OUR LADY OF LOURDES COLLEGE FOUNDATION College of Nursing and Midwifery Vinzons Avenue, Daet, Camarines Norte Sample Questionnaire (English Version) PATIENT ADHERENCE TO TUBERCULOSIS TREATMENT; BASIS FOR DRUG RESISTANCE PREVENTION 1. Profile A. Personal Background Please put check (√) on the blank that was provided: Age: __________ Gender: _______ Male _______ Female Civil Status: ___ Single ___ Married ___ Other (Please specify) __________ Educational Attainment. Please put check (√) on the blank that was provided: _____ Primary _____ High School _____ College _____ others Main Support Person/s: 1. Please put check (√) on the blank that was provided: ____ Spouse ____ Children/child ____ Brother ____ Grand Children ____ Sister ____ Friend ____ others B. HEALTH CONDITION Please put check (√) on the blank that was provided: 1. What year you were diagnosed of TB __________________ 2. In past 2 weeks which of the following are you experiencing? Check all that applies. a. Cough with thick sputum b. Night sweat? c. Decrease appetite d. Weight loss e. Fatigue f. Difficulty of breathing ____ yes ____ no ____ yes ____ no ____ yes ____ no ____ yes ____ no ____ yes ____ no ____ yes ____ no OUR LADY OF LOURDES COLLEGE FOUNDATION College of Nursing and Midwifery Vinzons Avenue, Daet, Camarines Norte 3. How do you adhere to your Tuberculosis drug therapy? A. Do you see to it that you have a ready supply of your medicine? Strongly Agree Agree Moderately Agree Disagree 4 3 2 1 B. Do you allow substitution of other drug brands? Strongly Agree Agree Moderately Agree Disagree 4 3 2 1 C. Do you take medication is out of stock or not available? Strongly Agree Agree Moderately Agree Disagree 4 3 2 1 D. Do you follow the given time in taking your medicine? What kind of scheduling material you use in reminding you to your medicine taking? Strongly Agree Agree Moderately Agree Disagree 4 3 2 1 4. Which of the following contribute to your adherence to TB treatment. Please rate by checking the following according to your agreement where: Strongly Agree Agree Moderately Agree Disagree 4 3 2 1 OUR LADY OF LOURDES COLLEGE FOUNDATION College of Nursing and Midwifery Vinzons Avenue, Daet, Camarines Norte A. Personal INDICATORS 1. Taking my anti TB medications will make me to heal faster. 2. Regular administration of my TB medication will kill the microorganism. 3. I fear of the reoccurrence of the disease so I attend to all my medication. 4. I do not want to spread the disease to my family. 5. I do not want to be branded as an “unclean” person. 6. I infer my healthcare provider explanation regarding the anti TB medication. 7. I follow the recommendation of my health care provider regarding mu situation. 8. I was made aware of how I on how I got the disease. 9. I supervene the precautions of my health care provider in taking other medication aside from the anti TB drugs 10. I am afraid to die so I went to the health institution to have myself to check by the physician. 4 3 2 1 OUR LADY OF LOURDES COLLEGE FOUNDATION College of Nursing and Midwifery Vinzons Avenue, Daet, Camarines Norte B. SIGNIFICANT OTHERS (Parents, Siblings, kin relatives and friends) INDICATORS 1. They closely attend to my medication needs. 2. They encourage me on taking my medication on time. 3. They monitor me about my medication trough mobile trough text or any means of communication whether I am away. 4. They discuss to me about the importance on taking my medication. 5. They get mad if I forgot my medication intake. 6. My family always guide me during medication. 7. My kin relatives able to seek advices with other persons affected with the disease on how they cope with the disease. 8. My friends monitor my medication to my attending physician. 9. My support person advice other immediate relatives to in helping to take the medication with caution. 10. My support person encourages member of the 4 3 2 1 OUR LADY OF LOURDES COLLEGE FOUNDATION College of Nursing and Midwifery Vinzons Avenue, Daet, Camarines Norte whole family to change lifestyles as to develop resistance. C. HEALTH CARE PROFESSIONALS (Doctor, Nurses, Midwives, BHW’s) INDICATORS 1. The Doctor explain the importance of medication compliance specially in TB medication. 2. The health provider emphasizes thoroughly the dosage, proper intake of the medicine. 3. When I am diagnosed with TB the nurse provides emotional support. 4. The nurse encourages me to take nutritious food, have more sleep, take exercise, lessen daily activity. 5. My doctor monitor me every month, encourage me to see him or her every month. 6. The BHW follow up my medication regimen in my house. 7. My health provider emphasizes not to take medication that have interaction with my anti TB medication. 8. Discusses with my significant others, immediate family how will they cope with TB disease. 9. Emphasize and explain that if any adverse effect in taking the medication or complication re occur go immediately to health institution. 4 3 2 1 OUR LADY OF LOURDES COLLEGE FOUNDATION College of Nursing and Midwifery Vinzons Avenue, Daet, Camarines Norte 10. Advice not to take medication that have interaction with anti TB drugs.
