Chapter 2

REVIEW OF RELATED LITERATURE

This chapter presented a review of related literature and studies relevant to the research

entitled “Factors Influencing Treatment Adherence on Tuberculosis among Enrolled Clients in

Marawi City A Mixed Methods Study.” The review synthesized theoretical and empirical works

related to tuberculosis (TB) treatment adherence, socio demographic factors, economic and

health system challenges, psychosocial influences, and lived experiences of TB enrolled clients.

The literature and studies reviewed provided a strong foundation for understanding the variables

of the study and identifying gaps that the present research sought to address. The review was

presented thematically, with each discussion supported by reliable sources arranged logically to

support the research framework.

Related Literature

Tuberculosis (TB) was identified as a chronic, communicable infectious disease caused

by Mycobacterium tuberculosis, an acid fast, aerobic, non motile, rod shaped bacterium. M.

tuberculosis possessed a unique lipid rich cell wall composed of mycolic acids, which rendered it

resistant to harsh chemical environments, desiccation, and destruction by traditional host

immune responses (World Health Organization [WHO], 2022). While the pathogen primarily

infected the lungs (Pulmonary TB), it could also disseminate via the hematogenous or lymphatic

systems to involve extrapulmonary sites (Extrapulmonary TB) such as the lymph nodes, pleura,

meninges, central nervous system, bones, joints, and genitourinary system. Understanding this

complex biological pathogenesis remained crucial because disease severity directly dictated

medication duration and physiological endurance.

 Primary Infection and Phagocytosis Upon reaching the alveoli, M. tuberculosis was

phagocytosed by resident alveolar macrophages. However, the bacillus prevented

phagolysosome fusion, surviving and multiplying intracellularly. This intracellular survival

mechanism allowed the pathogen to evade early innate clearance. Consequently, the host

immune system was forced to launch a prolonged adaptive cellular response.

Immune Response and Granuloma Formation Within 2 to 6 weeks, a cell mediated

immune response was initiated. T lymphocytes released cytokines (such as interferon gamma

and TNF alpha) to activate macrophages. Activated macrophages, epithelioid cells, and

Langerhans giant cells walled off the infected site, forming a microscopic nodule known as a

granuloma or Ghon focus. This structural containment prevented immediate bacterial

dissemination throughout the host.

Latent TB Infection In approximately 90% of immunocompetent individuals, the

immune system successfully sequestered the bacteria within the granuloma. The bacilli remained

viable but dormant; the individual remained asymptomatic and non infectious. However, this

latent state created a continuous risk of future reactivation. Host immune surveillance had to be

maintained perpetually to prevent bacterial escape.

Active TB Disease If the host’s immune system failed to contain the bacteria either

immediately or years later due to immunosuppression, aging, malnutrition, or stress, the

granuloma underwent caseous necrosis. The center liquefied, ruptured into adjacent airways, and

created lung cavities. This resulted in symptomatic, active, and contagious TB disease. Such

active destruction required long term, multi drug pharmacological regimens to achieve total

bacterial eradication.

Conceptual and Evolutionary Frameworks of Treatment Adherence

 Treatment adherence in tuberculosis care was defined as the extent to which a patient’s

behavior taking medication, following diets, or executing lifestyle changes corresponded with

agreed recommendations from a healthcare provider (WHO, 2022). Historical paradigms viewed

adherence strictly as passive compliance; however, modern nursing literature emphasized

adherence as a collaborative therapeutic contract (Gunawan et al., 2024). Rodgers’ evolutionary

concept analysis demonstrated that TB adherence encompassed biological, individual, social,

health service, and policy level dimensions (Gunawan et al., 2024). Achieving adherence

required an objective understanding of the treatment plan, effective provider patient

communication, and host confidence in the therapeutic alliance. Studies published in PubMed

indexed journals highlighted that TB adherence was a complex behavioral process rather than a

purely biomedical concern, where patients often struggled with long treatment duration, pill

burden, adverse drug effects, and competing life priorities (Munro et al., 2017).

Socio Demographic Profile and Clinical Determinants

Literature consistently identified demographic and clinical attributes as key predictors of

treatment completion. Younger patients were more likely to default due to employment demands,

mobility, and perceived invulnerability, while males frequently displayed lower adherence than

females due to work related migration, occupational demands, and social roles (Zenner et al.,

2017; Pradipta et al., 2018; WHO, 2022). Educational attainment directly governed health

literacy, enabling clients to navigate multi drug daily schedules and understand drug resistance

mechanisms. Individuals with higher educational attainment tended to show better adherence,

whereas low educational attainment was associated with misconceptions about TB and early

treatment discontinuation (Tola et al., 2016).

 Marital status served as a protective buffer, as spouses often provided emotional,

practical, and instrumental support (Pradipta et al., 2018). Income played a critical role, as low

income patients faced financial pressures and indirect costs that interfered with consistent clinic

attendance and medication intake (Pedrazzoli et al., 2019). Clinically, patients undergoing re-

treatment or those diagnosed with Drug Resistant TB (DR TB) faced severe pill burdens and

prolonged, toxic durations, which markedly heightened treatment fatigue and lowered adherence

compared to new, drug susceptible cases (Falzon et al., 2017). Patients with extrapulmonary TB

also discontinued treatment prematurely due to delayed symptom relief and reduced perception

of illness severity (Sharma & Mohan, 2020).

Structural Financial Constraints, Catastrophic Costs, and Economic Strain

Despite national policies offering free anti TB drugs under national programs, non

medical and indirect financial burdens remained significant obstacles. Patients routinely faced

out of pocket costs for daily transportation to TB DOTS centers, diagnostic re evaluations,

nutritional supplements, and severe wage loss resulting from physical debility or prolonged

clinic visits (Department of Health [DOH], 2020). A multi country study published in The

Lancet Global Health found that catastrophic costs remained a major cause of treatment

interruption among TB patients in low and middle income countries, forcing low income

households to prioritize immediate income generation over clinic visits (Pedrazzoli et al., 2019).

Consequently, economic strain severely undermined treatment completion even when

pharmaceutical drugs were distributed free of charge.

Health Systems Architecture, Accessibility, and Service Quality

The operational delivery of public health services directly regulated client adherence.

System level barriers included geographical isolation, long transit times to health centers,
extended clinic waiting hours, rigid medicine pick up schedules, and unexpected drug stockouts

(Gebreweld et al., 2018). Conversely, health systems that integrated flexible pick up schedules,

decentralized DOTS corners, respectful communication, empathetic counseling, and patient

centered counseling fostered therapeutic trust and significantly reduced lost to follow up (LTFU)

rates. These architectural elements highlighted that health facilities must actively adapt to patient

realities rather than expecting uniform compliance under rigid operational conditions.

Psychosocial Dynamics, Disease Stigma, and Family Support Systems

Tuberculosis remained heavily burdened by social stigma driven by fear of contagion,

social devaluation, and physical isolation. Stigma forced many clients to conceal their illness,

leading to fear of disclosure, avoidance of health facilities, irregular medication pickup, or

premature discontinuation to avoid public exposure (Courtwright & Turner, 2019). Mitigating

this burden required robust interpersonal support. Family members acted as critical “treatment

supporters” (Pengawas Menelan Obat or PMO) by providing medication reminders, emotional

reassurance, and practical help with daily chores, directly boosting client self efficacy and

treatment completion.

Cultural Realities, Traditional Beliefs, and Post Conflict Contexts

Health behaviors were deeply tied to socio cultural structures and community contexts. In

culturally distinct Muslim communities, such as the Meranaw population in BARMM, health

seeking behaviors were influenced by religious frameworks, family governance, and traditional

health beliefs. Moreover, in regions recovering from urban conflict or displacement (such as post

siege Marawi City), disrupted public health infrastructure, temporary relocation, and socio

economic displacement created unique structural barriers that complicated regular attendance at
healthcare facilities. Understanding these contextual nuances was vital for designing

interventions that resonated with local values and historical realities.

Intrinsic Motivation, Self Efficacy, and Psychological Resilience

Chronic illness literature stressed that long term medication adherence required

psychological resilience and strong intrinsic motivation (Nightingale et al., 2023). Clients who

possessed high intrinsic drive rooted in a desire to see their children grow, resume family

provider roles, or regain physical strength exhibited higher persistence despite severe drug side

effects like nausea, joint pain, or fatigue. Psychological resilience enabled clients to view

temporary treatment discomforts as necessary steps toward full recovery rather than reasons to

stop medication (Nightingale et al., 2023). Building psychological fortitude among patients

proved to be an indispensable non pharmacological component of treatment adherence.

Adverse Drug Reactions and Physiological Pill Burden

Therapy related factors, specifically adverse drug reactions, were well documented

physiological triggers for treatment default (Pradipta et al., 2018). First line anti TB drugs

frequently induced gastrointestinal distress, hepatotoxicity, joint pain (pyrazinamide induced

hyperuricemia), peripheral neuropathy, and skin eruptions. Without proactive clinical counseling

and side effect management by community health nurses, unmanaged ADRs led to spontaneous

self dose reduction or complete medication cessation by clients seeking temporary relief

(Pradipta et al., 2018). These physical symptoms often overwhelmed patients who lacked clear

guidance on managing side effects safely.

Health Literacy, Misconceptions, and Disease Transmission Knowledge

Health literacy encompassed a client’s ability to obtain, process, and understand basic

health information necessary to make informed health decisions (Xu et al., 2020). Widespread
misconceptions regarding TB transmission such as attributing the infection to hard physical

labor, heredity, or supernatural causes rather than bacterial infection led to inappropriate self care

and early drug default once clinical symptoms improved. Structured, literacy adapted patient

education corrected these misconceptions and reinforced the need to complete the full 6 month

regimen. Elevating disease knowledge empowered patients to become active participants in their

own recovery.

Related Studies

Empirical studies from global and local contexts provided evidence for the challenges

discussed in the literature, reinforcing the necessity for context specific research in Marawi City.

Foreign Studies

Tola et al. (2016) Conducted a mixed methods study in Ethiopia evaluating TB adherence

factors. Quantitative results demonstrated that higher educational attainment, steady

employment, and strong family support significantly increased adherence. The qualitative arm

revealed that catastrophic out of pocket costs and poor disease understanding were primary

drivers of default. These findings underscored the necessity of combining structural financial

assistance with comprehensive health education.

Horter et al. (2016) Studied the effects of family centered care on TB treatment

adherence across several African nations. The findings revealed that patients who received

consistent emotional and logistical support from family members were substantially more likely

to complete their medication regimen. Qualitative interviews emphasized that family

involvement reduced feelings of social isolation and helped patients cope with difficult drug side

effects. Ultimately, the study recommended formalizing household level support networks within

community health programming.

 Munro et al. (2017) Conducted a qualitative systematic review of TB adherence in low

and middle income nations. They identified four major themes influencing adherence structural

factors (poverty, health service access), personal factors (knowledge, attitudes), social context

(stigma, family dynamics), and health service dynamics (relationship with healthcare staff). The

synthesis revealed that adherence was heavily mediated by interconnected socio economic and

relational barriers. Consequently, successful TB management required holistic interventions

beyond standard drug distribution.

Zenner et al. (2017) Analyzed risk factors for TB treatment non adherence in a large

cohort study conducted in the United Kingdom. Results showed that younger age, substance use,

and unstable living conditions were significantly associated with treatment interruption. The

researchers noted that socially vulnerable populations experienced competing priorities that

overshadowed daily medication routines. They concluded that targeted social support services

were required alongside clinical care to maintain compliance.

Falzon et al. (2017) Investigated adherence patterns among patients with multidrug

resistant tuberculosis across multiple countries. The study revealed that long treatment duration

and severe adverse drug reactions led to higher rates of non adherence. Patients frequently

reported severe treatment fatigue due to high daily pill burdens and prolonged toxicity. The

authors emphasized the need for shorter, less toxic regimens combined with active side effect

monitoring.

Pradipta et al. (2018) Analyzed TB determinants in Indonesia using a quantitative cohort

design. Findings indicated that younger age, male sex, lack of treatment supporters (Pengawas

Menelan Obat or PMO), unemployment, and medication side effects were statistically significant

predictors of non adherence. The study emphasized that unmonitored physiological side effects
combined with social obligations increased treatment default. Thus, community based treatment

supporters were deemed vital for sustaining client motivation.

Wingfield et al. (2018) Examined the impact of poverty on tuberculosis treatment

outcomes in resource limited settings. The study found that patients living in poverty were more

likely to interrupt treatment due to competing survival needs. Financial vulnerability forced

many individuals to abandon clinic visits in favor of immediate daily wage generation. The

authors advocated for social protection schemes and economic mitigation strategies to shield

vulnerable households from treatment failure.

Pedrazzoli et al. (2019) Investigated catastrophic costs among TB patients across

multiple LMICs in a global study. Results demonstrated that despite free medication, indirect

costs specifically lost income and transportation costs led to a 3 fold increase in treatment default

rates among economically disadvantaged households. These hidden expenses placed immense

economic strain on families, frequently resulting in premature drug cessation. The study called

for comprehensive social protection policies to achieve universal health coverage goals.

Datiko et al. (2020) Conducted a qualitative study in Ethiopia examining patient

perspectives on healthcare worker interactions. Results showed that respectful communication,

empathetic counseling, and flexible medicine pick up times directly boosted patient compliance

and trust in the health system. Conversely, negative staff attitudes and rigid administrative

procedures created significant obstacles to care continuity. The findings highlighted provider

empathy as a key determinant of patient retention.

Xu et al. (2020) Examined the relationship between health literacy and treatment

completion among pulmonary TB clients in China. Quantitative regression revealed that patients

with low health literacy scores were 2.4 times more likely to discontinue medication prematurely
compared to those with high literacy. Limited health literacy directly hindered patients' ability to

comprehend dosing schedules and drug side effects. The study highlighted tailored health

education as a necessary strategy for improving treatment retention.

Thomas et al. (2020) Assessed health system barriers to TB treatment adherence in India.

The study identified long waiting times, inadequate counseling, and limited access to health

facilities as major contributors to non adherence. Patients frequently expressed frustration over

operational inefficiencies that disrupted their daily schedules. The authors concluded that

optimizing service quality and facility access was crucial for sustaining long term patient

engagement.

Sharma and Mohan (2020) Investigated treatment adherence challenges among patients

with extrapulmonary tuberculosis in India. The study found that delayed symptom improvement

often led patients to stop treatment early. Because extrapulmonary manifestations did not always

resolve rapidly, patients mistakenly assumed the medication was ineffective. The authors

stressed the importance of specialized patient counseling regarding slow clinical resolution in

extrapulmonary cases.

Al Sindi et al. (2024) Conducted a cross sectional study in Dili, Timor Leste, evaluating

medication adherence levels and health system determinants among adult TB clients. Results

showed a low adherence rate (73.6% non adherent/low adherence). Strong positive predictors of

adherence included favorable health service interactions, whereas high community stigma

significantly reduced adherence likelihood. The study concluded that improving healthcare

delivery while actively fighting community stigma was essential for rising adherence rates.

Nightingale et al. (2023) Investigated psychological distress, treatment adherence, and

coping mechanisms among TB clients in Uganda using a mixed methods approach. Quantitative
analysis revealed that clients with moderate to severe depression had a 3.2 times higher risk of

missing medication doses. Qualitative findings highlighted that intrinsic resilience and structured

family encouragement were key factors that helped clients persist through treatment. Integrating

mental health screening into routine TB care was recommended as a vital strategy.

Tesfaye et al. (2023) Conducted a cross sectional study in Eastern Ethiopia examining

structural barriers to anti TB drug adherence. Results indicated that travel distance to health

centers greater than 5 kilometers and daily transportation costs were significant predictors of

treatment interruption, supporting the need to address economic and geographic barriers. Long

distances forced low income patients to balance transportation expenses against household basic

needs. Decentralized medication delivery was suggested as a crucial policy mechanism.

Gebremichael et al. (2024) Performed a systematic review and meta analysis of 28

empirical studies across Sub Saharan Africa evaluating the impact of treatment supporters on TB

treatment adherence. Pooled odds ratios demonstrated that clients assigned a dedicated family or

community treatment supporter were 3.4 times more likely to complete therapy compared to

unsupported clients. The presence of a supporter provided both daily routine enforcement and

psychological encouragement. The study concluded that community based treatment supporters

remained a cornerstone of successful TB control programs.

Local Studies

Ylade et al. (2016) Conducted a study in the Philippines examining factors affecting TB

treatment adherence among enrolled clients. The findings showed that low income, limited

family support, and transportation difficulties contributed to non adherence. Financial constraints

severely restricted patients' ability to afford commute costs to local health units. The authors
stressed the need for community level support structures to alleviate these socio economic

bottlenecks.

Uy et al. (2018) Investigated TB related social stigma among urban and rural Filipino

patients using a mixed methods design. The study revealed that internalized stigma, fear of

discrimination, and fear of community isolation significantly delayed health seeking behavior

and led to covert, non adherent medication habits. Patients frequently skipped clinic visits to

prevent community members from learning about their diagnosis. The researchers concluded that

stigma reduction campaigns were urgently needed within local communities.

Miranda et al. (2019) Examined tuberculosis treatment outcomes in selected regions of

the Philippines. Results revealed that socio economic challenges continued to affect treatment

adherence despite free TB medications. Indirect costs and job insecurity were repeatedly

identified as major structural obstacles to consistent clinic attendance. The study highlighted that

free pharmaceuticals alone were insufficient without broader social support measures.

Tupasi et al. (2020) Examined nationwide TB program performance in the Philippines.

Findings emphasized that patient retention in long term treatment remained a national challenge,

with lost to follow up rates closely tied to poverty, treatment fatigue, and geographical distance

to health centers. The authors recommended decentralizing DOTS services to reduce travel

burdens on rural patients. Sustained retention required systemic program adaptations catering to

vulnerable populations.

Dela Cruz et al. (2020) Conducted a qualitative phenomenological study on the lived

experiences of Filipino TB clients during long term treatment. Themes highlighted that

household support systems, family obligations, emotional distress, financial burden, and

empathetic health workers were critical in motivating clients to maintain daily medication
routines despite external hardships. The emotional bond within families often served as the

primary motivation for patients to finish treatment. Empathetic interactions with health staff

further reinforced patient resolve during difficult phases of therapy.

Santos et al. (2021) Evaluated structured health education interventions in public health

centers in Luzon using a quasi experimental design. Results showed that patients who underwent

structured TB education sessions during the intensive phase showed a statistically significant

increase in treatment completion rates compared to those who received routine clinical care

alone. Educational modules helped demystify drug side effects and transmission myths.

Structured health education was recommended for standard implementation across primary care

facilities.

Bernardo et al. (2022) Examined TB program coverage and structural challenges in

post conflict communities in Mindanao. Findings highlighted that infrastructure deficits, post

conflict displacement, and poverty significantly lowered treatment completion rates compared to

non conflict areas. Disrupted facilities and temporary living arrangements rendered routine clinic

visits exceptionally difficult for displaced residents. The study emphasized the necessity for

tailor made public health approaches in post conflict environments.

Reyes et al. (2022) Evaluated community based counseling interventions and their

effect on TB treatment adherence in the Philippines. Findings showed that regular follow up and

counseling significantly improved adherence rates among TB patients. Personalized health

counseling helped build patient self efficacy and addressed personal anxieties early. The authors

advocated for continuous training of community health workers to deliver effective counseling.

Pangandaman et al. (2023) Investigated community based healthcare delivery and

health seeking behaviors in selected BARMM municipalities. Quantitative data showed that
financial instability, transportation costs, and geographical distance were major barriers to care

continuity. Qualitative themes highlighted the importance of culturally sensitive health

communication and the role of local health centers as safe environments for clients undergoing

long term treatment. Respecting local cultural norms proved vital for establishing institutional

trust among clients.

Rabe et al. (2023) Evaluated the economic burden and catastrophic health expenditures

among drug resistant TB (DR TB) clients in urban and semi urban health centers in the

Philippines. Findings revealed that 64.2% of DR TB affected households experienced

catastrophic costs (exceeding 20% of annual household income), driven primarily by lost daily

wages and travel costs. Catastrophic cost was significantly associated with treatment default. The

authors called for targeted financial subsidy programs for DR TB patients.

Navarro et al. (2023) Investigated culturally sensitive TB care practices in Mindanao.

The study found that culturally appropriate communication and respect for local beliefs enhanced

patient cooperation and adherence. When healthcare workers incorporated indigenous and

religious sensitivities into patient counseling, compliance rates improved significantly. The

findings demonstrated the importance of cultural competence in regional healthcare delivery.

Mukattil & Pangandaman (2024) Employed a mixed methods design among TB

enrolled clients in Jolo, Sulu (a comparable BARMM context). Quantitative findings identified

financial constraints (31.8%) and distance/transportation (20.5%) as primary adherence barriers.

Qualitative themes revealed Contagious yet treatable disease , Challenging family socio

economic status , Role justification within the family , and Treatment centers as havens . These

qualitative insights illustrated how patients balanced social obligations with clinical demands

within distinct socio cultural environments.

 Flores et al. (2025) Explored nurse perspectives and client experiences regarding

adherence barriers in Cabanatuan City through a qualitative study. Results revealed three core

themes Hidden Hurdles of TB Treatment (side effects, economic strains), Beyond Pills

Empowering TB Patients (family/social support), and The Patient’s Drive (self efficacy and

flexible health worker care). Nurses emphasized that client empowerment was key to

overcoming medication fatigue. Collaborative nurse patient relationships were shown to mitigate

structural treatment obstacles.

Maglangit & Hassan (2025) Conducted a descriptive cross sectional study assessing

health literacy, disease perception, and treatment adherence among adult TB clients in Lanao del

Sur. Results showed that 58.0% of respondents had moderate to low health literacy. Health

literacy was positively correlated with medication adherence. Clients with higher disease

knowledge reported fewer missed doses during the continuation phase. The study highlighted the

urgency of designing literacy appropriate educational tools for local populations.

Synthesis of the Reviewed Literature and Studies

The review of related literature and studies revealed that tuberculosis treatment adherence

was influenced by multiple interrelated factors rather than a single determinant. Foreign and

local studies consistently identified socio demographic variables such as age, sex, educational

attainment, marital status, and employment as significant predictors of adherence. Younger

patients, males, and those with lower educational levels were more likely to interrupt treatment

due to limited health literacy, work related demands, and lower perceived severity of the disease.

These findings emphasized that individual and social characteristics played an important role in

sustaining long term adherence to tuberculosis treatment.

 Economic and health system related factors also emerged as major influences on

treatment adherence. Although anti tuberculosis medications were provided free of charge,

indirect costs such as transportation, food expenses, and loss of income continued to hinder

treatment completion, particularly among economically disadvantaged patients. In addition,

foreign and local studies highlighted that poor access to health facilities, long waiting times,

inadequate counseling, and weak provider–patient relationships contributed to non adherence.

Conversely, patient centered care, regular follow up, and supportive health workers were found

to improve adherence outcomes.

Psychosocial and disease related factors further shaped patients’ adherence behavior.

Tuberculosis related stigma, fear of discrimination, lack of family support, and emotional

distress discouraged patients from continuing treatment, while strong family involvement and

community support enhanced adherence. Moreover, treatment related challenges such as long

treatment duration, medication side effects, and delayed symptom improvement increased the

likelihood of treatment interruption. Despite extensive foreign and local studies on these factors,

limited research had employed a mixed methods approach in culturally distinct settings such as

Marawi City. This gap underscored the importance of the present study in providing a

comprehensive and contextualized understanding of tuberculosis treatment adherence among

enrolled clients in the area.