Self-Study Modules on Tuberculosis
Module 9: Patient Adherence to Tuberculosis Treatment
Adherence to treatment means that a patient is following the recommended
course of treatment by taking all the prescribed medications for
the entire length of time necessary. TB is nearly always curable
if patients adhere to their TB treatment regimen. Adherence is important
because nonadherence is the patient's inability or refusal to take
TB drugs consistently as prescribed. This behavior is one of the
biggest problems in TB control.
There are many reasons why a person might have trouble completing
a regimen of TB drugs. One of the best predictors of adherence is
a patient's past adherence. However, it is important to keep in
mind that any patient can have barriers to adherence. Patients and
health care workers are both responsible for ensuring patients'
adherence. Patients must decide every day or week whether or not
to take their medicine. What they decide often depends on how much
help they get from the health care workers they see.
There are many strategies that may be used to ensure that patients
complete treatment. One strategy that may be used is case management.
There are three elements in any case management system: (1) assignment
of primary responsibility for the patient, (2) systematic regular
review of patient progress, and (3) a plan to address any barriers
to adherence. A health department employee (case manager) is assigned
primary responsibility and is held accountable for ensuring that
each patient is assessed and a treatment plan is established, that
each patient is educated about TB and its treatment, that therapy
is continuous, and that contacts are examined.
The health care worker will need to learn as much as possible about
the patient in order to assess potential adherence problems. Doing
an assessment means talking to a patient to get information on the
patient's medical history, current health problems, and other personal
information, with a particular emphasis on identifying the problems
most important to the patient as treatment begins. Unless special
efforts are made to identify their needs, some patients may be lost
to follow-up care.
The health care worker or other program staff should visit the
patient to begin the assessment as soon as possible. When the health
care worker begins to work with a patient, it is important to ask
what the patient believes about TB disease and treatment. The health
care worker should identify differences between what he or she believes
and what the patient believes early in treatment. One way to do
this is to ask several open-ended questions. When a patient's ideas
are different from the health care worker's, the health care worker
should accept that the patient has different views, and then make
sure the patient knows the health care worker's point of view about
Health information must be right for each patient's knowledge and
awareness of the problem. Patients are more likely to pay attention
to information that is relevant to their needs and does not require
abrupt changes in their normal daily activities. In general, patients
may be more likely to follow the treatment plan if they understand
their illness and the benefits of treatment. In presenting health
information, effective communication techniques should be used.
The health care worker and the patient can have serious problems
understanding each other if they do not speak the same language.
It is best to use trained medical interpreters, but there may not
be any in the health care worker's area. Other persons who are used
as interpreters are other health care workers who speak the patient's
language, the patient's family members, or people from the patient's
community. After the health care worker has identified an interpreter,
appropriate guidelines should be followed to make the best use of
There are many ways to encourage patients to adhere to treatment.
Giving directly observed therapy (DOT) is the most effective strategy
for making sure patients take their medicines. DOT means that a
health care worker or other designated individual watches the patient
swallow every dose of the prescribed drugs. DOT should be considered
for all patients because it is difficult to reliably predict which
patients will be adherent. Even patients who intend to take their
medicine might have trouble remembering to take their pills every
time. DOT ensures that the patient completes an adequate regimen,
lets the health care worker monitor the patient regularly for side
effects and response to therapy, helps the health care worker solve
problems that might interrupt treatment, and helps the patient become
Incentives and enablers may help patients agree to participate
in a DOT program and stay with it. Incentives are small rewards
given to patients to encourage them to either take their own medicines
or keep their clinic or field DOT appointments. Enablers are those
things that make it possible or easier for the patients to receive
treatment by overcoming barriers such as transportation difficulties.
Incentives and enablers should be chosen according to the patient's
special needs and interests, or the patients may not care if they
To improve adherence in children and adolescents, the health care
worker should work with the parents or caregivers. The health care
worker cannot assume that parents will give medications to their
children as prescribed; sometimes they do not. The health care worker
should do everything possible to make sure that parents support
their children's TB treatment. For example, the health care worker
can educate parents, warn parents of possible problems, give DOT,
use incentives and enablers, and give TB drugs in easy-to-take preparations.
To help patients complete treatment, the health care worker will
need to assess the extent to which various problems present barriers
to adherence. A "behavioral diagnosis" can be used to develop strategies
to improve each patient's treatment plan. The purpose of doing a
behavioral diagnosis is to identify the specific reasons why a patient
is not being adherent. At the start of treatment the patient should
be told about nonadherence and how it causes treatment failure and
further TB transmission. The health care worker should listen to
the patient's response and identify and resolve any barriers to
adherence. It is crucial that the health care worker and the patient
come to an agreement about taking TB medication.
There are many ways to help patients adhere to TB treatment. The
support of family, friends, and health care workers can be important
to patients trying to complete treatment. The patients should be
asked to identify persons who support their TB treatment and can
help them remember to take medications or keep their DOT appointments.
In addition, 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 some patients, a formal adherence agreement -- a written understanding
between the health care worker and a patient -- may be useful.
Different types of reminders can help patients keep appointments.
When a patient fails to keep an appointment, a health care worker
should call right away to schedule a new appointment. If the patient
repeatedly breaks appointments, a conference should be held with
all members of the health care team (physician, nurses, health care
workers, and other staff) so that the problem can be discussed and
resolved with help from the entire staff.
As a general rule, individuals have the right to ignore a doctor's
advice or refuse treatment if they wish. However, persons with infectious
TB may lose that right if health officials believe these persons
risk infecting others by not taking their prescribed medicine. Patients
who are unwilling or unable to adhere to treatment may be required
to do so by law. If the patient does not adhere to DOT voluntarily,
the next step may be DOT that is ordered by a public health official
or a court. TB control programs should not begin procedures for
confining patients to a treatment facility until after the patient
has shown that he or she is unable or unwilling to follow a treatment
regimen implemented outside such a facility.
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