Effective TB Interviewing for Contact Investigation: Self-Study Modules
The TB interview
Structure of the Interview
- Pre-Interview Activities
- Information and Education Exchange
- Contact Identification
The interview has five components, which are presented in detail in pages 8-17. The components are as follows:
At the end of this module is a checklist that summarizes the elements of the interview (page 25). This checklist can be used during the interview as a prompt and after the interview to evaluate whether the interview was complete. Note that some interview elements may vary depending on what information is required by the local health department. Information the interviewer provides to the patient may depend on the job responsibilities of the interviewer, including a combination of medical care, directly observed therapy, and congregate setting investigation.
I. Pre-Interview Activities
Before conducting the interview, the interviewer should organize and prepare for it by obtaining background information on the patient. This will assist the interviewer in forming a preliminary infectious period and developing an interview strategy.
- Review medical record – The record may contain information from hospital staff, infection control practitioners, or social workers.
- Review and note medical record information related to the diagnosis (site of disease, symptom history, bacteriologic and chest x-ray results, treatment, and recent or past known exposure to TB, including skin test results)
- Review and record social history, language and cultural barriers, and other medical conditions
- Note previous hospital admissions and any history of previous treatment, substance abuse, mental illness, or inability or unwillingness to communicate with other healthcare staff who may have interacted with the patient
- Assess the need for respiratory protection during the interview for both the interviewer and patient
- Obtain and record index patient locating information:
- Record name, address, telephone number, and additional locating information
- Collect and record next of kin, emergency contact, employer
- Establish a preliminary infectious period based on medical record review and local health department guidelines. This will be refined during the interview based on the patient’s verification of information.
- Develop a strategy for the interview process by analyzing information collected thus far. This should include looking for any unusual factors about the patient that will need to be considered, such as any other medical conditions, mental status, housing or money, transport, and social support needs.
- If possible, arrange an interview place and time convenient to the patient and satisfactory to the local health department time frame for the completion of interviews.
- Arrange and ensure privacy by seeking an interview time and place with minimal distractions and interruptions. Note: When a patient is hospitalized, the initial interview should take place in this setting.
As discussed later in Module 2, “Basics of Communication and Patient Education,” the very first interaction with the patient can influence the remainder of the interview. It is important from the beginning for the interviewer to provide an explanation of who he or she is and present a clear picture of the importance of the TB interview.
- Begin by building trust and rapport, as well as demonstrating respect. Introduce yourself and provide a business card or identification. If appropriate, shake the patient’s hand. Greet the patient using Mr./Ms. and family name and then ask the patient what he or she would prefer to be called. Explain your role in the tuberculosis control program. This includes your responsibility to protect the health of the public.
- Explain that the purposes of the interview are
- To provide TB information and answer any patient questions, and
- To identify people who have been exposed to TB so that they can be referred for medical evaluation.
- Emphasize confidentiality, yet inform the patient that relevant information may need to be shared with other health department staff or other people who may assist in congregate settings to most efficiently ascertain which contacts need to be evaluated. Also, note local laws regarding confidentiality when interviewing minors.
As the interview progresses, the interviewer should educate the patient on TB and the contact investigation process. As this occurs, the interviewer should continuously assess whether the patient understands the information being exchanged and appears invested in the interview process.
- Throughout the interview, determine the extent of trust and rapport being developed while observing the patient and assessing responses.
- Observe the patient’s body language and speech for comfort level and comprehension of information provided.
- Make note of any physical signs or behavior indicative of alcohol or substance abuse, nutritional status, lifestyle, and other conditions which may influence the patient’s level of cooperation
- Assess the patient’s communication skills, attitudes, concerns, and needs. As necessary, refine the interview strategy. This may include accomplishing less during the initial interview session and scheduling a follow-up interview
- Personal information – Explain that it is important to obtain and confirm the patient’s personal information. The following patient information should be collected and verified:1
- Full name
- Date of birth
- Place of birth (city, state/province, country)
- If born in a foreign country, date arrived in USA
- Travel destinations (when last there and for how long)
- Physical description (height, weight, race, other identifying characteristics)
- Current address and post office (PO) box or place of residence, including directions, if necessary
- Telephone number
- Length of stay at current address
- Marital status
- Next of kin (name, address, telephone number, other locating information)
- Emergency contact (name, address, telephone number, other locating information)
- Employer or school (name, address, telephone number, other locating information)
- Medical information and problem indicators
- Explain the importance of collecting accurate medical information
- Obtain and document the following patient information:
- Known exposure to TB (who, where, when) or knowledge of anyone with similar symptoms
- Past hospitalization(s) for TB (name, admission and discharge date[s])
- Other medical conditions, including HIV test results, if available
- Substance abuse (including frequency, type, how long)
- Medical provider for TB (private or clinic, name, address, telephone)
- Transportation availability to/from medical provider
- Directly observed therapy (DOT) plan, if known (where, when, by whom)
- Barriers to adherence
- Disease comprehension
- Use open-ended questions to determine the patient’s TB knowledge
- Reinforce the patient’s TB knowledge and correct any misconceptions. Explain mode of transmission and how TB affects the body, using language the patient can understand. Avoid using medical terms and recognize when to defer questions to appropriate personnel (see Module 2, “Basics of Communication and Patient Education”). Provide appropriate patient education materials.
- Symptom history – Review with the patient the following TB-related symptoms, including onset dates and duration:
- Hemoptysis (coughing up blood)
- Hoarseness or laryngitis
- Unexplained weight loss
- Night sweats
- Chest pain
- Loss of appetite
Recall of symptom onset can generally be poor. Mentioning prominent dates and major holidays can help the patient recall symptom onset. Cough, if present, is the most critical symptom in determining the infectious period.
- Discuss the elements of patient’s current diagnosis, including
- Tuberculin skin test results
- Site of disease
- Symptom history
- Chest x-ray and bacteriologic results
- Disease intervention behaviors – Explain the importance of the following interventions:
- Treatment regimen
- Explain that the patient’s medications kill TB germs when taken as prescribed. Reinforce the personal and public health benefits of taking the medicine.
- If trained to do so, identify and explain each prescribed drug and discuss potential side effects.
- Establish a specific schedule or reinforce existing schedule for outpatient treatment, including DOT.
- Review the local/state regulations mandating treatment adherence (if applicable).
- Infection control measures
- If the patient is infectious, review the importance of cough hygiene, e.g., using a mask or a tissue to cover the mouth and nose if coughing and sneezing. Explain proper disposal technique. Emphasize that covering the mouth and nose is an important measure the patient can take to protect others.
- Discuss the importance of adequate ventilation to protect others.
- Describe other measures as appropriate, i.e., home isolation, visitors to the home, and return to work or school.
- Maintaining medical care – Discuss the importance of
- Adherence to therapy while reemphasizing the significance of continuity of therapy;
- Sputum collection, chest x-rays, and physician evaluations;
- Adherence to all medical appointments and DOT, if ordered; and
- Adherence-enhancing strategies, e.g., available incentives, pill boxes, and reminder notes.
- Treatment regimen
- Infectious period
- Based on the information collected thus far, refine previously established infectious period.
- Review significance of infectious period with patient and discuss its role in contact identification.
While a brief explanation of a contact investigation should be provided at the beginning of the interview, a reemphasis prior to the elicitation of contacts is necessary. This reassures the patient of the importance of providing contacts’ names. It is also important at this time to reinforce confidentiality and to educate the patient on TB transmission.
- Introduce the contact identification process by reviewing the patient’s understanding of TB transmission. Stress the importance and urgency of the rapid and accurate identification of all priority contacts during the infectious period. Reinforce the importance of identifying contacts in order to protect family and friends from getting TB.
- Explain the difference between priority and nonpriority contacts. This should include a discussion of how TB is spread. It should be emphasized that transmission increases with duration and frequency of exposure and with exposure in closed spaces. These concepts should be explored with each named contact.
- Inform the patient that a congregate-setting investigation may be done in any place in which the patient reveals having spent prolonged time during the infectious period. The patient should be made aware that an appropriate site manager (e.g., supervisor, school principal) may be called in to assist in identifying persons in this setting, but that an emphasis on confidentiality will be maintained. With other medical conditions, the patient’s illness and identity are held in strict confidence. For an infectious disease such as TB, working with a third party in a congregate setting may be appropriate. The patient should know that if he or she chooses to tell others about his or her illness, or if others already know about the diagnosis, the health department will continue to maintain confidentiality and not reveal or confirm any patient information.
- Collect information about the patient’s contacts in the household/residence, workplace/school, other congregate settings, and social/recreational environments. If the patient’s responses contain conflicting information, ask about these inconsistencies in a nonconfrontational manner. Be aware that patients are being asked to recall detailed information over an extended period of time and may not remember information very clearly. Some patients, however, may intentionally provide vague or inconsistent information. In this case, the interviewer should re-emphasize the importance of contact identification and confidentiality (see Module 4 for additional strategies).
Contact tracing information – Obtain the following information as relevant to the patient’s infectious period (some information will require a field visit for confirmation):
- Type of housing (e.g., house, apartment, shelter, nursing home)
- Description of housing, including size of rooms, ceiling height (low or high), number of rooms, method of ventilation, and source of heating and cooling
- Additional addresses where patient spent time
- If employed: employer name, address, telephone number, full or part-time, hours per day/week, how long employed, transportation type to/from work, length of commute, occupation/type of work, indoor or outdoor work space, and enclosed or open work space
- If unemployed: source of income
- If attending school: name of school, address, telephone number, grade/year, hours per day/week, transportation type to and from school, and length of commute
- Social and recreational activities (e.g., hangouts, bars, team sports, community centers, band, choir, place of worship), including hours per day/week, and means of transportation
- Other congregate settings (e.g., armed services, hospital, nursing home, drug treatment center, detoxification center, shelter, group-living home, hotel, prison or jail), including name and dates of attendance
- Travel history (where, with whom, mode of transportation, person visited)
Contacts’ information should include locating and physical identifying details. Explain to the patient that the reason for collecting detailed information on each contact is to be able to locate these individuals as easily and quickly as possible and not to mistake them for others. Information should be gathered in three spheres:
- Household or living situation
- Workplace or school
- Social and recreational
The patient may not be able to provide full names or any names for some contacts, so the investigator who must locate the contacts in the field may need to rely on nicknames or physical descriptions, or both. Note that the patient may not be able to supply all of the details listed below and that the interviewer should decide how much information is needed based on what has already been collected.
Obtain the following information for activities occurring within the patient’s infectious period about all persons in each sphere. Information should include name/alias(es)/nickname(s), relationship to patient, age, sex, physical description, employer/school, and other locating information (include current address if no longer living in the household). Also, include hours of exposure per week and date(s) of first and last exposure. Include, with identified contacts, persons regularly socialized with and social/recreational establishments, including
- Close friends
- Sex partners
- Overnight guests and regular visitors to patient’s residence (e.g., neighbors,
friends, and relatives)
- Persons with whom drugs are used
- Overnight visits to any other location(s) (obtain address[es])
- Specifically ask about time spent with young children or immunocompromised individuals
- Congregate setting assessment
- Ask for a description of identified congregate settings, including size of rooms, ceiling height (low or high), number of rooms, method of ventilation, source of heating and cooling.
- Inform the patient that it will be necessary to make site visits to the home, workplace or school, and leisure establishments to assess the shared air environment to accurately structure the contact investigation.
- Stress patient confidentiality as well as the necessity of sharing information on a need-to-know basis with appropriate site management. Discuss the importance of a medical evaluation for each contact.
- Methods of referral
- Inform the patient that referrals and verified contacts’ medical evaluations should be carried out immediately
- Explain contact referral options (options may vary by state):
Patient should be given a choice of whether to inform contacts of their risk of exposure prior to the health department referral process. Discuss the referral options with the patient, deciding which contacts are appropriate for health department referral and for patient referral. Review with the patient how and when contact referrals will be made and where the contacts will be referred.
Health Department Referral: While protecting the patient’s right to privacy, the healthcare worker assumes full responsibility for locating and informing the contact about exposure and the need for a medical evaluation.
Patient Referral: The patient agrees to inform the contacts about exposure and the importance of speaking with the healthcare worker regarding the need for a medical evaluation. Remind the patient that this method will not protect his or her confidentiality. If necessary, rehearse with the patient how to inform contacts and what instructions they should be given regarding their medical evaluations. Inform the patient that the health department will follow up on anyone who does not respond within an agreed upon timeframe.
Explain that the index patient’s identity will be held in confidence during the investigation, and the same is true for all contacts’ confidentiality. The health department cannot reveal the results of medical evaluations (e.g., how many people are tuberculin positive, how many people have TB disease, who has been started on treatment) of contacts to the index patient, other contacts, or staff of congregate settings.
- Discuss re-interview time frame:
Explain that you will be visiting the patient again upon discharge from hospital, or within 10-14 days if the initial interview is at home, to obtain further information and answer additional questions.
Conclude the interview in a positive manner. Recognize the index patient’s participation in the interview, and make the patient feel that you are trustworthy and can be consulted with concerns as they arise, even after the interview.
- Request and answer the patient’s questions.
- Review and reinforce all components of the treatment plan.
- Evaluate the patient’s remaining needs or potential adherence problems.
- Restate the date of the next medical appointment, if known.
- Arrange for both a re-interview and home visit, if not already completed.
- Reinforce the procedures for referral of each contact.
- Provide information on how the patient can contact you.
- If appropriate, shake the patient’s hand, express thanks and appreciation, and close the interview.
While it is important for the interviewer to follow a systematic process to achieve the interview objectives, it is also important for the interviewer to demonstrate flexibility and respond to the patient’s needs. The patient may have questions, show signs of fatigue, or need assistance in some way, which may lead to a deviation from the interview agenda. Addressing these needs through recognition of concerns, problem solving, and referral to appropriate resources may be a minor set-back, but can eventually allow the interview to progress. For strategies on dealing with patient needs, see Module 4, “Special Circumstances.”