E:\2021\NERS APRIL 2021\13-jurn 85Nuwa, Kiik, The Effect of Self Management Education on Knowledge and ... The Effect of Self Management Education on Knowledge and Self Efficacy of Pulmonary TB Clients in Timor Tribal Community Muhammad Saleh Nuwa1, Stefanus Mendes Kiik2 1,2Department of Nursing, STIKes Maranatha Kupang, Indonesia JURNAL NERS DAN KEBIDANAN (JOURNAL OF NERS AND MIDWIFERY) http://jnk.phb.ac.id/index.php/jnk JNK History Article: Received, 08/01/2020 Accepted, 03/02/2021 Published, 05/04/2021 Keywords: Self Management Education, Knowl- edge, Self Efficacy, Pulmonary TB Article Information Abstract Background: Pulmonary Tuberculosis (TB) disease is still the main cause of death among the poor with low knowledge. Knowledge and self efficacy are the keys to the successful management of pulmonary TB. Objective: The purpose of this study was to investigate the effect of self management edu- cation (SME) by emphasizing the five pillars of TB management on knowl- edge and self efficacy of pulmonary TB clients in the Timor tribal community in Kupang, Indonesia. Methods: This quasi-experimental study was con- ducted on 30 primary pulmonary tuberculosis patients who undergoing treat- ment for 6 months with self-management educational interventions that had never been obtained before.The research was conducted from January to October 2020 in the working area of the Naibonat Community Health Center, Kupang Regency. The data were collected using a questionnaire on demo- graphic data, knowledge and self efficacy which had been tested for validity and reliability. The data were analyzed by the Paired T-test with SPSS 21. Results: The mean score of pre test knowledge and self efficacy of clients with pulmonary TB, respectively, 5.23 ± 1.04 and 4.77 ± 1.07 increased signifi- cantly to 6, 33 ± 1.18, and 7.13 ± 0.94 on the post test (P <0.001) with a large difference of increase of 1.10 ± 1.18 for knowledge and 2.37 ± 1.27 for self- efficacy. Conclusion and Recommendation: giving SME by emphasizing the five pillars of pulmonary TB management increases the knowledge and self- efficacy of pulmonary TB clients in the Timor tribal community. The recom- mendation of this study is that SME interventions can be used as one of the nursing interventions in the public health center in community empower- ment based pulmonary TB management. 85 Correspondence Address: STIKes Maranatha Kupang – NTT, Indonesia P-ISSN : 2355-052X Email: musa.nuwa@gmail.com E-ISSN : 2548-3811 DOI: 10.26699/jnk.v8i1.ART.p085–093 This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/) © 2021 Journal of Ners and Midwifery https://crossmark.crossref.org/dialog/?doi=10.26699/jnk.v8i1.ART.p085-093&domain=pdf&date_stamp=2021-04-15 https://doi.org/10.26699/JNK.V8I1.ART.P085-093 86 Jurnal Ners dan Kebidanan, Volume 8, Issue 1, April 2021, page 85–93 INTRODUCTION Pulmonary tuberculosis (TB) is a disease that attacks the lung parenchyma (WHO, 2020a). Until now, pulmonary TB disease is still the 10th cause of death in the world. It is estimated that 10 million people a r e infected with tuber culosis (T B) worldwide in 2018 which affects 5.7 million men, 3.2 million women, and 1.1 million children with 1.5 million people dying from this disease (WHO, 2018). Eight countries Accounted for 87% of the world’s total new TB cases in 2018 with India leading the tally, followed by China, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh, and South Africa. Treatment adherence is a major factor in the failure of the pulmonary TB treatment program (WHO, 2020 &Yakhelef et al., 2020). The prevalence of pulmonary TB in Indonesia is 420,994 cases in 2017 (data as of May 17, 2018). Based on gender, the number of new TB cases in 2017 in men was 1.4 times greater than in women. Based on the Tuberculosis Prevalence Survey, the prevalence in men is 3 times higher than in women. This is probably because men are more exposed to TB risk factors such as smoking and lack of adherence to taking medication. (KEMENKES RI, 2018a). Based on the data from the global TB report 2020, the prevalence of TB in Indonesia is known to be 570,289 cases in 2018 and decreased to 543,784 cases in 2019. This figure is not significant, because many cases of resistant TB are due to non- adherence to taking medication (WHO, 2020b). The province of East Nusa Tenggara (NTT) is one of the provinces with high TB cases. Based on the results of basic health research (2018), it is known that the number of patients diagnosed with TB is 0.27% of the national figure, namely 0.42% (KEMENKES RI, 2018b). Kupang is one of the districts with a high incidence of TB in NTT. In 2015, there were 162 cases, decreasing to 31 cases in 2016 and then increasing to 230 cases in 2017 and 461 cases in 2018 (NTT Provincial Statistics Agency, 2020). One of the biggest contributors to the increase in pulmonary TB cases in Kupang is the Timorese who live in the working area of the Naibonat Public Helath Center. In 2017 there were 69 cases and increased to 76 cases in 2018 (PuskesmasNaibonat Medical Record, 2020). Based on the results of interviews with the person in charge of the TB program at the Naibonat Public Helath Center, it is known that the Timorese are a community at risk because they are known for their lack of concern for their health. Several things cause this indifference, namely, ignorance, unwillingness, and stubbornness. This condition causes the health education provided to have no impact on increasing knowledge of attitudes and actions in pulmonary TB management. Many incidents of multiple drug resistance (MDR) TB are problems that arise due to non-compliance with ta king medica tion. T his ma kes the level of complexity of the TB problem even higher. Various efforts have been made to overcome the problem of pulmonary tuberculosis in the working area of the Naibonat Public Health Center including Directly Observed Treatment, Short- course (DOTS) which has been implemented since 1995, and health education. Health officers also activated the role of the Public Health Nurse, a program knock on the door of TB and TOSS TB (Find Treat until Cured) to reduce the incidence of pulmonary TB, but these efforts have not yielded maximum results. The low awareness of TB clients (Self-efficacy) is thought to be the most determining factor in the management of pulmonary TB in the Timor tribe community. Self-efficacy is defined as an individual’s belief in his or her abilities which is necessary for self- motivation (Moradi, Nasiri, Jahanshahi, Hajiahmadi, 2019 &Bahtiar, Nursasi, 2019). Lack of efficacy is one of the causes of lack of adherence to treatment protocols and negative health behaviors in pulmonary TB clients. Self-efficacy can be increased by providing information to clients (Ba htia r &Nur sa si, 2019) (Ma ula , Nur sa si, &Wiarsih, 2019). According to Masyfahani, (2019) pulmonary tuberculosis is a disease that is difficult to overcome even with the DOTS strategy. This is because the treatment takes a long time, and the sufferers need compliance. Handling TB clients apart from its emphasis on trea tment, we need to focus on empowering clients to be actively involved in pulmonary TB care. One effort that can be given is to provide self-management education (SME). SME is a method, guidelines, counseling, and behavioral intervention to increase knowledge and self-efficacy regarding tuberculosis and improve individual and family skills in managing pulmonary TB disease (Wei, Omar, 2017 &Masyfahani, 2019). The effectiveness of SME both in clients with pulmonary TB and in other diseases separately has 87Nuwa, Kiik, The Effect of Self Management Education on Knowledge and ... been widely studied. SME can improve the quality of life, medication adherence behavior, seeking medical assistance, blood pressure control and self- efficacy in pulmonary TB clients, obstructive pulmonary disease and hypertension (Benzo et al., 2013; Wang, Lang, Xuan, Li, & Zhang, 2017; Masyfahani, 2019; Jauhar, Nursasi, &Wiarsih, 2019; Li et al., 2019; Moradi et al., 2019) This study aims to determine the effect of SME on knowledge and self-efficacy of pulmonary TB clients in Timorese tribal communities in Kupang, NTT province by emphasizing the five pillars of pulmonary TB management, namely increasing knowledge, taking medication behavior, fulfilling nutrition, physical activity, and preventing TB disease transmission. METHODS Type of Research, Population, Sample, Re- search Setting This research was a quasi-experimental study with a one group pre-test and post-test design without a control group by giving SME intervention to 30 pulmonary TB clients. The first 1-3 months) recorded in the medical records of the Naibonat Health Center with the age of 20-60 years. This design does not involve randomization in assigning subjects to treatment units (Boswell, C., & Cannon, S..2020) SME intervention was given for 12 weeks in 6 months of research, starting from April-September 2020 with emphasing on the five pillars of pulmonary TB management, namely increasing knowledge, taking medication behavior, fulfilling nutrition, physical activity, and preventing TB disease transmission. Ethical Clearance and Measurement Tools This research protocol has passed the ethical test of health research at the Health Research Ethics Commission of the Buleleng Bali College of Health Sciences with number 081 / SK-KEPK-SB / III / 2020. The measuring instrument used in this study wa s a knowledge questionna ir e about pulmonary tuberculosis and self-efficacy of TB clients which had been tested for validity and reliability by Masyfahani, (2019). The knowledge questionnaire used in this study consisted of 10 questions consisting of 1 question about the meaning of pulmonary tuberculosis, 1 question about signs & symptoms of pulmonary tuberculosis, 1 question about pulmonary TB disease examination, 1 question about pulmonary TB treatment, 1 question about side effects. Pulmonary TB treatment, 2 questions about TB treatment suppor t, 2 questions a bout pulmona r y T B transmission, 1 question about pulmonary TB prevention. All questions are favorite questions. Self-efficacy questionnaire related to the ability to deal with pulmonary tuberculosis which consists of 10 questions using the Guttman scale as follows; 1 = sure and 0 = not sure. Everything is a favorable question. The highest score is 10 and the lowest is 0. The higher the value, the better self-efficacy, and vice versa. Research Procedure Intervention and data collection was carried out by researchers and 5 nurses whose perceptions had been similar to the research. The SME intervention was given 12 weeks with the following steps Step 1, Identification. In this step, a pre-test of the client’s knowledge and self-efficacy was carried out using a knowledge a nd self-effica cy questionnaire. Besides, clients are identified for the management of pulmonary TB on five pillars, namely related to knowledge, drug ingestion behavior, nutritional fulfillment, physical activity, and prevention of TB disease transmission. This activity is carried out in the first week. Step 2, Advice. In this step, the problems identified in the previous step are reported to the client a nd the client is infor med a bout T B management in the five pillars, namely knowledge, drug ingestion behavior, physical activity, nutrition and prevention of disease transmission, and positive behavior changes if they have positive behavior related to pulmonary TB. In step 2, individuals are given education on the five pillars. Step 2 was carried out at the second and third weeks of the intervention. Step 3, Consent: A written agreement is made with the Client regarding the behavior change objectives and activities required to achieve the goals. Therefore, for each problem identified in the first step, an action plan is developed based on the stated objectives. To ensure patient adherence to activities, a list of intended activities is made for each client and the client is asked to provide a written daily report in a notebook, with the help of family members, on involvement in physical activity, 88 Jurnal Ners dan Kebidanan, Volume 8, Issue 1, April 2021, page 85–93 nutritional fulfillment, ingestion of drugs and prevention of TB disease transmission. This stage is carried out from week 4 to week 11. Step 4, Behavioral counseling. In this step, TB clients who are not adherent to ingesting drugs, given activities, nutrition consumed, and disease prevention needs are given counseling according to the findings of each individual. Counseling is given if any problems are found in the patient until the completion of the 11-week intervention session. Step 5, Follow-Up Activities: At this stage, the patient is followed up once a week regarding drug ingestion behavior, physical activity, nutrition, and prevention of disease transmission. The client was also reminded by telephone call every day in the initial 3 weeks of the intervention, namely weeks 3, 4, and 5. In this session, the patient’s written report in the notebook was also assessed. To ensure compliance with the objectives set and activity plans made. Step 6. Evaluation: at this stage, an evaluation of the success of the intervention is carried out by providing a post test of the knowledge and self- efficacy of pulmonary TB clients. The post-test uses the same questionnaire during the pre-test. This stage is carried out at week 12. Data Analysis Univariate analysis was used to determine the client’s demographic characteristics (age, gender, and education level). The data are presented in the form of numbers and presentations, while the data of knowledge and self-efficacy are presented in the form of mean counts. A paired T-test was used to answer the objectives of this study. The analysis is said to be significant if the p-value <0.005, which indicates the influence of SME on knowledge and self-efficacy of pulmonary TB clients in Timorese tribal communities in NTT province, with the help of IBM software 21. RESULT Demographic Characteristics A total of 30 pulmonary tuberculosis patients who belong to the Timorese people were involved and were able to complete this intervention well. Table 1 provides a summary of client demographic data consisting of age, occupational, sex, and education level. Table I shows a total of 30 pulmonary TB patients. In general, 56.7% of the respondents were male. Most of the TB sufferers were at the age of 56-65 yea r s with the most occupa tions a s housewives. In general, the education level of TB clients is comparable between those who do not go to school and those who have primary school education as much as 26.7% Knowledge and Self Efficacy Knowledge and self-efficacy of clients with pulmonary tuberculosis were measured twice, namely before being given SME intervention at the first-week meeting and after being given SME intervention at week 12. The summary can be seen in Table 2. Table 2 shows the average knowledge and self-efficacy of TB clients before and after being Characteristic N Percentage (%) 1. Gender a. Male 17 56.7 b. Female 13 43.3 Total 30 100 2. Age a. 17-25 2 6.7 b. 26-35 8 26.7 c. 36-45 6 20.0 d. 46-55 4 13.3 e. 56-65 10 33.3 Total 30 100 3. Education a. Uneducated 8 26.7 b. Preliminary 8 26.7 c. Junior High school 7 23.3 d. Senior High school 7 23.3 Total 30 100 4. Occupation a. Housewife 13 43.3 b. Farmer 10 33.4 c. Private Workers 4 13.3 d. Students 3 10.0 Total 30 100 Source : Primarily data Table 1 Distribution of age, sex, occupation, and educa- tion level of clients with pulmonary tb in timor tribal communities in the work area of the Naibonat public health center, kupang, April- September 2020 89Nuwa, Kiik, The Effect of Self Management Education on Knowledge and ... Variables Mean ± SD Min-Max Normality Test Knowledge Pre Test 5,23±1,04 3-7 0,104 Post Test 6,33±1,18 4-9 0,056 self-efficacy Pre Test 4,77±1,07 3-6 0,096 Post Test 7,13±0,94 5-9 0,103 Source: Primarily data Table 2 Knowledge and self-efficacy of pulmonary tuberculosis clients before and after being given SME in timor tribal communities in the work area of the Naibonat public health center, Kupang, April-September 2020 given SME, which has a normal data distribution. The results also showed that the average client knowledge and self-efficacy were higher after intervening with SME Analysis of the influence of SME on knowl- edge and self-efficacy Analyzes were performed using the paired T- test to see the effects of the SME given over 12 weeks. The results can be seen in Table 3 below. Table 3 shows that there is a significant change in knowledge and self-efficacy of TB clients after being given SME with a value of p <0.001. This shows that SME can increase the knowledge and self-efficacy of the Timorese people who suffer from pulmonary TB. Variables (N=30) Mean ± SD 95% CI Min-Max P(value ) Knowledge Pre Test 5,23 ± 1,04 0,66 - 1,542 0,000 Post Test 6,33 ± 1,18 Deviation 1,100 ± 1,185 T Score df (29) = 5,086 self efficacy Pre Test 4,77 ± 1,07 1,89 - 2,84 0,000 Post Test 7,13 ± 0,94 Deviation 2,37 ± 1,27 T Score df (29)= 10,19 Source: Primarily data Table 3 Knowledge Analysis and Self Efficacy before and after being given SME to the community Timorese in the work area of the Naibonat public health center, Kupang, April-September 2020 DISCUSSION This study aims to determine the effect of SME on knowledge and self-efficacy of pulmonary TB clients by emphasizing the five pillars of TB management, namely increasing knowledge, taking medication behavior, fulfilling nutrition, physical activity, and preventing TB disease transmission. The results showed that there was an increase in the mean score of knowledge and self-efficacy after being given SME with a p-value <0.05. The research findings show that giving SME increases the knowledge and self-efficacy of clients with pulmonary TB. This finding is in line with two findings in previous studies, namely Masyfahani, (2019) and Jauhar et al., (2019). Masyfahani’s research, (2019) on 30 primary pulmonary TB clients, it was found that SME were able to increase medication compliance behavior and self-efficacy of pulmonary TB clients by giving intervention for 1 month. Jauhar, Nursasi, &Wiarsih, (2019) self- management can improve health care seeking behavior and compliance with pulmonary tuber- culosis clients taking medication and correlate with self-efficacy. Ja dga l’s r esea r ch, Na kha ei-mogha da m, Alizadeh-seiouki, Zareban, &Sharifi-rad, (2015) in Iran on providing education to TB clients also 90 Jurnal Ners dan Kebidanan, Volume 8, Issue 1, April 2021, page 85–93 improves clients’ knowledge and behavior about pulmonary TB initiatives. Another study that is also in line with the results of this study is the research of Sitanggang, Amin, &Sukartini, (2017) on self- coaching in TB clients where TB clients are given motivational health education and counseling for one month divided by 4 treatment sessions, it is known that health education is in the form of health coaching a ffects the incr ea se in knowledge, attitudes, and actions, and self-efficacy of pulmonary TB clients. In this intervention, a follow-up was also carried out after health education was given to each client. Increased knowledge and attitudes experienced by TB clients can change client actions in preventing TB transmission for the better. Health education can increase a person’s knowledge through the learning process by changing and influencing human beha vior in incr ea sing a wa r eness a nd self- confidence so that clients are aware and willing to change their behavior to be healthy (Sukartini, Kurniawati, &Makhfudli, 2020). This research intervention is also in line with Putra’s research, (2020) on clients with chronic obstructive pulmonary disease (COPD) given by SME through booklet media, it is known that SME incr ea ses client empower ment (knowledge, attitudes, actions, decision-making abilities, and self- efficacy) in 18 clients. COPD but not yet effective in reducing COPD symptoms this is due to the condition of the disease and comorbid factors experienced by the client. Increased knowledge and self-efficacy in Timorese people suffering from TB occurs because the SME approach given is carried out in 5 systematic steps and is oriented towards solving target problems carried out following what is felt or occurs in pulmonary TB clients. According to (Han & Park, 2016) SME can increase knowledge, medication adherence, and self-efficacy and can be developed based on the needs and characteristics of the target population with various cultural backgrounds. In this research, SME is given to the Timorese people who have different cultures and values and views about health and the use of health services. The Timor tribal community will use health service facilities if they are already suffering from a very serious disease. Education carried out with a systematic and gradual approach is the basis of the success of this therapy. Providing health education for pulmonary TB clients in this program is followed by individual counseling according to the problems found in the 5 pillars of pulmonary TB management. The goal is that TB clients are allowed to be independently responsible for their disease by being directly involved in the management of TB disease. All client activities related to ingesting drugs, physical activity, fulfilling nutrition, and TB disease prevention behavior are carried out by the client and assisted by their family. In line with this situation, Daniali, Eslami, &Maracy, (2017) explained that SME interventions need to be followed by home visits by health workers. The focus of intervention should really change the client’s medication practice, not just counseling, and providing social support to improve medication adherence. Clients must be made a schedule for taking medication and must be given reminders in taking medication and scheduled reports to health workers. Scheduled reports were also made by the TB client for each weekly home visit in this study. Masyfahani further, (2019) explained that SME is an educational program for clients that aims to increase knowledge and skills in disease control through behavior change to get better clinical results. Client education is an important aspect of management programs for clients with chronic diseases, such as diabetes mellitus, hypertension, and pulmonary tuberculosis. Education to clients is recommended to be given at the time of diagnosis and continued until the end of treatment. The goal is that patients have good self-management and are responsible for managing their disease (Sutandi, 2012; Lestari &Isnaini, 2018). The SME intervention in this study was given not only once but was continued at follow-up every week. This is done because the treatment and care of pulmonary TB is a long pr ocess that requires str ategies in managing the disease. With the provision of SME, it is hoped that the client’s knowledge can increase to increase self-efficacy which has an impact on his management in the management of pulmonary TB disease. Increasing the self-efficacy of pulmonary TB clients in this study is a process that cannot be separated from the client’s understanding of the disease. The point is that the increase in TB client self-efficacy occurs after the client understands about TB management in 5 pillars, namely increased knowledge, drug-taking behavior, the fulfillment of nutrition, physical activity, and prevention of TB disease transmission. 91Nuwa, Kiik, The Effect of Self Management Education on Knowledge and ... Several factors affect the self-efficacy of clients with chronic diseases such as pulmonary TB besides knowledge. According to Alligood, (2014) self-efficacy or self-confidence is a person’s ability to take certain actions that can develop from the learning process, own experiences, and experiences of other people. Islamic research, (2018) states that self-efficacy in clients with pulmonary tuberculosis is positively correlated with self-experience, observation of other people, verbal persuasion (infor ma tion a nd emotiona l suppor t), a nd physiological evaluation (the client’s physical and emotional state) affects pulmonary TB clients in undergoing treatment. Previous experience in achieving success or achievement is the strongest form of self-efficacy, experience in completing treatment during the intensive phase can form self-efficacy in completing the advanced phase of treatment. Various other related experiences will influence subsequent behavior. Pulmonary TB clients tend to observe the behavior of other pulmonary TB patients undergoing tr ea tment. The suffer er is a model who has similarities with the client. The failure or success of the model in treatment can affect the level of client self-efficacy. Information and emotional support provided optimally can increase the self- efficacy of pulmonary TB clients in demonstrating their ability to undergo treatment (Islami, 2018). Other factors that are thought to increase the self-efficacy of clients in this study are age and experience of undergoing treatment where clients in this study are clients who are undergoing treatment at the incentive stage with an average age of adults and the elderly. In the incentive stage, clients learn from the experience for advanced treatment, besides that TB clients also learn from the behavior of their fellow TB clients in undergoing treatment. Research by Weiwei Ding, Tong li, Qiying so, Maohua Yuan, (2018) regarding self-management in hypertensive clients, it is known that demographic characteristics, namely age are significantly related to self-efficacy and positively correlated with self- management in hypertensive sufferers where the more mature a person is, the better self is. client efficacy and the better self-management of the disease. Researchers argue that pulmonary tuberculosis patients in this study have good self-efficacy after ha ving sufficient knowledge thr ough SME interventions and also supporting factors such as age and learning from their own experiences so that they have a direct impact on behavior changes in disease management related to physical activity, fulfillment. nutrition, ingestion of drugs, and preventing TB disease transmission. CONCLUSIONS This study concluded that the educational self- management program for pulmonary TB clients by emphasizing the five pillars of pulmonary TB management, namely increasing knowledge, taking medication behavior, fulfilling nutrition, physical activity and preventing the transmission of TB disease had a significant positive effect on increasing client knowledge a nd self-effica cy in the management of pulmonary tuberculosis. SUGGESTIONS The recommendation of this research is that it is hoped that policy makers in both health services and the government, in this case the Health Office, can design training programs in the management of pulmonary tuberculosis by emphasizing 5 aspects, namely increasing knowledge, taking medication behavior, fulfilling nutrition, physical activity and preventing transmission. TB disease and train all health workers, especially nurses who work in health care centers, on the implementation of the 5 pillars of pulmonary TB management in providing nursing care. This intervention can also be used as a community nur sing inter vention in the management of pulmonary TB REFERENCES Alligood, M. R. (2014). Nursing Theorist and Their Work (8th ed.). United States: Elsevier. Badan Pusat Statistik Provinsi NTT. (2020). Jumlah Kasus Tuberkulosis (TB) Menurut Kabupaten/Kota di Provinsi Nusa Tenggara Timur, 2015-2018. Retrieved fr om BPS Provi nsi NT T websi te: ht t ps: / / ntt.bps.go.id/dynamictable/2018/08/31/763/jumlah- kasus-tuberkulosis-tb-menurut-kabupaten-kota-di- provinsi-nusa-tenggara-timur-2015-2017.html Bahtiar, & Nursasi, A. Y. (2019). Utilization of Interactive Educational Media in Improving Self Efficacy of Lung Tuberculosis Patients/ : Systematic literature review. Enfermería Clínica, 29(July), 101–105. https://doi.org/10.1016/j.enfcli.2019.05.006 Benzo, R., Vickers, K., Ernst, D., Tucker, S., Mcevoy, C., & Lorig, K. (2013). Development and Feasibility of a Self-management Intervention for Chronic 92 Jurnal Ners dan Kebidanan, Volume 8, Issue 1, April 2021, page 85–93 Obstructive Pulmonary Disease Delivered With Motivational Interviewing Strategies. Journal of Cardiopulmonary Rehabilitation and Prevention, 33(2), 113–122. https://doi.org/10.1097/HCR. 0b013e318284ec67 Boswell, C., & Cannon, S. (2020). Introduction to Nursing Researc h: Incorporat ing Evide nce - Based Practice (Fifth). | Burlington, Massachusetts: Jones & Bartlett Learning. Daniali, S. S., Eslami, A. A., & Maracy, M. R. (2017). The impact of educational intervention on self-care behaviors in overweight hypertensive women/ : A randomized control trial. ARYA Atheroscler, 13(1). Han, Y., & Park, Y. (2016). Effects of the hypertension selfmanagement program. Asia pacific Proceedings of Applied Science and Engineering for Better Human Life, 7, 48–51. Islami, N. S. (2018). Analisis Faktor Yang Berhubungan dengan Self Efficacy Klien TB Paru Dalam Menjalani Pengobatan di Puskesmas Wilayah Kota Surabaya. Universitas Airlangga. Jadgal, K. M., Nakhaei-moghadam, T., Alizadeh-seiouki, H., Zareban, I., & Sharifi-rad, J. (2015). Impact of Educational Intervention on Patients Behavior with Smear-positive Pulmonary Tuberculosis/ : A Study Using the Health Belief Model.Materia Socio Medica, 4 (May), 229–233. https://doi.org/10.5455/ msm.2015.27.229-233 Jauhar, M., Nursasi, A. Y., & Wiarsih, W. (2019). Evaluation of impact self-management counseling on h ea lt h -seekin g beh a vi or ’s sel f-effi ca cy pulmonary tuberculosis outpatients. Enfermeria Clinica, 29(2), 482–487. https://doi.org/https:// doi.org/10.1016/j.enfcli.2019.04.072 KEMENKES RI. (2018a). INFODATIN/ :Tuberkulosis. Jakarta: Pusat Data dan Informasi Kementrian Kesehatan RI. KEMENKES RI. (2018b). RISKESDAS 2018. Jakarta: Kementerian Kesehatan RI Badan Penelitian dan Pengembangan Kesehatan. Lestari, I. G., & Isnaini, N. (2018). Pengaruh Self Management Terhadap Tekanan Darah Lansia yang Mengalami Hipertensi. Indonesian Journal for Health Sciences, 02(01), 7–18. Li, X., Li, T., Chen, J., Xie, Y., An, X., & Lv, Y. (2019). A WeChat-Based Self-Management Intervention for Community Middle-Aged and Elderly Adults with Hypertension in Guangzhou , China/ : A Cluster- Randomized Controlled Trial. Environmental Research an Public Health, 16(2002), 1–12. Masyfahani, M. A. H. (2019). Pengaruh Self Management Education Berbasis Health Promotion Model Terhadap Pemberdayaan Klien Tuberkulosis. Universitas Airlangga. Maula, M., Nursasi, A. Y., & Wiarsih, W. (2019). The relationship between family ’ s informational support and self-efficacy of pulmonary tuberculosis client. Enfermería Clínica, (xx), 1–4. https://doi.org/ 10.1016/j.enfcli.2019.04.062 Moradi, M., Nasiri, M., Jahanshahi, M., & Hajiahmadi, M. (2019). The Effects of a Self Management Program Based on the 5 A’s Model on Self Efficacy among Older Men with Hypertension. Nursing and Midwifery Studies, 8, 21–27. https://doi.org/ 10.4103/nms.nms Putra, P. W. kusuma. (2020). Pengaruh Self Management Educat ion Te rhadap Pemberdayaan Pasi en Penyakit Paru Obstruksi Kronik (PPOK) di RSUD Wangaya Denpasar. Universitas Airlangga. Rekam Medik Puskesmas Naibonat. (2020). Rekam Medik Puskesmas Naibonat Maret 2020. Kupang: Rekam Medik Puskesmas Naibonat. Sitanggang, Y. A., Amin, M., & Sukartini, T. (2017). Health Coaching Berbasis Health Promotion Model Terhadap Peningkatan Efikasi Diri dan Perilaku Pencegahan Penularan Pada Pasien TB Paru. Jurnal Penelitian Kesehatan Suara Forikes, VIII(4), 172– 179. Sukartini, T., Kurniawati, S., & Makhfudli, M. (2020). The effect of health education through brainstorming and booklet method on behavior in prevention of pulmonary Tb transmission. Eurasian Journal Of Biosciences, 14, 2697–2702. Sutandi, A. (2012). Self Management Education ( DSME ) Sebagai Metode Alternatif Dalam Perawatan Mandiri Pasien Diabetes. Majalah Ilmiah Widya, (321), 47–52. Wang, C., Lang, J., Xuan, L., Li, X., & Zhang, L. (2017). The effect of health literacy and self-management efficacy on the health- related quality of life of hypertensive patients in a western rural area of China/ : a cross-sectional study. International Journal for Equity in Health, 16(58), 1–11. https:// doi.org/10.1186/s12939-017-0551-9 Wei, T., & Omar, M. (2017). Self-management approaches among hypertensive residents in nursing homes in Malaysia. Malaysian Family Physician, 12(3), 8– 17. Weiwei Ding, Tong li, Qiying su, Maohua Yuan, A. lin. (2018). Integra tin g fa ctors associ ated wi th hypertensive patients’ self-management using structural equation modeling/ : a cross-sectional study in Guangdong, China. Patient Preference and Adherence, 12, 2169–2178. https://doi.org/10.2147/ PPA.S180314 WHO. (2018). Global tuberculosis Report 2018. Geneva, Switzerland: WHO. WHO. (2020a). Definitions and Reporting Framework 93Nuwa, Kiik, The Effect of Self Management Education on Knowledge and ... for Tuberculosis – 2013 Revision (Updated December 2014 and January 2020). Switzerland: WHO Press, World Health Organization. WHO. (2020b). Global Tuberculosis Report 2020. Ganeva: World Health Organization. WHO. (2020c). Tuberculosis/ : Key facts. Retrieved December 10, 2020, from WHO website: https:// www.who. in t/ news-room / fa ct -sh eets/ deta il / tuberculosis Yakhelef, N., Audibert, M., Ferlazzo, G., Sitienei, J., Wanjala, S., Variane, F., … Huerga, H. (2020). Cost- effectiveness of diagnostic algorithms including lateral-flow urine lipoarabinomannan for HIV- positive patients with symptoms of tuberculosis. PLoS ONE , 1–17. h tt ps: / /doi. org/10.1371/ journal.pone.0227138.