Pharmacy Initiative

Pharmacy Initiative: TB DOTS in Barangay 693,694 and 674 Zone 73 Malate District Manila
Boonyapisomparn, Thunnapat; Duran, Merari Jane; Guab, Athelestine; Mercado, Grace; Paguntalan, Ariana; San Mateo, Ecclesia; Ugochukwu, Vivian and Vidallo, Yhiza18 October 2018
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ABTRACT
The Philippines is one of 30 countries with high burdens of tuberculosis (TB), with the estimated incidence rate of 322 per 100,000 population in 2015. The country also has one of the highest burden of multi-drug resistant tuberculosis. The government has a Reversed National Tuberculosis control programme which the internationally accepted DOTS (directly observed treatment short course) strategy is used. DOTS involves free diagnosis of TB and free medications for complete treatment duration minimum of 6-8 months or longer under direct supervision. Private-sector retail drug outlets are often the first point of contact for common health ailments, including tuberculosis (TB). Private-sector retail drug outlets are a key ally in ensuring that patients are referred to appropriate and high-quality treatment providers in their neighbourhood. The objective of this research was to know the level of the knowledge of pharmacists about TB DOTS referral programme and also the percentage compliance of these pharmacists to the TB DOTS Referral programme. The study was carried out by giving out questionnaires together with interview questions to twenty (20) pharmacists in barangay 693, 694 and 674 zone 73, Malate, Manila. The twenty pharmacists interviewed were all bachelor’s degree holder in pharmacy, 60% of them have been practicing pharmacy for more than 5 years and 95% of them claimed to know about the TB DOTS referral programme, 35% of them got the information from media while 30% from seminars and 5% from lectures. Out of the 95% pharmacists that are aware of TB dots referral programme, 65% 0f them do not refer patient, 25% refer less five (5) patients in a month and 10% refer (5-10) patients in a month. The 35% of pharmacists who refer patients for TB DOTS said that 65% of patients are uncooperative with the programme and the programme is only 30% very effective. According to Manila Health Department, Jose Fabella Healthcare Center which is located at 1004 Fermin St. Singalong Maynila, No patient has been referred by pharmacists in barangay 693,694 and 674.
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INTRODUCTION
The Philippines is one of 30 countries with high burdens of tuberculosis (TB), with the estimated incidence rate of 322 per 100,000 population in 2015. The country also has one of the highest burden of multi-drug resistant tuberculosis. Case notification has steadily increased since 2008 after eight years of stagnation, however the gap still appears to be substantial, with the increased initiative of the National TB Control Program (NTP), and significant progress has been made in TB control for the past decades. Nationwide DOTS coverage was achieved in 2003. Programmatic efforts have been undertaken for establishing partnerships with public and private
Health providers, facilitating nationwide expansion of TB diagnosis, and scaling-up Programmatic Management of Drug-resistant TB (PMDT).

As of 2014, the Philippines ranks 7th among the world’s 22 countries with a heavy tuberculosis (TB) burden. As the country accelerates its campaign to control the global epidemic, the Philippine Tuberculosis Initiatives for the Private Sector (PhilTIPS) joined the efforts to combat it through the Directly Observed Treatment Short-course (DOTS) strategy. As tuberculosis (TB) has been consistently listed as one of the Philippines’ top 6 causes of mortality and morbidity over the last 2 decades, equipping Healthcare providers with the competence to manage TB is not just imperative but also urgent. To address the problem of TB, the World Health Organization (WHO) adopted the Directly Observed Therapy Short-course (DOTS) strategy in 1991, which the Philippine National Tuberculosis Control Program (NTP) also adopted in 1996 and available in almost all rural health units and the health care centers.

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There are initiatives to engage all the healthcare providers such as public-private mix DOTS, the hospital DOTS, comprehensive unified policy mechanism and the promotion of the international standard of TB care. Although awareness of TB is high among general population, knowledge on causation and its transmission, DOTS is still low health seeking behavior and its non-dots providers’ poor treatment outcome was observed in some provinces and cities and DOTS doesn’t strictly observed in some of these areas. The initiative to increase access to DOTS by the population in need is still limited, community participation in TB control is through Barangay health workers and community pharmacists but still limited.
DOTS is the strategy recommended by the social health organization in the prevention and treatment of TB worldwide. The DOTS Program ensures that patient take each dose of anti-tuberculosis medication as prescribed and helps and prevent the emergence of drug resistance; promotion of adherence to its prescribed TB medication is implemented through a patient-centered approach includes facility access to treatment, choosing with the patients most convenient time and place for direct observation of treatment when possible providing other social part of health-care providers should know, understand and participate in its DOTS Program. Pharmacists could play important role in the prevention and management of TB. These role include provision of adequate TB drugs, improvement of TB patient’s adherence to their prescribed medications, and patient’s education about TB and its treatment. To implement this roles pharmacists must realize the importance of their roles, have enough knowledge and participate in the prevention and treatment program of TB.

In this research, the pharmacy initiative is being considered in the effective treatment TB using DOTS. This study was undertaken to assess the knowledge of the pharmacists, feasibility, effectiveness, compliance rate of the TB DOTS project in Barangay Malate district.

Background of the Study
Generally speaking it is rarely possible for a library or information center to have enough resources to fulfill the needs of its patients. What is usually being delivered is a portion of what a researcher actually need. Barangay health centers with the help of (LGUs) is widely known as the primary unit which is responsible for the general control and supervision of health personnel and facilities; the delivery of health services, regulatory functions, such as formulation and enforcement of ordinances related to health, nutrition, and all the other public health-related matters. The intent was to strengthen the health system as it works at the community (barangay) level where patients and health services meet. A strong health system at the barangay level will be able to improve the quality of the services they are giving to the patient as well as collecting the concise data of the disease. The delivery of a TB control program services will help them to reduce the burden of TB in the community in the long term.
Based on the World Health Organization (WHO) said TB is the sixth leading cause of death and illness in the country, killing 28,000 yearly.  The usual affected victims of TB are the group of young and old people, smokers and people with weakened immune systems due to HIV, malnutrition, cancer, kidney disease and diabetes. Due to the 260,000 cases of TB deaths in the year 2011, Philippines as one of the four countries that account for 93 percent of TB cases in the Western Pacific region.

Tuberculosis (TB), often thought of a disease from the past, is still rampant in large parts of the world. With 1.5 million deaths annually, it is the most important cause of death due to an infectious disease worldwide. With this known facts, many of us had become so familiar with this disease which may led to the restriction of the desire to find better cure. That’s why it is very important to create an awareness and to find initial treatments for this disease. Developing a new shorter and simpler treatment and better diagnostics as well as implementing technology in the health care system is a great potential innovation.

Statement of the Problem
Tuberculosis remains as one of the leading causes of morbidity and mortality for many years. World Health Organization works with the local governments of different country in establishing and implementing the TB DOTS program to reduce the cases of tuberculosis as well as to help the patient about the proper treatment and management of the disease. But the problem is how knowledgeable the pharmacists are about their role in TB DOTS? How about their compliances? Are they doing their part or do they know what to do when they encounter patient asking for medicine, or patient that has a symptoms of tuberculosis? Do they know the factors on how tuberculosis spread? In the Philippines, every barangay has its own TB DOTS wherein each patient who has tuberculosis is referred there to get a medical attention. Because of the widespread of tuberculosis in the Philippines the number of patients became higher. To expound the pharmacy initiative of TB DOTS, one needs to determine the causes, modes of spread, extent and pattern of the disease and the government’s action to prevent.
Significance of the Study
This research study aims to provide information and for better understanding of tuberculosis problem in the community and as well as to measure the compliance of Pharmacists as the key stakeholders for the success of TB DOTS program. Thus, the results of this study would be beneficial to the general public in raising awareness and possible treatment and prevention about the said disease. It could also be beneficial in enabling to understand the role of pharmacists in the prevention and management of Tuberculosis under the TB DOTS.

Furthermore, this study will be a significant endeavor in contributing to the efforts of our government in partnership with our healthcare practitioners in reducing cases of tuberculosis.

Objective
1. To learn which group of people that have the most and least cases of tuberculosis in the chosen barangay.

2. To learn the extent and pattern of the disease and to the government’s action to prevent the epidemic disease.

3. To find out if the pharmacists are aware of TB DOTS.

4. To measure the pharmacist knowledge about tuberculosis in Barangay 694, 693, and 674 Malate District Manila.

5. To find out percentage compliance of pharmacists to the TB DOTS.

METHODOLOGY
Research design
The research is utilized as a descriptive method using quantitative approach, it is associated with statistical techniques for data analysis. It will generate from in-depth interviews, focus group discussions and participatory observation. In-depth interviews, we will be conducting with the health care practitioners in this field in order to collect information about the problems occurred during the TB Program implementation in Barangay 693,694 and 674 Zone 73 Malate, Manila and focus group discussions will be conducted with the pharmacists. Meetings will be organized with health workers who provide DOT services at special TB departments, primary healthcare centers or any place convenient for patients.

Setting of the Study
The research will be conducted in a community setting specifically in Barangay 693,694 and 674 Zone 73 Malate district Manila. Which health centers, TB DOTS centers and community pharmacies were preferred to be observed and evaluated. The regions were selected based on its accessibility for Philippine Women’s University students. Considering that there are schools situated within this area, data gathering of tuberculosis (positive patients) is of high regards as it will pose the probability of exposure of students.

Subject and Respondents
The respondent of the research are the community pharmacist and health care practitioners/ workers that provides DOT services within the Barangay 693,694 and 674 Zone 73 Malate District Manila.

Sample size computation / Sampling technique
An estimated number of 20 Pharmacist and 3 public health workers as the sample size to be used for the purpose of collecting primary data. Simple random sampling technique will be performed, where we select a group of subject for study from a larger group.

Research instrument
The instrument used was a researcher-made questionnaire checklist to gather the needed data for the pharmacist’s profile. In the preparation of the instruments, the requirements in the designing of good data collection instrument were considered. Open – ended options were provided to accommodate to free formatted views related to the topic.
Letters will be written to the concerned bodies to obtain permission and cooperation for data collection. Barangays were briefed about the confidentiality of their respondents and the importance of providing the right information. Informed verbal consent was secured from the study subjects to participate in the research. The intervention provided was adolescent friendly and culturally acceptable.

Participatory Observation will be conducted by observing community settings, behavior of health workers, patients, accompanying family members and other health personnel. The health centers situated in that area is chosen for the participatory observation. Things which were observed included the health care facilities aiding the DOTS implementation and conduciveness of the community environment to counseling and dissemination of useful health information through banners, displays and posters and counselling. The observation was limited to only the DOTS centers of the area and community pharmacies.

Validation and reliability test of instrument
To achieve content validity, all the items were constructed to assess the accuracy and appropriateness of the instrument used. The result can be generalized from a sample to the chosen population. The reliability of the questionnaires will be observed from the consistency in responses, test rate method will be used to reveal the consistency.

RESULTS AND DISCUSSIONS
A survey was distributed to the pharmacist assigned at barangay 693,694 and 674 zone 73 Malate District Manila, having a total of 20 respondents. There were 19 female and 1 male pharmacists that partook in the survey. The purpose was to accurately find out the factors and trace out the compliance of the pharmacist in refers to TB DOTS program.

Table 1
Highest Educational Level Attained
Ranking No. Statement %
1 20 Bachelor’s Degree 100
2 0 Master’s Degree 0
3 0 Doctorate’s Degree 0
Table 1 shows that out of 20 respondents, all of them has a Bachelor’s degree in Pharmacy. Vianzon R et al (2011), compared economic outcomes of directly entering community pharmacy practice after earning a doctor of pharmacy (PharmD) vs earning a PhD after earning a PharmD and then entering a career in academia or industry. However it did not consider the effects of other educational tracts, residency training and/or pharmacy career paths such as hospital.

Table 2
Number of years been practicing as a Community Pharmacist
Ranking No. Statement %
1 12 > 5 year 60
2 4 1-3 years 20
3 3 <1 year 15
4 1 3-5 years 5
Table 2 shows that 60% of the respondents were practicing more than 5 years as community pharmacists which is the majority among the 4 statements. 1-3 years of practice ranked as the second that is 20% while less than 1 year ranked as the third which is 15%. 3-5 years of practice in community setting ranked as the least among the 4 statements that only includes 5% of the respondents. According to Thamby SA et al (2014), a community pharmacist practiced for 10 years filling prescriptions and seeking ways to help patients. Continuing to develop programs.

Table 3
Aware of the TB DOTS program implemented by the government
Ranking No. Statement %
1 19 Yes 95
2 1 No 5
Awareness on DOTS program obtained by the participants are listed in table 3. This study proved that 95% of the pharmacists have heard and known about the DOTS program. According to Samal and Dehury (2017), Health education activities should be directed to improve the knowledge of slum dwellers regarding the modes of TB transmission and availability of free treatment at public health facilities.

Table 3.1
Source of Information about TB DOTS
Ranking No. Statement %
1 7 Media 35
2 6 Seminar 30
3 3 Other 15
3 3 Lecture 15
Table 3.1 was answered only by the respondents who said “yes” on table number 3. Of the 19 participants, as many as 7 participants (35%) and 6 participants (30%) got information about TB program through media and seminar, respectively. As many as 3 (15%) of them got information through lecture. Mkele G. (2010), mentioned that pharmacists have known about DOTS program from different sources of information. Understanding the DOTS program is required. In the future, policy makers should place priority on improving the pharmacists’ knowledge on TB. According to this study, nearly all of the pharmacists argued that they could manage the use of anti-TB medicines and provide information about the medicines.

Table 4
Referral of the program of TB DOTS in pharmacy
Ranking No. Statement %
1 13 No 65
2 7 Yes 35
Table 4 shows the statement of the pharmacists in terms of their referral of the program of TB DOTS in pharmacy. 13 (65%) of the participants said that they don’t refer patients to TB healthcare center, their reason is because not all community pharmacies doesn’t comply with this government program while 7 (35%) of the participants said that they refer patients to the healthcare centers that couldn’t afford to buy the tuberculosis medications. Squire SB et al (2001), mentioned that education and exposure of private practitioners to the TB program improves referral of TB suspects from private practitioners to the national TB program. We recommend that the TB program provides all private practitioners with information about the DOTS strategy and TB suspect referral forms, and organizes regular visits to private practitioners.

Table 4.1
Frequency of referrals on TB patient for TB DOTS
Ranking No. Statement %
1 13 Never 65
2 7 Often 35
3 0 Very often 0
Table 4.1 shows how frequent does the pharmacist referred TB patients for TB DOTS. The 13 participants who answered “No” from the previews question answered “Never” to this affirmation while the 7 (35%) participants said that they often refer patients to TB DOTS when the patient is having a visible sign and symptoms of tuberculosis and also if the patient is having financial shortage to his/her anti-tuberculosis medication. Squire SB et al (2001), mentioned that education and exposure of private practitioners to the TB program improves referral of TB suspects from private practitioners to the national TB program. We recommend that the TB program provides all private practitioners with information about the DOTS strategy and TB suspect referral forms, and organizes regular visits to private practitioners.

Table 4.2
Number patients referred for TB DOTS in a month
Ranking No. Statement %
1 13 0 65
2 5 < 5 25
3 2 5-10 10
4 0 10-20 0
5 0 >20 0
Table 4.2 shows the number of patients that the pharmacist referred to TB DOTS in a month. Once more, the 13 (65%) participants answered 0 referrals which is the majority among the statement. Less than 5 patients was referred by the 5 (25%) participants and 5-10 patients was referred by 2 (10%) of the participants. Bell, et al (2015), Pharmacies’ ongoing commitment to the referral was strongly associated with referral. Increased advocacy among the high number of non?referring pharmacies may improve referral performance. Factors negatively associated with referral may need investigation.

Table 4.3
Adherence of patients for recommendation on TB DOTS program
Ranking No. Statement %
1 13 No 65
2 7 Yes 35
Table 4.3 shows the adherence of the patients to pharmacist recommendation regarding the TB DOTS. 13 (65%) of the participants said that patients are not complying on the pharmacists while 7 (35%) of them said that patients adhere to their recommendation. In 2014, drug-sensitive TB patients were reported by the NTP as loss to follow-up. Based on guidance from the Expert Group, they assumed for the modeling that the interruption occurred three months into treatment for those patients who returned to treatment. Based on Expert Group opinion, they assumed that 2% of these patients are likely to have had undiagnosed multidrug resistant TB because of a loss of fallow up during due to interruption occurred in three months treatment (National TB Control Program, 2014).

Table 4.4
Cooperation of the patients with the TB DOTS program referral
Ranking No. Statement %
1 13 Uncooperative 65
2 5 Cooperative 25
3 2 Very cooperative 10
Table 4.4 shows the level of cooperation of the patients with the TB DOTS program referral. 13 of the participants said that patients are not being cooperative when it comes to pharmacist recommendation while 5 (25%) of them. Non-adherence is often due to patient-related factors but can also be a result of service delivery issues, such as stock-outs of TB medicines. An uninterrupted and sustained supply of quality assured anti-TB medicines is essential to achieving successful program outcomes (Collins D. et al, 2016).

Table 5
Effectiveness of TB DOTS in community setting
Ranking No. Statement %
1 13 Effective 65
2 6 Very effective 30
3 1 Not effective 5
Table 5 shows the effectiveness of TB DOTS in community setting. 13 (65%) of the participants said that the program is effective and 6 (30%) of the participants said that it very effective while 1 disagreed and said that the program is not effective at all. According to National TB Control Program, The Philippines has achieved improvements in case detection and exceeded the target for treatment success despite numerous challenges, particularly in making services accessible in difficult geographic and socioeconomic settings. The country aims to further improve access to diagnostic and treatment services, especially for highly vulnerable groups.

Interview
Collection of the information regarding TB DOTS compliance and evaluation was held at Manila Health Department, Jose Fabella Healthcare Center which is located at 1004 Fermin St. Singalong Maynila. This healthcare center holds 27 barangays which 10 of this are non-depressed and 17 are depressed areas. This research focuses on barangay 693, 694 and 674 zone 73 Malate District Manila. Barangay 694 doesn’t have much cases of tuberculosis because it is a non-depressed area that means it is a commercial sector and is not squatter area. Data that is gathered in a year of 2017-2018 under TB DOTS program have 2 patients in barangay 693, 3 patients in barangay 674 zone 73 and no patients at barangay 694. Government actions are giving free medicine for TB patients and the TH DOTS programs. There are no referral received from any pharmacy at all.

CONCLUSION AND RECOMMENDATIONS
It is concluded from the findings that referral can play a very important role in improving continuation and adherence in TB patients. In fact, in routine management of TB no systematic advice and counseling is provided to the patient that results in inappropriate management of compliance in tuberculosis patients with DOTS. From the results of the survey, it is evident that there is a big barrier between Jose Fabella Health Care Center and the pharmacists within its proximity on TB DOTS initiative program of the government. Thus getting a minimal referral rate for TB patient costumers for the program. Hence, success rate of this study cannot be concretely measured due to the fact that most of the respondents do not refer their patients to Jose Fabella Health Care Center, with some who even admitted they had no knowledge of what the program entails.
Based on the final findings of this research, the following recommendations for future studies have been made:
1. Community pharmacists should attend seminars for providing and management of TB medications, patient’s adherence and monitoring of anti-TB medications and their side effects.

2. The government should sponsor seminars for pharmacists on TB DOTS Initiative program. That way they will know the roles of pharmacists on this and how to efficiently implement it.

3. Community healthcare centers should also have a connection with the community pharmacists within their area so they can monitor whether they do referrals and counseling.

4. It should be highlighted by the policy makers that the pharmacists’ potency should be utilized and enhanced especially in early detection of TB cases in communities to optimize TB care and control.
References
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Collins D et al (2016). Economic Cost of Non-Adherence to TB Medicines Resulting from Stock-Outs and Loss to Follow-Up in the Philippines. Arlington, VA: Management Sciences for Health.
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Nakatani H, Buchmann M. (2011). The role of the pharmacist in tuberculosis care and control, WHO FIP Joint Statement.
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National TB Control Program (2014). Updated 2010–2016 Philippine Plan to Action on Tuberculosis; Department of Health.

Vianzon R et al (2011). The tuberculosis profile of the Philippines, advancing DOTS and beyond. Western Pacific Surveillance and Response Journal.
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