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Effective TB Interviewing for Contact Investigation: Facilitator Led Training Guide 2006

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10. Course Activities

Facilitator

Activity 6:  TB Interview Strategy Exercise

Objectives
  • To identify the content of the TB interview
  • To formulate a strategy for the TB interview
  • To practice the TB interview
     
Time Allotted

95 minutes total

  • 5 minutes of instruction
  • 30 minutes for group work
  • 30 minutes for group interview
  • 15 minutes for facilitator/small group discussion
  • 15 minutes for large group discussion
     
Pre-Course Procedures

Ask three experienced TB interviewers from outside of this course to lead this exercise.  These individuals (group leaders) will play the roles of the patients described.  They should become familiar with their roles prior to the course and be able to spontaneously react to the interviewers as well as give feedback about interviewing skills.  Provide a copy of one of the three patient information sheets to each group leader.

Photocopy the “Interview Planning Sheet” on page 54 for all participants. 

Photocopy the three cases on pages 55-57 for all participants and group leaders.

Photocopy the “TB Interview Checklist” on pages 58-59 for all participants.
 

Procedure

Divide the participants into three evenly numbered groups by asking them to count off by 3.  Then ask all of the 1s, 2s, and 3s to gather in locations you designate.

Pass out cases #1, #2, and #3 to each person.  Assign each group only one of the cases attached, e.g., group 1’s participants should all receive case #1.

Pass out the “Interview Planning Sheet” on page 54 to each participant. 

Pass out the “TB Interview Checklist” on pages 58-59 to each person.

Ask the participants to use the interview planning sheet to plan how to conduct an interview.  Instruct them that each person in the group should pick a portion of the interview to conduct.  All group members must participate in the planning process.  They will interview the mock patient as a group.

Ask each participant to write notes on how they plan to conduct an interview based on the information they know.  Give each group about 30 minutes to prepare for the interview.  After 25 minutes, give all of the groups a verbal warning that there are 5 minutes left to complete their planning.

After 30 minutes, ask each group to assemble chairs in a circle with the mock patient included.  Ask them to sit in the order in which they will be conducting the interview.  Have an informal timer be part of the group to keep people on track.  Each part of the interview should be allotted an equal amount of time.  So, if one participant is involved in more sections than another, then his or her time should be adjusted accordingly. 

Upon completion of the interview, the leader can break and give some feedback to the participants about how he or she felt as the patient and on the participants’ interviewing skills.

At the end of all the interviews, reconvene the class for a discussion. Ask for a volunteer from each group to read the case description and then explain how the process went.  The group leaders who were in the patient roles may also contribute and mention positive skills they observed in the groups.  This discussion should be about 15 minutes.
 

Tips
  • If you have an uneven number of people in each group, ask the less experienced interviewers to do more of the interviewing to gain greater experience.  While they may not be comfortable with this arrangement, it is the best way to build their skills.
  • Cases can be doubled up for very large groups so that the individual groups do not become too big, i.e., more than 1 group can work with the same case.
  • All of the patients are gender-specific, but gender can be changed to fit the person portraying the patient, if so desired. 
  • You may modify any of the cases to fit local demographics of the patient population.

 

Participant

Activity 6:  Interview Planning Sheet

Participant Handout
(all groups)

Your group has 30 minutes to design a TB interview outline, including the questions you plan to ask. In this case, the TB interview has been broken into 6 parts: Introduction, General TB Education, TB Education Based on the Patient’s Diagnosis, Education about the Contact Investigation Process, Contact Identification, and Referral Process/Conclusion. Each member of the group is responsible for one or more parts of the interview. After planning, your group will have 30 minutes to interview your patient, with each person responsible for his or her portion of the interview. While conducting the interview, your group’s members should act as though you are one interviewer to keep continuity and flow. After the interview is complete, the group and the patient can discuss the interview and then convey the whole experience back to the rest of the class. You may use the TB Interview Checklist during your interview.

Interview Portion Content/Questions
Introduction  
General TB Education  
TB Education Based on the Patient’s Diagnosis  
Education about the Contact Investigation Process  
Contact Identification  
Referral Process/Conclusion  

 

Particpant Leader

Activity 6:  Group #1
Case 1

Group #1 Participant/
Leader Info. p. 1

Walter is a 47-year-old single, unemployed male. He is a veteran, receives a small disability pension, and sometimes picks up odd jobs in warehouses and diners. He lives in a single–room-occupancy hotel.

Three weeks ago, Walter was brought by the police to the emergency room of General Hospital for treatment of stab wounds to the right arm and cuts on the neck and face resulting from a fight outside of a tavern. Upon admission, he was intoxicated, appeared poorly nourished and underweight, and had a productive cough.

A chest X-ray revealed an infiltrate in the left upper lobe; sputum smear results were positive for AFB (2+). He was started on a standard four-drug regimen (INH, RIF, PZA, EMB) of anti-TB medications and remained hospitalized for 5 days. Against medical advice, Walter insisted on leaving the hospital. On the day of discharge, the infection control nurse instructed him to go to the clinic the next day for outpatient care. Walter failed to keep the appointment. During the field investigation the next day, you found Walter lying on a park bench near the hotel where he lives. Walter agreed to ride with you to the clinic, a distance of 6 miles from his hotel.

The clinician at the clinic had left orders for the staff to counsel Walter and put him on DOT. Two hours after arriving at the clinic, Walter had not received these services. He asked to speak with you but was told that you had left for the field and were not expected back until morning. Walter then left the clinic without being seen by staff.

You have relocated Walter in the field and, after much persuasion, brought him back to the clinic for an interview.

 

Participant  

Leader

Activity 6:  Group #2

Group #2 Participant/
Leader Info., p. 2

As a new student in the school district, Evan, age 6, had to receive a Mantoux tuberculin skin test by the school nurse. The skin test was positive at 15 mm. Evan was referred to the chest clinic by the school nurse. The school nurse initially referred him to his own private physician but was told that the family had only recently moved to the area and had neither a family physician nor health insurance. Evan was told that he could not attend school until medical clearance was obtained.

Evan’s mother, Ms. Smith, was very anxious about the possibility that her son had TB. She had brought Evan to the clinic 2 days ago to be seen by the physician. They were accompanied by Evan’s 13-year-old brother. The physician ordered a chest X-ray. The X-ray showed hilar adenopathy. An attempt to induce sputum was unsuccessful. Gastric aspirates were collected, and were negative on smear. The physical exam showed that Evan had lost some weight and had a low-grade fever. A diagnosis of suspected pulmonary TB was made with cultures pending. A standard pediatric regimen (INH, RIF, PZA) was prescribed, and Ms. Smith was advised to keep Evan at home until his next clinic appointment. Ms. Smith and Evan’s older brother were administered tuberculin skin tests at the initial clinic visit. 48 hours later, the test results were interpreted as negative.

You have been sent to Evan’s home for an interview. Evan is at home, but asleep. An elderly neighbor, who was asked by Evan’s mother to check on Evan during the day, is walking out of the house as you arrive. Ms. Smith has just returned from work and you are there to interview her.

 

Particpant   Leader

Activity 6:  Group #3

Group #3 Participant/
Leader Info., p. 3

David, a 27-year-old postal worker, tested positive for HIV 14 months ago.  He was given a tuberculin skin test at that time, the result of which was negative.  Three weeks ago, he began experiencing chills, fever, loss of appetite, and an unproductive cough.  He thought that he had the flu, took some aspirin, and rested.

When David’s condition did not improve after 2 weeks, he consulted his private physician, who was aware of his HIV infection.  The physician prescribed an antibiotic and decongestant cough formula and referred David for a chest X-ray.  The X-ray, read the same day, revealed an infiltrate with cavitation in both lungs.  The next day, David returned to his physician, who advised that further tests were needed to rule out or confirm a diagnosis of pulmonary TB.  He was advised to continue the cough syrup and antibiotic, and arrangements were made for an evaluation at the health department on Monday.

At the health department, David was given a skin test and had sputum specimens induced.  After reviewing the chest X-ray, clinical findings, and history, the doctor prescribed David a four-drug anti-TB regimen compatible with his HIV medications.  He was instructed to return to the clinic in 3 days to receive his skin test result and bacteriology report. 

Upon return, David learned his skin test result was 7 mm.  The lab report for smear result indicated AFB (2+).  The clinician made a diagnosis of suspected pulmonary TB (culture results pending) and ordered DOT.  David was then sent to your office for an interview.

 

Partcipant

Activity 6:  TB Interview Checklist

Checklist, p. 1

Introduction

  • Introduce self
  • Provide identification
  • Explain role in TB control
  • Build trust and rapport
  • Explain purpose of interview
  • Ensure confidentiality

Information and Education Exchange

  • Observe patient’s physical and mental state and evaluate communication skills
  • Collect and confirm the following information:
     

– Name
– Alias(es)/nickname(s)
– Date of birth
– Address
– Telephone Number
– Next of kin
– Other locating information
– Physical description
 

– Known exposure to TB
– Recent hospitalization(s) for TB
– Medical provider for TB
– Transportation availability
– Other medical conditions
– Outpatient/DOT plan
– Barriers to adherence

  • Assess disease comprehension/provide TB education
  • Obtain/confirm TB symptom history
  • Discuss basis of patient’s current diagnosis
  • Discuss disease intervention behaviors (treatment, infection control, and medical appointments)
  • Refine infectious period and review significance with patient
     

Contact Identification

  • Focus on infectious period
  • Explain priority and nonpriority contacts based on exposure
  • Stress importance of identification of all close contacts
  • Collect information on patient’s contacts in the household/residence, workplace, school, other congregate settings, social/recreational environments during the infectious period including:
     

– Name
– Alias(es)/nickname(s)
– Age, race, and sex
– Address and telephone number

– Other locating information
– Physical description
– Hours of exposure per week
– Dates of first and last exposure
 

  • Discuss site visits and sharing of information on a need-to-know basis and reinforce confidentiality
  • Discuss patient vs. health department referrals

Conclusion

  • Request, then answer patient’s questions
  • Review and reinforce adherence plan
  • Restate next appointment (if known)
  • Arrange re-interview and home visit (if not already completed)
  • Leave name and telephone number
  • Thank patient and close interview

 
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