The Tuberculosis Behavioral and Social Science Research Forum Proceedings
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Section II. Presentations and Panel Discussions
Psychosocial, Social Structural, and Environmental Determinants of Tuberculosis Control
Donald E. Morisky, Sc.D., M.S.P.H., Sc.M.
Professor, School of Public Health Department of Community Health Sciences, University of California, Los Angeles
Day 1, Morning Session
Dr. Morisky presented research results from two randomized studies of adherence to anti-TB regimens. The first study used cognitive and behavioral outcome markers, such as knowledge, beliefs, values, and attitudes, to assess the effectiveness of an educational intervention. Participants were randomized to one of three intervention groups: 1) educational counseling, 2) incentives/rewards, 3) a combination of educational counseling and incentives/rewards, or to the control group. Those who participated in the educational counseling intervention showed a significantly higher level of medication compliance from baseline to exit interview. Dr. Morisky identified factors that may affect drop-out rates, such as ethnic background, gender, unemployment, homelessness, drug use, HIV status, primary language, and marital status.
The second study focused on foreign-born adolescents’ adherence to LTBI treatment. Determinants of these adolescents’ compliance with and completion of treatment were categorized as individual, environment, or other.
Individual determinants of compliance included:
- An understanding of the medical regimen;
- Belief in the benefits of treatment;
- Positive attitudes regarding treatment; and
- High levels of self-esteem and self-efficacy.
Environmental determinants of compliance included:
- Family member reinforcement in the home;
- Good patient/provider communication;
- Systematic approaches for patient monitoring, follow-up, and reinforcement;
- Convenience of picking up medication from the clinic; and
- Use of medication containers and cueing behaviors.
Other determinants of completion of care included:
- Regular appointment-keeping behavior;
- High levels of adherence;
- Use of community health workers;
- Reinforcement of positive behaviors by health care staff; and
- Use of peer counselors to clarify health concerns.
During the discussion with Forum participants, Dr. Morisky commented further on communication about non-adherence between patients and providers. Patients are often afraid of talking about non-adherence, and social desirability pressures further influence communication between patients and providers. To address this issue, families should be encouraged to provide positive reinforcement for patients who are adherent to their treatment regimens.