Improving Patient Adherence to Tuberculosis Treatment
Getting to Know Your Patient
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
- 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
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.
- Interpreters sometimes interject their own interpretation of
what has been said. This practice can result in the interpreter's
communicating incorrect information.
- Interpreters may fail to convey the shades of meanings in what
you and your patient are saying; this may result in misunderstandings.
- Using an interpreter introduces a third person into the relationship;
patients may be reluctant to discuss sensitive information in
the third person's presence.
- 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.
- 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:
- Plan the interview and decide what information you want to discuss
with your patient.
- Meet with the interpreter before the interview to discuss the
interview goals and to review the ground rules.
- Instruct the interpreter to use the patient's own words.
- Ask the interpreter to clarify questions or responses if they
are not clear.
- Keep the message simple and concrete.
- Present one point at a time.
- Present the message in short phrases.
- 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).
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
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.
- What do you think causes TB?
- What problems will your illness cause you?
- Why do you think you got sick when you did?
- What does TB do to your body?
- How severe do you feel your illness is?
- What treatment do you think you should receive for TB?
- What are the most important results you hope to receive from
- What are the main problems your illness has caused for you?
- What do you fear about your illness?
- How do your family members or close friends feel about your
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.
- Discuss openly and honestly any obvious differences in patient-provider
- Correct patient misinformation.
- 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.