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U.S. Department of Health and Human Services

  
Education Materials > Publications > Improving Patients Adherence to TB Treatment > Getting to Know Your Patient

Improving Patient Adherence to Tuberculosis Treatment (1994)

Getting to Know Your Patient

Section Topics

Obtaining Patient Information

For you to provide care that addresses the specific needs of your patients, it is important that you learn as much as possible about your patients' health history, beliefs and attitudes about TB, sources of social support, and potential barriers to treatment adherence. This information may come from a variety of sources. Frequently, patients with TB come to medical attention when they seek care for symptoms that are affecting their daily activities. Some of these symptoms are strongly suggestive of TB; others may suggest other health problems. Those of you who work in TB programs may first become aware of patients with active TB through referrals from other health care providers, such as physicians in private practice and staff of hospitals, correctional facilities, homeless shelters, nursing homes, as well as other public health clinics.

The amount and type of information communicated to TB program staff differ, depending on the referring agency. For example, if the diagnosis is made while the patient is in the hospital, the staff nurse, the discharge planner, or the infection control nurse usually makes a telephone referral to the TB program. A summary of the patient's health and social history should be given to the program staff.

Although the information obtained from the hospital staff is important baseline information, TB program staff usually complete an additional assessment. This assessment should include information about the patient's

  • health and social history
  • close contacts
  • barriers to adherence and follow-up care

Ideally, program staff should visit the patient to begin the assessment before the patient is discharged from the hospital. If this is not possible, the assessment can be started with the first patient encounter. If the patient is not hospitalized, a home visit should be made as soon as possible after notification. The information you obtain during these visits is confidential. Follow your agency's guidelines for maintaining the confidentiality of patient information.

To exchange information during the assessment, you and the patient must be able to communicate with each other. If you and the patient do not speak the same language, communication becomes particularly challenging.

Working with an Interpreter

Serious communication problems can occur when you and the patient do not speak the same language. Those of you who have access to interpreters may believe that the interpreter will solve your communication problems. You may not be aware that using an interpreter to translate health information can facilitate as well as hinder effective communications between you and your patients. The following are examples of problems you may experience when working with interpreters.

  1. Interpreters sometimes interject their own interpretation of what has been said. This practice can result in the interpreter's communicating incorrect information.
  2. Interpreters may fail to convey the shades of meanings in what you and your patient are saying; this may result in misunderstandings.
  3. Using an interpreter introduces a third person into the relationship; patients may be reluctant to discuss sensitive information in the third person's presence.
  4. The interpreter may be from the patient's community and have access to information about the patient that is not available to you. This may create a conflict between the interpreter and the patient if the patient withholds information you need, and the interpreter is aware of your need to know. Remember, your patient has to return to the community. Be mindful of the problems your patient may encounter if the interpreter does not keep the patient's health information confidential.
  5. There may not be linguistic equivalents that convey all of the concepts you and the patient are communicating. At best, the interpreter may be able to provide only an approximation of the messages.

To avoid some of these problems, use the services of trained medical interpreters. However, trained interpreters are not always available. Typically, the persons who function as interpreters are the patients' family members, volunteers from the community, or other staff of health care facilities who speak the patient's language. Family members and some volunteers from the community do not function well in this role because they are usually unfamiliar with medical terms. Both groups will be exposed to information about the patient that is personal and confidential, and there will be no way for you to ensure that the information is kept confidential.

If you must use family members as interpreters, avoid using children. Children in this role are apt to be exposed to sensitive information or be asked to convey information that the family considers inappropriate. Young children may become distressed. They also have less ability to understand and communicate detailed information.

After you have selected the appropriate person to interpret for you, follow these guidelines to improve the translations:

  1. Plan the interview and decide what information you want to discuss with your patient.
  2. Meet with the interpreter before the interview to discuss the interview goals and to review the ground rules.
  3. Instruct the interpreter to use the patient's own words.
  4. Ask the interpreter to clarify questions or responses if they are not clear.
  5. Keep the message simple and concrete.
  6. Present one point at a time.
  7. Present the message in short phrases.
  8. Allow the interpreter to translate each phrase before you continue.

Maintain eye contact with the patient during the interview, if this is culturally appropriate. Observing your patient's behavior when making eye contact may suggest whether or not the patient is comfortable with this behavior. For example, the patient who is not comfortable with direct eye contact may break off the contact and look away. Observing your patient's nonverbal behavior (such as facial expressions and body positioning) may give you clues about the patient's feelings. Ask the patient about any emotional reactions you have observed. This is important because the emotions behind statements can alter the meaning of the statements. After the interview has ended, meet with the interpreter once more and ask for comments on the patient's word content and emotions.

If you know a few words of the patient's language, use them. It may make the patient feel more comfortable by conveying your caring and interest. If you work in an area with a large number of patients who do not speak English, you might consider learning their language. At a minimum, you could learn some greetings and key words and phrases associated with TB services.

Remember, you must be able to establish effective communication with your patients with or without an interpreter to assess their health needs. This information will help you develop interventions that are specific to the needs of your patients (6 10).

Assessing Health Needs

TB program physicians or nurses are responsible for the initial assessment of patients' health needs. Other program personnel may also contribute their observations. The contents of the assessment may include the following categories:

  • medical history
  • history of previous TB infection or disease
  • TB risk factors, including HIV status
  • family history of health problems
  • social and occupation information
  • physical examination findings
  • Mantoux tuberculin skin test results
  • chest x-ray results
  • bacteriologic examination results
  • names and number of contacts
  • patient's perceptions about TB
  • barriers to adherence
  • health education needs
  • resources to facilitate treatment completion

Assessing Patients' Perceptions about TB

A complete evaluation of the patient's health needs should include an assessment of the patient's perceptions about TB. This is important because it will identify similarities in, as well as differences between, your patient's and your perceptions about TB and its treatment. The patient's perceptions about TB (what causes TB, what TB does to the body, how severe it is, signs of TB, why it occurs when it does, personal and social problems caused by TB, and how it is treated) may be different from your understanding of the disease process and the treatment of it. Because these differences increase the likelihood of misunderstanding and thus of nonadherence, it is important to identify these differences early in treatment.

One technique for identifying differences in patients' and health care providers' understanding of TB is to ask a series of exploratory questions. The following questions have been used in a variety of clinical situations (11,12). They may help you understand how your patients view their illness.

  1. What do you think causes TB?
  2. What problems will your illness cause you?
  3. Why do you think you got sick when you did?
  4. What does TB do to your body?
  5. How severe do you feel your illness is?
  6. What treatment do you think you should receive for TB?
  7. What are the most important results you hope to receive from this treatment?
  8. What are the main problems your illness has caused for you?
  9. What do you fear about your illness?
  10. How do your family members or close friends feel about your TB?

These questions can be incorporated into an existing health assessment or an ongoing assessment of patients' educational needs and treatment adherence. The questions may be reworded in accordance with your patients' cultural, linguistic, and educational backgrounds. The number and sequence of the questions may be changed to meet the needs of your specific situation.

However, the most important point to remember about assessing your patients' perceptions about TB is to first create an atmosphere of trust and acceptance so that your patients will feel comfortable discussing their thoughts with you.

  1. Discuss openly and honestly any obvious differences in patient-provider perceptions.
  2. Correct patient misinformation.
  3. Support discussions with objective information, such as chest radiographs or laboratory reports.

Remember, when patients' perceptions are different from your own, you should acknowledge these differences. Accept that the patient has a different point of view and then make sure the patient understands your point of view about TB. You can make it clear that although you do not share your patients' views, you respect them. Understanding your patients' perspective is an important step toward establishing a trusting relationship, which increases the likelihood of adherence.

 


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination - http://www.cdc.gov/tb

Please send comments/suggestions/requests to: hsttbwebteam@cdc.gov, or to
CDC/Division of Tuberculosis Elimination
Communications, Education, and Behavioral Studies Branch
1600 Clifton Rd., NE - Mailstop E-10, Atlanta, GA 30333