Self-Study Modules on Tuberculosis
Module 9: Patient Adherence to Tuberculosis Treatment
In this module, you will learn how to help patients adhere
to a TB treatment regimen. 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 can lead to
serious problems. A nonadherent TB patient may remain sick, spread
TB to others, develop and possibly spread drug-resistant disease,
and even die as a result of interrupted treatment. Likewise, it is
also important that persons with latent TB infection (LTBI) who are
prescribed a regimen for LTBI adhere to the regimen. Completion of
therapy for LTBI can prevent people with TB infection from developing
TB disease. The patient's success in completing a TB regimen depends
to a large extent on the health care worker's ability to understand
him or her, support the patient throughout therapy, and anticipate
or solve problems as they arise.
This module describes methods the health care worker can use
to get to know his or her patients, assess their ability and willingness
to adhere to treatment, use proven methods to improve patient adherence,
and solve common problems that arise during treatment. Also included
is advice on the use of legal remedies to nonadherence when less
restrictive methods have been exhausted and a patient does not cooperate
with public health officials. By using the recommendations in this
module, the health care worker should be able to help his or her
patients remain adherent and successfully complete their TB treatment
Another important issue that is not addressed in this module
is the adherence of health care workers to published recommendations
and guidelines. The prescription of an inadequate treatment regimen
(e.g., a 6-month regimen that does not contain rifampin) or the
failure to order recommended diagnostic tests (e.g., drug susceptibility
testing of the initial isolate from a patient's sputum) are serious
problems that can lead to treatment failure. As you consider the
problems that can lead to a patient's failure to adhere to a regimen,
keep in mind that the burden of TB treatment completion does not
rest solely on the patient.
After working through this module, you will be able to:
- Define adherence and describe why it is important to TB treatment.
- List six reasons why a patient might be nonadherent.
- Describe a case management system.
- Explain why and when it is important to assess a patient's knowledge
and beliefs about TB disease and its treatment.
- Define open-ended questions and explain how they can help you
learn about a TB patient.
- Discuss the role of patient education in improving adherence.
- List eight techniques that can be used to communicate effectively
- List eleven guidelines that can help the health care worker
make the best of an interview assisted by an interpreter.
- Define DOT, list its advantages and disadvantages and who should
be considered for DOT, and describe the tasks involved in delivering
- Define incentives and enablers; describe what their purposes
are, how to determine which ones to use for each patient, and
what are some sources.
- List five ways to promote adherence in children and describe
why adolescents are at high risk for nonadhe.rence.
- Explain the purpose of a behavioral diagnosis, and list 13 examples
of barriers to adherence and the methods to overcome the barriers.
- Describe how a patient's beliefs about health or medical care
can affect TB treatment.
- List eight specific things that can be done to form an effective
partnership with TB patients.
- Describe who can provide support to a patient and the role they
can play in helping or hindering the patient in being adherent.
- Discuss how the treatment regimen can be tailored to the individual
and why this may improve adherence.
- Describe a formal adherence agreement.
- Give three examples of methods to help patients keep appointments.
- Give four examples of nonadherent behavior that could warrant
legal action against the patient.
- Describe the progressive interventions that TB control programs
should attempt before a court orders involuntary confinement.
Lists of terms were introduced in each of the five core Self-Study
Modules on Tuberculosis (Modules 1-5). Please refer to the
core modules or their Glossary if you encounter unfamiliar terms
related to TB that are not defined in this New Terms section.
Look for the following new terms in this module.
adherence to treatment - following the recommended
course of treatment by taking all the prescribed medications for
the entire length of time necessary
adherence agreement - a written understanding
between a health care worker and a patient that indicates the activities
they both agree to carry out. For some patients, this written commitment
increases the likelihood of adherence
alternative medicine - health care other than
conventional, scientifically tested, medicinal treatment; includes
herbal remedies, yoga, meditation, acupuncture, and other practices
intended to maintain or improve health
assessment - talking to a patient to find out
about his or her medical history, knowledge about TB, feelings and
beliefs about TB treatment, and other pertinent information
barrier - anything that can prevent a patient
from being able to adhere to a TB treatment regimen
behavioral diagnosis - used to find out what is
causing a patient to have problems with adherence and to develop
strategies to improve the patient's treatment plan
case management - a system in which a specific
health department employee is assigned primary responsibility for
the patient, systematic regular review of patient progress is conducted,
and plans are made to address any barriers to adherence
clinic-based DOT - directly observed therapy delivered
in a TB clinic or comparable health care facility
combined pill - fixed-dose combination capsule
or tablet that may enhance patient adherence. In the United States,
the Food and Drug Administration has licensed fixed-dose combinations
of isoniazid and rifampin (Rifamate) and of isoniazid, rifampin,
and pyrazinamide (Rifater)
court-ordered DOT - directly observed therapy
that is administered to a patient by order of a public health official
or a court with the appropriate authority; used when patients have
been nonadherent despite the best efforts of TB program staff
directly observed therapy for latent TB infection (LTBI)
- a strategy devised to help patients at especially high risk of
developing TB disease adhere to treatment for LTBI; a health care
worker or another designated person watches the patient swallow
each dose of the prescribed drugs
enablers - those things that can make it possible
or easier for the patients to receive treatment
field-based DOT - directly observed therapy delivered
in a setting outside the TB clinic or a comparable health care facility;
possible sites for field DOT include a doctor's office, the patient's
home or workplace, a school, a public park, or a restaurant
folk medicine - medicinal beliefs, knowledge,
and practices associated with a particular culture or ethnic group.
Folk medicine is usually handed down by cultural tradition and practiced
by health care workers specially trained in that tradition; not
all members of a given culture or ethnic group will use its folk
health care worker - a person who provides health
care or health services to patients, such as physicians, physician's
assistants, nurse practitioners, nurses, and outreach workers
incentives - small rewards given to patients to
encourage them to either take their own medicines or keep their
clinic or field DOT appointments
latent TB infection (LTBI) - also referred to
as TB infection. Persons with latent TB infection carry the organism
that causes TB but do not have TB disease, are asymptomatic, and
are noninfectious. Such persons usually have a positive reaction
to the tuberculin skin test
nonadherence - the patient's inability or refusal
to take TB drugs as prescribed
open-ended question - a question that cannot be
answered with a simple "yes" or "no." Open-ended questions are designed
to elicit the patient's knowledge, feelings and beliefs, by beginning
with words such as "What," "Why," "Who," "How," and "When," that
demand an explanation. Such questions are used to explore complex
issues that do not have a finite or predetermined set of responses
treatment for LTBI - medication that is given
to people who have latent TB infection to prevent them from developing