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Module 9: Patient Adherence to Tuberculosis Treatment
Reading Material

Problem Solving

Behavioral Diagnosis

The goal of patient education is to help change patients' behaviors by teaching them the importance of following the treatment plan. However, past experience has shown that patient education alone is often not enough to ensure adherence. Problems such as scheduling conflicts or being inadequately motivated to adhere can lead to treatment failure even in a patient who is quite knowledgeable about TB disease. (In fact, health care workers have been known to fail to adhere to TB treatment!)

To help patients complete treatment, the health care worker will need to assess the extent to which such problems present barriers to adherence. A behavioral diagnosis can be used to find out what is causing a patient to have problems with adherence and to develop strategies to improve each patient's treatment plan. Table 9.5 presents some examples of this approach. The purpose of doing a behavioral diagnosis is to identify the specific reasons why a patient is not being adherent. Different patients will have different reasons. Once a patient's specific set of adherence problems are known, the health care worker can devise an individualized plan of action to overcome the difficulties and promote adherence. Table 9.6 provides some additional methods to improve adherence through quality of interactions with the patient, patient education, treatment, and clinic operations.
 

Table 9.5
Behavioral Diagnosis: A Tool for Enhancing Adherence

Barriers to Adherence Examples of Methods to Overcome Adherence Barriers
Lack of knowledge Assess patient's knowledge, beliefs, and feelings about TB
Use health education, provide written materials
Forgetfulness Get help from family or friends
Simplify the regimen or use combination pills
Link pill taking with other activities
Provide special pill dispensers and memory cues
Use DOT
Lack of motivation Point out the dangers of nonadherence and benefits of therapy
Increase the frequency of visits
Provide incentives and set short-term goals
Use DOT
Fear of side effects Allow extra time to discuss known side effects
Provide reassurance
Make staff available to answer questions
Use DOT
Lack of skills in pill taking Demonstrate correct pill taking
Have the patient practice with guidance
Use DOT
Lack of support from family or friends Make home visits
Encourage family or friends to accompany patient on clinic visits
Use DOT
Poor relationship with the health care worker Develop communication skills
Be accessible throughout care
Work on attitudes about patients and DOT
Change health care workers
Provide social services
Lack of money to pay for health care Provide free care, facilitate third-party payment
Refer to social worker
No sick leave available Provide clinic appointments during off hours
Use DOT at work site
Long clinic waiting time Keep to scheduled appointment times
Make efficient use of patient visits
Have separate appointments for drug refills
Other medical conditions or physical limitations Use a home health nursing service
Use DOT
Complex regimen Simplify the regimen
Associate the regimen with other activities
Use combined capsules
Use DOT
Medication side effects Take medication before or after meals, as indicated
Evaluate medication options
Change drugs or dosages

 

Table 9.6
A Quick Reference: Methods to Improve Adherence

Issues Improvement Methods
Quality of interaction with the patient Create a partnership.
Ask patients when and how they take TB drugs, and what they take. Don't assume they are adherent.
Give each patient adequate time at every visit.
Don't intimidate or frighten the patient; be positive.
Get oral and written commitments from the patient.
Treat the person, not just the disease.
Understand and address different cultural values and beliefs.
Adapt treatment to lifestyle.
Make social service referrals.
Patient education Give vital information first in the patient interview.
Be clear with instructions; the patient is likely to be anxious after hearing the diagnosis.
Follow oral instructions with written instructions.
Be clear from the start about the length of the regimen.
Don't overload the patient with too much information at one time; avoid jargon.
Use educational materials that are culturally and linguistically appropriate for the patient.
Be alert for signs or indications that the patient may not be literate.
Assess the patient's beliefs about TB; when possible, integrate beliefs into the treatment plan.
Review instructions; ask patient for feedback to ensure understanding.
Describe the specific adherence behaviors required.
Clarify the patient's questions and respond clearly.
Treatment Schedule the initial appointment soon after diagnosis.
Use appointment reminders.
Follow up quickly on missed appointments.
Tailor the regimen to the patient's needs; allow the patient some options.
Keep the regimen as simple as possible.
Give clear instructions about medication side effects.
Clinic operations Ensure a physical environment that is comfortable to patients.
Ensure that staff are polite and courteous with patients and culturally sensitive.
Ensure that schedules and practices are tailored to the patients' needs.
Ensure that record keeping, pharmacy, and lab services are quick and easy for patients.
Nurture staff morale; provide training as needed.
Provide for strict confidentiality of patient information.
Provide appropriate services that match the demographic features of the patient population (e.g., meals or snacks for homeless patients).
Provide interpreters, if needed.

Adapted from Sumartojo E. Adherence to the tuberculosis treatment plan. In: Cohen FL, Durham JD, eds. Tuberculosis: A Sourcebook for Nursing Practice. New York, NY: Springer Publishing Co.; 1995: chap 7.

Discuss Different Health Beliefs with Patients

Sometimes cultural, religious, or other personal beliefs affect a patient's TB treatment. It is important for the health care worker to sincerely respect the beliefs of the patient. Sometimes patients seek medical advice from folk healers or alternative practitioners. The health care worker may encounter patients who use folk remedies along with their prescribed medications. For example, in some Asian cultures, TB medicines are considered "hot" and need to be countered with something "cold," such as green leafy vegetables.

Take the time to learn about the patient's cultural beliefs. If the patient thinks that the health care worker does not respect his or her beliefs, it could cause the patient to distrust the health care worker. A patient may come from a background that includes the use of alternative medicine (health care other than conventional, scientifically tested, medicinal treatment including herbal remedies, yoga, meditation, acupuncture, and other practices intended to maintain or improve health). Likewise, the patient may practice folk medicine (medicinal beliefs, knowledge, and practices associated with a particular culture or ethnic group. Folk medicine is usually handed down by cultural tradition and practiced by health care workers specially trained in that tradition; not all members of a given culture or ethnic group will use its folk medicine practices). The health care worker should find out if there are barriers to the acceptance of conventional medical practices. A discussion about the patient's beliefs and health practices may help the health care worker to individualize treatment so that it is acceptable to the patient.

When folk or alternative practices are safe, health care workers should consider including them in the treatment plan. For example, some people believe in the healing power of prayer. These persons may be more willing to take medications after saying a brief prayer, so accepting their belief in prayer is an important aspect of treatment. If a patient is taking an herbal remedy, the health care worker should check with the patient's physician or pharmacist to be sure it will not cause side effects or interact adversely with the patient's TB drugs. He or she should ask patients who have concerns about nutrition supplements or interactions with TB drugs to discuss this with their clinician.

While it is important to respect the patient's beliefs, it is just as important for the health care worker to clearly present the rationale for taking TB drugs for a full course of treatment. The health care worker can do a great deal to help the patient adhere and incorporate his or her beliefs into the treatment, but it is crucial that both come to an agreement about taking TB medication.

Develop a Partnership with the Patient

Patients make independent decisions every day about whether they will take medication or participate in DOT. The health care worker must recognize the important role of the patient in making decisions about treatment. For this reason, the health care worker should develop a partnership with the patient. Effective partnerships call for specific behaviors from the health care worker:

  • Listen and try to understand the patient's knowledge, beliefs, and feelings about TB disease and treatment
  • Be open minded about the patient's beliefs and cultural expectations
  • Recognize and address the patient's fears about the illness
  • Understand and fulfill the patient's expectations about treatment, when possible
  • Communicate clearly so that the patient can understand the messages
  • Avoid criticizing the patient's adherence behavior; suggest behavior changes respectfully
  • Treat the patient with dignity and respect
  • Be consistent in what is done and told to the patient

Encourage the Patient to Seek Support

The support of family, friends, and health care workers can be important to patients trying to complete treatment. The health care worker should ask his or her patients to identify persons who support their TB treatment and can help them remember to take medications or keep their DOT appointments. Such persons might include

  • Family members
  • Friends
  • Teachers
  • Social workers
  • Landlords
  • Clergy
  • Neighbors

With the patient's permission (because of the patient's right to privacy), family members, friends, or others may be included in educational sessions so that they also understand the patient's diagnosis, and what he or she needs to do. However, a health care worker should avoid making a family member responsible for the patient's adherence; this may be an unfair burden.

On the other hand, parents, spouses, or others in authority in the family or community may prevent patients from taking medications, or may reject or cause problems for the person with TB. If this happens, the health care worker should try to educate such persons about TB and include them in discussions about treatment decisions. Always maintain the patient's confidentiality (see Module 7, Confidentiality in Tuberculosis Control).

Individualize the Medication Regimen

To improve adherence, the medication regimen should be tailored to the patient. If possible, the regimen should be simplified and changed within acceptable therapeutic limits to match the patient's lifestyle. For example, the patient's physician can prescribe

  • An intermittent regimen for a patient whose schedule doesn't permit daily DOT appointments

  • A combined pill, which is a fixed-dose combination capsule or tablet that may enhance patient adherence, for patients with difficulty swallowing. In the United States, the Food and Drug Administration has licensed fixed-dose combinations of isoniazid and rifampin (Rifamate) and of isoniazid, rifampin, and pyrazinamide (Rifater).

Patients who are not on DOT sometimes find it useful to monitor their pill-taking by checking off doses on a daily calendar. A calendar can help patients remember the days they need to take medicine and engage them in determining their own schedule. A weekly pill box may also help patients monitor their pill-taking.

For some patients, a formal adherence agreement -- a written understanding between the health care worker and a patient -- may be useful. A sample adherence agreement is presented in Figure 9.7. A patient should dictate or write down the activities he or she agrees to carry out (such as taking medicine as prescribed), in return for specific services, activities, or incentives from the health care worker. For some patients, this written commitment increases the likelihood of adherence. The patient should be asked to sign the agreement next to the health care worker's signature and be given a copy to keep. The health care worker should review the agreement with his or her patient periodically to assess how well both are doing and to make changes as needed.

Figure 9.7  This an example of a sample adherence agreement between a patient and a health care worker.

Help Patients Keep Appointments

There are three methods to help patients keep their appointments (Table 9.7):

  • Remind patient of appointment

  • Contact no-shows and make another appointment

  • Use other alternatives for patients who repeatedly break appointments

Different types of reminders can help patients keep appointments. If the patient has a permanent address, the health care worker can send a reminder postcard, mailed so that it arrives 1 or 2 days before the appointment. If the patient has a telephone, it might be better to call -- that way the health care worker will know if the patient received the message. Another benefit of using telephone reminders is that it gives the health care worker an opportunity to counsel patients, and help them solve scheduling and transportation problems or other obstacles to adherence. Remember to be aware of confidentiality issues when leaving telephone or written messages for TB patients (see Module 7, Confidentiality in Tuberculosis Control, for information on maintaining confidentiality).

Patients can also be given appointment cards or appointment calendars at each visit to remind them of their next visit. Sometimes the health care worker can find out what problems a patient is having by contacting no-shows, either with a telephone call on the same day or with a home visit. When a patient fails to keep an appointment, call right away to schedule a new appointment. If the patient fails to keep the new appointment, visit the patient at home or call him or her on the phone. Use this discussion to counsel the patient and to identify and solve problems that interfere with appointment keeping.

If the patient repeatedly breaks appointments, use other alternatives. Hold a conference with all members of the health care team (physician, nurses, other health care workers, and staff) so that the problem can be discussed and resolved with help from the entire staff. The patient could also be included in this conference. The health care worker may need to try several different strategies to help the chronically nonadherent patient, and possibly even consider legal alternatives (see Legal Remedies, pages 80-85).
 

Table 9.7
Examples of Methods to Help Patients Keep Appointments

Examples of Methods to Overcome Adherence Barriers
Remind patient of appointment Contact the no-shows and make another appointment

Use other alternatives for patients who repeatedly break appointments

  • Send a post card

  • Call the patient by phone (opportunity to counsel)

  • Give an appointment card

  • Give an appointment calendar

  • Call the same day as the appointment
  • Visit the patient at home
  • Hold a conference with all members of the health care team
  • Possibly include the patient in the conference
  • Consider legal alternatives

 
Study Questions 9.29-9.32

9.29. Who can provide support to a patient and help the patient remember to take medications?

9.30. What are two things the health care worker can do to tailor the regimen to the patient's lifestyle?

9.31. What is a formal adherence agreement?

9.32. What three methods can be used to help patients keep their appointments?

Answers 


 
Case Study 9.8
Ms. Johnson is a 68-year-old widow with active TB disease. She has several other health problems, including obesity, osteoarthritis, and poorly controlled diabetes. She needs a cane to help her walk and often becomes anxious when she leaves her apartment. She lives in a low-income housing block 3 miles from the TB clinic and does not have transportation. Ms. Johnson's two children live outside the state and visit infrequently.
  • Conduct a behavioral diagnosis of Ms. Johnson's potential barriers to completing her TB treatment and the methods that can be used to overcome the barriers.

Answers 


 
Case Study 9.9
Mr. Sivaraman is a recent immigrant from India who is working two jobs to support his wife and three children. He has been on DOT for 2 months and his TB symptoms have greatly improved. Mr. Sivaraman has kept daily DOT appointments with the health care worker, but recently has missed two appointments and skipped his last clinic visit.
  • Why might Mr. Sivaraman be nonadherent?
  • What steps can the health care worker take to help Mr. Sivaraman keep his appointments and adhere to therapy?

Answers 

 
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