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Fostering and
Assessing
Adherence to
Treatment
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International Standards 9, 17
Fostering Adherence to Treatment
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
ISTC TB Training Modules 2009
Fostering Adherence to Treatment
Overview:
 General concepts
 Adherence factors
and interventions
 Comparison of
traditional care vs.
collaborative care
 Strategies to
improve adherence
International Standards 9, 17
ISTC TB Training Modules 2009
Fostering Adherence to Treatment
Assuming an
appropriate drug
regimen is
prescribed,
tuberculosis
treatment success
depends largely on
patient adherence.
ISTC TB Training Modules 2009
Factors Likely to Improve Adherence
 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
Munro S, et al. PLoS Medicine 2007; 4:e238
ISTC TB Training Modules 2009
Suggestions to Improve Adherence
 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
Munro S, et al. PLoS Medicine 2007; 4:e238
ISTC TB Training Modules 2009
Standard 9: Fostering Adherence to Treatment
(1 of 3)
To assess and foster
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.
ISTC TB Training Modules 2009
Standard 9: Fostering Adherence to Treatment
(2 of 3)
Supervision and
support should be
individualized and
draw on the full range
of recommended
interventions and
available support
services, including
patient counseling
and education.
 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
ISTC TB Training Modules 2009
Standard 9: Fostering Adherence to Treatment
(3 of 3)
 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 treatment or
DOT) and identification and training of a treatment
supporter (for TB and, if appropriate, for HIV) who is
acceptable and accountable to the patient and to the
health system.
 Appropriate incentives and enables, including
financial support, may also serve to enhance
treatment adherence
ISTC TB Training Modules 2009
Through the Eyes of Patients and Families
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
Khan MA, et al. Health Policy Plan 2005;20:354
(cited in Munro SA, et al. PLoS Medicine 2007;4:e238)
ISTC TB Training Modules 2009
Patient-Centered Care
Definition:
Care centered on
patients’ needs and
expectations
ISTC TB Training Modules 2009
Goal:
Improving treatment
outcomes through
improved adherence
The Five Dimensions of Adherence
Health system/
HCT-factors
Condition-related
factors
Social/economic
factors
Therapy-related
factors
Patient-related
factors
HCT = healthcare team
WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003
ISTC TB Training Modules 2009
Interventions
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
ISTC TB Training Modules 2009
Adherence: Social/Economic Factors
 Age
 Race
 Gender
 Poverty
 Illiteracy/Education level
 Unstable living conditions/homelessness
 Social upheavals (wars, natural disasters)
 Distance from treatment centers
 Costs of care
WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003
ISTC TB Training Modules 2009
Interventions: Social/Economic Factors
 Housing
 Food / food tokens
 Transport to
treatment settings
 Peer assistance
 Mobilizing communitybased organizations
 Cooperation between/among services
 Education of the community and providers to
reduce stigma
 Family and community support
WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003
ISTC TB Training Modules 2009
Healthcare Team / System-Related Factors
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
WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003
ISTC TB Training Modules 2009
Healthcare Team / System-Related Factors
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
ISTC TB Training Modules 2009
Through the Eyes of Patients and Families
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
Sanou A, et al. IJTLD 2004;8:1479
(cited in Munro SA, et al. PLoS Medicine 2007;4:e238)
ISTC TB Training Modules 2009
Healthcare Team / System-Related Factors
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
ISTC TB Training Modules 2009
Healthcare Team / System-Related Factors
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
WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003
ISTC TB Training Modules 2009
Therapy and Condition-Related Factors
Factors that affect adherence:
Therapy
 Dosing frequency
 Side effects
Condition
 Effects of symptoms
 Lack of symptoms
 Effects on functional status
 Associated depression
WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003
ISTC TB Training Modules 2009
Therapy and Condition-Related Factors
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
ISTC TB Training Modules 2009
Through the Eyes of Patients and Families
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
Green JA. Cult Med Psychiatry 2004; 28: 401
(cited in Munro SA, et al. PLoS Medicine 2007;4:e238)
ISTC TB Training Modules 2009
Through the Eyes of Patients and Families
….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
Ngamvithayapong J, et al. AIDS 2000;14:413
(cited in Munro SA, et al. PLoS Medicine 2007; 4:e238)
ISTC TB Training Modules 2009
Adherence: Patient Factors
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)
WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003
ISTC TB Training Modules 2009
Standard 17: Support and Services
(1 of 2)
 All providers should conduct a thorough
assessment for co-morbid conditions that
could affect tuberculosis treatment
response or outcome
 At the time the treatment plan is
developed, the provider should identify
additional services that would support an
optimal outcome for each patient and
incorporate these services into an
individualized plan of care
ISTC TB Training Modules 2009
Standard 17: Support and Services
(2 of 2)
This plan should include
assessment of and referrals
for treatment of other
illnesses with particular
attention to those known
to affect treatment outcome,
for instance care for
diabetes mellitus, drug and
alcohol treatment programs,
tobacco smoking cessation programs, and other
psychosocial support services, or to such services
as antenatal or well baby care
ISTC TB Training Modules 2009
Interventions: Patient Factors
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
WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003
ISTC TB Training Modules 2009
Traditional Care vs. Collaborative Care
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?
Patient sets goals
Compliance with
based on information
instructions.
from provider.
Noncompliance is a
Noncompliance is a
patient problem.
problem of strategies.
Bodenheimer T,et al. JAMA. 288: 2002, 2469-2475
ISTC TB Training Modules 2009
Traditional Care vs. Collaborative Care
Issue
How is
behavior
changed?
How are
problems
identified?
How are
problems
solved?
Traditional Care
Collaborative Care
External motivation
Internal motivation
through increased
patient
understanding
By the provider
By the informed
patient who can
recognize problems
By the provider
By the informed
patient with the
provider
Bodenheimer T,et al. JAMA. 288: 2002, 2469-2475
ISTC TB Training Modules 2009
Overall Administrative Strategies
 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)
WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003
ISTC TB Training Modules 2009
Fostering Adherence to Treatment
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
ISTC TB Training Modules 2009
Summary: ISTC Standard Covered*
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 individualizing 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 directlyobserved therapy (DOT) of medication.
*[Abbreviated version]
ISTC TB Training Modules 2009
Summary: ISTC Standard Covered*
Standard 17: All providers should conduct a thorough
assessment for co-morbid conditions that could
affect TB treatment response or outcome.
 The treatment plan should identify additional
services that would support an optimal outcome for
each patient and incorporate these services into an
individualized plan of care.
 This plan should include assessment of and
referrals for treatment of other illnesses with
particular attention to those known to affect
treatment outcome (diabetes mellitus, drug and
alcohol programs, tobacco smoking cessation
programs, and other psychosocial support services,
or to such services as antenatal or well baby care).
*[Abbreviated version]
ISTC TB Training Modules 2009
Alternate Slides
ISTC TB Training Modules 2009
Purpose of ISTC
ISTC TB Training Modules 2009
ISTC: Key Points
 21 Standards (revised/renumbered in 2009)
 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
ISTC TB Training Modules 2009
ISTC: Key Points
 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
ISTC TB Training Modules 2009
Questions
ISTC TB Training Modules 2009
Fostering Adherence to Treatment
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?
A. 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
B. Talk to her about directly-observed therapy as a way to help her
succeed with treatment and support her closely
C. 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
D. All of the above
ISTC TB Training Modules 2009
Fostering Adherence to Treatment
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:
A. 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 problemsolve jointly
B. 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
C. Provide written educational material for patients in appropriate
languages, and consider a peer-assistance program.
D. 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
ISTC TB Training Modules 2009
Fostering Adherence to Treatment
3. To develop a patient-centered system of care for TB, all
of the following would be good to consider except:
A. The patient may be involved in deciding which TB medications
they prefer to take in order to individualize treatment regimens
B. The patient’s needs and expectations regarding TB care
should be explored, looking for ways to improve adherence,
and thus, treatment outcomes
C. 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
D. Promote patient self-management through appropriate
education and support. Support should be individualized and
tailored to the cultural context
ISTC TB Training Modules 2009