Fostering and Assessing Adherence to Treatment

Fostering and Assessing Adherence to Treatment
ISTC Training Modules 2008 Fostering and Assessing Adherence to Treatment Instructor’s Guide Module: Fostering and Assessing Adherence to Treatment ISTC Standards covered: Standard 9 Module Time: Approximately 60 minutes Alternate slides: Introductory ISTC slides Interactive options: Ideas for interactive discussions are offered on many of the slides in this module. Participant discussion can enhance active learning, but will add more time to the lecture and must be planned for. Additional Material: Slides containing related material may be found in the following modules: Management of Drug-Resistant Tuberculosis Test Questions: May be attached or inserted within presentation for discussion purposes, or alternatively, combined with questions from other modules to produce evaluation tool. The full text of the ISTC and all supporting references are available at Other useful Resources/References: WHO. Adherence to Long-term Therapies: Evidence for action. WHO Munro S, et al Patient adherence to tuberculosis treatment: a systematic review of qualitative research. PLoS Medicine 4:2007 e238. WHO. Empowerment and involvement of tuberculosis patients in tuberculosis control. WHO/HTM/STB/ Bodenheimer T,et al. Patient self-management of chronic disease in primary care. JAMA. 288: 2002, [Image Credit: Lung Health Image Library/Jan van den Hombergh] Your name Institution/organization Meeting Date International Standard 9

Fostering Adherence to Treatment
ISTC Training Modules 2008 Objectives: At the end of this presentation, participants will be able to: Recognize that addressing a patient’s needs and expectations, and fostering a relationship of mutual respect between patient and provider are key elements in promoting treatment adherence Understand factors that may have a negative impact on patient adherence to treatment Utilize interventions to improve adherence to treatment It is intended that after completion of this module the student will be able to appreciate the many facets of a positive partnership between providers and patients that can foster mutual respect, which leads to improved adherence and successful treatment of TB. [Review objectives from slide]

ISTC Training Modules 2008 Overview: General concepts Adherence factors and interventions Comparison of traditional care vs. collaborative care Strategies to improve adherence [Review content of slide] In this presentation we will review the components of Standard 9. Factors that have a negative impact on adherence will be reviewed and the concept of patient centered care elaborated upon. General and specific strategies to make care truly patient-centered and to improve adherence will be discussed. This discussion should be interactive. Students should be encouraged to think about and suggest both positive and negative factors that influence adherence and suggest strategies to address the negative factors. Much of the discussion is not about science; it is about common sense and being sensitive to human needs. [Image Credit: Lung Health Image Library/Pierre Virot] International Standard 9

ISTC Training Modules 2008 Assuming an appropriate drug regimen is prescribed, tuberculosis treatment success depends largely on patient adherence. Adherence to the treatment regimen is a critical factor in determining treatment success. Treatment support to enhance adherence can be provided in a number of ways. Standard 9 addresses the need for developing acceptable schemes to ensure adherence and to address poor adherence when it occurs. [Image Credit: Lung Health Image Library/Gary Hampton]

Factors Likely to Improve Adherence
ISTC Training Modules 2008 Increase visibility of TB programs in the community Provide more information about the disease and treatment to patients and communities Increase support from family, peers, and social networks Minimize costs and inconvenience related to clinic visits There are a number of approaches that have been identified in a systematic review to be likely to improve adherence to treatment for TB. Most of these can be viewed in the broad sense to be part of a patient centered approach -- an approach that examines patients’ needs in a broad sense, not just disease related needs. [Review content of slide] [Reference: Munro S, et al. Patient adherence to tuberculosis treatment: a systematic review of qualitative research. PLoS Medicine 2007; 4:e238] Munro S, et al. PLoS Medicine 2007; 4:e238

Suggestions to Improve Adherence
ISTC Training Modules 2008 Increase provider flexibility and patient autonomy in choice of treatment support plan Increase patient-centered focus of interactions between providers and patients Address structural and personal factors; for example, through micro-financing and other empowerment initiatives Provide more information about the side effects of medications More ways to improve adherence include: [Review content of slide] Improving both patient and community understanding of the disease in general terms will aid in reducing the stigma associated with TB. Providing more specific information will let the patient know what he/she can expect in the way of improvement but also in side effects to minimize the likelihood of discontinuation of treatment without discussion with a provider. [Reference: Munro S, et al. Patient adherence to tuberculosis treatment: a systematic review of qualitative research. PLoS Medicine 2007; 4:e238] Munro S, et al. PLoS Medicine 2007; 4:e238

Standard 9: Fostering Adherence to Treatment
ISTC Training Modules 2008 (1 of 3) To foster and assess adherence, a patient-centered approach to administration of drug treatment, based on the patient’s needs and mutual respect between the patient and provider, should be developed for all patients. Standard 9: [Read Standard] The critical elements required to be compliant with this standard are first being able to identify the patient’s needs and, second, developing a mutually respectful relationship. [Image Credit: Lung Health Image Library/Jad Davenport]

ISTC Training Modules 2008 (2 of 3) Supervision and support should be gender-sensitive and age-specific and draw on the full range of recommended interventions and available support services, including patient counseling and education. Standard 9: [Read Standard] In understanding patient needs, it is important to understand both gender-sensitive and age-specific factors and take these into account in developing the approach to fostering treatment adherence. A large number of interventions are available; however, every situation and every individual is different. As stated previously, common sense and sensitivity are the most important characteristics required to develop an effective patient centered approach. [Image Credit: Lung Health Image Library/Gary Hampton]

ISTC Training Modules 2008 (3 of 3) A central element of the patient-centered strategy is the use of measures to assess and promote adherence to the treatment regimen and to address poor adherence when it occurs. These measures should be tailored to the individual patient’s circumstances and be mutually acceptable to the patient and the provider. Such measures may include direct observation of medication ingestion (directly observed therapy– DOT) by a treatment supporter who is acceptable and accountable to the patient and to the health system. Standard 9: [Read Standard] It is not possible to predict what measures might be most successful in fostering patient adherence; thus, there must be a mechanism for assessing adherence. It is most critical to identify poor adherence early in treatment before it has adverse effects, particularly drug resistance and further spread of infection. When poor adherence is identified, it must be addressed. Direct observation of medication by a treatment supporter (DOT) is both a way to assess compliance and to address poor compliance. However, it is logistically a difficult intervention to implement both for the patient and for the provider.

Through the Eyes of Patients and Families
ISTC Training Modules 2008 It just does not make sense as to why a grown person should be given medicines by someone else. I felt very awkward and tried to take my medicines myself. —Male TB patient, Pakistan [Review content of slide] [Interactive Option: Use quote from patient to generate discussion among participants. Explore patient’s perspective and factors that may contribute to his/her feelings. What possible interventions or means of support would be helpful from both the provider and the healthcare system?] [Reference: Khan MA, et al. Health Policy Plan 2005;20:354 (cited in Munro SA, et al PLoS Medicine 2007;4:e238)] Khan MA, et al. Health Policy Plan 2005;20:354 (cited in Munro SA, et al. PLoS Medicine 2007;4:e238)

Patient-Centered Care
ISTC Training Modules 2008 Patient-centered care is defined very simply as care centered on patients’ needs and expectations. Developing such an approach requires the provider to assess both the needs and expectations of patients. The needs are both technical/medical and include prescribing an effective drug regimen, but are also social and supportive such as determining the best means for supervising treatment given the patient’s particular circumstances. Assessing expectations requires both listening to and counseling/educating the patient as to what should be expected. The goal is also simple: to improve treatment outcomes. [Image Credit: Lung Health Image Library/Gary Hampton] Definition: Care centered on patients’ needs and expectations Goal: Improving treatment outcomes through improved adherence

The Five Dimensions of Adherence
ISTC Training Modules 2008 Health system/ HCT-factors Social/economic factors Condition-related factors Therapy-related factors There are at least five sets of factors that influence adherence. Despite evidence to the contrary, there is a widespread tendency to focus on patient-related factors as the main cause of poor adherence. Sociological and behavioral research during the past 40 years has shown that patients need to be supported, not blamed. Factors related to the condition/disease itself, the therapy, social/economic issues, and health system or healthcare team can all play a role in adherence. Often, less attention is paid to provider and health system-related factors. [Reference: WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003] Patient-related factors HCT = healthcare team WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

Interventions General comments:
ISTC Training Modules 2008 General comments: Interventions must be tailored to the particular situation and cultural context An approach developed in collaboration with patient achieves optimum adherence Important: Treatment support measures, not the treatment regimen itself, must be individualized to suit the unique needs of the patient Several studies have evaluated various interventions to improve adherence to TB therapy. There are a number of reviews that examine the evidence on the effectiveness of these interventions. These reviews and extensive programmatic experience demonstrate that there is no single approach to case management that is effective for all patients, conditions and settings. Consequently, interventions that target adherence must be tailored or customized to the particular situation and cultural context of a given patient. Such an approach must be developed in concert with the patient to achieve optimum adherence. This patient-centered, individualized approach to treatment support is now a core element of all TB care and control efforts. It is important to note that treatment support measures, and not the treatment regimen itself, must be individualized to suit the unique needs of the patient.

Adherence: Social/Economic Factors
ISTC Training Modules 2008 Age Race Gender Poverty Illiteracy/Education level Unstable living conditions/homelessness Social upheavals (wars, natural disasters) Distance from treatment centers Costs of care A multitude of social and economic factors influence adherence. Careful attention should be paid to providing age, race/ethnicity, and gender sensitive approaches to care. Commonly an analysis of the impact of these factors as well as others, depending on the circumstances, will need to be taken into account in designing management strategies. [Image Credit: Lung Health Image Library/Jad Davenport] [Reference: WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003] WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

Interventions: Social/Economic Factors
ISTC Training Modules 2008 Housing Food / food tokens Transport to treatment settings Peer assistance Mobilizing community- based organizations Cooperation between/among services Education of the community and providers to reduce stigma Family and community support Management strategies will need to be based both on an understanding of the culture and an understanding of the individual, as well as local resources. Individually tailored approaches will frequently be necessary. [Review content of slide] In addition to one-on-one support for patients being treated for TB, community support is also of importance in creating a therapeutic milieu and reducing stigma. Not only should the community expect that optimum treatment for TB is provided, but also, the community should expect, and play a role in promoting, conditions that facilitate and assist in ensuring that the patient will adhere to the prescribed regimen. [Interactive option: Ask participants to share examples of successful interventions used in their area that address social/economic adherence issues.] [Image Credit: Lung Health Image Library/Jad Davenport] [Reference: WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003] WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

Healthcare Team / System-Related Factors
ISTC Training Modules 2008 Factors that affect adherence: Lack of awareness and knowledge about adherence Lack of tools to assess adherence and address poor adherence Lack of tools to assist with patient behavioral change Suboptimal communication between healthcare team and patients Access to care Gaps in provision of care Health-care teams must be both knowledgeable and have access to appropriate tools to help improve adherence. First, and foremost, they must understand the impact of non-adherence on patient outcomes, disease transmission, and the risk of development of drug-resistance. The health system must then support the healthcare team with the necessary tools, communication system, and access to care. [Review content of slide] [Reference: WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003] WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

ISTC Training Modules 2008 Elements of the healthcare system necessary to deliver patient-centered care: Access and continuity: Continuity of care and a good relationship with a clinician is a key factor in patient satisfaction Coordination of care between/among settings: Identifying a specific care coordinator role within the healthcare team can improve communication Patient participation: Patients should be given a meaningful role in determining treatment supervision In accommodating the patient’s needs and expectations, once they have been identified, there are systematic and attitudinal barriers that must be addressed. Access to care is obviously essential and ideally is convenient to the patient. Continuity doesn’t necessarily mean seeing the same provider at each visit but at least seeing a provider who is familiar with the patient, either because of personal contact or because of well-documented clinical records. Commonly patients receive care in a number of facilities. To be optimally efficient, a designated healthcare coordinator can facilitate appropriate communication between caregivers. Patient counseling and education are key elements in enabling the patient to participate effectively in his/her care and to provide self management.

ISTC Training Modules 2008 The patients do not have adequate means to go to the health center to take their drugs. They just have camel, donkey or carts… and sometimes the state of some patients prevents them from using these. —Male family member of TB patient, Burkina Faso [Review content of slide] [Interactive Option: Use quote from patient to generate discussion among participants. Explore patient’s perspective and factors that may contribute to his/her feelings. What possible interventions or means of support would be helpful from both the provider and the healthcare system?] [Reference: Sanou A, et al. IJTLD 2004;8:1479 (cited in Munro SA, et al. PLoS Medicine 2007;4:e238)] Sanou A, et al. IJTLD 2004;8:1479 (cited in Munro SA, et al. PLoS Medicine 2007;4:e238)

ISTC Training Modules 2008 Elements of the healthcare system necessary to deliver patient-centered care: Availability of self-management support: Patients provide themselves with the vast majority of care they receive outside the hospital and should be equipped to do so Use of a collaborative care model: Fostering a patient-provider partnership and sharing responsibility for care empowers patients to manage their illnesses more effectively Fostering a true partnership/collaboration of shared responsibility between patient and provider can empower patients to actively partake in the management of their illnesses.

ISTC Training Modules 2008 Interventions: Ensure access to care Provide information to patients Support local patient organizations/groups Manage disease in partnership with patient Collaborative, multidisciplinary care Intensive staff supervision and use of DOT Interventions the healthcare team and health system may provide that may work to improve adherence include: [Review content of slide] [Interactive option: Ask participants to share examples of local healthcare team or health system issues that deter adherence, and interventions used in their area that help address them.] [Reference: WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003] WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

Therapy and Condition-Related Factors
ISTC Training Modules 2008 Factors that affect adherence: Therapy Dosing frequency Side effects Condition Effects of symptoms Lack of symptoms Effects on functional status Associated depression Achieving adherence is not an easy task, either for the patient or the provider. Anti-TB drug regimens consist of multiple drugs given for a minimum of six months, often when the patient feels well (except, perhaps, for adverse effects of the medications). While the illness may affect a patient’s functional status from a physical standpoint, attention should also be paid to the potential psychological effect on the patient, including increased stress or depression. [Image Credit: Lung Health Image Library/Jan van den Hombergh] [Reference: WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003] WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

Therapy and Condition-Related Factors
ISTC Training Modules 2008 Interventions: Education about tuberculosis and the need for treatment adherence Education on use of medications and adverse effects Use of fixed-dose combination preparations Agreements (written or verbal) to return for an appointment or course of treatment Continuous monitoring and reassessment Tailor treatment support to needs of patients Interventions for therapy and condition-related factors may include: [Review content of slide] [Interactive option: Ask for further examples from the participants.]

ISTC Training Modules 2008 I think that I feel healthy, my lungs are good, but I have a bit of fear that the sickness will return. But as I told you, I don’t want to take these pills because they make me sick, they hurt me…. —Female TB patient, Bolivia [Review content of slide] [Interactive Option: Use quote from patient to generate discussion among participants. Explore patient’s perspective and factors that may contribute to his/her feelings. What possible interventions or means of support would be helpful from both the provider and the healthcare system?] [Reference: Green JA. Cult Med Psychiatry 2004; 28: 401 (cited in Munro SA, et al. PLoS Medicine 2007;4:e238)] Green JA. Cult Med Psychiatry 2004; 28: 401 (cited in Munro SA, et al. PLoS Medicine 2007;4:e238)

ISTC Training Modules 2008 ….When my husband went back home, he was angry with himself and he was upset about everything. He refused to eat and rejected his medicine. He threw his pills away. He did not take TB medicines at all. —Female HIV+ TB patient, Thailand [Review content of slide] [Interactive Option: Use quote from patient to generate discussion among participants. Explore patient’s perspective and factors that may contribute to his/her feelings. What possible interventions or means of support would be helpful from both the provider and the healthcare system?] [Reference: Ngamvithayapong J, et al. AIDS 2000;14:413 (cited in Munro SA, et al. PLoS Medicine 2007; 4:e238)] Ngamvithayapong J, et al. AIDS 2000;14:413 (cited in Munro SA, et al. PLoS Medicine 2007; 4:e238)

Adherence: Patient Factors
ISTC Training Modules 2008 Adherence: Age, gender Race/ethnicity Stigma Understanding of disease and effects of treatment Cultural belief systems Altered mental status (substance abuse, mental illness, other illnesses) Commonly, treatments of the sort required for TB are inconsistent with the patient’s cultural milieu, belief system, and living circumstances. This is especially true when the patient feels much better after only a short time. Consequently, it is not surprising that, without appropriate treatment support, a significant proportion of patients with TB discontinues treatment before completion of the planned duration or are erratic in drug taking. There are also a number of individual patient-related factors that may effect adherence: these include any of many co-morbid conditions that are especially common in patients with TB: [Review content of slide] [Image Credits: Lung Health Image Library/Gary Hampton (top); Lung Health Image Library/Jad Davenport (bottom)] [Reference: WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003] WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

Interventions: Patient Factors
ISTC Training Modules 2008 Interventions: Developing a collaborative relationship Mutual goal setting Memory aids and reminders Incentives and/or reinforcements Reminder letters Telephone reminders or home visits for patients who default Interventions to aid the individual may include: [Review content of slide] Of these developing a collaborative relationship may be the most important. Commonly providers are not accustomed to considering a patient as a collaborator. This requires an attitudinal shift on the part of the provider. A comparison of traditional care with collaborative care is shown in the next 2 slides. The model was developed for management of chronic conditions such as hypertension or diabetes but suffices for TB as well, even though TB does not require lifelong treatment. [Interactive option: Ask again for ideas/examples from participants.] [Image Credit: Lung Health Image Library/Gary Hampton] [Reference: WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003] WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

Traditional Care vs. Collaborative Care
ISTC Training Modules 2008 Issue Traditional Care Collaborative Care Relationship between patient and provider Providers are experts who tell patients what to do. Patients are passive. Providers are experts about disease. Patients are experts about their lives. Principal caregiver? The provider. Patient and provider share responsibility. What is the goal? Compliance with instructions. Noncompliance is a patient problem. Patient sets goals based on information from provider. Noncompliance is a problem of strategies. Patient-centered care is a collaboration between the provider and the patient. In collaborative care the patient and provider share responsibility, recognizing that while providers are experts about the disease, patients are experts about their lives. In the short term, this approach to care is more difficult and time consuming for the provider. Patient – provider interaction and patient education are required. In the longer term, however, if a successful collaboration is developed, less time may be required and the likelihood of success is greater. This model is especially applicable to conditions such as TB that require care over a relatively long time period. [Reference: Bodenheimer T,et al. JAMA. 288: 2002, ] Bodenheimer T,et al. JAMA. 288: 2002,

Traditional Care vs. Collaborative Care
ISTC Training Modules 2008 Issue Traditional Care Collaborative Care How is behavior changed? External motivation Internal motivation through increased patient understanding How are problems identified? By the provider By the informed patient who can recognize problems How are problems solved? By the informed patient with the provider In collaborative care behavior change, problem identification and problem solving all rely on having an informed patient. As noted in the previous slide, patient education is required and is a major component of the patient-centered approach. Education and patient-provider collaboration contribute greatly to patient empowerment. Reviews of chronic disease management (asthma, type 2 diabetes, arthritis) have shown that education consisting only of providing information is not effective in improving outcomes. However, education focusing on self-management is more effective and has been associated with decreased costs and fewer hospitalizations in patients with chronic diseases. Although there are clearly differences in TB management, and these approaches have not been well studied in patients with TB, it is likely that the collaborative approach with appropriate patient education in self management will improve outcomes. Obviously the overall approach and the ways in which the collaboration are established will vary greatly depending on a number of patient characteristics, his/her circumstances, and the cultural milieu. Bodenheimer T,et al. JAMA. 288: 2002,

Overall Administrative Strategies
ISTC Training Modules 2008 Developing a “patients first” attitude in the clinic Staff training, motivation, and supervision Defaulter action (example: home visits) Reminders mailed in advance of appointments Encourage staff to identify incentives, enablers Provide reimbursements for visit costs Directly observed treatment (DOT) This slide lists actions to be taken. [Review content of slide] [Interactive option: Highlight/summarize some of the suggestions offered from the participants as well.] WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

ISTC Training Modules 2008 Summary: Consider patient’s needs Mutual respect between the patient and provider is key Consider all factors that may influence adherence Support measures must be tailored to the individual [Review content of slide] [Image Credit: Lung Health Image Library]

Summary: ISTC Standard Covered*
ISTC Training Modules 2008 Standard 9: To foster and assess adherence, a patient-centered approach, based on the patient’s needs and mutual respect between the patient and the provider, should be developed for all patients. Consider gender-sensitive and age-specific interventions and support. Use measures that assess and promote adherence, and address poor adherence when it occurs. These measures should be tailored to the individual, mutually acceptable, and may include directly-observed therapy (DOT) of medication. And in summary, the International Standards reviewed: [Review content of slide] [End] *[Abbreviated version]

ISTC Training Modules 2008 Alternate Slides Alternate Slides: Offer additional options that may be added or substituted into module. See Facilitator’s Guide for further information.

Purpose of ISTC ISTC Training Modules 2008 The International Standards for Tuberculosis Care (ISTC): Are intended to unite public and private sectors in providing a uniformly accepted level of care for all patients with, or suspected of having, TB. Describes the essential elements of TB care that should be available everywhere. Provides a vehicle for mobilizing professional societies globally in support of TB programs. Serves as a powerful advocacy tool to ensure that the essential elements are available. [Image Credit: Lung Health Image Library/Gary Hampton]

ISTC: Key Points 17 Standards
ISTC Training Modules 2008 17 Standards Differ from existing guidelines: standards present what should be done, whereas, guidelines describe how the action is to be accomplished Evidence-based, living document Developed in tandem with Patients’ Charter for Tuberculosis Care Handbook for using the International Standards for Tuberculosis Care The ISTC consist of 17 evidence-based standards. Standards differ from existing guidelines in that standards present what should be done, whereas, guidelines describe how the action is to be accomplished. To meet the requirements of the Standards, approaches and strategies, determined by local circumstances and practices and developed in collaboration with local and national public health authorities, will be necessary. There are many situations in which the level of care can, and should, go beyond what is specified in the Standards. The Standards should be viewed as a living document that will be revised as technology, resources, and circumstances change. Revisions to the original document released December 2005 are currently underway. Funded (Oct 1, 2004) by USAID via TBCTA, development was supervised by an international steering committee (28 members / 14 countries) chosen to represent perspectives relevant to tuberculosis care and control. The Standards are also intended to serve as a companion to and support for the Patients’ Charter for Tuberculosis Care developed in tandem with the Standards. A Handbook for using the International Standards for Tuberculosis Care is also available (2007). The Handbook presents suggestions and guidance, based mainly on country-level experiences, for using the ISTC as a tool to foster and guide the delivery of high-quality care by all practitioners providing TB care. [Resource:

ISTC: Key Points ISTC Training Modules 2008 Audience: all health care practitioners, public and private Scope: diagnosis, treatment, and public health responsibilities; intended to complement local and national guidelines Rationale: sound tuberculosis control requires the effective engagement of all providers in providing high quality care and in collaborating with TB control programs The Standards are addressed to all healthcare providers, private and public, who care for persons with proven tuberculosis or with symptoms and signs suggestive of TB. Three categories of activities are addressed by the Standards: diagnosis, treatment, and public health responsibilities of all providers. The ISTC are intended to be complementary to local and national TB control policies that are consistent with the World Health Organization (WHO) recommendations. In many parts of the world there is great variability in the quality of tuberculosis care, and poor quality care continues to plague global tuberculosis control efforts. Effective engagement of all providers in providing high quality care in collaboration with TB control programs is key to the promotion of sound tuberculosis control.

ISTC Training Modules 2008 Questions Questions: May be used for interactive discussion, course evaluation, or continuing medical education purposes. See Facilitator Guide for further information.

ISTC Training Modules 2008 1. A 62 year-old patient has been taking TB treatment for three months. She has hypertension and has been your patient for ten years. Although she has always been good at listening to all of your advice in the past, she has missed her last two appointments, and her husband now informs you that he is worried because she is not taking her TB medications at home as directed. He states that she rarely goes out of the house now, and she avoids her friends. In addition to asking about possible side effects from the medications, what else would be good to address during her next appointment? Ask how she is coping with the diagnosis, understanding that emotional factors such as fear, stigma, and depression may play a role in non-adherence Talk to her about directly-observed therapy as a way to help her succeed with treatment and support her closely Assess her understanding of TB disease and treatment, and ask her what she thinks might be interfering with her ability to take her medications as directed All of the above Correct Answer: D

ISTC Training Modules 2008 2. As a clinic caregiver and administrator, you note that the clinic has a high rate of TB treatment failure and default. Healthcare team and system interventions that could improve patient adherence and completion rates include all of the following except: Develop a joint case conference to discuss problem TB cases with doctors, nurses, and other clinic healthcare workers involved with the TB patients, to put together all aspects of patient care and problem-solve jointly Define a list of strict rules for adherence that patients must follow in order to receive care for tuberculosis at the clinic. Post the rules and enforce. All patients will see the same information, staff will not have to spend time reviewing issues with patients, and the clinic will run more efficiently Provide written educational material for patients in appropriate languages, and consider a peer-assistance program. Develop a reminder system to contact defaulters through letters and/or telephone, and consider a system of incentives or enablers that could help improve adherence Correct Answer: B

ISTC Training Modules 2008 3. To develop a patient-centered system of care for TB, all of the following would be good to consider except: The patient may be involved in deciding which TB medications they prefer to take in order to individualize treatment regimens The patient’s needs and expectations regarding TB care should be explored, looking for ways to improve adherence, and thus, treatment outcomes Foster relationships between patients and providers that rely on mutual respect and mutual responsibility toward a shared goal, rather than just offering expert advice and assuming passive compliance Promote patient self-management through appropriate education and support. Support should be gender-sensitive and age-specific, and should be tailored to the cultural context Correct Answer: A

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