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Choi and Sung: The Development of a Scale Assessing the Risk of Discontinuation of Tuberculosis Treatment
Original Article

Korean J Adult Nurs 2015;27(2):156-169.

Published online: NaN April 2015

DOI: https://doi.org/10.7469/kjan.2015.27.2.156

The Development of a Scale Assessing the Risk of Discontinuation of Tuberculosis Treatment

Jin Ok Choi1, Kyung Mi Sung2

1Masan National Hospital, Masan

2College of Nursing Institute of Health Sciences, Gyeongsang National University, Jinju, Korea

Corresponding author: Sung, Kyung Mi College of Nursing Institute of Health Sciences, Gyeongsang National University, 816-15 Tel: +82-55-772-8246, Fax: +82-55-772-8222, E-mail: sung@gnu.ac.kr Jinju-daero, Jinju 660-751, Korea.

Received 3 December 20144 April 2015       Accepted 8 April 2015

Copyright © 2015 Korean Society of Adult Nursing

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

This studyidentified the reasons why tuberculosis (TB) patients withhold treatment inabid todevelop a assessment scale to select patients who needs nursing intervention in the early stage and decrease the risk of discontinuationof treatment. Sample: There were two samples. A sample of 191 patients with TB and having primary treatment anda secondsample of N who were under re-treatment

Methods

The studydesignincluded qualitativeandquantitativemethods. Qualitativedatawerecollectedfromin-depthinterviewsof TBpatients under re-treatment. The quantitative data were collected from 191 patients with TB under primary treatment.

Results

Exploratory factor analysis revealed 11 factors explaining 69.6% of total variance. These factors were categorized into four subgroups. A depression scale was used to establish concurrent validity. The depression scale had a positive relationship (r=54) with the discontinuing of primary treatment. The internal consistency reliability for the four subgroups was over. 84. The confidence coefficient was Cronbach's .95. The final scale was a self-reported ⍺ four Likert scale including 50 items.

Conclusion

Reliability and validity was established for the scaleand the scale can be used to examine the risk of treatment discontinuation for TB. The scaleis animportant resource for nursing interventions in identifying and treating high risk clients.

Keywords: Tuberculosis, Scale, Risk assessment, Withholding treatment

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Figure 1.
Scale development process for measuring the risk of tuberculosis treatment discontinuation.
kjan-27-156f1.tif
Table 1.
Item Analysis and Inter-Item Correlation and Reliability for Initial 67 Items (N=191)
Item contents M±SD Corrected item-total correlation Cronbach's ⍺ if item is deleted
1. I have financial difficulties due to job loss after the onset of TB. 3.13±0.97 .20 .97
2. I feel weak in whole body after the onset of TB. 3.08±0.83 .41 .97
3. I am easily tired after the onset of TB. 3.15±0.82 .40 .97
4. I lost much weight after the onset of TB. 3.08±1.03 .22 .97
5. I am socially withdrawn due to TB. 3.12±0.87 .50 .97
6. I am unemployed due to TB despite attempts to be employed. 3.06±0.92 .51 .97
7. People distance me since the onset of TB. 2.78±1.04 .63 .97
8. I lost social position and self esteem after the onset of TB. 2.94±0.93 .61 .97
9. I feel anxious and lonely due to TB. 2.94±0.97 .61 .97
10. I cannot be close to my family due to fear of contamination. 3.12±0.89 .60 .97
11. I worry if my family has been contaminated due to my cough. 3.16±0.88 .45 .97
12. My family distances me since the onset of TB. 2.27±1.15 .60 .97
13. I cannot openly interact with friends since the onset of TB. 2.86±1.02 .61 .97
14. I am very anxious I cannot have a normal social life compared to my friends since the onset of TB. 2.96±0.96 .54 .97
15. My friends avoid me since the onset of TB. 2.55±1.11 .61 .97
16. I don't want to show anyone my lung photos. 2.91±1.03 .44 .97
17. I think TB is an embarrassing disease. 3.04±0.96 .49 .97
18. I am afraid I will be known as a TB patient. 3.08±0.92 .56 .97
19. I don't want to tell people I was hospitalized for TB. 2.98±0.85 .40 .97
20. I take my TB medication in secret. 2.63±1.02 .62 .97
21. My life has become a mess since I became a TB patient. 2.76±0.97 .47 .97
22. I feel shameful because I cannot function as a person since the onset of TB. 2.86±0.94 .64 .97
23. I feel I lost my value since the onset of TB. 2.87±0.99 .66 .97
24. I feel helpless/powerless due to the reality of TB. 2.97±0.91 .61 .97
25. I feel others reject me if/when I wear a mask. 2.82±0.96 .56 .97
26. I feel I have become a weak person since I became a TB care patient. 2.76±0.96 .56 .97
27. I don't want to accept I have a contagious disease. 2.66±1.00 .58 .97
28. I feel less desperate for medication since my symptoms improved. 2.44±1.02 .57 .97
29. My will to take medication is progressively decreasing. 2.21±1.10 .68 .97
30. I thought about stopping treatment after my symptoms improved. 2.15±1.04 .59 .97
31. I often forget the seriousness of TB. 2.24±1.00 .48 .97
32. I have tried alternative medicine because I did not know the importance of medication. 2.02±1.05 .59 .97
33. I feel a rush of stress and pressure when I see large amounts of drugs. 2.90±0.88 .50 .97
34. It is difficult to take medication on time due to irregular meals. 2.65±1.03 .50 .97
35. I don't want to take medication because meals are no longer enjoyable since the onset of TB. 2.81±0.97 .57 .97
36. Sometimes, I don't want to take medication due to repulsion against forced treatment. 2.44±1.08 .54 .97
37. I cannot take medication on time due to the presence of others/other people. 2.18±1.10 .68 .97
38. I fear taking medication due to severe drug side effects. 2.59±0.91 .66 .97
39. My whole body aches when I take medication. 2.56±0.90 .65 .97
40. TB medication is so strong it makes my stomach ache. 2.71±0.97 .53 .97
41. I am distressed by severe nausea and vomiting. 2.70±1.06 .60 .97
42. I get acid reflux and my breath smells bitter. 2.63±0.98 .51 .97
43. I am tired of taking so much medication at once. 2.93±0.93 .46 .97
44. Remembering to take medication on my own is difficult. 2.86±1.00 .46 .97
45. I cannot regularly care for TB treatment. 2.62±1.00 .42 .97
46. I cannot regularly take medication due to my irregular lifestyle. 2.65±1.02 .41 .97
47. I often cannot make hospital visits due to irregular working hours. 2.45±1.09 .46 .97
48. I delayed treatment due to difficulty in selecting a follow up hospital. 2.25±1.03 .54 .97
49. I am reluctant to visit the hospital because there are many tests and long waiting hours. 2.26±1.02 .51 .97
50. It is inconvenient to visit a follow up hospital because it is far. 2.32±0.94 .48 .97
51. Hospital visits are burdensome because I am busy at/with work. 2.29±1.02 .50 .97
52. I have quit medication on my own accord due to powerlessness from TB. 2.48±1.05 .57 .97
53. I forget to take TB medication if/when I drink alcoholic beverages. 2.65±1.05 .51 .97
54. I often forget to take TB medication on a regular basis. 2.39±1.03 .52 .97
55. I don't have enough patience with treatment. 2.63±0.97 .52 .97
56. If I miss a prescription date, I get lazy and not go afterwards. 2.62±1.02 .46 .97
57. I feel there are no visible improvements even if take medication. 2.53±0.86 .58 .97
58. I want to give up treatment, because I have lost trust in medical professionals. 2.01±0.99 .66 .97
59. I get nervous every time I get a test. 2.39±0.88 .53 .97
60. I feel TB medication is not a good treatment for me due to severe side effects. 2.14±0.97 .63 .97
61. I am anxious there seems to be no way to cure TB. 2.43±0.96 .54 .97
62. I feel there is no hope of improvement at my stage. 2.05±1.00 .62 .97
63. I fear I may die due to/ from TB. 2.46±1.06 .54 .97
64. I think TB will reoccur even if I am cured. 2.62±0.93 .44 .97
65. I am depressed only I got a disease. 2.40±0.96 .63 .97
66. I am anxious I will not be able to finish TB treatment due to medication tolerance. 2.49±0.96 .62 .97
67. I am hopeless, because I think I will never be cured. 2.25±0.99 .68 .97

TB=tuberculosis; Range of Inter-item correlation: .01 ＜r≤ .70.

Table 2.
Factor Analysis of the Scale of the Risk of TB Treatment Discontinuation (N=191)
Item contents Factor loading
1 2 3 4 5 6 7 8 9 10 11
Factor 1: Difficulties of interpersonal relationship
 15. My friends avoid me since the onset of TB. .74 .05 .27 .08 .24 .04 .07 .22 -.01 .08 -.12
 7. People distance me since the onset of TB. .73 .15 .15 .17 .20 .13 .01 .11 .12 .07 -.02
 14. I'm very anxious I cannot have a normal social life compared to my friends. .70 .30 -.05 .13 .03 .03 .14 .07 .05 .16 .04
 13. I cannot openly interact with friends since the onset of TB. .69 .25 .07 .17 .05 .22 .15 .10 -.08 .11 -.01
 9. I feel anxious and lonely due to TB. .66 .31 .13 .17 .05 .19 .03 .13 .17 -.18 .12
 8. I lost social position and self esteem after the onset of TB. .66 .32 .09 .10 .08 .24 -.11 .16 .18 -.11 .15
 12. My family distances me because of TB. .61 .07 .34 .17 .10 .20 .15 .11 -.23 .26 -.25
 6. I am unemployed due to TB despite attempts to be employed. .58 .18 .03 .20 .13 .16 -.08 -.08 .26 -.01 .20
 10. I cannot be close to my family due to fear of contamination. .56 .29 .16 .06 .11 .03 .28 .09 .22 .04 .06
Factor 2: Loss of self-competency as a human being
 24. I feel powerless due to the reality of TB. .20 .75 .22 .15 .01 .01 .11 -.02 .14 .14 .10
 23. I lost my value since the onset of TB. .30 .74 .19 .10 .07 .07 .16 .10 -.02 .11 .13
 22. I feel shameful because I cannot function as a person since the onset of TB. .36 .70 .06 .13 .05 .12 .06 .10 .04 .22 .05
 25. I feel others reject me if I wear a mask. .34 .67 .21 -.01 .03 .02 .09 .13 .07 -.12 .13
 27. I don't want to accept I have a contagious disease. .07 .62 .26 .14 .18 .12 .07 .23 .08 .01 -.18
 20. I take my TB medication in secret. .21 .60 .13 .11 .18 .15 .06 .44 -.05 .08 -.04
 26. I feel I have become a weak person since I became a TB care patient. .18 .59 .03 .20 .07 .29 -.05 .21 .06 .07 .01
 21. My life has become a mess since I became a TB patient. .18 .59 -.13 .18 -.04 .25 -.12 .07 .16 .31 .16
Factor 3: Loss of primary importance for therapeutic compliance
 31. I often forget the seriousness of TB. .01 .02 .75 .06 .10 .24 .10 -.01 .01 .08 .11
 28. I feel less desperate for medication since my symptoms improved. .05 .22 .72 .20 .11 .14 .06 .10 .09 -.05 -.06
 30. I thought about stopping treatment after my symptoms improved. .20 .02 .72 .03 .22 .18 .15 .10 .06 .10 .15
 29. My will to take medication is decreasing. .22 .17 .70 .27 .14 .18 .04 .10 .03 .09 .01
 32. I have tried alternative medicine because I did not know the importance of medication .16 .16 .61 .14 .13 .29 -.04 .14 -.07 .11 .07
 36. Sometimes, I don't want to take medication due to repulsion against forced treatment .06 .22 .59 .15 .30 -.01 .22 -.13 -.12 .12 .08
 58. I want to give up treatment, because I have lost trust in medical professionals. .20 .19 .57 .25 .42 .12 .01 -.02 -.03 .04 .05
Factor 4: Difficulties to overcome side effects from anti-TB medicines
 41. I am distressed by severe nausea and vomiting. .25 .13 .24 .78 .16 .02 .12 -.01 .03 .06 .03
 40. TB medication is so strong it makes my stomach ache. .14 .20 .16 .77 .12 -.01 .02 .02 .03 .11 -.07
 42. I get acid reflux and my breath smells bitter. .21 .03 .12 .76 .10 .06 .01 .05 .09 .13 .14
 43. I am tired of taking so much medication at once. .08 .11 .09 .70 -.05 .13 .26 .02 .01 .13 .20
 39. My whole body aches when I take medication. .14 .32 .24 .64 .18 .10 .07 .24 .09 -.09 -.05
Factor 5: Failure of medication adherence
 54. I often forget to take TB medication on a regular basis. .19 .05 .21 .11 .81 .12 .04 .16 .01 -.05 .12
 55. I don't have enough patience with treatment. .09 .05 .28 .14 .74 .04 .20 .01 -.01 .12 .07
 56. If I miss a prescription date, I get lazy and not go afterwards. .11 .10 .31 .08 .68 .15 .14 -.09 .03 -.01 -.14
 53. I forget to take TB medication when I drink alcoholic beverages. .23 .07 .07 .10 .63 .14 24 .20 -.05 .03 .25
Factor 6: Inconvenience of medical center use
 49. I am reluctant to visit the hospital because there are many tests and long waiting hours. .20 .17 .18 .11 .09 .78 .09 .02 .09 -.08 -.07
 50. It is inconvenient to visit a follow up hospital because it is far. .21 .10 .28 .01 -.03 .70 .04 .11 -.02 .14 .06
 48. I delayed treatment due to difficulty in selecting a follow up hospital. .16 .21 .22 .06 .18 .70 .21 -.01 .06 .07 -.21
 51. Hospital visits are burdensome because I am busy at/with work. .15 .09 .23 -.00 .15 .68 .06 .03 .06 .11 .29
 47. I often cannot make hospital visits due to irregular working hours. .04 .08 .17 .15 .36 .51 .38 -.05 .03 .01 -.06
Factor 7: Having difficulties in maintaining self-care for the TB
 45. I cannot regularly care for TB treatment. .08 .08 .24 .14 .12 .04 .80 .10 -.02 -.06 .09
 46. I cannot regularly take medication due to my irregular lifestyle. .18 .08 .02 .03 .24 .23 .77 .03 .06 .03 -.01
 44. Remembering to take medication on my own is difficult. .04 .05 .05 .46 .19 .17 .59 .07 .07 -.02 .19
Factor 8: A sense of shame as a TB patient
 18. I'm afraid I will be known as a TB patient. .38 .23 .13 .05 .07 .01 .12 .71 .12 .14 .13
 17. I think TB is an embarrassing disease. .38 .20 .10 -.05 .05 .05 .09 .71 .01 .17 .22
 19. I don't want to tell people I was hospitalized for TB. .02 .30 .01 .16 .04 .05 .01 .65 .05 -.08 -.22
Factor 9: Low physical strength to put up with the compliance
 3. I am easily tired after the onset of TB. .12 .04 .02 .12 .04 .12 .01 .09 .85 .17 .07
 2. I feel weak in whole body after the onset of TB. .22 .24 -.02 .05 -.05 .02 .07 .02 .79 .17 -.12
Factor 10: A pessimistic view of the outcome from TB therapy
 64. I think TB will reoccur even if I'm cured. .10 .17 .19 .16 -.01 .05 -.01 .09 .25 .78 -.03
 63. I fear I may die from TB. .11 .28 .18 .20 .12 .14 -.03 .06 .17 .67 .15
Factor 11: Emotional burden to take anti-TB medicines
 33. I feel a rush of stress and pressure when I see large amounts of drugs. .08 .18 .30 .34 .18 -.02 .12 .04 .05 .05 .57
 34. It is difficult to take medication on time due to irregular meals. .10 .26 .20 .23 .26 .05 .30 .02 -.16 .10 .52
 Eigen value 5.41 4.89 4.55 3.82 3.18 3.18 2.46 2.17 1.89 1.73 1.43
 Explained Variance (%) 10.8 9.8 9.1 7.7 6.4 6.4 4.9 4.3 3.8 3.5 2.9
 Accumulative Variance (%) 10.8 20.6 29.7 37.4 43.8 50.2 55.1 59.4 63.2 66.7 69.6

TB=tuberculosis.

Table 3.
Correlation between the Risk of TB Treatment Discontinuation and Depression (N=191)
Variables Risk of TB treatment discontinuation
F1 F2 F3 F4 F5 F6 F7 F8 F9 F10 F11 Total
r (p) r (p) r (p) r (p) r (p) r (p) r (p) r (p) r (p) r (p) r (p) r (p)
Risk of treatment discontinuation F1 1
   
F2 .65 1
  (＜.001)  
F3 .47 .45 1
  (＜.001) (＜.001)  
F4 .44 .44 .50 1
  (＜.001) (＜.001) (＜.001)  
F5 .37 .28 .56 .34 1
  (＜.001) (＜.001) (＜.001) (＜.001)  
F6 .41 .38 .53 .29 .48 1
  (＜.001) (＜.001) (＜.001) (＜.001) (＜.001)  
F7 .35 .29 .41 .44 .47 .39 1
  (＜.001) (＜.001) (＜.001) (＜.001) (＜.001) (＜.001)  
F8 .71 .57 .26 .24 .24 .25 .20 1
  (＜.001) (＜.001) (＜.001) (.001) (.001) (.001) (.005)  
F9 .34 .35 .116 .25 .06 .17 .12 .26 1
  (＜.001) (＜.001) (.111) (＜.001) (.45) (.016) (.093) (＜.001)  
F10 .37 .46 .39 .39 .21 .25 .20 .28 .37 1
  (＜.001) (＜.001) (＜.001) (＜.001) (.004) (＜.001) (.006) (＜.001) (＜.001)  
F11 .32 .40 .49 .49 .39 .24 .42 .22 .08 .32 1
  (＜.001) (＜.001) (＜.001) (＜.001) (＜.001) (.001) (＜.001) (.002) (.258) (＜.001)  
Total .81 .78 .77 .68 .62 .65 .58 .57 .38 .54 .57 1
  (＜.001) (＜.001) (＜.001) (＜.001) (＜.001) (＜.001) (＜.001) (＜.001) (＜.001) (＜.001) (＜.001)  
Depression .39 .41 .55 .40 .30 .33 .22 .24 .17 .32 .36 .54
(＜.001) (＜.001) (＜.001) (＜.001) (＜.001) (＜.001) (.003) (.001) (.017) (＜.001) (＜.001) (＜.001)

TB=Tuberculosis.

Table 4.
Reliability for the Final 50 Items (N=191
Variables Factor Factor name (number of item) M±SD Cronbach's ⍺ SEM
The stigma of being a TB patient F1 Difficulties of interpersonal relationship 2.84±0.70 .87 .25
F2 Loss of self-competency as a human being 2.79±0.74 .89 .24
F8 A sense of shame to become a TB patient (20 items) 3.03±0.76 .78 .36
Sub-total     2.92±0.65 .93 .16
Loss of patient role for TB treatment F3 Loss of primary importance for therapeutic compliance 2.21±0.79 .88 .28
F10 A pessimistic view of the outcome from TB therapy (9 items) 2.53±0.89 .74 .45
Sub-total     2.49±0.69 .87 .21
An obstacle to complete treatment for the TB F4 Difficulties to overcome side effects from anti-TB medicines 2.71±0.78 .86 .29
F6 Inconvenience of medical center use 2.31±0.80 .84 .32
F9 Low physical strength to put up with the compliance (12 items) 3.12±0.75 .80 .34
Sub-total     2.70±0.67 .84 .19
A lack of will to the therapeutic adherence F5 Failure of medication adherence 2.57±0.84 .84 .34
F7 Having difficulties in maintaining self-care for the TB 2.71±0.84 .78 .40
F11 Emotional burden to take anti-TB medicines (9 items) 2.77±0.84 .70 .46
Sub-total     2.69±0.71 .85 .28
Total   50 items 2.66±0.54 .95 .12

SEM=standard error of measurement; TB=tuberculosis.

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