Measurement of Adherence Level of Pulmonary Tuberculosis Drugs use in Patients in the Primary Health Centers in Karawang Regency, West Java, Indonesia, using MMAS Instrument

Aims: This study aims to determine the level of drug adherence in patients with pulmonary tuberculosis at the Cilamaya Kulon Primary Health Center area, Karawang Regency, West Java, Indonesia. Study Design: The measurement of adherence level was carried out using the MMAS (Morisky Medication Adherence Scale) instrument. Place and Duration of Study: This study was conducted at Cilamaya Kulon Primary Health Center area, specifically in Bayur Lor and Pasirukem Primary Health Centers, Karawang Regency, West Java, Indonesia, from July to September 2021. Methodology: A cross-sectional design with a purposive sampling data collection method was used. Furthermore, the subjects were pulmonary TB patients from the Bayur Lor and Pasirukem Primary Health Centers, Karawang Regency. The instrument used was the MMAS questionnaire Original Research Article Arfania et al.; JPRI, 33(54A): 115-120, 2021; Article no.JPRI.77471 116 sheet, and data analysis was performed using SPSS (version 22.0) and continued with statistical tests using the chi-square test. Results: The results showed there was no significant relationship (p>0.05) between age, gender, educational status, employment status, income level, smoking status, duration of treatment, drugs side effects, medication supervision, and patient motivation for drugs adherence in the Cilamaya Kulon Primary Health Center area. Furthermore, the level of medication adherence of pulmonary TB patients at this Primary Health Center area was high with a value of 84.13%. Conclusion: Adherence to medication in pulmonary TB patients was not influenced by age, gender, educational status, employment status, income level, smoking status, duration of treatment, drug side effects, medication supervision, and patient motivation. Therefore, the adherence level is included in the high category.


INTRODUCTION
Tuberculosis (TB) is an infectious disease of the lung tissue and is caused by Mycobacterium tuberculosis. Pulmonary TB can affect people of all ages with different clinical presentations ranging from mild to severe symptoms. Until now, no single country in the world is free from TB, and the number of associated morbidity and mortality is quite high [1]. According to the WHO Global Tuberculosis Report 2021 data, it is estimated that 9.9 million people are confirmed to have TB in 2020, which is equivalent to 127 cases per 100,000 population, and an estimated 1.3 million deaths globally. This disease can be found in anyone, regardless of age or gender. In fact, adult men accounted for 56% of all TB cases in 2020, while women accounted for 33% and children 11%. Indonesia is the third country with the highest TB burden in the world after India (26%) and China (8.5%), with a total of 8.4% of the total number of cases globally [2]. Based on data from the Indonesian Ministry of Health in 2020, as many as 845,000 TB cases were reported with 13,947 deaths. Furthermore, West Java is reported to be the highest province contributing to TB with 123,021 cases [3].
Based on data from the Karawang City Health Office in 2021, there are currently 2,329 cases of pulmonary TB spread across 50 health centers, including Bayur Lor and Pasirukem Primary Health Centers with 32 and 31 cases, respectively [4]. The magnitude and extent of the problems caused by TB require all parties to be committed and work together for its control. The losses caused by this disease are large, not only from the health aspect but also from the socioeconomic aspects. Hence, adherence to antituberculosis drugs is required to achieve successful treatment. Also, adherence is important for healthy living and is influenced by behavioral factors. Treatment as prescribed by a doctor will be effective as long as the patient obeys instructions [5]. Therefore, this study aims to determine the level of anti-tuberculosis drug adherence in patients with pulmonary TB in the Cilamaya Kulon Primary Health Center area, specifically in Bayur Lor and Pasirukem Primary Health Centers, Karawang Regency, West Java, Indonesia.

Subject and Instrument
This study used a cross-sectional design with a purposive sampling data collection method. The subjects were pulmonary TB patients from the Cilamaya Kulon Primary Health Center area, specifically in Bayur Lor and Pasirukem Primary Health Centers, Karawang Regency, West Java, Indonesia. The instrument used was the MMAS (Morisky Medication Adherence Scale) questionnaire. Before the study, ethical approval was obtained from the Research Ethics Committee, Faculty of Medicine, Padjadjaran University, and written permission were obtained from the head of the Primary Health Center area.

Data Collection
Data collection was carried out from July to September 2021. The sample was 63 patients who were diagnosed with pulmonary tuberculosis and recorded in their medical record, received anti-tuberculosis drugs, redeemed prescription drugs at the Primary Health Center, and met the inclusion and exclusion criteria.

Inclusion criteria
o Patients who are willing to be respondents. The respondents filled out an informed consent as evidence of willingness to participate in this study, respondent information sheets, and MMAS questionnaires according to their current conditions and perceptions.

Data Analysis
Data analysis was performed using SPSS (version 22.0) and continued with statistical tests using the chi-square. The dependent variable was patient adherence to the use of antituberculosis drugs expressed in percentage. Meanwhile, the independent variables were patient characteristics related to the level of adherence consisting of age, gender, educational status, employment status, income level, patient motivation, smoking status, and duration of pulmonary TB treatment. A descriptive analysis was then used to explore the characteristics of pulmonary TB patients.

RESULTS AND DISCUSSION
The respondents' characteristics showed the proportion of male pulmonary TB patients (52.38%) was higher than females (47.62%). This is in accordance with Marçôa et al, which showed that pulmonary TB was more common in men than women [6]. Furthermore, the majority of the patients were in the 15-64 years age group, and their educational level was considered to be relatively low. Education is one of the external factors that affect a person's health where those with a high educational background usually act more preventively on a disease. Therefore, the higher a person's educational level, the better the acceptance of information about treatment, and the better the adherence [7].
This study showed there was no significant relationship (p>0.05) between age, gender, educational status, employment status, income level, smoking status, duration of treatment, drug side effects, medication supervision, and motivation for drug adherence in patients with pulmonary TB in the Cilamaya Kulon Primary Health Center area (Table 1). This finding showed there are no factors that affect medication adherence in pulmonary TB patients. This study also showed the level of medication adherence in patients with pulmonary TB at the Cilamaya Kulon Primary Health Center area was included in the high category with a value of 84.13% (Table 2). This is because counseling related to the importance of drug adherence was often carried out, hence patients understand the importance of adherence in their treatment process. This adherence will aid their complete and prompt recovery. Some of the outreach and education activities to the community that are often carried out include home care, personal hygiene, regular consultations with the medical team, and others. These activities can be seen in Fig. 1 below.

Fig. 1. Counseling and education activities for pulmonary TB patients
One of the most influential factors in patient recovery is medication adherence. This is defined as the behavior to take medicine according to the type, dose, mode of administration, time interval, and the number of days as prescribed by the doctor [8,9,10]. Pulmonary TB patients who take their medication regularly can reduce the risk for treatment failure by 3.76 times compared to those who do not regularly take medication [11].

DISCLAIMER
The products employed in this study are routinely and often used in our field of study and country. There is no conflict of interest between the writers and makers of the products because we do not plan to use them as a means of pursuing legal action, but rather to further knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT
As per international standard or university standard, respondents' written consent has been collected and preserved by the author(s).