# Situation: The father, 40, a construction worker, has bacteriologically confirmed pulmonary tuberculosis (TB) and started treatment 2 months ago at the Rural Health Unit (RHU), 12 km from home. The family of five lives in a one-room house with small windows that are kept closed. The children are 3, 7, and 12 years old. A barangay health station (BHS) with a midwife is within walking distance of the home. The family cannot pay the daily fare to the RHU, and the father has missed 9 of his doses in the last 2 weeks. He wants to continue treatment. Which arrangement for his remaining doses is BEST?

> source: MyMerci (mymerci.kr)  
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> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: The father, 40, a construction worker, has bacteriologically confirmed pulmonary tuberculosis (TB) and started treatment 2 months ago at the Rural Health Unit (RHU), 12 km from home. The family of five lives in a one-room house with small windows that are kept closed. The children are 3, 7, and 12 years old. A barangay health station (BHS) with a midwife is within walking distance of the home.

The family cannot pay the daily fare to the RHU, and the father has missed 9 of his doses in the last 2 weeks. He wants to continue treatment. Which arrangement for his remaining doses is BEST?

## 보기

1. Have the BHS midwife watch him take each daily dose **✔ 정답**
2. Have him take his doses at the RHU on days he can pay the fare
3. Have his 12-year-old son watch him take each dose at home
4. Give him a 1-month supply to take at home on his own

**정답: 1**

## 해설

Every option removes part of the fare problem, but after many missed doses each dose should be taken under the observation of a trained, responsible treatment supporter, and the BHS within walking distance provides this without cost of travel. A month's supply without supervision repeats the conditions under which doses were missed, a 12-year-old child is not a responsible treatment supporter for an adult, and taking doses only on days he can pay keeps the treatment intermittent, risking failure and drug resistance.

## 심화 해설

Core issue

The father has bacteriologically confirmed pulmonary TB and has already missed 9 doses in 2 weeks. The central problem is not simply access to drugs, but ensuring that every remaining dose is actually swallowed under the direct observation of a trained, responsible treatment supporter. Once a patient has demonstrated this degree of non-adherence, unsupervised or weakly supervised options reproduce the conditions that led to missed doses and increase the risk of treatment failure and drug resistance.

Why option 1 is the best arrangement

The BHS midwife is a trained health worker located within walking distance of the home, so the family does not need to pay daily transportation to the RHU. Having the midwife observe each daily dose provides directly observed therapy without travel cost. The World Health Organization–endorsed DOT strategy requires that a health worker, community volunteer, or family member observe and record each dose to strengthen adherence [3]. In this scenario, the midwife is the only option that combines training, accountability, and zero transportation cost.

The systematic review and meta-analysis by Wright et al. compared community-based DOT with clinic DOT and found that community-based delivery can achieve TB treatment outcomes comparable to conventional clinic-based observation [1]. In this case, the BHS functions as the community-based DOT site, and the midwife serves as the community health worker. This arrangement removes the fare barrier while preserving the essential element of direct observation.

Why the other options are unsafe

Option 2, taking doses at the RHU only on days the family can pay the fare, keeps treatment intermittent. Intermittent or irregular ingestion of antituberculous drugs is a major driver of acquired drug resistance and treatment failure. The Cochrane review by Karumbi and Garner emphasizes that incomplete treatment may lead to failure of cure and development of drug resistance [3]. Relying on the family’s ability to pay creates exactly the kind of irregularity that must be avoided.

Option 3, having the 12-year-old son observe each dose, places a child in the role of treatment supporter for an adult. A school-age child is not a trained or responsible treatment supporter, and this arrangement also shifts a clinical responsibility onto a minor. While family members can serve as DOT observers in some programs [3], the appropriateness of the observer depends on maturity, training, and reliability. A 12-year-old does not meet that standard for supervising an adult’s TB treatment.

Option 4, giving a 1-month supply for self-administration, abandons direct observation entirely. The patient has already missed 9 doses under conditions of unsupervised or poorly supervised intake. The Cochrane reviews comparing DOT with self-administration consistently note that DOT is a strategy to improve adherence because many patients do not complete treatment on their own [3]. Providing a month of medication without observation would repeat the very circumstances in which non-adherence occurred.

Pathophysiology and clinical reasoning

Pulmonary TB requires at least 6 months of continuous treatment [3]. The intensive phase, usually the first 2 months, is designed to rapidly kill actively multiplying bacilli and reduce infectivity. The continuation phase then eliminates persisting organisms to prevent relapse. Missing 9 doses during this period means the serum drug levels fall below the threshold needed to suppress mycobacterial growth, allowing surviving bacilli to resume replication. When drug exposure is intermittent, mycobacteria with spontaneous resistance mutations are selectively favored, which is the biologic basis for acquired drug resistance.

Because the father is a construction worker living in a one-room house with closed windows and three young children, the public health stakes are high. Continued sputum positivity from interrupted treatment prolongs household transmission risk. The 3-year-old and 7-year-old are especially vulnerable to progression from latent infection to active disease. Ensuring reliable, observed treatment is therefore both a clinical and a household infection-control priority.

Comparison of DOT arrangements

| Arrangement | Observer | Travel cost | Adherence protection | Judgment |
| --- | --- | --- | --- | --- |
| BHS midwife observes daily dose | Trained health worker | None, within walking distance | Strong, direct observation every dose | Best choice |
| RHU only on days fare is affordable | RHU staff | Variable, often unaffordable | Weak, intermittent dosing | Risk of failure and resistance |
| 12-year-old son observes at home | Child, untrained | None | Unreliable, inappropriate responsibility | Not acceptable |
| 1-month supply, self-administered | None | None | Absent, repeats non-adherence conditions | Unsafe |

Watch out! The presence of a nearby health facility does not by itself solve the adherence problem. The key is that the observer must be trained, responsible, and accessible without cost. Among the choices, only the BHS midwife satisfies all three conditions.

Key point! After multiple missed doses, the priority is to restore daily directly observed therapy through the most accessible trained provider. Removing the transportation barrier while maintaining observation is the central clinical decision in this scenario.References (research sources)

- [1]Community-based directly observed therapy (DOT) versus clinic DOT for tuberculosis: a systematic review and meta-analysis of comparative effectiveness.Meta-analysis/systematic reviewWright CM, Westerkamp L, Korver S, Dobler CC (2015) · DOI: 10.1186/s12879-015-0945-5

- [3]Directly observed therapy for treating tuberculosis.Research articleKarumbi J, Garner P (2015) · DOI: 10.1002/14651858.CD003343.pub4

## 임상 시나리오

Community-Based DOT for Non-Adherent TB PatientEnsuring Adherence Without Travel Cost
For a patient who has missed 9 doses in 2 weeks, every remaining dose must be taken under direct observation by a trained, responsible treatment supporter. The BHS midwife provides this service within walking distance, eliminating the daily transportation cost to the RHU.

Community-based DOT, such as at a BHS, achieves treatment outcomes comparable to clinic-based DOT. The midwife serves as the community health worker, observing and recording each dose to strengthen adherence.

CautionNever give a 1-month supply without supervision to a patient with demonstrated non-adherence, as this repeats the conditions that caused missed doses. A 12-year-old child is not a responsible treatment supporter for an adult.

## 핵심 개념

- **Directly Observed Therapy (DOT)** — A strategy where a trained health worker or designated person watches the patient swallow each dose of anti-TB medication to ensure adherence.
- **Treatment Supporter** — A trained, responsible individual who observes and records each dose taken by a TB patient.
- **Adherence** — The extent to which a patient follows the prescribed treatment regimen, including taking all doses at the correct times.
- **Drug Resistance** — The ability of TB bacteria to survive treatment, often caused by incomplete or intermittent therapy.
- **Barangay Health Station (BHS)** — A community-level health facility in the Philippines, typically staffed by a midwife, providing basic health services.

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