TB Notes Newsletter
No. 1, 2014
Background and statement of problem
Low health literacy is a well-documented problem in the United States. Nearly 9 out of 10 U.S. adults have difficulty using routine health information; only 12 percent of English-speaking adults in the United States have proficient health literacy skills. Recent refugees and immigrants are among the populations most likely to experience limited health literacy.1 Maine detects an average 450 latent M. tuberculosis infections annually, of which 80% are in foreign-born persons. (Note: while latent TB infection [LTBI] is not a nationally reportable condition, some states have implemented reporting of LTBI; Maine is among these.) In Maine, as in other states, public health nurses (PHNs) have the role of educating patients about the signs and symptoms associated with isoniazid (INH) therapy, i.e., hepatotoxicity. Despite these efforts, there is evidence that not all patients understand the health risks, thereby compromising their LTBI treatment.
The Public Health Nursing Program and the TB Program are in two separate divisions within the Maine Center for Disease Control and Prevention. However, they work closely together on prevention, diagnosis, treatment, and management of LTBI and TB disease.
During 2010–2011, two patients in Maine with LTBI were hospitalized for acute INH-associated hepatotoxicity; one of the hospitalized patients was U.S. born, with a primary language of English. Each patient had received Public Health Nursing Program services, including, at a minimum, the following:
- Monthly in-person education (including provision of educational materials) about signs and symptoms of potential adverse events and steps to take if they occur (stop taking medicine and contact provider), and
- Monthly PHN services, which include being monitored for adherence to, and tolerance of, the prescribed treatment regimen.
Investigation of the first case by the national Centers for Disease Control and Prevention (CDC) revealed that standard procedures had been followed by all public health staff providing TB services to the patients. The patients had been informed more than once about signs and symptoms of potential adverse events of INH, as well as what to do if such events occurred: stop taking the INH and call their health care providers (PHN or physician). Both patients had continued to take INH despite worsening symptoms, and neither called a health care provider to report the events. CDC investigators who reviewed the two illnesses recommended that consideration be given to increasing the amount of education and information provided to LTBI patients about the signs and symptoms of potential adverse events caused by INH and the patient's proper response.
Methods: pilot-project implementation, April 2012–April 2013
In 2011, staff of the Maine TB Program and the Public Health Nursing Program planned and developed a pilot project to implement the CDC recommendations. The main goal of the project was to improve the education provided to LTBI patients about the risks of INH therapy and actions to take if signs and symptoms of an adverse event occurred. The TB program contracted with a graphic designer and worked with him to develop the images to be used in the educational materials. In collaboration with the PHNs, images were chosen depicting the side effects potentially associated with INH therapy, to use on education materials. The PHNs were also asked to give their preferences for the items that would display the medication safety messages.
After reviewing all of the LTBI referrals that Maine had received the previous year, the team found that the majority of individuals listed country of birth as Somalia and their preferred language as Somali. For this reason, despite the fact that neither of the two prior patients with adverse events were Somali, the project team chose Somali participants for a focus group and chose that additional language for the materials. Thus, a focus group of Somali women, most of whom spoke Somali and not English, met to assist in the development of educational materials culturally and linguistically matched to the needs of these women and to choose images most representative to them of potential adverse events.
Staff of the TB and PHN programs worked together to develop patient education materials that would meet the cultural and linguistic needs of LTBI patients (8½" x 11" tear sheets, pill box cover, calendar, and magnet; Figures 1 and 2). These include images of signs and symptoms of INH adverse events and steps to take if any occur. A written description of each image was provided in Somali and English on the tear sheet.
In addition to these materials, the Teach Back method was used to improve PHN-patient communication. Teach Back is a teaching method in which the learner repeats back what he or she heard from the instructor to verify correct understanding of the information. If what is repeated is inaccurate, the messages and the explanations are repeated until the learner's understanding and recall are both accurate.
The team also developed a four-question interview form (Figure 3). The interview form, together with the Teach Back technique, was designed to capture patients' demonstration of their understanding of the name of their LTBI medication, eight potential signs and symptoms of adverse events of the medication, and what they should do if they experienced any of those signs and symptoms.
Training for the project and the Teach Back method was provided for PHNs, both in person and through Adobe Connect, in April 2012. (Note: Adobe Connect is a web conferencing platform for web meetings, eLearning, and webinars.) This marked the start of the pilot project.
During LTBI treatment, a PHN is assigned to every high-risk patient, including foreign-born patients, and conducts monthly LTBI visits. All new high-risk LTBI patients taking INH were eligible to enroll in this project. During the project period, on visit #1, the PHN was to complete the four-question interview to determine the patient's baseline recall of information about INH. The PHN would use the calendar, pill box, and Teach Back technique to re-instruct the patient. On visit #2, Teach Back was to be used with tear sheets to educate on signs and symptoms of adverse events. On visit #3, the PHN would use the same four-question interview to assess the patient's recall of signs and symptoms of adverse events and what to do if they occur. After each visit, the PHN was asked to document that Teach Back was used and to fax the interview forms to the TB control staff, and also to enter the information into CareFacts™, the electronic medical record system used by PHNs.
For the duration of the project period, the PHNs were asked to document that they had provided a specific medication safety message to patients using the interview form and the Teach Back methodology. Several months into the project, PHNs integrated the interview form into the electronic medical record system, CareFacts™, so that PHNs could fill out the electronic interview and not have to fill out and fax the paper form. The PHNs were then able to use the interview in paper form, electronic form (integrated into CareFacts™ after the project was initiated), or both to assess the patient's knowledge and to deliver the medication safety message.
Throughout the project, TB Control and nursing staff met routinely to discuss progress and challenges and make necessary adjustments. Midway through the project, TB control and PHN staff completed a preliminary analysis of data from the interview forms and surveyed the PHNs. In April 2013, the 1-year pilot project was completed and analyzed, and PHNs adapted a modified version of the project into their LTBI policies. The findings were shared with PHNs and providers through presentations at PHN Supervisor and TB Cohort Review meetings.
Analysis and significant findings
Upon project completion, TB control and nursing program staff analyzed three elements:
- The information from the interview forms, to look for change in patient knowledge;
- Change in documented patient knowledge, behavior, and status (KBS) related to LTBI medication adverse events; and
- PHN experience and ideas, via electronic survey and informal interviews.
Analysis of interview forms
Analysis shows that the goal of delivering the safety messages and assessing patient response at the first and third PHN visit was partially met. The electronic health record reflected that 226 patients had received LTBI services by PHN. Of these, 74 patients (33%) had first and third visits documented by interview form completion. A variety of patient and PHN circumstances adversely affected the ability of the PHNs to provide first- and third-visit interviews. Patients changed place of residence and experienced complex health and cultural issues, and there were data entry errors. As a result, 152 (67%) of the patients eligible to be in the project did not have complete data and were therefore unable to be analyzed for change in knowledge or behavior related to LTBI medication safety.
Among the 74 patients with both first and third visits documented, 17 (23%) were unable to name the medication at the first visit, but were able to name it at the third visit. Also, 15 (20%) of project patients were unable to verbalize any of the eight signs and symptoms at their first Teach Back visit, but were able to report on an average of three additional signs and symptoms by their third visit. Most notably, 61 (83%) of patients who received a third visit gave the desired response that they should first stop their medications and then call a PHN or provider if they experienced signs and symptoms. No signs and symptoms of severe adverse events occurred during the project period.
Analysis of patients' KBS
Nursing assessments were documented in each patient's nursing care plan using the Omaha System terminology.2 This system provides PHNs with a mechanism for describing patient outcomes related to their knowledge, behavior, and status (KBS). PHNs rated and recorded their patients' KBS on initial, interim, and discharge visits. The KBS ratings documented for former patients discharged from the PHN project (n=127) and those still being served by PHNs (n=44) by project completion were compared to initial KBS ratings collected when the patient was first enrolled by a PHN. (Note: 45 patients did not receive a KBS rating beyond the initial rating, thus their data could not be included in and analyzed for this project.) Of the 171 patients who received initial and subsequent ratings, both the discharge and last rating averages showed improvement when compared to average initial KBS ratings. Delivery of project services probably contributed to this improvement, but was not exclusive of other nursing service variables.
Post-project, the PHN program has elected to continue the main components of this project, with modifications. Documentation of using Teach Back is now exclusively electronic and is required at the first PHN visit, but at subsequent visits is left to the discretion of the nurse. The PHN program plans continued data analysis of project results as part of its ongoing quality improvement, strategic planning, and performance management activities.
Analysis of Nursing Survey
In October 2012, a nine-question electronic survey using the tool Survey Monkey was sent to all 50 PHNs, who were encouraged to participate. Thirty (60%) completed the survey. Key findings included the following:
- If the same materials were ordered again, 90% of PHNs surveyed would use them.
- PHNs selected the calendar and tear sheets as most useful, and the magnets and pill boxes as least useful.
- In addition to Somali and English, PHNs requested the materials be translated into additional languages; French was the most requested language by PHNs.
TB control staff had resources to translate the tear sheets into one additional language, so French was selected. Because of program budget constraints, only the tear sheets could be re-ordered, not the calendars, magnets, or pill boxes. The health department now offers the following language and INH medication options for tear sheets: French with English and Somali with English.
- When the interview form became available in CareFacts™, and faxing the form was no longer a requirement, PHNs did not complete a significant number of Visit 3 electronic forms, leaving 152 (67%) of patients who were in the project with incomplete data.
- There was some variability among PHNs in skill, comfort, and experience with LTBI patients and the Teach Back method.
- It was unknown if PHNs' personal preferences for certain tools introduced bias.
- There was no control group—all new LTBI patients were supposed to be enrolled in the project.
By increasing some patients' knowledge about recognizing and correctly responding to signs and symptoms of INH adverse effects, we were able to partially achieve our original project goal. We cannot definitively prove a direct causation between this project and actual improved patient medication safety, because other nursing interventions occurred simultaneously. However, PHNs' use of educational tools and the Teach Back technique did increase patient recall of signs and symptoms of INH adverse events, and actions to take if these occur.
In addition, KBS analysis showed that patients were taking action to improve their health. Most notably, there were no severe adverse events related to medication toxicity in the project period. This increase in patient knowledge and behaviors will ideally translate into fewer adverse events, improved adherence to LTBI therapy, and higher treatment completion rates. Through this and other collaborative projects, we aim to achieve a reduction in the number of TB cases in Maine, our ultimate and long-term goal.
Recommendations include further analysis of
- CareFacts™ data
- Participation levels of each PHN (i.e., what percent of each PHN LTBI patients were included in both first and third visits)
- Tools used, and whether PHN or patient choice influenced outcome
- Patient experiences and language preferences
Figure 1: INH tear sheet in English and Somali (Click for larger image)
Figure 2: Educational materials — tear sheets, pill box, calendar, magnet
Figure 3: Interview Form (Click for larger image)
- U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, National Action Plan to Improve Health Literacy; 2010: Washington, DC.
- Martin Karen S., RN, MSN, FAAN. The Omaha System: A Key to Practice Documentation, and Information Management. Reprinted 2nd edition. Martin Associates; Omaha, Nebraska: 2005. http://www.omahasystem.org/overview.html
Lori Wolanski, MPH, Pamela Correll, MS, RN, & Ted Hensley, RN, MSN
Maine Center for Disease Control and Prevention