THE IMPROVEMENT OF FAMILY S INDEPENDENCE IN TAKING CARE CLIENT WITH TUBERCULOSIS THROUGH SUPPORT GROUP INTERVENTION Ni Putu Ariani, Nyoman Sudja Bogor Nursing Program, Bandung Health Polytechnic E-mail : dewariani@yahoo.com ABSTRACT Care and treatment of Tuberculosis requires a long time, so that family support is needed. Families with tuberculosis clients are people with certain health conditions that require information and sharing to solve the problem together, with the guidance of professionals. This study aims to find out the effect of interventions on family support groups against the independence of the family in caring for tuberculosis clients. This study uses a quasi experimental design with pre post test control group and intervention in family support groups. A total of 120 sample were taken consisted of 60 people with intervention group and 60 people as a control group. The results showed that there was a significant difference between before and after intervention of the client with intervention. Meanwhile, there was no significant difference between before and after intervention for the control group. Likewise, there were significant differences in independence of the families in caring clients with tuberculosis between the intervention and control groups after the intervention. The conclusion is that a model of intervention of family support can enhance the independence of the families in caring tuberculosis clients. This intervention model can be applied in other places as one of the model of intervention to improve the independence of the family in caring for tuberculosis clients. Keywords: family support, tuberculosis, support group INTRODUCTION Tuberculosis (TB) in Indonesia is a major public health problem. Indonesia is the 5 th highest country in the number of tuberculosis in the world after India, China, South Africa and Nigeria. It is estimated that the number of tuberculosis patients in Indonesia about 5.8% of the total number of tuberculosis patients in the world. Each year there are about 429,730 new cases with the death of 62,246 people. The incidence of positive TB-BTA cases around 102 per 100,000 population (Min. of Health-RI, 2014). Six provinces with the highest tuberculosis are West Java, Papua, Jakarta, Gorontalo, Banten and West Papua. Tuberculosis cases in West Java is about 138 per 100,000 population, and in the city of Bogor is about 143 per 100,000 population, with the total number of TB patients of 1,434 people (West Java Provincial Health Office, 2012). The Government has organized national TB control program. National TB control programs implemented DOTS strategy (directly observed treatment shortcourse chemotherapy) nationally in all health care units (CGU), especially health centers that are integrated into primary health care. The main focus is the discovery and healing DOTS patients, priority is given to the type of infectious TB patients. Attempted treatment program includes two phases, namely an early stage and advanced stage. The initial phase of treatment was administered daily for 2 months, intended to effectively reduce the number and power transmission of germs. Treatment of advanced stage is the stage to kill germs remnants that still exist in the body so that the patient can heal and prevent recurrence. This strategy will decide the transmission of TB and reducing incidence of tuberculosis in the community. Find and cure the patient is the best way in order to prevent transmission of tuberculosis (Min. of Health-RI, 2014). The failure of the program is still going on, marked by the increasing cases of tuberculosis, the TB germs double immunity against anti-tuberculosis drugs (OAT) increased as a result of the case could not be healed (MDR TB). Number of MDR TB in Indonesia, which is about 6,620. The main factors causing the occurrence of resistance of bacteria to the OAT is a provider of services, family support, and patient non-compliance, as well as program / system of health care that affect the management of treatment of TB patients who do not conform to the standard and quality set (Min. of Health-RI, 2014).
Patients' adherence to TB treatment program, only about 32.8%. The level of compliance in taking medication is determined by family support. Further stated in the results of an observational study with cross sectional design accomplishments, that the higher the family support the higher level of compliance of patients taking medication (Hutapea, 2006). The family is one of the social support systems that naturally related to health (Pender, Murgaugh & Parson, 2002). Family support is an attitude, action, and family acceptance towards patients (Friedman, Bowden & Jones, 2003). In many opportunities, families contribute in treating individuals, providing support, and help in the healing process (Department of educational and training 2008). The family as a support group is a group of people with specific conditions which are overcome along with the guidance of professional staff (Randall, 2003). More Pender, Murdaugh & Pearson (2002) argued that, motivate and support groups help people to be aware of and able to independently take care of and solve problems on their own. This statement is supported by Friedman, Bowden & Jones (2003) who suggested that a person who has a strong support tend to adopt and maintain healthy behavior, compared with individuals who no support. The support group offering emotional support, sense of belonging as well as coping facilities and an informed understanding about the disease (Lamak, Kusnanto & Goddess, 2014). Adequate support and guidance, the individual will be pushed to reach the way out to the problems faced (Handayani, Sriati & Widianti, 2013). As a family support system, the family s understanding regarding task of the family about the health of the family, is necessary for independent families in caring for TB clients. Independence of the family is oriented on the task of family health in addressing health issues that include: (1) accept the officer, (2) receive health care treatment care plan, (3) know and can reveal health problems correctly, (4) health facilities as recommended, (5) do simple nursing actions as recommended, (6) take precautions active, (7) perform actions increase (promotion) actively (Min. of Health-RI, 2006) Similar views were expressed by Parker in (Handayani, Sriati & Widianti, 2013), that independence is a condition in which a person does not depend on the authority and does not need direction. Independence includes the ability to take care of themselves and solve their own problems. In an effort to achieve the independence of the family required a form of community nursing strategy; health education, group process, empowerment and partnership (Hitchcock, et al. 1999). Based on the theory and the concept of independence of the family above, then to achieve the independence, a community nursing intervention strategy is required through family support groups approach (family support group). Intervention of family support groups (family support group) is a nursing intervention strategy community nursing to improve the independence of the family through a family approach (care giver) in group situations through providing knowledge of the introduction of the TB problem, treatment of TB clients, practices to increase independence, understanding the use of health facilities for TB treatment and TB prevention efforts, as well as promotive efforts. Yenny (2012) also affirmed that the support group interventions carried out through the steps of: (1) forming groups, (2) knowledge and skills in the support group, (3) assistance and guidance in doing counseling support groups and home visits. The results of a qualitative study on the assessment of the five families duties with a family member suffering from TB, with the result: "The family should be given complete information about pulmonary tuberculosis, and need to be involved in the care of family members who suffer from pulmonary tuberculosis" (Wahyudi, Upoyo & Kuswati, 2008 ). The objective of this study was to investigate the effect of the family support groups intervention on the independence of the family in caring for TB clients. METHOD The design of the study was Quasi experimental with pre-post test to the control group as well as the intervention on the family support group. Intervention of family support groups was held once a week for 6 weeks. The activities were consisting of; provided briefing knowledge on TB problem recognition, treatment of TB clients, practices to increase the independence of family care for TB clients at home, provide insight into the use of health facilities and client TB treatment programs, as well as the practice of TB prevention efforts and cough etiquette. The population in this study were the families who have family members who suffer from pulmonary tuberculosis in the city of Bogor. While the sample were the families who give care (care giver) for TB clients, which exist in four sub-districts in the city of Bogor. The criteria of the samples
are: (1) age adults (21-59 years), (2) whose clients have TB live in one house and (3) responsible for looking after as primary care giver, (4) willing to become respondents, and (5) able to speak bahasa Indonesia. The sampling strategy was using cluster multistage sampling method. The sample selection based on a cluster with multiple stages according to geographical area. The total sample of 120 people, consisting of 60 people the intervention group and 60 people as a control group. The instrument used was a questionnaire regarding independence of the family in caring for TB clients, developed by researchers include namely; receiving clerk, receive health care, revealing the problem, health facilities, nursing action is simple, take steps to prevent, and doing promotion. Before collecting data, first tested the validity and reliability of the test instrument with Alpha Crombach test. This research was carried out for 5 months ie from June to October 2015. The collected data were then analyzed using the Wilcoxon test for dependent test, and using the Mann-Whitney test for independent test (Hastono, 2007). RESULT AND DISCUSSION Both groups showed that the majority of the family care givers were women, ie 85% in the intervention group, and 58.3% in the control group. The formal education of the family care giver were mostly low, namely elementry and secondary schools ie 58.3% of the intervention group and 78.3% of the control group. Almost all (93.3%) of families caring for clients with TB in the intervention group were married, as well as the majority of families in the control group (76.7%) was also married. The number of family members who belong to a small family in which the number of family members is less than four (4) live with clients, either for the intervention group or the control group, (53.3% in the intervention group and 55% in the control group). In terms of work status of families who care for clients with TB, both groups of the intervention and the control groups were in more than half (65% of intervention and 53.3% of control groups) did not work. Regarding the amount of family income, majority of both the intervention group and the control group (90% and 91.7%) have a high income (more than UMR of Rp 2.658.155/month (70% of the intervention group and 61.7% in the control group). Families with a single parent were only a small portion (1.7% in the intervention group and 11.7% in the control group). The results of non-parametric test with Wilcoxon test for abnormal distribution curve, can be seen in Table 1 Table 1. The family independence of the sample before and after intervention in intervention and control groups, in Bogor City, 2015 (n=120) No Variable n Mean SD Deviation P. Value 1 Family independence in intervention group Pre test 60 29.02 4.466 3.11 Post test 60 32.13 3.143 2 Family independence in control group Pre test 60 29.27 3.723 0.7 Post test 60 29.20 3.635 Dependent test Wilcoxon 0.000 0.816 The results of analysis showed that the average family independence in intervention group before intervention (pre-test) was 29.02 and after intervention (post-test) increased to 32.13 with p value = 0.000. It can be concluded that there is a significant difference between the independence of the family in caring client withtb before and after the intervention of family support groups. For the control group, the average independence of the family in the pre-test was 29.27 and in post-test was
29.20, indicating no increase but decrease 0.7 with p value = 0816. It means that there is no difference independence of the control group between pre and post-test Furthermore, the results of independent bivariate analysis among two groups after the treatment using the Mann-Whitney test, can be seen in Table 2. Table 2. The independence difference between the intervention group and control group (post test) in Bogor, 2015 No Variable N Mean SD Mean Rank P. Value 1 Family independence in intervention group 2 Family independence in control group Independent test Mann-Withney 60 32.13 7.87 76.48 60 27.20 7.22 44.52 0.000 The results of analysis showed that the average value of independence of the family in caring for TB clients after intervention of family support intervention group was 32.13, while in the control group was 27.20. The value of mean rank in the intervention group was 76.48 and the mean rank in the control group was 44.52, with p value = 0.000. It means that there were significant differences in term of independence between intervention family group control family group. The results showed a significant difference between before and after intervention in terms of independence of the family support groups for the intervention group, whereas for the control group there was no difference. Likewise, the results of independent test analysis for independence of the family in caring for TB clients after intervention in the intervention group and the control group showed a significant difference. Changes independence of the family in caring for client with TB empirically prove that the intervention model of family support groups were able to increase the independence of the family in caring for family members with TB. Social support that formed through group is very important to improve physical and mental health and can affect health behaviors, especially the independence of the family in caring for TB clients. Participatory education included groups discussion and regular follow-up will be more effective than the traditional approach, which focuses on the dissemination of information (William, Alarcon, Scatenavilla, et al, 2007). The independence of the family is increasing after getting intervention for family support group as a network of interpersonal relationships that provide friendship, help and emotional support. Group activities showed a concern, encouragement, empathy, service assistance, information and empowerment each other (Department of educational Training, 2008). Intervention strategy of family support group is an intervention strategy in the community nursing to increase the independence of the family through a family approach (care giver) in group situations ranging from the familiar problems, independence in performing nursing, use of health facilities, treatment, prevention actively and family were able to make efforts to increase health (promotion) Research of Nagarkar, Dhake and Jha (2012) in a qualitative study in the district of Pune in rural Maharastra (India), with 115 respondents, by doing 15 times the FGD, reported that the result of support and good care was considered as recipients of attention, help in daily routines, emotional support, morale, and motivation in the early recovery efforts. Family awareness of support needs to be strengthened through counseling, motivation in each visit as the key to success in clients completed treatment for TB
The success in the treatment or use of health facilities is one component of family independence. Research of Siswanto, Yanwirasti, and Usman (2015) suggested that there are very significant relationship between family support and medication adherence on the client pulmonary TB (p = 0.04). TB client's medication adherence for the client with family support was much higher compared with that of no family support. Other research in Surabaya by Hutapea (2006) also showed that the higher the level of family support the higher is the adherence of Pulmonary TB clients with a correlation coefficient of r = 0.210 and p value 0,001. Individuals who live in a supportive environment, to have better conditions than those do not have social support (Lamak, Kusnanto & Goddess, 2014). Eradication Program of Tuberculosis (TB P2) in Indonesia showed a significant increase in patients every year. Efforts to address and prevent the disease has not shown significant results, so it is not able to reduce morbidity and mortality. The most common problem is the difficulty of detecting patients with pulmonary TB BTA (+), and regular treatment on the client. Untreated TB cases will certainly continue to be a source of infection (Hutahaean, 2013). Therefore, activities in enhancing social support for families through family support is absolutely needed in enhancing the independence of the family and prevent the transmission, as well as improving the quality of life of clients. Research of Hutahaean (2013) in Sanglah Hospital also noted that the higher social support will results in higher quality of life for TB clients. To improve the independence of the family through a family support group, family also trained in preventing the transmission, treatment, regular medication and the use of health facilities so that quality of life is expected to increase. The family support group offering emotional support, sense of belonging, coping facilities and an informed understanding of the disease CONCLUSION AND RECOMMENDATION The family support group model was proven effectively increase the independence of the family in caring for clients with Tuberculosis. This is demonstrated by the findings that there were significant differences in the independence of family in caring of client with TB between before and after the intervention. The results of this study can be used as a model approach for community nurses in conducting family nursing, to increase the independence of the family in caring for clients with Tuberculosis. For the teacher of community nursing, these findings could be developed in the form of community service in improving the health status of the community, particularly through efforts to increase the independence of the family in caring for TB clients REFERENCES Departemen Kesehatan RI., (2006). Pedoman kegiatan perawat kesehatan masyarakat di Puskesmas. Jakarta : Direktorat Bina Pelayanan Keperawatan DepKes RI. Departemen of educational and training (The State of Queensland), (2008). Family Support, (Online), (educational. qld.gov.au/studenservice/peer support.html., diakses tanggal 02 Juni 2010). Dinkes Provinsi Jawa Barat, (2012). Profil Kesehatan. Bandung: Dinkes. Friedman, M.M., Bowden, V.R., & Jones, E.G., (2003). Family nursing : Research, theory& practice. Fifth edition. New Jersey : Pearson Education, Inc. Handayani, D., Sriati, A., & Widianti, E., (2013). Gambaran tingkat kemandirian pasien dalam mengontrol halusinasi setelah mengikuti TAK stimulasi persepsi. Jurnal Keperawatan Padjadjaran, 1(1), 60-65. Hutapea., P, (2006). Pengaruh dukungan keluarga terhadap kepatuhan minum obat anti Tuberkulosis, (Online), (www.google.scholar, diakses tanggal 02 Agustus 2014).
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