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Education Materials > Publications > Improving Patients Adherence to TB Treatment > Problem Solving

Improving Patient Adherence to Tuberculosis Treatment (1994)

Problem Solving

Social, economic, and health problems other than TB may impede the patient's progress toward completing TB treatment. To minimize the effects of these problems on treatment, develop a problem-solving strategy to collect relevant information that will help you identify problems, anticipate potential problems, and initiate appropriate interventions. Address the problems systematically. One example of a basic approach to problem-solving has the following five steps:

  1. Identify problems.
  2. Analyze the causes of the problems.
  3. Form objectives for an action plan.
  4. Develop and implement the action plan.
  5. Evaluate the implementation and outcomes of the plan.
  1. Identify problems. Assess the patient for problems by obtaining information about the patient from several sources: health assessments, review of medical records and laboratory reports, ongoing interviews with the patient and significant others, home visits, and feedback from referral agencies (such as substance abuse treatment centers and housing agencies). Review and analyze this information for evidence of barriers to treatment completion, such as the patient's inability to keep clinic appointments because of work schedule. Further review this information to identify patient strengths and other factors, such as strong family support that may facilitate treatment completion.
  2. Analyze the causes of the problems. After you have identified the problems, prioritize them and discuss them with your patient. The purpose of the discussion is to give you an opportunity to present the problems as you perceive them and to give the patient an opportunity to agree or disagree with your list of problems and to identify other problems that may not be apparent to you. The discussion will also give you an opportunity to discuss the causes of the problems. List the possible causes and rank them from most probable to least probable. Develop a plan of action for dealing with the most probable causes of your patient's problems.
  3. Form objectives for an action plan. Objectives are statements that describe a desired outcome or performance; they are statements of what should be or should occur (statements of intent). Correctly stated objectives should contain these criteria (31):
    • a time frame for completing the objective
    • an active verb (e.g., give, identify, explain)
    • the desired activity or action
    • criteria for evaluating achievement

    An example of a measurable objective: Starting in January and continuing until therapy is completed, Mrs. Jones will meet the outreach worker at Grant Park every Tuesday and Thursday at 10 A.M. to receive DOT.

  4. Develop and implement a plan of action. At this point, begin to plan an appropriate course of action. This consists of interventions to eliminate the causes of each problem (several strategies have been discussed elsewhere in this booklet) and help you meet the objectives for your plan. Encourage the patient's input in finding solutions. Keep in mind that the best solution may be a compromise, including elements of what you think is the best approach and what the patient thinks is best.

    To individualize the interventions, consider the patient's daily routine, occupation, and social networks. Develop a plan of action that is convenient for the patient and that allows the patient to maintain as much independence as possible. For the objective in step 3, the interventions necessary to carry out the desired activities might include providing Mrs. Jones with bus tokens so that she can get to Grant Park for DOT.

  5. Evaluate the implementation and outcomes of the plan. The evaluation of the plan of action measures the success of the problem-solving strategy. It answers the following questions:
    • Has the intervention been implemented?
    • Has the objective been achieved, or has progress toward achievement been made?
    • Has the cause of the problem been eliminated?
    • Has the problem been solved?

    The evaluation of the interventions is ongoing. Problems will be resolved, and new problems may emerge throughout the treatment period. Modify interventions any time you recognize them as ineffective. Consult with or make referrals to other health care providers to ensure the completion of TB treatment.

    Effective strategies for improving adherence are those that remove the specific barriers that a person is experiencing. Thus, gaining an understanding of the difficulties associated with behavior change and taking time to get to know your patients their experiences with illness, their cultural backgrounds, and the communities from which they come are essential.


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

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