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Module 9: Patient Adherence to Tuberculosis Treatment
Background

In this module, you will learn how to help patients adhere to a TB treatment regimen. When medical treatment is complicated or lasts for a long time, as in the treatment for TB disease, patients often do not take their medication as instructed. This can lead to serious problems. A nonadherent TB patient may remain sick, spread TB to others, develop and possibly spread drug-resistant disease, and even die as a result of interrupted treatment. Likewise, it is also important that persons with latent TB infection (LTBI) who are prescribed a regimen for LTBI adhere to the regimen. Completion of therapy for LTBI can prevent people with TB infection from developing TB disease. The patient's success in completing a TB regimen depends to a large extent on the health care worker's ability to understand him or her, support the patient throughout therapy, and anticipate or solve problems as they arise.

This module describes methods the health care worker can use to get to know his or her patients, assess their ability and willingness to adhere to treatment, use proven methods to improve patient adherence, and solve common problems that arise during treatment. Also included is advice on the use of legal remedies to nonadherence when less restrictive methods have been exhausted and a patient does not cooperate with public health officials. By using the recommendations in this module, the health care worker should be able to help his or her patients remain adherent and successfully complete their TB treatment regimens.

Another important issue that is not addressed in this module is the adherence of health care workers to published recommendations and guidelines. The prescription of an inadequate treatment regimen (e.g., a 6-month regimen that does not contain rifampin) or the failure to order recommended diagnostic tests (e.g., drug susceptibility testing of the initial isolate from a patient's sputum) are serious problems that can lead to treatment failure. As you consider the problems that can lead to a patient's failure to adhere to a regimen, keep in mind that the burden of TB treatment completion does not rest solely on the patient.

Objectives

After working through this module, you will be able to:

  • Define adherence and describe why it is important to TB treatment.
  • List six reasons why a patient might be nonadherent.
  • Describe a case management system.
  • Explain why and when it is important to assess a patient's knowledge and beliefs about TB disease and its treatment.
  • Define open-ended questions and explain how they can help you learn about a TB patient.
  • Discuss the role of patient education in improving adherence.
  • List eight techniques that can be used to communicate effectively with patients.
  • List eleven guidelines that can help the health care worker make the best of an interview assisted by an interpreter.
  • Define DOT, list its advantages and disadvantages and who should be considered for DOT, and describe the tasks involved in delivering DOT.
  • Define incentives and enablers; describe what their purposes are, how to determine which ones to use for each patient, and what are some sources.
  • List five ways to promote adherence in children and describe why adolescents are at high risk for nonadhe.rence.
  • Explain the purpose of a behavioral diagnosis, and list 13 examples of barriers to adherence and the methods to overcome the barriers.
  • Describe how a patient's beliefs about health or medical care can affect TB treatment.
  • List eight specific things that can be done to form an effective partnership with TB patients.
  • Describe who can provide support to a patient and the role they can play in helping or hindering the patient in being adherent.
  • Discuss how the treatment regimen can be tailored to the individual and why this may improve adherence.
  • Describe a formal adherence agreement.
  • Give three examples of methods to help patients keep appointments.
  • Give four examples of nonadherent behavior that could warrant legal action against the patient.
  • Describe the progressive interventions that TB control programs should attempt before a court orders involuntary confinement.

New Terms

Lists of terms were introduced in each of the five core Self-Study Modules on Tuberculosis (Modules 1-5). Please refer to the core modules or their Glossary if you encounter unfamiliar terms related to TB that are not defined in this New Terms section.

Look for the following new terms in this module.

adherence to treatment - following the recommended course of treatment by taking all the prescribed medications for the entire length of time necessary

adherence agreement - a written understanding between a health care worker and a patient that indicates the activities they both agree to carry out. For some patients, this written commitment increases the likelihood of adherence

alternative medicine - health care other than conventional, scientifically tested, medicinal treatment; includes herbal remedies, yoga, meditation, acupuncture, and other practices intended to maintain or improve health

assessment - talking to a patient to find out about his or her medical history, knowledge about TB, feelings and beliefs about TB treatment, and other pertinent information

barrier - anything that can prevent a patient from being able to adhere to a TB treatment regimen

behavioral diagnosis - used to find out what is causing a patient to have problems with adherence and to develop strategies to improve the patient's treatment plan

case management - a system in which a specific health department employee is assigned primary responsibility for the patient, systematic regular review of patient progress is conducted, and plans are made to address any barriers to adherence

clinic-based DOT - directly observed therapy delivered in a TB clinic or comparable health care facility

combined pill - fixed-dose combination capsule or tablet that may enhance patient adherence. 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)

court-ordered DOT - directly observed therapy that is administered to a patient by order of a public health official or a court with the appropriate authority; used when patients have been nonadherent despite the best efforts of TB program staff

directly observed therapy for latent TB infection (LTBI) - a strategy devised to help patients at especially high risk of developing TB disease adhere to treatment for LTBI; a health care worker or another designated person watches the patient swallow each dose of the prescribed drugs

enablers - those things that can make it possible or easier for the patients to receive treatment

field-based DOT - directly observed therapy delivered in a setting outside the TB clinic or a comparable health care facility; possible sites for field DOT include a doctor's office, the patient's home or workplace, a school, a public park, or a restaurant

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

health care worker - a person who provides health care or health services to patients, such as physicians, physician's assistants, nurse practitioners, nurses, and outreach workers

incentives - small rewards given to patients to encourage them to either take their own medicines or keep their clinic or field DOT appointments

latent TB infection (LTBI) - also referred to as TB infection. Persons with latent TB infection carry the organism that causes TB but do not have TB disease, are asymptomatic, and are noninfectious. Such persons usually have a positive reaction to the tuberculin skin test

nonadherence - the patient's inability or refusal to take TB drugs as prescribed

open-ended question - a question that cannot be answered with a simple "yes" or "no." Open-ended questions are designed to elicit the patient's knowledge, feelings and beliefs, by beginning with words such as "What," "Why," "Who," "How," and "When," that demand an explanation. Such questions are used to explore complex issues that do not have a finite or predetermined set of responses

treatment for LTBI - medication that is given to people who have latent TB infection to prevent them from developing TB disease

 
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