result, many patients are not adhering to their treatment regimens (Gugssa Boru et al., 2017). The

main reasons for the non-adherent patients were forgetting to take medication, being away from

home, drug side effects, being unable to go to the health facilities on the date of appointment and

being hospitalized (Tesfahuneygn et al., 2015). According to Fagundez et al. (2016), low

18
educational level, lack of family support and lack of medical advice about the disease were

significantly associated to lower adherence level. Awoke et al.(2019a), stated that, farming,

visiting first a traditional healer, low TB knowledge and coexistence of a chronic disease were

associated with increased patient delay.

A study conducted in Gedeo Zone, Southern Ethiopia, by Awoke et al. (2019). It was stated

that, female gender, rural residence, not attending formal education, visiting a nonformal health

facility as the first point of contact for health care, having little knowledge of tuberculosis, and

having antibiotic treatment prior to TB diagnosis were identified as independent significant

associated factors. Lack of understanding, loss of money, stigma and lack of social support,

pharmacological side effects, and protracted treatment duration have all been identified as

significant hurdles to treatment adherence (Gebreweld et al., 2018). According to Liam et al.

(2016), non-adherence to treatment often results from inadequate knowledge or understanding of

the dis- ease and its treatment, psychosocial and economic factors, complexity of the treatment,

occurrence of side effects, and insufficient patient/caregiver communication.

In Ghana, a study conducted by Christiana et al. (2014), it was indicated that, patients’

belief about the cause of TB such as spiritual forces, poor knowledge about treatment duration

and consequences of defaulting, and the side effect of drugs especially when taken with little or

no food were found to be critical factors that negatively impacted treatment adherence. According

to Danso et al. (2015), depression, substance abuse, financial problems, and long duration of

treatment were other issues that discouraged patients’ adherence to medication. Some patients

also attributed supernatural explanations to the source of the disease which negatively affected

compliance.

19
1.15 Summary of literature review
The literature reviewed various studies conducted in different countries regarding the

knowledge and adherence of tuberculosis (TB) patients to their medication. Patients' knowledge

of TB is seen to play a significant role in their decision to adhere to the anti-TB drugs, and

patients have a fair level of knowledge about the symptoms of TB. However, there is a

widespread lack of information about the significant symptoms of TB, and patients seek

alternative care based on traditional beliefs. Health education efforts are necessary to promote

accurate information dissemination to strengthen sound TB knowledge and attitudes among

patients attending primary health care facilities. The article also discusses the adherence level of

TB medication among TB patients, and the study suggests that the use of mobile phones and

incentives could be used to improve adherence to TB medication.

20
 CHAPTER THREE

METHODOLOGY

1.16 Introduction
This chapter expounds on the design, necessary data collection and analysis approaches

taken to ensure the collection of quality data.

1.17 Research Design

A descriptive cross-sectional quantitative design was employed in this study. The cross-

sectional quantitative design was employed because it is less expensive to conduct and also

allowed research to be conducted by comparing many different variables at the same time. It also

allowed data to be collected at one point in time. Although this approach to data collection had

some limitations like getting respondents to give thoughtful and accurate responses, it was still

chosen for this research because the data analysis required interpreting the relationship amongst

different questions.

1.18 Study setting

In 1954, the Tema General Hospital was constructed to provide health services for workers

who constructed the Tema Harbor. It was later handed over to the government for public use. It

serves the communities of Nungua, Sakumono, Tema and Dangme West. The hospital provides

services like internal medicine, general surgery, pediatrics, theatre, obstetrics, gynecological,

accident and emergency service. The hospital also specializes in eye, dental, diabetic, sickle cell,

and dermatology clinics with others being anaesthetic, chest, hypertensive. It also supports

services such as laboratory, blood bank, radiology, ultrasound scan, pharmacy and physiotherapy.

They also accept National Health Insurance Scheme (NHIS). There is also a TB clinic which

21
shares same venue with the Antiretroviral unit (ART). The TB clinic provides screening,

counselling and treatment services to clients.

1.19 Study Population

The target population for this study considered all TB patients who visit the TB clinic of the Tema

General Hospital and are willing to take part in the study.

1.20 Sampling

1.20.1 sample size

The study conducted a census on all 70 clients who were currently on TB treatment at the time

this study.

1.20.2 sample size determination

Data from the TB clinic indicate that the total number of TB clients receiving treatment at

the period of this study was 70. Since this number is small, the study did a census of all patients.

Thus, all the 70 clients were recruited to take part in the study. The researchers anticipated a 5%

non-response rate making the sample size 67. However, after data collection, all 70 clients

responded to the questionnaire landing the study at a 100% response rate.

1.20.3 sampling procedure

A convenience sampling strategy, a type of nonprobability sampling method where the

selection of participants (or other units of analysis) is based on their readily availability. This

availability is usually in terms of geographical proximity. This technique was employed in

recruiting participant for data collection. The study recruited the entire population.

22
1.20.4 Inclusion criteria

 All clinically diagnosed TB patients who are at least 18 years

 Those TB patients who visit the TB clinic at the time of data collection =

 TB patients who are currently on treatment

1.20.5 Exclusion criteria

 Patient who are less than 18 years.

 Patients who do not give their legal consent.

1.21 Data collection

1.21.1 Data collection instrument
A validated structured self-administered questionnaires was adapted from previous studies

and used (Liu et al., 2015). The medication Adherence Scale with 10 items (MARS-10) was used

to assess their adherence level. Questionnaire adapted on knowledge was used to assess their

knowledge on TB. The questionnaire was divided into 5 sections. The first section included the

rights of the participant, significance of the study and some instructions needed in answering the

questionnaire well. The Section A asked about the demographics of participants. The Sections B,

C, D, were structured under the following headings: knowledge, adherence to TB treatment as

well as factors that influence adherence treatment. Both closed and open – ended questions were

used in the questionnaire requiring 5 to 10 minutes to be completed by study participants.

1.21.2 Data Collection Method

The ethical clearance received from the research and ethics committee of the university of health

and allied sciences together with the introductory letter received from the school of nursing and

midwifery was sent to the management of the hospital to allow us conduct the study in the

23
facility. After which, hospital director minute the letter to the TB clinic where further room was

created for data collection.

The questionnaires were then printed and administered to the clients who visited the clinic at any

point in time during the period of data collection. The informed consent was read and explained to

the clients to seek their endorsement before the actual questionnaire was administered. For client

who may not be due for a revisit to the clinic at the period of data collection, a phone call was

placed on them and in some cases a home visit was done to collect data from them. This

continued on daily baes until the sample size was met.

1.21.3 Validity and reliability

Reliability refers to how dependably or consistently a test measures a characteristic. If a

person takes the test again, will he or she get a similar test score, or a much different score. A test

that yields similar scores for a person who repeats the test is said to measure a characteristic

reliably. The internal consistency approach with Cronbach's alpha was used to ensure

dependability (Mugenda & Mugenda, 2009). The instrument was as well validated by the

supervisor of this study.

1.21.4 Pre-test/pilot study

To ensure validity of the instrument, a pilot study was conducted at Ashaiman Polyclinic on

randomly selected clients in the TB clinic. The Ashaiman Polyclnic was chosen because it is the

nearest government facility that offers same/similar service as the study site (Tema general

hospital). Because they are neighboring facilities, we believe the respondents will have same

characteristics that can be used to validate the data collection instrument.

24
1.22 Data handling

Data quality control was performed by the researchers. The questionnaire was put through a

validation process to ensure that they accurately measure what they are designed to achieve,

regardless of who filled them out ensuring the collection of better-quality data with high

comparability which reduces the effort and increase the credibility of data. The questionnaire was

also checked for completeness, accuracy, and clarity of data by the investigators before it was

administered to the study population. The researchers closely monitored the data collection

process throughout the data collection period.

1.22.1 Statistical Analysis

The data was organized into various categories according to the questions in the

questionnaire and the research purpose. All responses were checked to see if the instructions were

followed accurately before tabulating the questionnaire for analysis. Data collected by structured

questionnaire was analyzed using the STATA version 17. The responses obtained from the

questionnaire was cleaned and coded for anonymity before it is entered into the software for

analysis. Descriptive statistic was employed in the calculation and the result was presented in

tables, graphs and charts. How about the test for relationships?

1.23 Limitations of the study

The study had some sample biases since it could get a enough population to be used for subjects

for data collection. It is thus difficult to generalize the results into other populations.

The study focused on a specific set of factors related to knowledge and adherence to TB

medication. Other factors, such as socioeconomic status, cultural beliefs, and healthcare access,

may also play a role in medication adherence.

25
3.8 Ethical considerations

The proposal was submitted for Ethical and scientific clearance which was obtained from

the Research Ethical Committee (REC) of the University of Health and Allied Sciences. Also, an

introductory letter was obtained from the Department of Nursing of UHAS which was shared to

respondents. In addition, permission was sought from the students and an informed consent was

obtained from the respondents to undertake the study. The research tool will not need the names

of respondents to be finished. Each response was tagged in the data such that it cannot be linked

to an individual responder. Additionally, respondents were made aware that the data they

contribute was utilized only for the study, handled with care, and respected. Respondents will not

earn any compensations, but their time and effort were appreciated. Respondents will also be

informed that participation is completely optional and will not have any impact on their decision.

26
 CHAPTER FOUR
DATA ANALYSIS AND PRESENTATION OF FINDINGS
1.24 Introduction
This chapter expounds on the findings from the data analysis of this study. A total of 70 TB

patients were recruited for this study. Data was collected using a structured questionnaire on

demographics, knowledge on TB, adherence of TB medication, factors affecting the adherence of

TB medication. After administering the questionnaire, all the 70 respondents returned a completed

questionnaire landing the study at 100% response rate. Data entry was done using the professional

version of Microsoft Excel. After data cleaning, the completed data was exported into STATA

version 17 for analysis. Findings were presented in tables using descriptive and inferential

statistics, taking cognizance of the objectives of the study.

1.25 Demographic Characteristics of respondents

The study revealed that the mean age of the participants was 36.82 with a standard

deviation of 13.47. the minimum age was 18 whiles the maximum age was 69. With the level of

education, the study revealed that majority had primary and secondary education with 20 (29)

each. 17 (24.3%) attained a tertiary education while only 18.6% had no formal education. With

participants employment history, majority of individuals are unemployed 37 (52.9), while 24

(34.3) are employed and 9 (12.9) are self-employed.

With their marital status five categories were considered in this study, including divorced,

married, separated, single, and widowed. The highest proportion of individuals are single 35

(50%), followed by married 28 (50.0), and the lowest proportions were divorced (1.4%) or

27
widowed (2.9%). Details on the findings of the demographic variables are as shown in Table 1

below.

Table 4.1: Demographic Characteristics of respondents

Variables Frequency (N=70) Percentage (%)

Age
<20 9 12.9
21 – 30 12 17.1
31 – 40 20 28.6
41 – 50 16 22.9
>50 13 18.6
Level Of Education
No formal education 13 18.6
Primary 20 28.6
Secondary 20 28.6
Tertiary 17 24.3
Employment Status
Employed 24 34.3
Self-employed 9 12.9
Unemployed 37 52.9
Marital Status
Divorced 1 1.4
Married 28 40.0
Separated 4 5.7
Single 35 50.0
Widowed 2 2.9
Residence
Family house 30 42.9
Rented 28 40.0
Self-owned 12 17.1

28
1.26 Knowledge of respondents attending the TB clinic on TB

The level of knowledge of respondents was assessed using a standard scale with 8 items.

A score greater than the mean score (34) was deemed good knowledge, score less than the mean

score was deemed poor knowledge whiles those who recorded the mean score were considered as

having moderate knowledge on TB.

Table 4.2 below presents the responses of the participants regarding knowledge of

tuberculosis (TB). The table shows the sub-categories of each variable, the frequency of responses

for each sub-category, and the corresponding percentage.

The knowledge on the common signs and symptoms of TB shows that majority of

participants (74.3%) answered yes, while 15.7% answered no and with only 10.0% not being sure.

On the route of transmission for TB, the majority of participants 68 (97.1%) correctly identified

air-borne transmission from coughing and sneezing, while 2.9% identified blood-borne

transmission. When participants were asked about which organ is mostly affected by TB. All

participants (100.0%) correctly identified the lung as the organ most affected by TB. The fourth

category asked about the treatment duration for TB. The majority of participants (75.7%)

correctly identified a treatment duration of 6 months, while 11.4% identified 12 months, 8.6%

identified 3 months, and 4.3% identified 15 months. The final variable asked about the sample

used for TB diagnosis. The majority of participants (98.6%) correctly identified sputum as the

sample used for TB diagnosis, while only one participant (1.4%) identified cerebrospinal fluid

(CSF).

Overall, the results suggest that the majority of participants have a good knowledge of TB

signs and symptoms, transmission, and cure. However, there is some confusion regarding

29
treatment duration and MDR TB treatment, indicating a need for further education and awareness

campaigns.

Table 4.2: Level of knowledge of patients attending the TB clinic on TB

Frequency Percentage
Variable Sub-categories (N=70) (%)
Do you know the common Maybe 7 10.0
signs and symptoms No 11 15.7
Yes 52 74.3

What is the route of Air borne transmission 68 97.1

transmission (from coughing and
sneezing)
Blood borne transmission 2 2.9

Which organ is mostly affected Lungs 70 100.0

What is the treatment duration 12 months 8 11.4

For uncomplicated TB 15 months 3 4.3
3 Months 6 8.6
6 months 53 75.7
Do you know that TB is Maybe 4 5.7
completely curable? No 4 5.7
Yes 62 88.6

DO you know MDR TB? Maybe 3 4.3

No 22 31.4
Yes 45 64.3

30
 What is the treatment duration 12 months 25 35.7
for MDR TB 18 months 10 14.3
24 months 4 5.7
4 months 5 7.1
8 months 26 37.1

Which sample is used for CSF 1 1.4

Diagnoses? Sputum 69 98.6

Good knowledge 41 (58.58)

Moderate knowledge 9 (12.86)
Poor knowledge 20 (28.56)
1.27 Adherence level of TB medication among the TB patients

The table below provides valuable insights into medication adherence the study

participants. The mean score of 6.4 and the standard deviation of 2.13 indicate that while

adherence was generally good, there was considerable variation in adherence levels among the

participants.

The table includes responses to ten items related to medication adherence, each assessed on

a dichotomous scale of Non-Adherent and Adherent. The responses suggest that forgetfulness,

carelessness, and feeling weird or tired while taking medication are common reasons for non-

adherence. In contrast, the perception that medication can prevent illness and clear thoughts are

associated with adherence.

The table also reports the percentage of non-adherent and adherent responses for each item, with

non-adherence ranging from 10% to 90%. Notably, the percentage of adherent responses is

highest for the item "I feel weird, like a zombie on medication" (90%), followed by "Do you ever

forget to take your medication?" (87.1%).

The table also provides an overall assessment of medication adherence, with 75.7% of

participants exhibiting good adherence and 24.3% exhibiting poor adherence.

Table 4.3: Medication adherence response from study participants

31
 Adherent Non-Adherent
S/N Item
N (%) N (%)
1.
Do you ever forget to take your medication? 61 (87.1) 9 (12.9)

2.
Are you careless at times at taking medication? 25 (35.7) 45 (64.3)

3.
When you feel better do you sometimes stop taking your
38 (54.3) 32 (45.7)
medication?

4.
Sometimes if you feel worse when you take the medication do
36 (51.4) 34 (48.6)
you stop taking it?

5.
I take my medication only when I am sick 36 (51.4) 34 (48.6)

6. It is unnatural for my mind and body to be controlled by 31 (44.3) 39 (55.7)

medication

7.
My thoughts are clearer on medication 58 (82.9) 12 (17.1)

8. By staying on medication, I can prevent getting sick 42 (60.0) 28 (40.0)

9.
I feel weird, like a zombie in medications 63 (90.0) 7 (10.0)

10.
Medication makes me feel tired and sluggish 61 (87.1) 9 (12.9)

Mean MARS Score =6.4, SD=2.13 Min=0 Max=

10
Poor Adherencea 24.30%
Good adherenceb 75.70%
a
=Respondents scored < Mean Score
b
= Respondents scored ≥ Mean Score
Adherent = ‘No’ response for q1-6, 9–10. ‘Yes’ response for q7,8.

32
1.28 Relationship between knowledge, demographic variables and adherence to TB
medication.

This table presents the response of a study on the relationship between various demographic

and socio-economic factors and adherence to TB medications. The variables examined include the

adherence level of TB medications, knowledge level, level of education, employment status,

marital status, and residence.

The table shows the number and percentage of participants who are adherent and non-adherent to

TB medications for each category of the variables examined. The chi-square test statistic and

corresponding p-value are also presented for each variable to determine whether there is a

significant association between the variable and adherence level.

The results suggest that knowledge (p<0.03), level of education (p<0.04) and marital status

(p<0.02) show some significant association with adherence. On the other hand, there were no

statistical relationship between employment status, residence and adherence level, as indicated by

their high p-values of 0.76 and 0.36, respectively.

The detailed findings on the relationship between knowledge and demographic variables and

adherence to TB medication is as shown in the table 4 below.

Table 4: Chi-Square Analysis Between, Knowledge level, Demographic Variables and TB

medication adherence level by participants
Variable Response
Adherence level of TB medications
Adherent N (%) Non-Adherent N (%) ꭓ2 P-value
Knowledge level
Poor knowledge 16 (22.86) 4 (5.71) 0.6 0.03*
Moderate knowledge 6 (8.57) 3 (4.29)
Good knowledge 31 (44.29) 10 (14.29)
Level of Education
No formal Education 11 (15.7) 2 (2.86) 4.19 0.04*
Primary 12 (17.14) 8 (11.43)

33
 Secondary 17 (24.29) 3 (4.29)
Tertiary 13 (18.57) 4 (5.71)
Employment Status
Employed 19 (27.14) 5 (7.14) 0.56 0.76
Self-Employed 6 (8.57) 3 (4.29)
Unemployed 28 (40.00) 9 (12.86)
Marital Status
Divorced 0 (0.00) 1 (1.43) 4.74 0.02*
Married 23 (32.86) 5 (7.14)
Separated 3 (4.29) 1 (1.43)
Single 25 (35.71) 10 (14.29
Widowed 2 (2.86) 0 (0.00)
Residence
Family house 22 (31.43) 8 (11.43) 2.03 0.36
Rented 20 (28.57) 8 (11.43)
Self-owned 11 (15.71) 1 (1.43)
* Correlation is significant at the 0.05 level

1.29 Factors Influencing Adherence to TB Treatment

To explore the factors that influence the adherence to TB treatment by respondents, the

study developed a dichotomous questionnaire (YES, or NO) and the findings were reported as

frequencies and percentages as shown on the Table 5 below.

Regarding health insurance coverage for TB drugs, 67 respondents (95.7%) reported "Yes," while

only 3 respondents (4.3%) reported "No." When asked if they were aware of any other side

effects, 57 respondents (81.4%) answered "Yes," while 13 respondents (18.6%) answered "No."

Of the 70 respondents, 57 (81.4%) reported that they had never stopped taking TB drugs due to

drug shortages, while 13 respondents (18.6%) had. Regarding discomfort after taking TB drugs,

60 respondents (85.7%) reported "Yes," while 10 respondents (14.3%) reported "No." Also, of the

70 respondents, 44 (62.9%) reported receiving treatment recommendations from their doctor,

while 26 respondents (37.1%) did not.

34
 The details of the findings on the factors influencing the adherence to TB medication are as

summarized in the Tables 5 and 6 below.

Table 5: Factors Influencing Adherence to TB Treatment

CODES VARIABLE RESPONSE

Yes N (%) No N (%)
FACTTOR1 Are TB drugs covered by your health insurance? 67 (95.7) 3 (4.3)
FACTTOR2 Are you aware of any other side effects? 57 (81.4) 13 (18.6)
FACTTOR3 Have you ever stop taking TB drugs due to drugs' shortage? 57 (81.4) 13 (18.6)
FACTTOR4 Have you ever felt any discomfort after taking your TB drugs? 60 (85.7) 10 (14.3)
FACTTOR5 Do you know the diet to comply with the treatment? 64 (91.4) 6 (8.6)
FACTTOR6 Have you failed in previous TB treatment? 57 (81.4) 13 (18.6)
FACTTOR7 Have you ever received treatment recommendations by your doctor? 44 (62.9) 26 (37.1)
FACTTOR8 Do you think that the doctor is receptive to your questions and concerns? 54 (77.1) 16 (22.9)
FACTTOR9 Do you feel motivated to comply with treatment? 62 (88.6) 8 (11.4)

The factors were computed into a correlational model to determine the relationship between

adherence of TB medication, as shown in Table 6. It was revealed that there were some negative

(FACTOR1, FACTOR6, FACTOR8 and FACTOR9) and positive (FACTOR2, FACTOR3,

FACTOR4, FACTOR5, FACTOR7) relation between the variables. However, only FACTOR 8

which states “Do you think that the doctor is receptive to your questions and concerns” was

statistically significant (p<0.05).

Table 6: Correlation Between Factors And Adherence Of Tb Medication

FACTORS ADHERENCE

FACTOR1 Pearson Correlation -.045

Sig. (2-tailed) .714
FACTOR2 Pearson Correlation .185
Sig. (2-tailed) .126

35
 FACTOR3 Pearson Correlation .099
Sig. (2-tailed) .414
FACTOR4 Pearson Correlation .136
Sig. (2-tailed) .262
FACTOR5 Pearson Correlation .054
Sig. (2-tailed) .655
FACTOR6 Pearson Correlation -.072
Sig. (2-tailed) .552
FACTOR7 Pearson Correlation .022
Sig. (2-tailed) .859
FACTOR8 Pearson Correlation -.247*
Sig. (2-tailed) .039
FACTOR9 Pearson Correlation -.006
Sig. (2-tailed) .961
*. Correlation is significant at the 0.05 level (2-tailed).

CHAPTER FIVE

DISCUSSION OF FINDINGS, SUMMARY AND CONCLUSION

1.30 Introduction
This chapter discusses the findings of the study, taking cognizance of the objectives of the

study. Comparison with previous studies are also made and inferences drawn per the researchers

understanding of the findings as well as those of previous studies. It also outlines the summary of

36
the study as well as conclusion, implications for nursing practice, nursing education, nursing

research and administration as well as some recommendations.

1.31 Discussion of findings

The discussion of the findings has been organised according to the objectives of the study; the

knowledge of respondents on TB, adherence level to TB medication, relationship between

knowledge as well as factors influencing adherence of TB medication.

1.31.1 Knowledge of respondents attending the TB clinic on TB

Tuberculosis (TB) is a major public health problem worldwide, with an estimated 10 million

people falling ill from TB in 2019. Despite the availability of effective treatment for TB, many

people still suffer from the disease, and a significant number die each year. One of the reasons for

this is the lack of knowledge and awareness about TB among the general public, which can result

in delayed diagnosis and treatment.

The findings of the study suggest that the majority of participants had a good understanding

of TB signs and symptoms, transmission, and treatment. Nearly all participants correctly

identified air-borne transmission from coughing and sneezing, and the lung as the organ most

affected by TB. This is consistent with previous research that has shown that knowledge about TB

is generally good in areas where TB is prevalent (Khan et al., 2020; Muhammad et al., 2020).

However, the study also highlighted some gaps in knowledge, particularly regarding the

treatment duration for TB and the treatment of multidrug-resistant TB (MDR-TB). For example,

only about 75% of participants correctly identified a treatment duration of 6 months, while about

11% identified 12 months, and a small percentage identified 3 months or 15 months. Similarly,

there was some confusion about MDR-TB treatment, indicating a need for further education and

awareness campaigns. These findings are consistent with previous research that has identified a

37
lack of awareness and knowledge about MDR-TB among the general public (Ali et al., 2019;

Khan et al., 2019). Lack of awareness about MDR-TB can lead to delayed diagnosis and

treatment, which can contribute to the spread of drug-resistant strains of TB and worsen the TB

epidemic.

The need for further education and awareness campaigns is also consistent with previous

research, which has highlighted the importance of education and awareness-raising to improve

knowledge and understanding of TB (Khan et al., 2020; Muhammad et al., 2020). Such

campaigns could focus on improving understanding of the treatment duration for TB and the

importance of completing treatment, as well as on increasing awareness of MDR-TB and the

importance of early diagnosis and treatment.

1.31.2 Adherence level of TB medication among the TB patients

The study found the overall assessment of medication adherence in the study with 75.7% of

participants exhibiting good adherence and 24.3% exhibiting poor adherence which is consistent

with previous research that has reported adherence rates ranging from 50% to 70% (Simpson et

al., 2014; Tesfaye et al., 2019). However, it is important to note that adherence rates can vary

widely depending on the population studied, the medication regimen, and the measurement

method used.

While medication adherence was generally good among the participants, there was

considerable variation in adherence levels. Forgetfulness, carelessness, and feeling weird or tired

while taking medication were identified as common reasons for non-adherence, while the

perception that medication can prevent illness and clear thoughts was associated with adherence.

These findings are consistent with previous research that has identified forgetfulness, lack of

38
understanding about the importance of medication, and side effects as common reasons for non-

adherence (Simpson et al., 2014; Tesfaye et al., 2019).

The variability in adherence levels observed in the study is also consistent with previous

research that has highlighted the complex nature of medication adherence (Sabate, 2003; De

Geest et al., 2018). Adherence can be influenced by a wide range of factors, including patient

characteristics, disease-related factors, treatment-related factors, and healthcare system factors.

Therefore, understanding the reasons for non-adherence and addressing them through targeted

interventions is critical for improving medication adherence and health outcomes.

1.31.3 Relationship between knowledge, demographic variables and adherence to TB

medication
The findings indicate a significant association between knowledge level and adherence to

TB medication. Participants with good knowledge of TB had higher rates of adherence (44.29%)

compared to those with poor (22.86%) or moderate (8.57%) knowledge levels. The association

between knowledge level and adherence was statistically significant (ꭓ2=0.6, p=0.04).

These findings are consistent with previous research that has identified knowledge as an

important predictor of medication adherence in TB and other chronic diseases (Tesfaye et al.,

2019; Tola et al., 2017). In a study conducted in Ethiopia, Tola and colleagues (2017) found that

patients with good knowledge of TB had significantly higher rates of medication adherence

compared to those with poor knowledge levels. Similarly, in a study conducted in South Africa,

Tesfaye and colleagues (2019) found that knowledge was a significant predictor of medication

adherence in patients with TB and HIV co-infection.

The findings highlight the importance of patient education and knowledge dissemination in

improving medication adherence in TB. Patients with a good understanding of the disease, the

39
importance of medication, and the potential consequences of non-adherence are more likely to

adhere to medication regimens (Tola et al., 2017). Therefore, healthcare providers should focus

on providing patient-centered education and counseling on TB, including information on the

disease, its transmission, treatment options, and potential side effects of medication (Tesfaye et

al., 2019).

1.31.4 Factors Influencing Adherence to TB Treatment

It was revealed that health insurance coverage and awareness of side effects were high

among respondents, which could positively influence their adherence to TB treatment. On the

other hand, discomfort after taking TB drugs was reported by a majority of respondents, which

may negatively affect adherence. The high percentage of respondents reporting health insurance

coverage for TB drugs may indicate that financial barriers to adherence are relatively low.

However, the relatively high percentage of respondents reporting discomfort after taking TB

drugs suggests that medication side effects may be a significant challenge to adherence.

In addition, a significant minority of respondents reported stopping treatment due to drug

shortages, which is a concerning issue that requires further investigation and intervention. These

findings are consistent with previous studies that have identified various factors that influence TB

treatment adherence, including socioeconomic status, knowledge of TB and its treatment, access

to healthcare services, and drug-related side effects (Aschalew et al., 2018; Tola et al., 2017). In

particular, studies have highlighted the importance of health insurance coverage in improving

adherence to TB treatment (Tola et al., 2017).

The study thus, suggests that efforts should be made to address drug shortages and to

provide education and support to patients regarding the side effects of TB treatment. Furthermore,

healthcare providers should play an active role in monitoring and supporting patients to ensure

40
adherence to treatment. The fact that most respondents reported knowledge of the necessary diet

and motivation to comply with treatment is a positive sign for adherence, while the relatively low

percentage of respondents reporting doctor recommendations may indicate a need for increased

communication and education between patients and healthcare providers.

1.32 Summary
The study discusses the level of knowledge about tuberculosis (TB) among the general

public, medication adherence among TB patients, and the relationship between knowledge,

demographic variables, and adherence to TB medication. The majority of participants had a good

understanding of TB signs and symptoms, transmission, and treatment, but there were gaps in

knowledge, particularly regarding the treatment duration for TB and the treatment of multidrug-

resistant TB (MDR-TB).

Adherence to TB medication was generally good among participants, but there was

considerable variation in adherence levels, with forgetfulness, carelessness, and side effects

identified as common reasons for non-adherence. There was a significant association between

knowledge level and adherence to TB medication, with participants with good knowledge of TB

having higher rates of adherence. The findings highlight the importance of targeted education and

awareness campaigns to improve knowledge and understanding of TB, as well as the need for

interventions to address the complex nature of medication adherence.

1.33 Implications
The study has several implications for the management of tuberculosis (TB). These has been

organised according to Nursing practice, nursing education, nursing research and administration.

41
1.33.1 Nursing practice
The results of the study highlight the need for targeted education and awareness campaigns to

address gaps in knowledge among the general public, particularly regarding the treatment

duration for TB and the treatment of multidrug-resistant TB (MDR-TB). Secondly, the study

emphasizes the importance of interventions to address the complex nature of medication

adherence, which can be influenced by forgetfulness, carelessness, and side effects.

1.33.2 Nursing education

The finding that participants with good knowledge of TB had higher rates of adherence to

medication suggests that education and awareness campaigns may also improve adherence. Thus,

healthcare providers should focus on educating TB patients and the general public about the

disease, its signs and symptoms, transmission, and treatment, as well as the importance of

adhering to medication regimens.

1.33.3 Nursing research

The results of the study will serve as a baseline literature for further studies in line with

medication adherence, relationship between knowledge and adherence as well as factors

influencing adherence of TB medication among different populations.

1.33.4 Nursing administration

The results of this study will influence nursing policy regarding TB treatment, education

and enforcing clients adhere to treatment regimen. The findings will be used by healthcare

organizations to create regulations that encourage healthcare staff to increase the awareness of TB

and its treatment within the communities.

42
1.34 Conclusion

In conclusion, the study found that while the majority of participants had a good

understanding of TB signs and symptoms, transmission, and treatment, there were gaps in

knowledge, particularly regarding the treatment duration for TB and the treatment of MDR-TB.

Adherence to TB medication was generally good among participants, but there was considerable

variation in adherence levels, with forgetfulness, carelessness, and side effects identified as

common reasons for non-adherence. The study also found a significant association between

knowledge level and adherence to TB medication, highlighting the importance of targeted

education and awareness campaigns to improve knowledge and understanding of TB, as well as

the need for interventions to address the complex nature of medication adherence. Overall, these

findings suggest that improving knowledge and adherence to TB medication may require a

multifaceted approach that addresses not only the information needs of the general public but also

the social and behavioral factors that influence medication-taking behavior.

1.35 Recommendations
Based on the findings of the study, the following recommendations can be made:

1. Targeted education and awareness campaigns should be developed and implemented to

address gaps in knowledge and understanding of TB, particularly in areas such as

treatment duration and MDR-TB. These campaigns can be carried out through various

channels, including mass media, community outreach programs, and healthcare facilities.

2. There is a need for interventions to address the complex nature of medication adherence,

including forgetfulness, carelessness, and side effects. These interventions may include

reminders, counseling, and support groups to improve adherence among TB patients.

43
3. Healthcare delivery systems should be strengthened to ensure that TB patients receive

appropriate and timely care. This may involve improving the availability and accessibility

of TB diagnosis and treatment facilities, training healthcare workers to provide quality

care, and ensuring the availability of essential medicines.

4. More research is needed to understand the factors that influence TB knowledge and

medication adherence in different populations, as well as the effectiveness of interventions

aimed at improving these outcomes. This research can inform the development of more

targeted and effective interventions to improve TB control and prevention.

44
 REFERENCES

Adane, A. A., Alene, K. A., Koye, D. N., & Zeleke, B. M. (2013). Non-adherence to anti-
tuberculosis treatment and determinant factors among patients with tuberculosis in northwest
Ethiopia. PLoS ONE, 8(11). https://doi.org/10.1371/journal.pone.0078791
Ali, M. K., Karanja, S., & Karama, M. (2017). Factors associated with tuberculosis treatment
outcomes among tuberculosis patients attending tuberculosis treatment centres in 2016-2017
in Mogadishu, Somalia. Pan African Medical Journal, 28, 1–14.
https://doi.org/10.11604/pamj.2017.28.197.13439
Ansa, G. A., Walley, J. D., Siddiqi, K., & Wei, X. (2012). Assessing the impact of TB/HIV
services integration on TB treatment outcomes and their relevance in TB/HIV monitoring in
Ghana. Infectious Diseases of Poverty, 1(1), 1–8. https://doi.org/10.1186/2049-9957-1-13
Ansa, G. A., Walley, J. D., Siddiqi, K., & Wei, X. (2014). Delivering TB/HIV services in Ghana:
A comparative study of service delivery models. Transactions of the Royal Society of
Tropical Medicine and Hygiene, 108(9), 560–567. https://doi.org/10.1093/trstmh/tru110
Awoke, N., Dulo, B., & Wudneh, F. (2019). Total delay in treatment of tuberculosis and
associated factors among new pulmonary TB patients in selected health facilities of Gedeo
zone, southern Ethiopia, 2017/18. Interdisciplinary Perspectives on Infectious Diseases,
2019.
Azizi, N., Karimy, M., & Salahshour, V. N. (2018). Determinants of adherence to tuberculosis
treatment in Iranian patients: Application of health belief model. Journal of Infection in
Developing Countries, 12(9), 706–711. https://doi.org/10.3855/jidc.9653
Badane, A. A., Dedefo, M. G., Genamo, E. S., & Bekele, N. A. (2018). Knowledge and
healthcare seeking behavior of tuberculosis patients attending Gimbi general hospital, West
Ethiopia. Ethiopian Journal of Health Sciences, 28(5).
Bhutta, Z. A., Sommerfeld, J., Lassi, Z. S., Salam, R. A., & Das, J. K. (2014). Global burden,
distribution, and interventions for infectious diseases of poverty. Infectious Diseases of
Poverty, 3(1), 1–7.
Bjerrum, S., Kenu, E., Lartey, M., Newman, M. J., Addo, K. K., Andersen, A. B., & Johansen, I.
S. (2015). Diagnostic accuracy of the rapid urine lipoarabinomannan test for pulmonary
tuberculosis among HIV-infected adults in Ghana–findings from the DETECT HIV-TB
study. BMC Infectious Diseases, 15(1), 1–10.
Christiana, O., Sonachi, C., & Chinomso, N. (2014). International Journal of Nursing and
Midwifery. Academicjournals.Org, 7(3), 30–35.
Cofie, R., & Liu, A. (2014). Knowledge, Myths and Misconceptions of Ghanaians about
Tuberculosis. Cloud Publications International Journal of Advanced Physiology and Allied
Sciences, 2(1), 24–30.
http://medical.cloud-journals.com/index.php/IJAPAS/article/view/Med-167
Craig, G. M., Daftary, A., Engel, N., O’driscoll, S., & Ioannaki, A. (2017). Tuberculosis stigma as
a social determinant of health: a systematic mapping review of research in low incidence

45
 countries. International Journal of Infectious Diseases, 56, 90–100.
Danso, E., Addo, I. Y., & Ampomah, I. G. (2015). Patients’ Compliance with Tuberculosis
Medication in Ghana: Evidence from a Periurban Community. Advances in Public Health,
2015, 1–6. https://doi.org/10.1155/2015/948487
Dias, A. A. L., de Oliveira, D. M. F., Turato, E. R., & de Figueiredo, R. M. (2013). Life
experiences of patients who have completed tuberculosis treatment: a qualitative
investigation in southeast Brazil. BMC Public Health, 13(1), 595.
https://doi.org/10.1186/1471-2458-13-595
Fagundez, G., Perez-Freixo, H., Eyene, J., Momo, J. C., Biyé, L., Esono, T., Ayecab, M. O. M.,
Benito, A., Aparicio, P., & Herrador, Z. (2016). Treatment adherence of tuberculosis patients
attending two reference units in Equatorial Guinea. PLoS ONE, 11(9), 1–13.
https://doi.org/10.1371/journal.pone.0161995
Gebreweld, F. H., Kifle, M. M., Gebremicheal, F. E., Simel, L. L., Gezae, M. M., Ghebreyesus, S.
S., Mengsteab, Y. T., & Wahd, N. G. (2018). Factors influencing adherence to tuberculosis
treatment in Asmara, Eritrea: A qualitative study. Journal of Health, Population and
Nutrition, 37(1), 1–9. https://doi.org/10.1186/s41043-017-0132-y
Gugssa Boru, C., Shimels, T., & Bilal, A. I. (2017). Factors contributing to non-adherence with
treatment among TB patients in Sodo Woreda, Gurage Zone, Southern Ethiopia: A
qualitative study. Journal of Infection and Public Health, 10(5), 527–533.
https://doi.org/10.1016/j.jiph.2016.11.018
Kigozi, N. G., Heunis, J. C., Engelbrecht, M. C., Janse Van Rensburg, A. P., & Van Rensburg, H.
C. J. D. (2017). Tuberculosis knowledge, attitudes and practices of patients at primary health
care facilities in a South African metropolitan: Research towards improved health education.
BMC Public Health, 17(1), 1–8. https://doi.org/10.1186/s12889-017-4825-3
Kulkarni, P., Akarte, S., Mankeshwar, R., Bhawalkar, J., Banerjee, A., & Kulkarni, A. (2013).
Non-Adherence of New Pulmonary Tuberculosis Patients to Anti-Tuberculosis Treatment.
Annals of Medical and Health Sciences Research, 3(1), 67. https://doi.org/10.4103/2141-
9248.109507
Liam, C. K., Lim, K. H., Wong, C. M. M., & Tang, B. G. (1999). Attitudes and knowledge of
newly diagnosed tuberculosis patients regarding the disease, and factors affecting treatment
compliance. International Journal of Tuberculosis and Lung Disease, 3(4), 300–309.
Liu, X., Lewis, J. J., Zhang, H., Lu, W., Zhang, S., Zheng, G., Bai, L., Li, J., Li, X., Chen, H.,
Liu, M., Chen, R., Chi, J., Lu, J., Huan, S., Cheng, S., Wang, L., Jiang, S., Chin, D. P., &
Fielding, K. L. (2015). Effectiveness of Electronic Reminders to Improve Medication
Adherence in Tuberculosis Patients: A Cluster-Randomised Trial. PLOS Medicine, 12(9),
e1001876.
M’Imunya, J. M., Kredo, T., & Volmink, J. (2012). Patient education and counselling for
promoting adherence to treatment for tuberculosis. Cochrane Database of Systematic
Reviews. https://doi.org/10.1002/14651858.cd006591.pub2
Marahatta, S. B., Yadav, R. K., Giri, D., Lama, S., Rijal, K. R., Mishra, S. R., Shrestha, A.,
Bhattrai, P. R., Mahato, R. K., & Adhikari, B. (2020). Barriers in the access, diagnosis and
treatment completion for tuberculosis patients in central and western Nepal: A qualitative

46
 study among patients, community members and health care workers. PLoS ONE, 15(1), 1–
18. https://doi.org/10.1371/journal.pone.0227293
Mondal, M. N. I., Nazrul, H. M., Chowdhury, M. R. K., & Howard, J. (2014). Socio-demographic
factors affecting knowledge level of Tuberculosis patients in Rajshahi City, Bangladesh.
African Health Sciences, 14(4), 855–865.
Mulu, W., Mekonnen, D., Yimer, M., Admassu, A., & Abera, B. (2015). Risk factors for
multidrug resistant tuberculosis patients in amhara national regional state. African Health
Sciences, 15(2), 368–377. https://doi.org/10.4314/ahs.v15i2.9
Mweemba, P., Haruzivishe, C., Siziya, S., Chipimo, P., Cristenson, K., & Johansson, E. (2012).
Knowledge, attitudes and compliance with Tuberculosis treatment, Lusaka, Zambia. Medical
Journal of Zambia, 35(4), 121–128. https://doi.org/10.4314/mjz.v35i4.56064
Náfrádi, L., Nakamoto, K., & Schulz, P. J. (2017). Is patient empowerment the key to promote
adherence? A systematic review of the relationship between self-efficacy, health locus of
control and medication adherence. PLOS ONE, 12(10), e0186458.
Naidoo, P., Peltzer, K., Louw, J., Matseke, G., Mchunu, G., & Tutshana, B. (2013a). 2013
Predictors of TB and ART medication non-adherence in Public primary care patients in SA.
Naidoo, P., Peltzer, K., Louw, J., Matseke, G., Mchunu, G., & Tutshana, B. (2013b). Predictors of
tuberculosis (TB) and antiretroviral (ARV) medication non-adherence in public primary care
patients in South Africa: a cross sectional study. BMC Public Health, 13(1), 396.
https://doi.org/10.1186/1471-2458-13-396
Nezenega, Z. S., Gacho, Y. H. M., & Tafere, T. E. (2013a). Patient satisfaction on tuberculosis
treatment service and adherence to treatment in public health facilities of Sidama zone, South
Ethiopia. BMC Health Services Research, 13(1), 1–8. https://doi.org/10.1186/1472-6963-13-
110
Nezenega, Z. S., Gacho, Y. H., & Tafere, T. E. (2013b). Patient satisfaction on tuberculosis
treatment service and adherence to treatment in public health facilities of Sidama zone, South
Ethiopia. BMC Health Services Research, 13(1), 110. https://doi.org/10.1186/1472-6963-13-
110
Nglazi, M. D., Bekker, L.-G., Wood, R., Hussey, G. D., & Wiysonge, C. S. (2013). Mobile phone
text messaging for promoting adherence to anti-tuberculosis treatment: a systematic review.
BMC Infectious Diseases, 13(1), 566. https://doi.org/10.1186/1471-2334-13-566
Osei, E., Akweongo, P., & Binka, F. (2015). Factors associated with DELAY in diagnosis among
tuberculosis patients in Hohoe Municipality, Ghana. BMC Public Health, 15(1), 1–11.
https://doi.org/10.1186/s12889-015-1922-z
Peltzer, K., Naidoo, P., Matseke, G., Louw, J., Mchunu, G., & Tutshana, B. (2012). Prevalence of
psychological distress and associated factors in tuberculosis patients in public primary care
clinics in South Africa. BMC Psychiatry, 12(1), 89. https://doi.org/10.1186/1471-244X-12-
89
Sajjad, S. S., Sajid, N., Fatimi, A., Maqbool, N., Baig-Ansari, N., & Amanullah, F. (2020). The
impact of structured counselling on patient knowledge at a private TB program in Karachi.
47
 Pakistan Journal of Medical Sciences, 36(1), S49–S54.
https://doi.org/10.12669/pjms.36.ICON-Suppl.1713
Salifu, R. S., & Hlongwana, K. W. (2021). Frontline healthcare workers’ experiences in
implementing the TB-DM collaborative framework in Northern Ghana. BMC Health
Services Research, 21(1), 1–11. https://doi.org/10.1186/s12913-021-06883-6
Singhania, A., Wilkinson, R. J., Rodrigue, M., Haldar, P., & O’Garra, A. (2018). The value of
transcriptomics in advancing knowledge of the immune response and diagnosis in
tuberculosis. Nature Immunology, 19(11), 1159–1168.
Siregar, R. R., Sari, E., Gultom, D. M., & Ahmadi, H. (2022). The Relationship between
Knowledge and Attitude of Pulmonary TB Patients on the Prevention of Pulmonary TB
Disease Transmission at Puskesmas Padangmatinggi. Science Midwifery, 10(3), 2110–2114.
Subbaraman, R., de Mondesert, L., Musiimenta, A., Pai, M., Mayer, K. H., Thomas, B. E., &
Haberer, J. (2018). Digital adherence technologies for the management of tuberculosis
therapy: mapping the landscape and research priorities. BMJ Global Health, 3(5), e001018.
https://doi.org/10.1136/bmjgh-2018-001018
Tachfouti, N., Slama, K., Berraho, M., & Nejjari, C. (2012). The impact of knowledge and
attitudes on adherence to tuberculosis treatment: A case-control study in a moroccan region.
Pan African Medical Journal, 12(1), 1–8.
Tasnim, S., Rahman, A., & Hoque, F. M. A. (2012). Patient’s knowledge and attitude towards
tuberculosis in an urban setting. Pulmonary Medicine, 2012.
https://doi.org/10.1155/2012/352850
Tesfahuneygn, G., Medhin, G., & Legesse, M. (2015). Adherence to Anti-tuberculosis treatment
and treatment outcomes among tuberculosis patients in Alamata District, northeast Ethiopia.
BMC Research Notes, 8(1), 1–11. https://doi.org/10.1186/s13104-015-1452-x
Tola, H. H., Shojaeizadeh, D., Tol, A., Garmaroudi, G., Yekaninejad, M. S., Kebede, A., Ejeta, L.
T., Kassa, D., & Klinkenberg, E. (2016). Psychological and Educational Intervention to
Improve Tuberculosis Treatment Adherence in Ethiopia Based on Health Belief Model: A
Cluster Randomized Control Trial. PLOS ONE, 11(5), e0155147.
Tomás, B. A., Pell, C., Cavanillas, A. B., Solvas, J. G., Pool, R., & Roura, M. (2013).
Tuberculosis in migrant populations. A systematic review of the qualitative literature. PLoS
ONE, 8(12), 1–12. https://doi.org/10.1371/journal.pone.0082440
Ventola, C. L. (2015). The antibiotic resistance crisis: part 1: causes and threats. Pharmacy and
Therapeutics, 40(4), 277.
Viney, K. A., Johnson, P., Tagaro, M., Fanai, S., Linh, N. N., Kelly, P., Harley, D., & Sleigh, A.
(2014). Tuberculosis patients’ knowledge and beliefs about tuberculosis: A mixed methods
study from the Pacific Island nation of Vanuatu. BMC Public Health, 14(1), 1–12.
https://doi.org/10.1186/1471-2458-14-467
WHO. (2018). Compendium of WHO guidelines and associated standards: ensuring optimum
delivery of the cascade of care for patients with tuberculosis. In World Health Organization
(Issue June
48
 APPENDIX III: CONSENT FORM
RESEARCH OPERATIONS OFFICE
INSTITUTE OF HEALTH RESEARCH
UNIVERSITY OF HEALTH AND ALLIED SCIENCES
RESEARCH ETHICS COMMITTEE (REC)
PROTOCOL CONSENT FORM

Section A- BACKGROUND

INFORMATION

Title of Study: Adherence to treatment regimen by tuberculosis patients: a study at the tb

clinic of the Tema general hospital

Principal Investigator: MENSAH NANCY

Certified Protocol
Number

Section B– CONSENT TO PARTICIPATE IN RESEARCH

General Information about Research

The main aim of the study is to examine the adherence to treatment regimen by tuberculosis

patients at the Tema general hospital. You have been chosen to partake in it because you fall

within the inclusion criteria which and consents to participate in the survey. You will be assisted

to fill the questionnaire where appropriate. The questionnaire has 5 sections.

The questionnaire will be divided into 5 sections. The first section included the rights of the

participant, significance of the study and some instructions needed in answering the questionnaire

well. The Section A asked about the demographics of participants. The Sections B, C, D, were

49
structured under the following headings: knowledge, adherence to TB treatment as well as factors

that influence adherence treatment. Both closed and open – ended questions were used in the

questionnaire requiring 5 to 10 minutes to be completed by study participants. The results of the

study will be purely for academic purposes. Therefore, information provided by answering the

questions should be nothing but the truth and purely subjective.

Benefits/Risks of the study

There shall be no monetary benefits as no payments of cash will be given to you. Apart from the

time taken to fill the questionnaire, there is no known and anticipated risk or hazard involved in

participation of this study.

Confidentiality

Confidentiality of the participants will be ensured. Data and other study documents such as

consent forms would be stored on a computer and email for at least five years after the study.

Only the researchers, the supervisor, participant, and the independent coder have access to the raw

data. If you agree to partake in the study a consent form will be given to you to sign. As a

participant, you have the right to access the information collected from you. Anonymity of

participants will be ensured by assigning codes to each participant. These codes will be used when

quoting participants in the findings chapter.

Compensation

There would be no form of incentives before and after participation. Your involvement will solely

base on volunteerism. Your participation will however be duly acknowledged.

Withdrawal from Study

Your participation in this study is basically free and voluntary. Therefore, you have the right to

withdraw from the study at any point in time you wish to without any consequences. However,

50
you are encouraged to stay and finish your participation as your opinion is highly needed in this

study.

What happens after study or when the participant changes his/her mind?

Findings from this study will be used basically for academic purposes. Data and other study

documents such as consent forms would be kept under lock and key and also stored in computer

and email for at least five years after the study. Results will be communicated and disseminated

through academic publications in journals.

Contact for Additional Information

You can contact the individuals below in case of any clarifications and further information

regarding this study. Mensah Nancy – 054 193 2370 or nancymensah957@gmail.com

If you have any questions about your rights as a research participant in this study you may contact

the Administrator of the Research Ethics Committee, IHR, University of Health and Allied

Sciences at rec@uhas.edu.gh or +233- 362-196-193.

Section C- PARTICIPANT AGREEMENT

"I have read or have had someone read all of the above, asked questions, received answers

regarding participation in this study, and am willing to give consent for me, my child/ward to

participate in this study. I will not have waived any of my rights by signing this consent form.

Upon signing this consent form, I will receive a copy for my personal records."

________________________________________________
Name of Participant
_________________________________________________ _______________________
Signature or mark of Participant Date
If participant cannot read and or understand the form themselves, a witness must sign here:

51
I was present while the benefits, risks and procedures were read to the volunteer. All questions

were answered and the volunteer has agreed to take part in the research.

_________________________________________________
Name of witness
________________________________________________ _______________________

Signature of witness / Mark Date

I certify that the nature and purpose, the potential benefits, and possible risks associated with

participating in this research have been explained to the above individual.

__________________________________________________

Name of Person who Obtained Consent

___________________________________________ ______________________

Signature of Person Who Obtained Consent Date

APPENDIX IV: SURVEY QUESTIONNAIRE

A1 AGE Less than or equal to 20 [ ], 21 to 25 [ ], 26 to
30 [ ]

31 to 35 [ ], 36 to 40 [ ], 41 to 45 [ ] , 46 to
50 [ ]

≥ 50 [ ]
A2 LEVEL OF EDUCATION No formal education [ ], Primary [ ],
Secondary [ ]
Tertiary [ ]
A3 EMPLOYMENT STATUS Unemployed [ ]

Self-employed [ ]

Employed [ ]

52
 Specify ……………………
A4 MARITAL STATUS Single [ ] Married [ ] Divorced [ ]

Widowed [ ] Separated [ ]

A5 RESIDENCE Self- owned [ ] Rented [ ]

ADHERENCE TO TREATMENT REGIMEN BY TUBERCULOSIS PATIENTS: A

STUDY AT THE TB CLINIC OF THE TEMA GENERAL HOSPITAL

SECTION A: SOCIO DEMOGRAPHIC CHARACTERISTICS

Please indicate your response in this section “[ ]” provided by ticking “√”

SECTION B : KNOWLEDGE OF PATIENTS ATTENDING THE TB CLINIC ON TB

Please indicate your response in this section “[ ]” provided by ticking “√” regarding the
knowledge on TB.
1. Do you know the common sign and symptoms of Tuberculosis (TB) disease?
a) Yes [ ] b) No [ ]
2. Do you know what the route of transmission of TB is?
a) Air borne transmission (from coughing and sneezing) [ ]
b) Blood borne transmission [ ] c) Sexual transmission [ ]
3. Heart
a) Heart [ ] b) Lungs [ ] c) Bones [ ] d) Kidney [ ]
4. What is the treatment duration of TB?
a) 3 months [ ] b) 6 months [ ] c) 12 months [ ] d) 15 months [ ]
5. Do you know that TB is completely curable?

53
 a) Yes [ ] b) No [ ]
7. Do you have/had any TB Patient in your home?
a) Yes [ ] b) No [ ]
8. Do you have/had any TB patient in your relatives or neighbors?
a) Yes [ ] b) No [ ]
9. Do you know (Multi Drug Resistant) MDR TB?
a) Yes [ ] b) No [ ]
10. What is the treatment duration of MDR TB?
a) 4 months [ ] b) 8months [ ] c) 12 months [ ] d) 18 months [ ] e) 24 Months [ ]
11. Do you know XDR TB (Extremely Drug Resistant TB)?
a) Yes [ ] b) No [ ]
12. Do you think that XDR TB is non-curable?
a) Yes [ ] b) No [ ]
13. Which sample is used for diagnosis of Tuberculosis?
a) Blood [ ] b) Sputum [ ] c) Urine [ ] d) CSF [ ]

SECTION C : ADHERENCE LEVEL OF TB MEDICATION AMONG THE TB PATIENTS

Please indicate your response in this section “[ ]” provided by ticking “√” regarding your
adherence level of TB medication among the TB patients.
YES
S/N Item NO

11. Do you ever forget to take your medication?

12. Are you careless at times at taking medication?

13.
When you feel better do you sometimes stop taking your medication?

14.
Sometimes if you feel worse when you take the medication do you stop taking it?

15. I take my medication only when I am sick

16. It is unnatural for my mind and body to be controlled by medication

54
 17. My thoughts are clearer on medication

18. By staying on medication, I can prevent getting sick

19. I feel weird, like a zombie in medications

20. Medication makes me feel tired and sluggish

SECTION D : FACTORS INFLUENCING ADHERENCE TO TB TREATMENT

Please indicate your response in this section “[ ]” provided by ticking “√” regarding factors
Factors influencing adherence to TB treatment.
CODE VARIABLE RESPONSE

YES NO
C1 Are TB drugs covered by your health insurance?
C2 Are you aware of any other side effects?
C3 Have you ever stop taking TB drugs due to drugs'
shortage?
C4 Have you ever felt any discomfort after taking your
TB drugs?

55
C5 Do you know the diet to comply with the treatment?
C6 Have you failed in previous TB treatment?
C7 Have you ever received treatment recommendations
by your doctor?
C8 Do you think that the doctor is receptive to your
questions and concerns?
C9 Do you feel motivated to comply with treatment?
C10 Do you feel depressed for having the disease?
C11 Have you noticed changes in your lifestyle due to this
illness?
C12 Do you feel emotionally supported by your family?

56