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Module 9: Patient Adherence to Tuberculosis Treatment
Summary

Adherence to treatment means that a patient is following the recommended course of treatment by taking all the prescribed medications for the entire length of time necessary. TB is nearly always curable if patients adhere to their TB treatment regimen. Adherence is important because nonadherence is the patient's inability or refusal to take TB drugs consistently as prescribed. This behavior is one of the biggest problems in TB control.

There are many reasons why a person might have trouble completing a regimen of TB drugs. One of the best predictors of adherence is a patient's past adherence. However, it is important to keep in mind that any patient can have barriers to adherence. Patients and health care workers are both responsible for ensuring patients' adherence. Patients must decide every day or week whether or not to take their medicine. What they decide often depends on how much help they get from the health care workers they see.

There are many strategies that may be used to ensure that patients complete treatment. One strategy that may be used is case management. There are three elements in any case management system: (1) assignment of primary responsibility for the patient, (2) systematic regular review of patient progress, and (3) a plan to address any barriers to adherence. A health department employee (case manager) is assigned primary responsibility and is held accountable for ensuring that each patient is assessed and a treatment plan is established, that each patient is educated about TB and its treatment, that therapy is continuous, and that contacts are examined.

The health care worker will need to learn as much as possible about the patient in order to assess potential adherence problems. Doing an assessment means talking to a patient to get information on the patient's medical history, current health problems, and other personal information, with a particular emphasis on identifying the problems most important to the patient as treatment begins. Unless special efforts are made to identify their needs, some patients may be lost to follow-up care.

The health care worker or other program staff should visit the patient to begin the assessment as soon as possible. When the health care worker begins to work with a patient, it is important to ask what the patient believes about TB disease and treatment. The health care worker should identify differences between what he or she believes and what the patient believes early in treatment. One way to do this is to ask several open-ended questions. When a patient's ideas are different from the health care worker's, the health care worker should accept that the patient has different views, and then make sure the patient knows the health care worker's point of view about TB.

Health information must be right for each patient's knowledge and awareness of the problem. Patients are more likely to pay attention to information that is relevant to their needs and does not require abrupt changes in their normal daily activities. In general, patients may be more likely to follow the treatment plan if they understand their illness and the benefits of treatment. In presenting health information, effective communication techniques should be used.

The health care worker and the patient can have serious problems understanding each other if they do not speak the same language. It is best to use trained medical interpreters, but there may not be any in the health care worker's area. Other persons who are used as interpreters are other health care workers who speak the patient's language, the patient's family members, or people from the patient's community. After the health care worker has identified an interpreter, appropriate guidelines should be followed to make the best use of the interview.

There are many ways to encourage patients to adhere to treatment. Giving directly observed therapy (DOT) is the most effective strategy for making sure patients take their medicines. DOT means that a health care worker or other designated individual watches the patient swallow every dose of the prescribed drugs. DOT should be considered for all patients because it is difficult to reliably predict which patients will be adherent. Even patients who intend to take their medicine might have trouble remembering to take their pills every time. DOT ensures that the patient completes an adequate regimen, lets the health care worker monitor the patient regularly for side effects and response to therapy, helps the health care worker solve problems that might interrupt treatment, and helps the patient become noninfectious sooner.

Incentives and enablers may help patients agree to participate in a DOT program and stay with it. Incentives are small rewards given to patients to encourage them to either take their own medicines or keep their clinic or field DOT appointments. Enablers are those things that make it possible or easier for the patients to receive treatment by overcoming barriers such as transportation difficulties. Incentives and enablers should be chosen according to the patient's special needs and interests, or the patients may not care if they receive them.

To improve adherence in children and adolescents, the health care worker should work with the parents or caregivers. The health care worker cannot assume that parents will give medications to their children as prescribed; sometimes they do not. The health care worker should do everything possible to make sure that parents support their children's TB treatment. For example, the health care worker can educate parents, warn parents of possible problems, give DOT, use incentives and enablers, and give TB drugs in easy-to-take preparations.

To help patients complete treatment, the health care worker will need to assess the extent to which various problems present barriers to adherence. A "behavioral diagnosis" can be used to develop strategies to improve each patient's treatment plan. The purpose of doing a behavioral diagnosis is to identify the specific reasons why a patient is not being adherent. At the start of treatment the patient should be told about nonadherence and how it causes treatment failure and further TB transmission. The health care worker should listen to the patient's response and identify and resolve any barriers to adherence. It is crucial that the health care worker and the patient come to an agreement about taking TB medication.

There are many ways to help patients adhere to TB treatment. The support of family, friends, and health care workers can be important to patients trying to complete treatment. The patients should be asked to identify persons who support their TB treatment and can help them remember to take medications or keep their DOT appointments. In addition, 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 some patients, a formal adherence agreement -- a written understanding between the health care worker and a patient -- may be useful.

Different types of reminders can help patients keep appointments. When a patient fails to keep an appointment, a health care worker should call right away to schedule a new appointment. If the patient repeatedly breaks appointments, a conference should be held with all members of the health care team (physician, nurses, health care workers, and other staff) so that the problem can be discussed and resolved with help from the entire staff.

As a general rule, individuals have the right to ignore a doctor's advice or refuse treatment if they wish. However, persons with infectious TB may lose that right if health officials believe these persons risk infecting others by not taking their prescribed medicine. Patients who are unwilling or unable to adhere to treatment may be required to do so by law. If the patient does not adhere to DOT voluntarily, the next step may be DOT that is ordered by a public health official or a court. TB control programs should not begin procedures for confining patients to a treatment facility until after the patient has shown that he or she is unable or unwilling to follow a treatment regimen implemented outside such a facility.

Additional Reading

Centers for Disease Control and Prevention. Improving Tuberculosis Treatment and Control: An Agenda for Behavioral, Social, and Health Services Research. Proceedings of Tuberculosis and Behavior: National Workshop on Research for the 21st Century; 1994 Aug 28-30; Bethesda (MD). Atlanta: Centers for Disease Control and Prevention; 1995.

Centers for Disease Control and Prevention. Tuberculosis control laws -- United States, 1993: Recommendations of the Advisory Council for the Elimination of Tuberculosis (ACET). MMWR. 1993;42(RR-15):1-28.

Etkind SC. The role of the public health department in tuberculosis. Med Clin of Nor Amer. 1993;77(60):1303-14.

How to Be "Streetwise"-- and Safe. National Crime Prevention Council and Federal Protective Service. Brochure NCPB-002. (Can be ordered by calling 1-800-548-0325.)

Improving Patient Adherence to Tuberculosis Treatment. Atlanta: Centers for Disease Control and Prevention; 1994.

Lewis ID, Hallburg JC. Strategies for safe home visits. Urban Health. 1980;9(6):40-41.

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.

Enablers and Incentives. Columbia: American Lung Association of South Carolina and South Carolina Department of Health and Environmental Control, Division of Tuberculosis Control; 1989.

 
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