Patient Education - MANAGING TB AT THE RAION LEVEL potx

The work upon which this publication is based was performed in part under Grant
Agreement 118-G-00-99-00112 (WHO) and PASA 118-P-00-98-00165
(DHHS/CDC) funded by the U.S. Agency for International Development. The
opinions expressed herein are those of the author(s) and do not necessarily reflect
the views of the U.S. Agency for International Development.

Additional funding was provided by the World Health Organization and the
Centers for Disease Control and Prevention.

2003


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Patient Education

Module 11 – Table of Contents

11.1 Introduction to Patient Education 1
11.2 Effective Communication Techniques 2
1121.1

Ask questions and listen. 3

11.2.2

Make interactions with the patient a positive experience. 6

11.2.3

Speak clearly and simply 6

11.2.4

Use the appropriate language level 7

11.2.5

Limit the amount of information given at any one time. 7

11.2.6

Discuss the most important topics first and last. 7

11.2.7

Repeat important information 7

11.2.8

Use concrete examples. 8

11.2.9

Encourage the patient to ask question. 8

11.2.10

Ask checking questions 8

11.3 Educating the TB Patient (First Meeting) 9
Exercise 1: Role Play – Initial Health Education about TB 13

11.4 Continue Patient Education Throughout Treatment 15
Exercise 2: Role Play – Continuing Health Education about TB 18

11.5 Facilitating Adherence to TB Treatment 20
1154.1

Reasons for Non-adherence 20

11.5.2

Explaining the Importance of Adherence 22

Exercise 3: Written Exercise and Discussion – Problem Solving 25

11.6 Summary 26





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11.1 Introduction to Patient Education
Education of the patient is a critical part of treating tuberculosis. The health worker
must communicate with a patient clearly and supportively from the time of
diagnosis, throughout the long treatment process, and until the patient is cured. The
patient’s family will also need information, advice, and support.

At the time of diagnosis, patients need basic information about tuberculosis and
how it is spread. They may be afraid and need reassurance that TB can be cured.
They need an explanation of the treatment process and the necessity of directly
observed treatment. In some cases, health workers may have to persuade patients
who feel that daily treatment will be too time-consuming and inconvenient.

Daily or thrice-weekly interactions with patients for directly observed treatment
offer many opportunities for health education. At every visit, health workers need
to show a welcoming and supportive attitude so that patients will be willing to
return for the next treatment.

Patient education is very important in the intensive phase of treatment. However, it
is vital to a successful treatment outcome that patient education be an ongoing
process throughout the duration of treatment.

Learning Objectives: This module describes the necessary steps health care
workers must take to educate TB patients on their disease and course of treatment
from diagnosis through completion of treatment. All training courses for health
care workers should include instruction in patient education skills. The
information, examples, and exercises in this module will assist the raion TB

Coordinator in prioritizing and supervising the implementation of patient education
at the raion level. At the end of the module, the raion TB Coordinator should be
able to:
• Identify effective communication skills useful for all health education
• Effectively communicate important TB information to the patient throughout
treatment
• Explain the importance of adhering to the prescribed treatment
• Identify issues that may affect patient adherence to treatment


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11.2 Effective Communication Techniques
Effective communication is more than just talking or giving advice. It involves
asking questions, listening carefully, trying to understand a patient’s worries or
needs, demonstrating a caring attitude, and helping to solve problems. Good
communication begins when the health worker sees the patient promptly, addresses
the patient by name, and offers a comfortable place for the patient to sit. It
continues as the health worker makes eye contact, speaks in a respectful tone of
voice, and encourages the patient to ask questions.

Effective communication is not only needed to teach patients important messages
about TB and its treatment. Effective communication is critical to encourage
patients to return for the next treatment visit.

This section of the module will describe effective communication skills that can be
used when providing health education messages to patients and their families.

Table 11.1 summarizes the communication skills described in this module. The
right side of the table shows the purpose of each skill in the context of health
education about TB.

Table 11.1 Summary of Effective Communication Skills
Communication Skill Purpose
• Ask questions and listen
• Encourage the patient to ask
questions
Understand the patient’s medical history
Understand the patient’s current
knowledge about TB
Identify and help solve any problems
the patient may have with treatment
• Make the interaction with the patient
a positive experience
Motivate the patient to continue
treatment
• Speak clearly and simply
• Use the appropriate language level
• Limit the amount of information
• Discuss the most important topics
first and last
• Repeat important information
• Use concrete examples
• Encourage the patient to ask
questions
• Ask checking questions
Ensure that the patient understands and

remembers important messages about
TB and treatment
Ensure that the patient knows exactly
what to do next


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The communication skills highlighted in Table 11. 1 above are discussed in further
detail below.

11.2.1 Ask questions and listen.
Asking questions and listening carefully to the responses are important skills to use
to:
• understand the patient’s medical history,
• understand the patient’s current knowledge of TB, and
• identify and help solve problems with treatment.

Communication with the patient should always be two-way. Health care workers
should ask questions and listen carefully to answers given by the patient.

Open-Ended Questions
An open-ended question is one that cannot be answered with a simple “yes” or
“no.” Open-ended questions are designed to learn about the patient’s knowledge,
feelings, and beliefs by beginning with words that elicit an explanation, such as
“who,” “what,” “when,” “why,” and “how.” In addition, phrases that begin with
“Tell me about” or “Explain to me” may be helpful in eliciting information from the
patient. Such questions are used when a health care worker needs to explore

complex issues that do not have a finite or predetermined set of responses.
However, sometimes it may be necessary to ask a direct “yes” or “no” question.

Throughout treatment, the health care worker should ask the patient about his or her
concerns regarding TB and adherence to the prescribed regimen. Below are
examples of questions that health care workers can use during the initial health
assessment and subsequent interactions with the patient throughout the course of
treatment. The questions below are merely a starting point. Whenever possible, the
health care worker should adapt such questions according to the patient’s age,
family situation, education level, and cultural background. The more the health
care worker is aware of the patient’s ideas and concerns about TB and the needed
treatment, the better prepared the health care worker will be to anticipate and
resolve problems that can arise.


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Examples of Questions to Ask to Understand the Patient’s Medical History
The questions below are examples of questions that health care workers can use to
learn more about the patient’s symptoms, family contacts, and previous treatments.
Some of these questions may be used to find out whether a patient needs to have a
sputum test. Others may be used after a TB patient has been diagnosed.

• How are you feeling?
• When did you first become sick?
• What are the symptoms? Have you had fever?
• What caused you to go to the doctor?

• What medicines are you taking now?
• How long have you had a cough?
• How many people live with you? What ages?
• Does anyone else in your household have a cough? Who? For how long?
• Which of your symptoms, if any, have you had before?
• What kinds of medicines did you take then? How long did you take them?
• Have you ever been treated for tuberculosis?
• (In areas where HIV is common) Do you know your HIV status?
• (For women of childbearing age) Are you pregnant?

Examples of Questions to Ask to Understand the Patient’s
Current Knowledge About TB
Before giving health education messages, health care workers can ask questions to
determine what the patient already knows about TB, or what misconceptions the
patient may have about TB disease and its treatment.

• What do you think your illness might be?
• What do you understand tuberculosis to be?
• What do you think TB does to your body?
• How serious do you think your illness is?
• What do you think causes tuberculosis? How is it spread?
• What do you fear about your illness?
• How did you feel when you were told you had TB?
• What do you think your family members and friends will think about your
TB?
• What have you heard about the sputum microscopy test for TB?
• What do you know about the medicine used to treat TB?
• What have you heard about curing TB?

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By asking questions the health care worker can tailor the health education messages
to the needs of the particular patient. Health care workers can build on accurate
information that the patient already knows and believes, and concentrate on giving
new information and correcting misconceptions.

Examples of Questions to Ask to Identify and Help Solve Problems
The following questions might be asked when arranging for directly observed
treatment or identifying obstacles to treatment adherence:

• How long do you think you need to take medicine to treat your illness?
• How do you feel about taking your medicine?
• How far away is your home?
• How did you travel to the health center?
• How long did it take you to come here today?
• Where do you work?
• What are your working hours?
• What is your marital status?
• Do you have any children? How many? How are they cared for?
• Do your children go to school? Where?
• Where do people usually go for health care in your village?
• Are you likely to move? If so, when and where? How long will you stay?
• Who is someone who always knows where to find you? Where does this
person live?

The following questions might be asked at daily visits to check for side effects
of treatment:
• How are you feeling?

• Have you had any problems?

Heath care workers should be trained to ask patients about side effects from the TB
medicine they are taking. Health care workers should be able to distinguish
between common and serious side effects, and should be able to assist patients in
the management of side effects. For more information on side effects from TB
medication, please see Module 3, Administering TB Treatment, Annex B.


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11.2.2 Make interactions with the patient a positive experience.
It’s not only what is said and done, but how it is said and done, that will help the
patient understand health education messages and adhere to treatment. The health
care worker should make interactions with patients a positive experience by being
encouraging and supportive throughout the treatment process.

By demonstrating a caring and respectful attitude toward the patient, the health care
worker can make it more likely that the patient will return each day for treatment.
A caring attitude can be demonstrated through actions, words, body language, tone
of voice, and eye contact.

When health care workers interact with patients, they should address the patient by
name, and respect the patient’s time by attending to the patient as soon as possible.

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 care
workers can make it clear that even if they do not share the patient’s views, they
respect them. Knowing and respecting the patient’s views will improve the
working relationship and make the patient more likely to be adherent.

The health care worker should keep in mind that judgments about the patient’s
lifestyle, beliefs, and behaviors might be conveyed through nonverbal body
language. This form of communication can also negatively affect the health care
worker’s relationship with the patient. The health care worker should be objective
and nonjudgmental.

TB treatment is a long process. In order to motivate the patient to continue
treatment, health care workers can provide praise and encouragement at every visit.
They can say, for example, “I’m glad to see you. You are doing the right thing by
coming for treatment every day.”

11.2.3 Speak clearly and simply.
Simple, nonmedical terms should be used in explanations to the patient. Health
care workers should be specific about the behaviors expected from the patient.

For example, it is much more helpful to say, “This pill will help you get better,”
than to say, “This drug, isoniazid, is a bactericidal agent that is highly active against
Mycobacterium tuberculosis.”

Using words that are familiar to patients can make the information relevant to them,
therefore increasing the likelihood that the patient will comply with the prescribed
treatment regimen.

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11.2.4 Use the appropriate language level.
Written information should match the patient’s reading level. Persons with a limited
education may only be able to understand very basic materials, however highly
educated patients may prefer more detailed information. Visual cues are very
useful, such as a calendar in which the patient has to mark off each day he ore she
takes the medicine.

11.2.5 Limit the amount of information given at any one time.
A patient may not be able to remember the important components of the treatment
plan if too much information is given at one time or if he or she is not prepared to
receive detailed information. The patient could possibly be overwhelmed and may
be experiencing fear over the diagnosis of TB disease. It is possible that the patient
could still be very sick and may be unable or unwilling to participate fully in an
education session. The health care worker should be aware of the patient’s ability
to pay attention and absorb health education messages and should schedule follow-
up education sessions with the patients as needed.

11.2.6 Discuss the most important topics first and last.
People remember information presented at the beginning and at the end of a session
more easily than they do the information presented in the middle. Health care
workers should tell the patient what is expected of him or her before they explain
test results, the expected outcome of a procedure, or treatment. The health care
worker should organize the topics to be discussed in the order of their importance.
he most essential topics (such as the importance of completing the treatment or the
importance of identifying side effects) should be discussed first and last. For
example, early in the first session the health care worker might say, “To get well,
you must take four of these capsules every day.” This information should be
reviewed again before leaving the patient.

11.2.7 Repeat important information.
Some people need to hear new information several times before they will remember
it. Health care workers should repeat key messages throughout the session, have
the patient repeat the information, and then in later sessions review material that
was previously presented. For example, topics can be introduced by saying, “As we
discussed earlier (or last time) ”


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11.2.8 Use concrete examples.
To make information easy to remember, concrete examples should be used. For
example, the health care worker can actually show the patient the pills while
explaining what the course of treatment will be. Likewise, the health care worker
can demonstrate the steps of sputum collection for the patient instead of just
explaining the steps.

11.2.9 Encourage the patient to ask questions.
Patients should feel comfortable asking questions about information they do not
understand. After giving instructions or an explanation, health care workers can
pause and ask, “Do you have any questions? I know this is a lot of information at
once.”

Patients may be timid and concerned about appearing uneducated. Or they may be
nervous and simply want to leave the health center in a hurry. It may take courage
for them to ask questions. Patients should be praised for asking questions. For

example, health care workers can say:
• “I’m glad you asked that question ”
• “Good question ”

Health care workers should answer all questions thoughtfully and carefully.

11.2.10 Ask checking questions.
Checking questions are questions intended to find out what a person has learned, in
order to provide more information or clarify instructions as needed. Checking
questions should be used at the end of an explanation to ensure that the patient
understands the health education messages given. Checking questions can also be
used at the end of a visit to ensure that the patient understands what to do next.

For example, to make sure that a patient knows what to do when instructed to bring
back an early morning sputum for a follow-up sputum exam, a health care worker
might ask the following checking questions:
• “When will you cough up the sputum?”
• “Where will you cough up the sputum?”
• “What container will you use?”
• “When will you bring the sample back to me?”
• “Why is this so important?”

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Asking checking questions requires patience. A patient needs to be given time to
think and answer. If the patient is silent, the impulse of the health care worker may
be to answer the question or quickly ask a different question.

The patient may know the answer but be slow to respond for several reasons. The
patient may be giving a wrong answer. The patient may be timid. The health care
worker should wait for an answer and give encouragement.

Sometimes the patient may give an incomplete or unclear answer to a checking
question. If this occurs, the follow-up questions can be used to see if the patient
really understands.

If the patient answers incorrectly or cannot remember, the patient should not be
made to feel uncomfortable. Misconceptions should be clarified and checking
questions can be asked again.

11.3 Educating the TB Patient (First Meeting)
The first meeting with a TB patient usually takes place when a patient receives the
results of diagnostic tests and is started on treatment for TB, or when the patient is
registered in the TB Patient Register (TB 03). The initial meeting with the patient
provides the opportunity to communicate essential information about TB and its
treatment.

The first meeting with a patient also provides a good opportunity for the health care
worker to gather information from the patient. The health care worker should ask
about the patient’s medical history, current knowledge about the disease, and
personal circumstances in order to tailor health education messages to the patient’s
needs.

The first meeting with the patient is very important and should be used to
• establish the foundation for a good relationship with the patient based on
mutual trust and understanding;
• confirm what the patient’s address will be after discharge and gather
information on contacts who may have been infected with TB;

• begin an assessment of the patient’s knowledge, attitudes, and beliefs about
TB;
• discuss the importance of adherence to the TB treatment regimen;

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In addition, the first meeting with the patients provides the opportunity to:
• get to know the patient;
• educate the patient about TB;
• look for factors that may affect the patient’s adherence to treatment; and
• arrange a follow-up visit with the patient.

The health care worker’s relationship with the patient will develop over time as
treatment progresses and the patient’s health improves. However, the initial meeting
is often the patient’s first encounter with the TB Specialized Services and therefore
is very important.

The initial meeting marks the beginning of the health care worker’s relationship
with a patient and therefore requires a certain amount of planning. For the initial
interview to be successful, a public health worker should:
• clearly understand aims of the meeting;
• plan the meeting properly so that sufficient time could be devoted to each topic
discussed;
• listen to the patient’s concerns referring to TB and its treatment;
• share all the necessary information with the patient.

During the initial contact with a patient it is important to provide essential

information regarding TB. Care should be taken not to overwhelm the patient.

It is important to establish a level of comfort with the patient so that he or she feels
comfortable enough to ask questions. Continually asking the patient questions
during the initial discussion, to ensure the information is being understood
correctly, can help in this process. More detailed information can be provided by
the health care worker during subsequent visits with the patient.

The topics to be discussed during the initial contact include, but are not limited to,
the following:

What Is Tuberculosis?
The health care worker should explain in simple terms what TB is and what type of
TB the patient has (for example, TB of the lungs). TB is an illness caused by a
germ. TB germs can settle anywhere in the body. One of the most common places
for TB to develop is in the lungs. When TB damages the lungs, a person coughs up
sputum and may not be able to breathe easily. Without proper treatment, a person
can die from TB.

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TB Can Be Cured
The patient should be reassured that with the right drug treatment, TB is a curable
disease. The patient must take all of the prescribed drugs for the entire treatment
time in order to be cured.

Treatment of TB
Treatments differ between new patients and patients who have been treated for TB

before (re-treatment patients). Re-treatment patients need a stronger treatment
regimen to be cured. Health care workers should provide general information about
the patient’s treatment, such as:
• Length of treatment
• Where the patient will receive treatment during the intensive phase
• Where the patient will receive treatment during the continuation phase

Necessity of Directly Observed Treatment
Health care workers should explain the importance of directly observed treatment
as a standard of care for all patients. The health worker must watch the patient
swallow all the drugs. This will ensure that the patient takes the correct drugs
regularly for the required time. If injections are needed, they will be given
properly.

For example, if the patient does not take all of the drugs, he or she will continue to
spread TB to others, and his or her TB will not be cured. It is dangerous to stop or
interrupt treatment, because then the disease may become incurable.

If the patient plans to move, they should inform the health worker so that
appropriate measures can be taken to ensure continuation of treatment in the new
location.

How Tuberculosis Spreads
The health care worker should explain that anyone can get TB. TB spreads when
an infected person coughs or sneezes, spraying TB germs into the air. Others may
breathe in these germs and become infected.

Patients must also understand the importance of making sure all family members
exposed to the disease (contacts) who have symptoms of TB go to the closest health
care facility for screening of TB. In particular, children under age 5 should be

screened, because they are at risk of developing severe forms of the disease.


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Symptoms of TB
Patients should be able to recognize symptoms of TB in family members, friends,
and other contacts. The main symptom is a cough which lasts for 3 or more weeks.

Usually, a person also has one or more of the symptoms listed below:
• Weight loss
• Tiredness
• Fever
• Night sweats
• Chest pain
• Shortness of breath
• Loss of appetite
• Coughing up blood-stained sputum

How to Prevent Tuberculosis from Spreading
Health care workers should explain how to prevent TB from spreading. Taking
regular treatment for TB and being cured helps to prevent the spread to others in the
family and community. The patient should also
• cover the mouth and nose when coughing or sneezing, and
• open windows and doors to allow fresh air to flow through the home.

There is no need to eat a special diet or to sterilize dishes or household items.

Importance of Completing Treatment
Patients should understand that shortly after they begin treatment, they will most
likely begin to feel better, but it is important to continue taking the medications.
The patient must understand that just because he or she feels better, it does not
mean that the disease has been cured. Health care workers should further explain
that if the patient does not take all of the medicine, multidrug- resistant TB can
develop, which is much more difficult to treat.

What to Expect; What to Do Next
During the intensive phase of treatment, the patient may be hospitalized. The
health care worker should discuss what this means for the patient, and what the
patient can expect as part of treatment.

The patient should also be reminded to identify family members who may need to
be tested for TB, such as children under 5 years old and family members with a
cough or other symptoms of TB.


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Exercise 1
Role Play – Initial Health Education About TB

For this exercise your facilitator will divide you into groups of three to enact a role-
play. In this role-play, a 40-year-old patient, Mr. A.V. Sokolov, has come to the
health center to hear the results of his sputum tests.

In the role-play one person will act as the health worker, one as the patient, and one
as an observer. Then you will trade roles and repeat the role-play. By repeating the
role-play several times, each person will eventually have a turn in each role.

Instructions for the Health Worker
In this role-play your goal is to use good communication skills to:
1. Ask the patient questions, and
2. Cover relevant health education messages for the first meeting with the TB
patient.

To ensure that you include all of the necessary questions and messages, refer to the
text on pages 3-12 of this training material.

The box below shows the information that you already know about the patient.

Information for the Health Worker – Role Play Exercise A
The patient’s name is Mr. Sokolov Alexander Vasilyevitch. He is 40
years old. About a week ago he came to the health center because of
chronic cough. Three sputum samples were taken and sent to be tested.
Two were positive for TB (–, 1+, 2+). Mr. Sokolov has come back to
hear the results of the test.
When he arrived at the health center today he was weighed. His weight is
68 kg.


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Instructions for the Patient

As the patient, you should respond realistically to the health worker. The box
below provides background information such as your name, age, attitude, and
personal circumstances. You may make up additional information (consistent with
the role) as needed.

Information for the Patient – Role Play Exercise B
Your name is Mr. Sokolov Alexander Vasilyevitch.You are 40 years old. You
are a busy man with steady employment. When you hear that you have TB, you
find it hard to believe. You had an older friend who had TB, and the friend died.
You are very fearful; you do not believe there is a cure for TB.
You believe TB is caused by eating food that is contaminated with germs.
However, you believed that as a healthy, middle-aged man, you were very
unlikely to get this disease.
You have had coughs before, but never for this long. In the past you have taken
cough syrups. You have never been treated for TB.
You live in an apartment with your wife and two children (ages 4 and 6). Your
wife has also been coughing. The apartment is on the other side of the city and
not convenient to the health center. You work near the health clinic.
You are not likely to move or change employment any time soon.

Instructions for the Observer
Refer to pages 3-12 as you observe the role-play. Observe the interactions between
the patient and health care worker. Ensure that the following topics are covered:
• What is tuberculosis
• TB can be cured
• Treatment of TB
• Necessity of directly observed treatment

• How TB spreads
• Symptoms of TB
• How to prevent TB from spreading
• Importance of completing treatment
• What to expect; what to do next

After the role-play, comment on what was done well and what could be improved.

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11.4 Continue Patient Education Throughout Treatment
As discussed earlier, patient education is a continuous process throughout
treatment. Health care workers should continue to give health education messages
at every encounter. Health care workers will have many opportunities to interact
with patients during daily or thrice weekly visits for directly observed treatment. It
is always important to use effective communication skills, such as asking questions,
showing a caring attitude, praising and encouraging the patient, and using simple
language.

At each encounter with the patient, the health care worker can choose a few
appropriate messages to teach or reinforce. It is important to emphasize different
health education messages at different times during treatment. For example, at the
early visits, the health care worker may want to emphasize information about TB
and how it spreads. It is also important to remind the patient to bring family
members for testing. Messages about side effects are also important early in
treatment. The patient may need to be reassured in order to continue taking the
drugs.

As treatment continues, the need to explain the importance of follow-up sputum
exams will become more of a priority. As the patient feels better, it is also
important to convince the patient that it is important to continue treatment and very
dangerous to stop.

When the health care worker meets with the patient, the first few minutes should be
spent checking to see if the patient remembers the information that was previously
discussed regarding treatment of tuberculosis.

The information below describes what health education topics should be discussed
with the patient on a continuous basis.

Type and Color of Prescribed Drugs/Injection
Because it is important for the patient to know what to expect throughout treatment,
the different types of drugs the patient will be taking should be explained. This is
the case whether the patient is to receive pills or injections from the health care
worker.

Amount and Frequency of Drugs/Injection
The patient should understand the number of tablets, capsules, or injections he or
she will be taking, how often, and for how long. For example, “You will be taking
1 red capsule and 8 white tablets every day for 2 months.”


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Possible Side Effects of Drugs/Injection

Common side effects of the anti-tuberculosis drugs should be described to the
patient. The health care worker should also explain that if the patient experiences
any side effects during the treatment, he or she should immediately report those side
effects to the doctor or nurse.

At every encounter, health care workers can ask patients, “How are you feeling?” or
another general question such as, “Have you had any problems after taking the
drugs?” Health care workers can help patients identify and manage side effects.
Patients should respond as directed in the table below. Also, additional information
on side effects and their management is found in Module 3, Administering
Treatment.

Table 11.2 Overview of Side Effects and Their Management
Minor Side Effects Management
Anorexia, nausea, abdominal pain Take drugs with food, milk, or gruel
Joint pains Aspirin
Burning sensation in feet Pyridoxine 100 mg daily
Orange/red urine Reassure patient that this is expected
Major Side Effects Management
Itching of skin, skin rash
Deafness (confirm this is not due to
ear wax)
Dizziness, lack of balance
Jaundice (yellow skin or eyes)
Vomiting and confusion
Difficulty with vision
Stop anti-TB drugs.
Refer the patient urgently to a
physician.

Treatment During the Continuation Phase
Most patients will receive treatment and treatment monitoring on an outpatient,
ambulatory basis during the continuation phase. This will be a significant change
for patients who received the intensive-phase treatment in a hospital setting.
Patients need to know where and when to go for their treatment and treatment
monitoring during the continuation phase. Health care workers need to ask
questions to identify any potential barriers that would prevent the patient from
adhering to treatment.


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Frequency and Importance of Sputum Examinations/
Simple Explanation of Sputum Results
Each pulmonary patient needs an explanation about the request for sputum samples
for treatment monitoring. All patients will be requested to provide a sputum
specimen several times during the treatment of tuberculosis. A lab technician will
examine the sputum with a microscope. If the lab technician sees TB germs in the
sputum, the patient is still very sick. If the technician does not see TB germs in the
sputum, the patient is getting better, but must continue to take the drugs.

The patient should be informed when and how sputum samples will be collected
during the course of treatment. The results of sputum examination can affect the
course of treatment. For example,
• After 2 (3) months of the initial phase of treatment, the sputum must be tested.
There should be no TB germs, or fewer TB germs, visible through the
microscope. If after 2 months there are still visible TB germs in the sputum,
the patient may need an extra month of initial phase treatment. If there are no

visible TB germs, the patient is ready for the next phase of treatment.
• During the continuation phase of treatment, another sputum exam must be
done. This exam is very important. If no TB germs are seen, the patient
continues the same treatment. If TB germs are seen, the treatment must be
changed.
• The last sputum exam is just before the end of treatment. If no TB germs are
found at this final exam, and at least one or more earlier exams, the patient is
considered cured. It is very important to have all of the sputum exams to know
that the patient is cured.

What happens if the patient takes only some of the drugs
or stops treatment?
Patients should be educated on the importance of taking a full course of treatment.
They should be reminded that if they take drugs irregularly they can remain
infectious and spread TB to family, friends, and co-workers. In addition, if they
don’t take all the drugs as prescribed they will remain sick and may develop TB
that is resistant to drugs, and therefore, difficult to cure.

What Happens if the Patient Plans to Move While on Treatment?
When a patient plans to travel or move from the area where he or she is receiving
treatment, the health care worker should be informed. The health care worker
should communicate with TB specialists in the area where the patient plans on
moving to ensure there is continuity of care, and that final treatment outcomes are
reported back to the referring area.

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18

Exercise 2
Role Play – Continuing Health Education About TB


As in the previous role-play exercise, you will be divided into groups of three and
will rotate roles. The “patient” in this role-play is a woman, Mrs. Smirnova, L.N.,
has been hospitalized for intensive-phase treatment. She is a smear-positive,
category 1 patient. Mrs. Smirnova still has a lot of questions about her medication,
their side effects, and how long she needs to be on treatment. The health worker
will need to emphasize the most relevant messages for Mrs. Smirnova.

Instructions for the Health Worker

Your goal is to use good communication skills to:
1. Ask the patient questions, and
2. Cover relevant health education messages for the particular patient.

To ensure that you include all of the necessary questions and messages, refer to the
text on pages 3-17 of this training material.

The box below shows the information that you already know about the patient.

Information for the Health Worker – Role Play Exercise C
Mrs. Smirnova L.N. is 30 years old and has been hospitalized for
intensive-phase treatment. She is a smear-positive, category 1 patient.
Mrs. Smirnova still has a lot of questions about her medication, their side
effects, and how long she needs to be on treatment. She has two young
children.

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Instructions for the Patient
As the patient you should respond realistically to the health worker. The box below
provides background information such as your name, age, attitude, and personal
circumstances. You may make up additional information (consistent with the role)
as needed.

Information for the Patient – Role Play Exercise D
Your name is Mrs. Smirnova L. N. You have been hospitalized for the
intensive phase treatment. You have been in the hospital for 2 weeks now.
You have orange-red urine and some joint pain. You believe the medicine is
causing these symptoms and you want to stop your medicine.
Besides, you are starting to feel better and don’t think you need any more
medicine.
You want to know how long you have to stay in the hospital and when the
doctor will let you go home.
You have a husband and two children at home (age 2 and 3 years old). Your
husband does not have a cough. You explain that as soon as you are better,
you are going to move.

Instructions for the Observer
Refer to pages 3-17 as you observe the role-play. Observe the interaction between
the patient and health care worker. Ensure that the health care worker addresses the
issues outlined below, as needed:
• Type and color of prescribed drugs/injections
• Amount and frequency of drugs/injections

• Side effects of drugs/injections
• Treatment during the initial phase
• Frequency and importance of sputum exams, and the meaning of their results
• Treatment during the continuation phase
• What happens if the patient takes only some of the drugs or stops treatment
• What happens if the patient plans to moves while on treatment

After the role-play, comment on what was done well and what could be improved.


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20
11.5 Facilitating Adherence to TB Treatment
One of the main goals of the raion TB Coordinator is to ensure that health care
workers within the raion are facilitating adherence to TB treatment among TB
patients. This section of the module discusses adherence and nonadherence issues
and provides measures health care workers can implement in an effort to decrease
barriers to adherence among TB patients. By understanding reasons for non-
adherence, health care workers may be able to tailor patient education activities to
each patient.

Adherence to Treatment
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. However, because of the ramifications of TB if left untreated, the concern
is not with adherence, but rather with nonadherence to treatment.

Nonadherence
Nonadherence is the patient’s inability or refusal to take TB drugs as prescribed.
When medical treatment is complicated or lasts for a long time, as in the treatment
for TB disease, patients often do not take their medication as instructed. This
behavior is one of the biggest problems in TB control and can lead to serious
consequences. A non-adherent patient with TB disease may
• remain sick longer or have more severe illness,
• spread TB to others,
• develop and spread drug-resistant TB, or
• die as the result of interrupted treatment.

11.5.1 Reasons for Nonadherence
There are many reasons why a person might have trouble completing a regimen of
TB drugs; some are listed below. Many of the reasons for non-adherence can be
addressed through patient education.
• Once a patient no longer feels sick, he or she often thinks that it is all right to
discontinue taking the TB medication. TB symptoms can improve
dramatically during the initial phase of treatment (the first 8 weeks). However,
unless patients continue treatment for at least 6 months, some tubercle bacilli
may survive, putting patients at risk for a relapse of TB disease and the
development of drug-resistant organisms.
• Patients sometimes do not fully understand the treatment regimen, such as how
to take their drugs, or the reasons for the long duration of TB treatment. This
lack of knowledge can lead to lack of motivation to complete a regimen.

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• Some patients have strong personal or cultural beliefs about TB disease, such
as how it should be treated and whom they can turn to for help. When TB
treatment conflicts with these beliefs, patients can become fearful, anxious, or
alienated from their health care workers.
• Certain patients lack the skills necessary for following a health care worker’s
instructions and adhering to a prescribed regimen. Elderly patients with
limited mobility or manual dexterity, patients with substance abuse or mental
health problems, and young children are particularly at risk for problems with
adherence.
• Lack of access to health care can also be a significant barrier to successfully
completing a TB regimen. In particular, during the continuation phase when
patients are not hospitalized, special efforts must be made to reach and provide
care to patients without a permanent address or a means of transportation.
Patients with jobs may have work schedules that conflict with clinic hours.
Some patients may need reassurance that their TB disease and treatment will
be kept confidential.
• Some patients, especially recent immigrants, may not be able to find a health
care worker who speaks their language. A language barrier can present
significant problems for adherence, as patient education and support services
can have little effect. Unless a good interpreter is found, such patients may be
unable to continue treatment.
• Some patients have poor relationships with health care workers. When
patients and health care workers fail to establish a trusting relationship, this
lack of a relationship can influence patient adherence. If a patient trusts and
has confidence in his or her health care worker, he or she is more likely to
follow instructions and advice and to cooperate with the health care worker.
Patients may also be more likely to bring questions and concerns regarding
adherence to the health care worker’s attention.
• Finally, some patients may have a lack of motivation to adhere to a TB
regimen. If patients have many competing priorities in their lives such as

substance abuse, homelessness, or sickness from other diseases (e.g., HIV),
taking TB medication may not be considered a priority by the patient.

Each patient is unique and may have his or her own reasons for nonadherence. One
of the best predictors of adherence is a patient’s past adherence. If a patient was
nonadherent in the past, it is likely that he or she will encounter similar problems
with the current treatment regimen. However, it is important to keep in mind that
any patient can have problems with adherence. Barriers are anything that can
prevent a patient from being able to adhere to a TB treatment regimen. Although
adherence is hard to predict, the more the health care worker knows about the
patient, the better he or she will be able to understand and address the patient’s
problems.