Self-Study Modules on Tuberculosis
Module 9: Patient Adherence to Tuberculosis Treatment
The goal of patient education is to help change patients' behaviors
by teaching them the importance of following the treatment plan.
However, past experience has shown that patient education alone
is often not enough to ensure adherence. Problems such as scheduling
conflicts or being inadequately motivated to adhere can lead to
treatment failure even in a patient who is quite knowledgeable about
TB disease. (In fact, health care workers have been known to fail
to adhere to TB treatment!)
To help patients complete treatment, the health care worker will
need to assess the extent to which such problems present barriers
to adherence. A behavioral diagnosis can be used
to find out what is causing a patient to have problems with adherence
and to develop strategies to improve each patient's treatment plan.
Table 9.5 presents some examples of this approach. The purpose of
doing a behavioral diagnosis is to identify the specific reasons
why a patient is not being adherent. Different patients will have
different reasons. Once a patient's specific set of adherence problems
are known, the health care worker can devise an individualized plan
of action to overcome the difficulties and promote adherence. Table
9.6 provides some additional methods to improve adherence through
quality of interactions with the patient, patient education, treatment,
and clinic operations.
Behavioral Diagnosis: A Tool for Enhancing Adherence
|Barriers to Adherence
||Examples of Methods to Overcome
|Lack of knowledge
|| Assess patient's knowledge, beliefs, and feelings about
Use health education, provide written materials
|| Get help from family or friends
Simplify the regimen or use combination pills
Link pill taking with other activities
Provide special pill dispensers and memory cues
|Lack of motivation
|| Point out the dangers of nonadherence and benefits of therapy
Increase the frequency of visits
Provide incentives and set short-term goals
|Fear of side effects
|| Allow extra time to discuss known side effects
Make staff available to answer questions
|Lack of skills in pill taking
|| Demonstrate correct pill taking
Have the patient practice with guidance
|Lack of support from family or friends
|| Make home visits
Encourage family or friends to accompany patient on clinic
|Poor relationship with the health care worker
|| Develop communication skills
Be accessible throughout care
Work on attitudes about patients and DOT
Change health care workers
Provide social services
|Lack of money to pay for health care
|| Provide free care, facilitate third-party payment
Refer to social worker
|No sick leave available
|| Provide clinic appointments during off hours
Use DOT at work site
|Long clinic waiting time
|| Keep to scheduled appointment times
Make efficient use of patient visits
Have separate appointments for drug refills
|Other medical conditions or physical limitations
|| Use a home health nursing service
|| Simplify the regimen
Associate the regimen with other activities
Use combined capsules
|Medication side effects
|| Take medication before or after meals, as indicated
Evaluate medication options
Change drugs or dosages
A Quick Reference: Methods to Improve Adherence
|Quality of interaction with the patient
|| Create a partnership.
Ask patients when and how they take TB drugs, and what they
take. Don't assume they are adherent.
Give each patient adequate time at every visit.
Don't intimidate or frighten the patient; be positive.
Get oral and written commitments from the patient.
Treat the person, not just the disease.
Understand and address different cultural values and beliefs.
Adapt treatment to lifestyle.
Make social service referrals.
|| Give vital information first in the patient interview.
Be clear with instructions; the patient is likely to be
anxious after hearing the diagnosis.
Follow oral instructions with written instructions.
Be clear from the start about the length of the regimen.
Don't overload the patient with too much information at
one time; avoid jargon.
Use educational materials that are culturally and linguistically
appropriate for the patient.
Be alert for signs or indications that the patient may not
Assess the patient's beliefs about TB; when possible, integrate
beliefs into the treatment plan.
Review instructions; ask patient for feedback to ensure
Describe the specific adherence behaviors required.
Clarify the patient's questions and respond clearly.
|| Schedule the initial appointment soon after diagnosis.
Use appointment reminders.
Follow up quickly on missed appointments.
Tailor the regimen to the patient's needs; allow the patient
Keep the regimen as simple as possible.
Give clear instructions about medication side effects.
||Ensure a physical environment that is comfortable to patients.
Ensure that staff are polite and courteous with patients
and culturally sensitive.
Ensure that schedules and practices are tailored to the
Ensure that record keeping, pharmacy, and lab services are
quick and easy for patients.
Nurture staff morale; provide training as needed.
Provide for strict confidentiality of patient information.
Provide appropriate services that match the demographic
features of the patient population (e.g., meals or snacks
for homeless patients).
Provide interpreters, if needed.
Adapted from Sumartojo E. Adherence to the tuberculosis treatment
plan. In: Cohen FL, Durham JD, eds. Tuberculosis: A Sourcebook
for Nursing Practice. New York, NY: Springer Publishing Co.;
1995: chap 7.
Discuss Different Health Beliefs with Patients
Sometimes cultural, religious, or other personal beliefs affect
a patient's TB treatment. It is important for the health care worker
to sincerely respect the beliefs of the patient. Sometimes patients
seek medical advice from folk healers or alternative practitioners.
The health care worker may encounter patients who use folk remedies
along with their prescribed medications. For example, in some Asian
cultures, TB medicines are considered "hot" and need to be countered
with something "cold," such as green leafy vegetables.
Take the time to learn about the patient's cultural beliefs. If
the patient thinks that the health care worker does not respect
his or her beliefs, it could cause the patient to distrust the health
care worker. A patient may come from a background that includes
the use of alternative medicine (health care other
than conventional, scientifically tested, medicinal treatment including
herbal remedies, yoga, meditation, acupuncture, and other practices
intended to maintain or improve health). Likewise, the patient may
practice 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
medicine practices). The health care worker should find out if there
are barriers to the acceptance of conventional medical practices.
A discussion about the patient's beliefs and health practices may
help the health care worker to individualize treatment so that it
is acceptable to the patient.
When folk or alternative practices are safe, health care workers
should consider including them in the treatment plan. For example,
some people believe in the healing power of prayer. These persons
may be more willing to take medications after saying a brief prayer,
so accepting their belief in prayer is an important aspect of treatment.
If a patient is taking an herbal remedy, the health care worker
should check with the patient's physician or pharmacist to be sure
it will not cause side effects or interact adversely with the patient's
TB drugs. He or she should ask patients who have concerns about
nutrition supplements or interactions with TB drugs to discuss this
with their clinician.
While it is important to respect the patient's beliefs,
it is just as important for the health care worker to clearly present
the rationale for taking TB drugs for a full course of treatment.
The health care worker can do a great deal to help the patient adhere
and incorporate his or her beliefs into the treatment, but it is
crucial that both come to an agreement about taking TB medication.
Develop a Partnership with the Patient
Patients make independent decisions every day about whether they
will take medication or participate in DOT. The health care worker
must recognize the important role of the patient in making decisions
about treatment. For this reason, the health care worker should
develop a partnership with the patient. Effective partnerships call
for specific behaviors from the health care worker:
- Listen and try to understand the patient's knowledge, beliefs,
and feelings about TB disease and treatment
- Be open minded about the patient's beliefs and cultural expectations
- Recognize and address the patient's fears about the illness
- Understand and fulfill the patient's expectations about treatment,
- Communicate clearly so that the patient can understand the messages
- Avoid criticizing the patient's adherence behavior; suggest
behavior changes respectfully
- Treat the patient with dignity and respect
- Be consistent in what is done and told to the patient
Encourage the Patient to Seek Support
The support of family, friends, and health care workers can be
important to patients trying to complete treatment. The health care
worker should ask his or her patients to identify persons who support
their TB treatment and can help them remember to take medications
or keep their DOT appointments. Such persons might include
- Family members
- Social workers
With the patient's permission (because of the patient's right to
privacy), family members, friends, or others may be included in
educational sessions so that they also understand the patient's
diagnosis, and what he or she needs to do. However, a health care
worker should avoid making a family member responsible for the patient's
adherence; this may be an unfair burden.
On the other hand, parents, spouses, or others in
authority in the family or community may prevent patients from
taking medications, or may reject or cause problems for the person
with TB. If this happens, the health care worker should try to
educate such persons about TB and include them in discussions
about treatment decisions. Always maintain the patient's confidentiality
(see Module 7, Confidentiality
in Tuberculosis Control).
Individualize the Medication Regimen
To improve adherence, the medication regimen should
be tailored to the patient. If possible, the regimen should be
simplified and changed within acceptable therapeutic limits to
match the patient's lifestyle. For example, the patient's physician
An intermittent regimen for
a patient whose schedule doesn't permit daily DOT appointments
A combined pill, which is a
fixed-dose combination capsule or tablet that may enhance
patient adherence, for patients with difficulty swallowing.
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).
Patients who are not on DOT sometimes find it useful
to monitor their pill-taking by checking off doses on a daily
calendar. A calendar can help patients remember the days they
need to take medicine and engage them in determining their own
schedule. A weekly pill box may also help patients monitor their
For some patients, a formal adherence agreement
-- a written understanding between the health care worker and
a patient -- may be useful. A sample adherence agreement is presented
in Figure 9.7. A patient should dictate or write down the activities
he or she agrees to carry out (such as taking medicine as prescribed),
in return for specific services, activities, or incentives from
the health care worker. For some patients, this written commitment
increases the likelihood of adherence. The patient should be asked
to sign the agreement next to the health care worker's signature
and be given a copy to keep. The health care worker should review
the agreement with his or her patient periodically to assess how
well both are doing and to make changes as needed.
Figure 9.7 This an example of
a sample adherence agreement between a patient and a health care
Help Patients Keep Appointments
There are three methods to help patients keep their
appointments (Table 9.7):
Remind patient of appointment
Contact no-shows and make another appointment
Use other alternatives for patients who repeatedly
Different types of reminders can help patients keep
appointments. If the patient has a permanent address, the health
care worker can send a reminder postcard, mailed so that it arrives
1 or 2 days before the appointment. If the patient has a telephone,
it might be better to call -- that way the health care worker
will know if the patient received the message. Another benefit
of using telephone reminders is that it gives the health care
worker an opportunity to counsel patients, and help them solve
scheduling and transportation problems or other obstacles to adherence.
Remember to be aware of confidentiality issues when leaving telephone
or written messages for TB patients (see
Module 7, Confidentiality in Tuberculosis Control, for information
on maintaining confidentiality).
Patients can also be given appointment cards or
appointment calendars at each visit to remind them of their next
visit. Sometimes the health care worker can find out what problems
a patient is having by contacting no-shows, either with a telephone
call on the same day or with a home visit. When a patient fails
to keep an appointment, call right away to schedule a new appointment.
If the patient fails to keep the new appointment, visit the patient
at home or call him or her on the phone. Use this discussion to
counsel the patient and to identify and solve problems that interfere
with appointment keeping.
If the patient repeatedly breaks appointments, use
other alternatives. Hold a conference with all members of the
health care team (physician, nurses, other health care workers,
and staff) so that the problem can be discussed and resolved with
help from the entire staff. The patient could also be included
in this conference. The health care worker may need to try several
different strategies to help the chronically nonadherent patient,
and possibly even consider legal alternatives (see Legal Remedies,
Examples of Methods to Help Patients Keep Appointments
|Examples of Methods to Overcome
|Remind patient of appointment
||Contact the no-shows and make another appointment
Use other alternatives for
patients who repeatedly break appointments
- Call the same day as the appointment
- Visit the patient at home
- Hold a conference with all members of the health care
- Possibly include the patient in the conference
- Consider legal alternatives
|Study Questions 9.29-9.32
can provide support to a patient and help the patient
remember to take medications?
9.30. What are two things the health care worker can
do to tailor the regimen to the patient's lifestyle?
9.31. What is a formal adherence agreement?
9.32. What three methods can be used to help patients
keep their appointments?
|Case Study 9.8
Ms. Johnson is a 68-year-old widow with active TB disease.
She has several other health problems, including obesity,
osteoarthritis, and poorly controlled diabetes. She needs
a cane to help her walk and often becomes anxious when she
leaves her apartment. She lives in a low-income housing
block 3 miles from the TB clinic and does not have transportation.
Ms. Johnson's two children live outside the state and visit
- Conduct a behavioral diagnosis of Ms. Johnson's potential
barriers to completing her TB treatment and the methods
that can be used to overcome the barriers.
|Case Study 9.9
Mr. Sivaraman is a recent immigrant from India
who is working two jobs to support his wife and three children.
He has been on DOT for 2 months and his TB symptoms have
greatly improved. Mr. Sivaraman has kept daily DOT appointments
with the health care worker, but recently has missed two
appointments and skipped his last clinic visit.
- Why might Mr. Sivaraman be nonadherent?
- What steps can the health care worker take to help
Mr. Sivaraman keep his appointments and adhere to therapy?