Improving Patient Adherence to Tuberculosis Treatment
Predicting Patient Adherence
Always be aware that any patient can be nonadherent. Although many
health care providers believe that they can predict whether a particular
patient will take medication as prescribed, research data indicate
that providers on the average are correct only about 50% of the
Know the patient's history. Once you know more about your patient,
you can predict adherence more accurately. One of the strongest
predictors is a patient's history of adherence. Try to determine
whether the patient has had difficulty maintaining adherence with
TB medications or with other regimens. Although poor adherence is
not a personality trait, a history of adherence problems, particularly
with TB medications, will help you anticipate a problem.
Ask the patient. Sometimes a patient may have strong reasons for
not wanting to take medications. Ask your patient about his or her
knowledge and beliefs concerning the causes and treatment of TB.
Asking about your patient's beliefs is an important way of identifying
signals for nonadherence.
A CDC study concluded that there are many reasons why a person
might not want to take TB medications. For example,
- Immigrants and refugees may fear that having TB disease or infection
will make them subject to legal action, such as deportation, so
they may give the appearance of being adherent by picking up refills
(although they may not take the medicines).
- Many foreign-born persons have histories of BCG inoculation
and believe that they cannot develop TB.
- Persons vulnerable to TB may have other life demands that are
of higher priority to them than preventing or curing TB.
- Many people think of public health as part of the "system"
that they have come to mistrust; some may believe that public
health interventions will actually cause disease or attempt to
hurt a group of people because of their race.
- Some patients who use alcohol or drugs fear the side effects
that may result from their taking TB medications while taking
- Having TB carries a stigma for many people and may lead to shame,
fear of social rejection, or fear of the loss of a job.
- Attending a treatment center for TB may mean taking time off
work or other essential competing activities.
- Many patients are afraid that TB drugs will cause dangerous
side effects and lead to illness or costly medical interventions.
- Some groups may not believe that health care providers can correctly
diagnose or treat TB and that the drugs prescribed are ineffective
or inappropriate for members of their racial or national group.
- Many groups have strong cultural beliefs about health and treatment
for disease that may compete with the prescribed regimen for TB.
Clearly, people may have reasons, which are logical to them, for
not taking medications. Identify these reasons and provide health
education (see Assessing Patients'
Perceptions about TB).
Ask patients their concerns about TB. Patients who believe that
their disease or infection is a serious problem are more likely
to take TB medications. Ask patients which close friends or family
members are concerned about their health and will help them remember
to take medications. In general, it seems that adherent patients
are those who believe that they have the support of family members
and of the doctor or other providers. Find out if your patients
understand what you have told them about TB; ask them to explain
it in their own words. Adherent patients tend to understand the
causes of TB and its treatment.
Look for early warning signs. It is important for you to monitor
for adherence early during treatment in order to anticipate future
problems. It is probably correct to say that "adherence predicts
adherence," so the patient's own behavior may be the strongest
cue to what the patient will do in the future. However, patients
with active disease who are initially adherent will begin to feel
well after a few weeks of treatment and may then forget their medication
or believe that it is no longer needed. Therefore, even patients
who have followed the regimen early in treatment should be monitored
and given assistance to ensure continuing adherence after symptoms
have been relieved.
Avoid reliance on demographic information. Keep in mind that demographic
factors (such as age, sex, race, ethnicity, occupation, income,
and education) are inconsistent or unreliable predictors of adherence
with TB medications. The real predictors of nonadherence may be
poor access to health information or services.