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Compliance with tuberculosis therapy
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TUBERCULOSIS
COMPLIANCE WITH TUBERCULOSIS THERAPY Carol J. Pozsik, RN, MPH
The skin testing is done. The sputum reports are on the chart and the chest radiographs read. The diagnosis is tuberculosis (TB) and 6 months of chemotherapy with the appropriate drugs has been prescribed. The patient should be cured with this treatment. This is a perfect scenario, but totally dependent on the patient taking all his medications. Ensuring the regular intake of drugs to achieve a cure is as important as making the diagnosis of TB. Simply prescribing the medicines is not enough? THE PROBLEM OF NONCOMPLIANCE
Health professionals who work with patients with TB face difficult problems getting patients to comply with the prescribed therapy. In 1990, program management reports received by the Centers for Disease Control (CDC) from state and big city TB control programs showed that approximately 24.2% of patients failed to complete therapy within a 12month period and that in some areas the figure was as high as 55%.6 The CDC also reported that in 1991, 1413 (5.4%) of the 26,283 newly reported cases of TB were recurrent cases. Sixty (4.2%) of these patients had TB more than two times (Centers for Disease Control, unpublished data, 1991). Finally, drug-resistant TB has become a great concern in the United States. CDC recently conducted a nationwide survey of drug resistance among all TB cases provisionally reported during the first 3 months of 1991. Overall, 14.9% of patients tested had organisms resistant From the Tuberculosis Control Division, South Carolina Department of Health and Environmental Control, Columbia, South Carolina MEDICAL CLINICS OF NORTH AMERICA VOLUME 77· NUMBER 6 • NOVEMBER 1993
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to at least one antituberculosis drug, and 3.3% had organisms resistant to both isoniazid and rifampin. 4 One of the problems recognized by the CDC in their action plan to fight multidrug-resistant TB was that if TB patients do not take their medications correctly, their organisms may develop drug resistance. 5 All this is compelling evidence that patients who have TB who do not appropriately complete therapy must be carefully and continually assessed for medication noncompliance, and appropriate interventions rapidly applied. HISTORICAL EVIDENCE OF NONCOMPLIANCE
Before there was chemotherapy for TB, the patient and the physician had little control of the outcome of treatment for TB. The patient could follow the treatment regimen of the day, which consisted of rest, improved nutrition, and fresh air, and still in 50% of the cases, death was inevitable. 2 Many patients desperately followed the "rest" method of cure, but still fell victim to the "White Plague." When the long awaited chemotherapy for TB finally became available, it brought new problems. Being hospitalized in a sanatorium did not ensure compliance with treatment. Many of the drugs were unpleasant to take and ex-sanatorium workers have described the drugs' properties to peel paint off hospital walls. Patients also spit the drugs outside the windows making the ground snow white with the powder of TB medicines. Despite the fact that some patients were openly noncompliant, they were still allowed to be responsible for taking their own medications. After the physician diagnosed the disease and prescribed the appropriate medications, the medical model of the day dictated that the remaining responsibility for treatment was left up to the patient. The nurses' role was to dutifully follow the patient, seeing to it that the patient received the appropriate radiographs, submitted regular sputum specimens, and kept appointments for the chest clinic. And in keeping with the medical model of the day, if the patient did not take the medicine, it was not the nurse's fault! Family members, friends, physicians, and nurses may have suspected, or even known, that the patient was not taking the drugs, but there was no purposeful intervention such as supervised treatment by a nurse, as there is today. If the patient openly rebelled and refused treatment, that patient was aggressively removed to the sanatorium and put on the locked ward. Patients did improve despite receiving partial treatment. Some went on to be cured permanently and others improved to the point where it was thought that cure had probably taken place. Years later, some of these persons who were "cured" relapsed causing needless illness and suffering, and sometimes even death in the community. GROUPS AT RISK FOR NONCOMPLIANCE
Recent estimates indicate that 40% to 50% of patients do not use medicines as prescribed. lO Another source states that it may be expected
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that approximately 33% of patients will fail to follow medical recommendations. 12 Experienced US TB controllers anecdotally estimate medication noncompliance to range from 20% to 80%, and it may be as high as 100% in some groups. There is no one group or social class who can be identified as being the most at-risk for noncompliance. Even the best educated members of society can be noncompliant with medications. Neither does being poor and living in substandard housing mean that the patient is shiftless and will not comply. There is no positive predictor of noncompliance. In day to day practice, we know that certain behavioral patterns or historical information about patients can be very useful in predicting compliance. From experience we know that the following groups of patients require careful scrutiny because they tend to be at higher risk for noncompliance. Previous Treatment Failures
Persons who have failed previously at taking anti-TB medications either for treatment of disease or for preventive therapy are very high risk. Most likely their treatment failures were human failures to take medications. Others at high risk are patients who have had difficulty in complying with other medical therapies such as oral contraceptives, antihypertensives, special diets such as diabetic diets, and weight control. Substance Abusers
Most important to the person actively abusing either drugs, alcohol, or other addictive substances is the maintenance of the "high" that comes from the addictive substance. While under the influence, disorganization develops, cognitive thinking becomes impaired and, thus, priorities are distorted. Taking medications may interfere with the euphoria that the patient feels. Many patients also become nauseated and vomit when they are drinking and taking medications. Therefore, they choose only to drink and not take medicines. Mental, Emotional, and Physical Impairments
Certain patients have impairments that initially mayor may not be apparent to the provider and, thus, a complete and ongoing assessment should be made of mental, physical, and emotional status. Patients with mental illness disorders or mental retardation, those with cerebrovascular insufficiency, Alzheimer's disease, and other such impairments have difficulty remembering to take medicines on a regular basis. Persons with unstable mental disorders are also unlikely to take medicines as prescribed and in fact may be susceptible to taking overdoses in periods of anguish or anger. Special care should also be taken to assess persons
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who say that they are unable to swallow the pills. They may have physical disorders such as strictures, which prohibit the passage of pills through the esophagus into the stomach. Other physical impairments such as quadriplegia, severe arthritis, and muscle disorders may restrict the management of routine medications. Persons Who Ought to Be the Most Trustworthy
This group is the most frustrating for the provider to manage because their risk of noncompliance appears to be so low. They are cooperative, pleasant, and interested in their therapy. They want to be educated about their disease process and ask all the right questions, indicating their interest. From the beginning they appear to be the most likely to be the "good patient." These are the people who are well respected in the community and are considered to be the most responsible by their peers. They may be persons who hold responsible positions such as lawyers, physicians, clergy, college professors, school teachers, and law enforcement officers. They may be sweet older men and women, polite teenagers, or the all-American mom. They keep their appointments, are extremely polite and respectful to the medical staff, and pick up medicines on time. They are human with frailties, the worst of which is not taking their medicine as prescribed. They know it's important and "intend to," but other things get their attention and they forget. Unfortunately, health care workers are among those who are the most problematic to deal with as reported by Miller and Snider,ll and Fox. s Blatantly Honest
Some patients are blatantly honest that they have terrible pill-taking habits and will confess it immediately. Others are blatantly honest about the fact that they do not intend to take the medications at all. These patients, although frustrating, give the provider "up front" information that saves time and energy in the long run. It is very helpful to know a patient's compliance status and allows the proper course to be followed to get the patient to complete therapy. Always ask, "Will you take your medicine?" Poor Relationships Between Caregivers and Patients
Relationships between any care giver and the patient can be stressful at times. An academic degree in medicine or nursing does not guarantee that the provider will always like the patient or vice versa. These clashes are frequently major causes of patient noncompliance. If the provider is aggressive or too forceful in approach, a power struggle begins. If the provider appears impassive and without backbone, certain patients will
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easily take control of their own treatment programs. Lost clients frequently disappear for these reasons. New staff members should be educated to the fact that such relationship problems can only be solved by changing the provider of service and that even the staff person with the best track record in relationships can have this problem occasionally. Persons Who Have Failed on Preventive Treatment
Preventive therapy taken compliantly has been shown to be 93% effective in preventing the progression of TB infection to disease. 9 It is rather common to go through TB case records and find patients who picked up an adequate supply of preventive treatment and still developed disease. Persons inexperienced with TB might think that these were treatment failures, when in fact, they are people failures. The number of pills these patients actually took while on preventive treatment was insufficient to prevent them from progressing on to disease. It is difficult to understand why patients would make the effort to travel to clinics to pick up medications on a monthly basis, and then not take them. This is in fact a very common occurrence. ENHANCING THE PATIENT-CAREGIVER RELATIONSHIP
The treatment for TB infection and disease is necessarily long and boring. It can also be aggravating, especially if the drugs cause unpleasant side effects. Getting the patient through the peaks and valleys of treatment requires great skill. Whoever cares for the patient must be able to develop and maintain a meaningful relationship that hinges on clear and effective communication and a mutually agreed upon plan for treatment. Miscommunication can be a threat to any form of personal interaction, be it casual or formal exchange. Some of the problems contributing to miscommunications in medical settings are the use of specialized technical vocabulary, cultural differences between patients and providers, and institutional constraints on the forms of interaction that can take placeY Specialized Technical Vocabulary
TB is a complex disease. Many well-educated medical personnel require long-term, day to day dealings with the disease before they truly begin to understand all of its nuances. Imagine the lay person who has TB infection or disease and is going to talk to the physician or nurse for the first time. In the majority of cases, the patient is not well educated. The patient probably has many questions and may be afraid of dying or
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being sent away to a sanatorium. The provider is eager to educate the patient, and in this zeal may tell the patient more than he or she ever wanted to know, or certainly could even understand. This is a common practice. How much is too little to tell and how much is too much? This kind of assessment only happens over time with many meaningful encounters between the patient and the caregiver. Even with long-term education and continual assessment of the patient's knowledge, patient's health beliefs and behaviors do not necessarily change as a result of the provision of technical or factual information about the disease. In the end, it is the relationship between the patient and the provider that makes the real difference in whether or not the patient will take the medicine. It is for this reason that it is best to assign one primary caregiver to the patient during the course of therapy.12 Cultural Differences
The concepts involved in education about TB between patient and provider are difficult enough when dissimilar educational levels exist. When the factor of cultural differences is added, relationships and communications become increasingly more complex. If the physician's office or clinic is in a predominantly ethnic neighborhood, the obvious choice for clinic staff should be those who would ethnically and culturally relate the best with the patients. In some clinics in large cities of the United States, staff members may speak several languages so that patients are served in their own tongues and with specific cultural understanding. Compliance is obviously increased where this kind of targeted patient care exists. Institutional Constraints
The best services for patients that encourage compliance are those in which the patient perceives no barriers to receiving the service. The patient may feel uncomfortable in the clinic or physician's office setting, may have to wait a long time for services, and may be reluctant to ask questions because he or she does not want to appear stupid. He may feel that his appearance is inferior to others at the clinic or office. The structure of the clinic may be forbidding. Persons at the front desk may immediately influence his feeling about the setting. There may be rules governing the clinic routine that are not easily understood. He may be embarrassed when asked to pay something for the service and he is unable to do so. All these things for the patient may be barriers. The staff may not even perceive that there is a problem and then they wonder why the patient does not keep appointments. Issues of Control
A patient may have diabetes and does not wish to take his insulin. Family and friends may worry for him, but he hurts no one but himself.
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A patient refuses cancer treatment. While there is concern for him, his decision will ultimately affect no one's health but his. Self-determination can apply in other disease entities, but in TB, the patient does not have the right to refuse treatment for the disease and continue to expose others to infectious bacilli. Many patients are upset by the fact that they have no choice when it comes to TB treatment. They are angry that laws govern the control of TB. They believe that this is an infringement on their rights. Some will immediately say that they are not going to take the medicine. Others who want to rebel will quietly act out in a variety of ways to show that they are in control of their own treatment program. Unless the primary care giver is firm, but loving in approach, the patient retains control and the battle for compliance is on. Frequently, the use of social work intervention is very helpful in resolving these situations. MANAGING NONCOMPLIANT PATIENTS
There are a variety of strategies to deal with noncompliance, some of which are not very effective, because patients learn very quickly how to circumvent the system. The caregiver must continually evaluate compliance and be very flexible, so that changes can be made easily. The following strategies can be tried, but from the beginning of therapy, the caregiver must face the possibility that every patient who is noncompliant might eventually have to be switched to more aggressive methods such as directly observed therapy (DOT). Pill Counts
Pill counting is a method that can be used early in therapy. It is best done with the nurse making surprise home visits to determine whether or not the patient is actually removing the pills from the container. This method will not tell you whether the patient is actually taking them, only that they are gone from the container. Caution must be observed when using this method, because it is one of the easiest for the patient to circumvent. It can be effective with the elderly and for others who cannot remember to take medicines regularly. The use of a daily pill reminder container marked with the days of the week also helps the elderly and the forgetful. These containers are available from drug stores at a minimal cost. If there is any question at all that the patient may be removing pills from the container to coincide with the nurses visits, use of the pill counter must be stopped and DOT begun. Urine Testing for Drugs or Their Metabolites
There are several simple methods for testing the patient's urine for the presence of anti-TB drugs or their metabolites. This testing is accom-
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plished through the use of simple chemical tests or through a commercially prepared "dipstick." The CDC has published details for the purchase of these materials. 3 The effectiveness of these tests can be questionable because the amount of time elapsed since the medications were taken will affect the results of the test. Another method of monitoring compliance is to examine the color of the urine of patients who are taking rifampin. Rifampin turns the urine an orange col or, but again, this is affected by the amount of time elapsed since taking the medicines. Both these methods can be circumvented by patients if the tests are conducted at predictable times. Surprise home visits will prevent this from happening. Blood Testing for the Presence of Antituberculosis Drugs
Blood testing is available, but it is a very costly method for detecting the presence of anti-TB drugs in the blood. It is usually used to measure peaks and troughs of the drugs. Blood tests are performed by either the CDC or the National Center for Immunology and Respiratory Medicine in Denver, Colorado. Far more practical and dependable are other interventions mentioned in this article such as DOT. DOT
One of the earliest principles learned in medicine is that in order to make sure that the patient takes the medicine, you must watch him swallow it. Therefore, the most effective strategy to ensure compliance and subsequent cure is to consider DOT for all patients. This is now the standard of care in the United States. 2 DOT is most often done by health departments or by other outpatient clinics who provide TB services. It is preferable to have an experienced nurse do a professional patient assessment for DOT. (This can be done by calling the local health department or TB clinic.) Depending on the complexity of the case and the patient's physical status, the nurse may administer the DOT or it may be delegated to another health care worker such as an outreach worker. DOT is given two or three times a week, usually after an initial period of daily therapy. Its effectiveness has been repeatedly demonstrated in controlled research studies and is less costly and easier to administer than daily therapy.2 Physicians who are attempting to manage patients through their own offices should be alert to the realities of the number of patients who are truly noncompliant as is outlined in this article. To ensure compliance, the physician should refer the patient to either the health department or a clinic facility where DOT is provided. If the physician prefers to manage the case through his office staff, DOT can be handled by them as well. Before assuming the responsibility of monitoring therapy, any staff
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should be made aware of the prevalence of noncompliance and be taught to assess for it. They should be reminded that no matter who the patient is, the plan should always include being prepared to use DOT. It should be kept in mind that DOT is a positive intervention, not a punitive one. To give a TB patient his medicine is as positive an act as giving a patient with diabetes his insulin when he is unable to do it for himself. Many health care providers fail to use DOT because they feel some guilt at using this intervention, i.e., taking away the patient's rights. Much of their reluctance is having to explain to the patient why he is being placed on this closely supervised treatment. It is especially important to note that if the patient is allowed to take his own treatment initially, he should be properly prepared in case future developments require switching him to DOT. The patient can be told that in the future he may be moved to twice-weekly observed treatment to accelerate the completion of therapy. In addition, the patient can be told that this method of treatment will be given by a nurse who will monitor for side effects and the effectiveness of the new treatment plan. Or, it can be said that the treatment will be observed by an outreach worker who will report directly to the physician or nurse the patient's status. In this way, the treatment can move faster and patient progress be better monitored. The fact that the patient forgets to take his medicine shoul~ be mentioned, but in such a way that the patient does not feel punished. All efforts should be made to prevent animosity between the provider and the patient. The patient simply moves to a new phase in his treatment plan, for which he has been properly prepared. How to Do DOT
Believing in DOT. Many people are hesitant to do DOT because they do not know how to get started. The first and most essential component of doing DOT is believing in it! If the physician, the nurse, and the entire office team do not support the concept of DOT as a standard of care, then DOT is doomed from the start. Each staff member must share the enthusiasm that this is the only way to ensure compliance. A positive attitude, "This is the way we do it here," will give the patient confidence and assurance that the care givers are competent and that he is in good hands. Where to Give DOT. Picking the place to give DOT must be mutually agreed on by both patient and staff member. Don't ask the patient to meet at a place where it is impossible for him to be. In other words, don't make him come to the office or clinic if it is 20 miles away and he has no ride. Either arrange the ride for him by giving bus fare or money to pay someone to bring him. A larger issue is this: If the patient can't come in, someone must go out! That is a rule that must be observed in any good TB control program. Be flexible with the time to meet for the treatment. Don't ask the patient to meet you if he can't miss work during working hours. Make another arrangement with him, perhaps on his lunch hour or after work. When very difficult work schedules seem impossible to overcome, consider using other sources of medical care
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that are staffed around the clock, e.g., hospital emergency rooms, nursing homes, and urgent care facilities. Often "deals" can be worked out with these facilities to provide DOT as a community service at no charge. Confidentiality. The patient's confidentiality must be preserved. Provide the therapy where he feels secure. He may let you come to his house only if you don't wear a uniform or if you don't come in a county marked vehicle. The patient may have requests to preserve his confidentiality that are unusual. He may ask you to meet him in an elevator, in a supermarket, or on a street corner. Although the provider might think it ridiculous, it is best to do as the patient asks if you want to get him successfully treated. This is not a power struggle to see who comes out the winner! Maintaining Personal Safety. The provider should maintain his own personal safety and still preserve the patient's integrity. If the provider feels that the site chosen by the patient is unsafe, then negotiation should occur and another place should be chosen. If the patient lives in a high crime neighborhood, he should not be made to come all the way downtown to the clinic when he could be met two blocks away from his home in a safer place. It is important to remember that living in a poor neighborhood doesn't mean that this patient is a bad person or does bad things. It may just mean that he cannot afford to live in better surroundings. Delegating Others to Give Medicines. In the past it has been fairly standard for the provider to entrust family members with the responsibility of giving medicines to the patient. This concept also had extended over to persons who had other close relationships with the patient, e.g., girlfriends, neighbors, and friends. From vast experience, it has been found that this practice is undesirable in many cases. Emotional ties can be too close, and if the patient becomes difficult, the deputized caregiver may back off and not give all or part of the medications. An example might be the mother of a young child who gets especially exasperated when the child continuously spits out the medicine. The parent finally gives up because the child is feeling better. The parent wants to appear responsible to the physician or nurse, giving the impression that he or she has done the "right thing." Often, the truth is altered regarding how much medication got into the child. The same holds true for caregivers of adult patients who have been deputized to give medicines. Many experienced nurses will relate instances in which they have delegated responsibility to family members and instead of a positive experience have placed a heavy burden on the family's shoulders. Family relationships are important and should be strengthened not weakened by this delegation of responsibility. Because of the serious personal and public health consequences of TB, these experienced nurses now take this responsibility themselves. They have learned not to impose new stressors into often fragile family relationships, just to save themselves some time. There have been many very successful situations in which delegation of medication responsibility can be given to others. Persons such as teachers, school nurses, employee health nurses, law enforcement offi-
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cers, bosses, clergy, and others without emotional ties to the patient can make the completion of therapy happen. Other Problems Encountered in DOT (Dirty Tricks)
Providing DOT does give a measure of security that the patient is receiving his medicine. He may receive it, but not swallow it. Certain patients who are intent on not taking their medications will go through all sorts of antics to keep from swallowing their pills during DOT. It is for this reason that the observer must be attuned to some of these unusual patient "tricks." Probably the most common of these is to hide the pills under the tongue or in the cheek. Another is to never release the pills from the hand into the mouth, keeping them in the palm and then throwing them away. Spitting pills into an opaque drinking cup is another trick, as is faking a cough, then spitting the pills into the palm of the hand. Some patients fake a cough, then palm the pills and slide them into a shirt pocket or down into their pants. Most bizarre is the occasional patient who swallows the medicines and then when the nurse is out of sight, intentionally vomits them up. Other patients tell the nurse that they need to go to the bathroom and take the pills, then they spit them in the toilet. Obviously, there are probably many other methods that patients use to avoid swallowing medicines. The motivation for these dirty tricks is as hard to understand as the patient who comes to pick up bottles of medicine faithfully every month, then takes none of them. It is important to remember that just watching the patient put the pills in his mouth is not enough. There must be assurance that he has swallowed them, even if he must be made to open his mouth and allow the nurse to look inside. In the case of the patient who intentionally vomits, it may even be necessary to have the patient sit in the clinic for at least one half hour after he swallows the medicines to assure that he will not vomit. Although this discussion may be distasteful to some readers, it is a reality, and is necessary to keep in mind when patients fail to convert their sputum or improve clinically after all other possible reasons have been exhausted. USING INCENTIVES AND ENABLERS TO ENHANCE COMPLIANCE
One of the most successful programs used today in many TB control programs is the use of incentives and enablers to enhance completion of therapy.! Incentives are small rewards given to patients either to encourage them to take their own medicines or to entice them to maintain regular clinic visits or field visits for DOT. Enablers are those things that "enable" the patient to receive treatment. They may be bus tokens, driver's license fees, car batteries, a fan belt, or babysitting money so that the mother can go to the clinic.
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Incentives can be small or large, and can be food, goods, or services. What might be an incentive for one patient, might not be for another. Therefore, incentives must be specially tailored to the individual patient or they might not be successful. For example, a patient who is hungry will respond readily to certain foods. The patient who is cold will appreciate a pair of warm socks or a used sweater. A child might like an occasional tea party with the nurse, being read a story, an ice cream cone, or having her finger nails painted when the nurse comes. A mother may be motivated if gifts are brought for her children, such as notebook paper and pencils for school. A handful of flowers picked from a nurse's yard is a bright spot in the day of an elderly patient. The caregiver who is especially sensitive to the individual patient's needs is the one who will be successful in using incentives and enablers to help complete the patient's therapy. As many nurses, outreach workers, and other care givers have found, it is not what you give the patient, it is what you give of yourself. Taking the time to choose something that is meaningful and special to that person is easily understood by even the most hard-hearted patient. Many patients who fight for control of their treatment situation and give the staff a hard time have never had a meaningful relationship with anyone. Consequently, the use of incentives and the gift of self becomes a life-changing experience for the patient and the staff member as well. SUMMARY
The treatment experience in TB control can be a very rewarding time for both the patient and the provider. If the patient is made to feel that the provider cares for him as a person, a meaningful relationship can develop and can have a positive influence on the patient's behavior in taking medications and perhaps even in the direction of his lifeY Noncompliance with medications unfortunately has been a "given" in the TB control program. The successful program must be patient centered and include the following components: (1) fair and equal treatment of all patients, (2) patient involvement in the plan of care, (3) the most current patient treatment and services, including the availability of DOT for patients with TB infection and disease, and (4) rewards for patients and staff for positive behavior in the completion of treatment. Given current levels of staffing and other resources, some noncompliance will continue even in the best TB programs. Caring and knowledgeable staff members who support the patient-centered approach can make TB treatment a positive experience for both the patient and themselves. References 1. American Lung Association of South Carolina: Using Incentives and Enablers in the
Tuberculosis Control Program (booklet). Columbia, S.c., American Lung Association of South Carolina, 1989
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2. American Thoracic Society: Control of tuberculosis in the United States. Am Rev Respir Dis 146:1624, 1992 3. Centers for Disease Control: Improving Patient Compliance in Tuberculosis Treatment Programs. Division of Tuberculosis Elimination, CDC 20, 1989, P 20 4. Centers for Disease Control: National Action Plan to Combat Multi-Drug Resistant Tuberculosis. Division of Tuberculosis Elimination, CDC 1, 1992, P 91 5. Centers for Disease Control: National Action Plan to Combat Multi-Drug Resistant Tuberculosis. Division of Tuberculosis Elimination, CDC 19, 1992, P 19 6. Centers for Disease Control: Program Management Reports, United States. Division of Tuberculosis Elimination, CDC 1990 7. Chaulet P: Treatment of Tuberculosis: Case Holding Until Cure. WHO/TB/83.l41. Geneva, World Health Organization, 1983 8. Fox W: Compliance of patients and physicians: Experience and lessons from tuberculosis 1. Br Med J 287:101, 1983 9. International Union Against Tuberculosis Committee on Prophylaxis: Efficacy of various durations of isoniazid preventive therapy for tuberculosis: Five years of follow-up in the IUAT trial. Bull WHO 60:555,1982 10. Ley P: Communicating with Patients: Improving Communication, Satisfaction and Compliance. New York, Chapman and Hall, 1988, p 61 11. Miller B, Snider D: Physician noncompliance with tuberculosis preventive measures. Am Rev Respir Dis 135:1, 1987 12. Sbarbaro J: The patient-physician relationship: Compliance revisited. Annals of Allergy 64:325,1990 13. West C, Frankel RM: Miscommunication in medicine. In Coup land N, et al (eds): Miscommunication and Problematic Talk. Sage Publications, 1991, pp 167-194
Address reprint requests to Carol J. Pozsik, RN, MPH South Carolina Department of Health and Environmental Control Tuberculosis Control Division Michael D. Jarrett Building Box 101106 Columbia, SC 29211
TUBERCULOSIS
COMPLIANCE WITH TUBERCULOSIS THERAPY Carol J. Pozsik, RN, MPH
The skin testing is done. The sputum reports are on the chart and the chest radiographs read. The diagnosis is tuberculosis (TB) and 6 months of chemotherapy with the appropriate drugs has been prescribed. The patient should be cured with this treatment. This is a perfect scenario, but totally dependent on the patient taking all his medications. Ensuring the regular intake of drugs to achieve a cure is as important as making the diagnosis of TB. Simply prescribing the medicines is not enough? THE PROBLEM OF NONCOMPLIANCE
Health professionals who work with patients with TB face difficult problems getting patients to comply with the prescribed therapy. In 1990, program management reports received by the Centers for Disease Control (CDC) from state and big city TB control programs showed that approximately 24.2% of patients failed to complete therapy within a 12month period and that in some areas the figure was as high as 55%.6 The CDC also reported that in 1991, 1413 (5.4%) of the 26,283 newly reported cases of TB were recurrent cases. Sixty (4.2%) of these patients had TB more than two times (Centers for Disease Control, unpublished data, 1991). Finally, drug-resistant TB has become a great concern in the United States. CDC recently conducted a nationwide survey of drug resistance among all TB cases provisionally reported during the first 3 months of 1991. Overall, 14.9% of patients tested had organisms resistant From the Tuberculosis Control Division, South Carolina Department of Health and Environmental Control, Columbia, South Carolina MEDICAL CLINICS OF NORTH AMERICA VOLUME 77· NUMBER 6 • NOVEMBER 1993
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to at least one antituberculosis drug, and 3.3% had organisms resistant to both isoniazid and rifampin. 4 One of the problems recognized by the CDC in their action plan to fight multidrug-resistant TB was that if TB patients do not take their medications correctly, their organisms may develop drug resistance. 5 All this is compelling evidence that patients who have TB who do not appropriately complete therapy must be carefully and continually assessed for medication noncompliance, and appropriate interventions rapidly applied. HISTORICAL EVIDENCE OF NONCOMPLIANCE
Before there was chemotherapy for TB, the patient and the physician had little control of the outcome of treatment for TB. The patient could follow the treatment regimen of the day, which consisted of rest, improved nutrition, and fresh air, and still in 50% of the cases, death was inevitable. 2 Many patients desperately followed the "rest" method of cure, but still fell victim to the "White Plague." When the long awaited chemotherapy for TB finally became available, it brought new problems. Being hospitalized in a sanatorium did not ensure compliance with treatment. Many of the drugs were unpleasant to take and ex-sanatorium workers have described the drugs' properties to peel paint off hospital walls. Patients also spit the drugs outside the windows making the ground snow white with the powder of TB medicines. Despite the fact that some patients were openly noncompliant, they were still allowed to be responsible for taking their own medications. After the physician diagnosed the disease and prescribed the appropriate medications, the medical model of the day dictated that the remaining responsibility for treatment was left up to the patient. The nurses' role was to dutifully follow the patient, seeing to it that the patient received the appropriate radiographs, submitted regular sputum specimens, and kept appointments for the chest clinic. And in keeping with the medical model of the day, if the patient did not take the medicine, it was not the nurse's fault! Family members, friends, physicians, and nurses may have suspected, or even known, that the patient was not taking the drugs, but there was no purposeful intervention such as supervised treatment by a nurse, as there is today. If the patient openly rebelled and refused treatment, that patient was aggressively removed to the sanatorium and put on the locked ward. Patients did improve despite receiving partial treatment. Some went on to be cured permanently and others improved to the point where it was thought that cure had probably taken place. Years later, some of these persons who were "cured" relapsed causing needless illness and suffering, and sometimes even death in the community. GROUPS AT RISK FOR NONCOMPLIANCE
Recent estimates indicate that 40% to 50% of patients do not use medicines as prescribed. lO Another source states that it may be expected
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that approximately 33% of patients will fail to follow medical recommendations. 12 Experienced US TB controllers anecdotally estimate medication noncompliance to range from 20% to 80%, and it may be as high as 100% in some groups. There is no one group or social class who can be identified as being the most at-risk for noncompliance. Even the best educated members of society can be noncompliant with medications. Neither does being poor and living in substandard housing mean that the patient is shiftless and will not comply. There is no positive predictor of noncompliance. In day to day practice, we know that certain behavioral patterns or historical information about patients can be very useful in predicting compliance. From experience we know that the following groups of patients require careful scrutiny because they tend to be at higher risk for noncompliance. Previous Treatment Failures
Persons who have failed previously at taking anti-TB medications either for treatment of disease or for preventive therapy are very high risk. Most likely their treatment failures were human failures to take medications. Others at high risk are patients who have had difficulty in complying with other medical therapies such as oral contraceptives, antihypertensives, special diets such as diabetic diets, and weight control. Substance Abusers
Most important to the person actively abusing either drugs, alcohol, or other addictive substances is the maintenance of the "high" that comes from the addictive substance. While under the influence, disorganization develops, cognitive thinking becomes impaired and, thus, priorities are distorted. Taking medications may interfere with the euphoria that the patient feels. Many patients also become nauseated and vomit when they are drinking and taking medications. Therefore, they choose only to drink and not take medicines. Mental, Emotional, and Physical Impairments
Certain patients have impairments that initially mayor may not be apparent to the provider and, thus, a complete and ongoing assessment should be made of mental, physical, and emotional status. Patients with mental illness disorders or mental retardation, those with cerebrovascular insufficiency, Alzheimer's disease, and other such impairments have difficulty remembering to take medicines on a regular basis. Persons with unstable mental disorders are also unlikely to take medicines as prescribed and in fact may be susceptible to taking overdoses in periods of anguish or anger. Special care should also be taken to assess persons
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who say that they are unable to swallow the pills. They may have physical disorders such as strictures, which prohibit the passage of pills through the esophagus into the stomach. Other physical impairments such as quadriplegia, severe arthritis, and muscle disorders may restrict the management of routine medications. Persons Who Ought to Be the Most Trustworthy
This group is the most frustrating for the provider to manage because their risk of noncompliance appears to be so low. They are cooperative, pleasant, and interested in their therapy. They want to be educated about their disease process and ask all the right questions, indicating their interest. From the beginning they appear to be the most likely to be the "good patient." These are the people who are well respected in the community and are considered to be the most responsible by their peers. They may be persons who hold responsible positions such as lawyers, physicians, clergy, college professors, school teachers, and law enforcement officers. They may be sweet older men and women, polite teenagers, or the all-American mom. They keep their appointments, are extremely polite and respectful to the medical staff, and pick up medicines on time. They are human with frailties, the worst of which is not taking their medicine as prescribed. They know it's important and "intend to," but other things get their attention and they forget. Unfortunately, health care workers are among those who are the most problematic to deal with as reported by Miller and Snider,ll and Fox. s Blatantly Honest
Some patients are blatantly honest that they have terrible pill-taking habits and will confess it immediately. Others are blatantly honest about the fact that they do not intend to take the medications at all. These patients, although frustrating, give the provider "up front" information that saves time and energy in the long run. It is very helpful to know a patient's compliance status and allows the proper course to be followed to get the patient to complete therapy. Always ask, "Will you take your medicine?" Poor Relationships Between Caregivers and Patients
Relationships between any care giver and the patient can be stressful at times. An academic degree in medicine or nursing does not guarantee that the provider will always like the patient or vice versa. These clashes are frequently major causes of patient noncompliance. If the provider is aggressive or too forceful in approach, a power struggle begins. If the provider appears impassive and without backbone, certain patients will
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easily take control of their own treatment programs. Lost clients frequently disappear for these reasons. New staff members should be educated to the fact that such relationship problems can only be solved by changing the provider of service and that even the staff person with the best track record in relationships can have this problem occasionally. Persons Who Have Failed on Preventive Treatment
Preventive therapy taken compliantly has been shown to be 93% effective in preventing the progression of TB infection to disease. 9 It is rather common to go through TB case records and find patients who picked up an adequate supply of preventive treatment and still developed disease. Persons inexperienced with TB might think that these were treatment failures, when in fact, they are people failures. The number of pills these patients actually took while on preventive treatment was insufficient to prevent them from progressing on to disease. It is difficult to understand why patients would make the effort to travel to clinics to pick up medications on a monthly basis, and then not take them. This is in fact a very common occurrence. ENHANCING THE PATIENT-CAREGIVER RELATIONSHIP
The treatment for TB infection and disease is necessarily long and boring. It can also be aggravating, especially if the drugs cause unpleasant side effects. Getting the patient through the peaks and valleys of treatment requires great skill. Whoever cares for the patient must be able to develop and maintain a meaningful relationship that hinges on clear and effective communication and a mutually agreed upon plan for treatment. Miscommunication can be a threat to any form of personal interaction, be it casual or formal exchange. Some of the problems contributing to miscommunications in medical settings are the use of specialized technical vocabulary, cultural differences between patients and providers, and institutional constraints on the forms of interaction that can take placeY Specialized Technical Vocabulary
TB is a complex disease. Many well-educated medical personnel require long-term, day to day dealings with the disease before they truly begin to understand all of its nuances. Imagine the lay person who has TB infection or disease and is going to talk to the physician or nurse for the first time. In the majority of cases, the patient is not well educated. The patient probably has many questions and may be afraid of dying or
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being sent away to a sanatorium. The provider is eager to educate the patient, and in this zeal may tell the patient more than he or she ever wanted to know, or certainly could even understand. This is a common practice. How much is too little to tell and how much is too much? This kind of assessment only happens over time with many meaningful encounters between the patient and the caregiver. Even with long-term education and continual assessment of the patient's knowledge, patient's health beliefs and behaviors do not necessarily change as a result of the provision of technical or factual information about the disease. In the end, it is the relationship between the patient and the provider that makes the real difference in whether or not the patient will take the medicine. It is for this reason that it is best to assign one primary caregiver to the patient during the course of therapy.12 Cultural Differences
The concepts involved in education about TB between patient and provider are difficult enough when dissimilar educational levels exist. When the factor of cultural differences is added, relationships and communications become increasingly more complex. If the physician's office or clinic is in a predominantly ethnic neighborhood, the obvious choice for clinic staff should be those who would ethnically and culturally relate the best with the patients. In some clinics in large cities of the United States, staff members may speak several languages so that patients are served in their own tongues and with specific cultural understanding. Compliance is obviously increased where this kind of targeted patient care exists. Institutional Constraints
The best services for patients that encourage compliance are those in which the patient perceives no barriers to receiving the service. The patient may feel uncomfortable in the clinic or physician's office setting, may have to wait a long time for services, and may be reluctant to ask questions because he or she does not want to appear stupid. He may feel that his appearance is inferior to others at the clinic or office. The structure of the clinic may be forbidding. Persons at the front desk may immediately influence his feeling about the setting. There may be rules governing the clinic routine that are not easily understood. He may be embarrassed when asked to pay something for the service and he is unable to do so. All these things for the patient may be barriers. The staff may not even perceive that there is a problem and then they wonder why the patient does not keep appointments. Issues of Control
A patient may have diabetes and does not wish to take his insulin. Family and friends may worry for him, but he hurts no one but himself.
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A patient refuses cancer treatment. While there is concern for him, his decision will ultimately affect no one's health but his. Self-determination can apply in other disease entities, but in TB, the patient does not have the right to refuse treatment for the disease and continue to expose others to infectious bacilli. Many patients are upset by the fact that they have no choice when it comes to TB treatment. They are angry that laws govern the control of TB. They believe that this is an infringement on their rights. Some will immediately say that they are not going to take the medicine. Others who want to rebel will quietly act out in a variety of ways to show that they are in control of their own treatment program. Unless the primary care giver is firm, but loving in approach, the patient retains control and the battle for compliance is on. Frequently, the use of social work intervention is very helpful in resolving these situations. MANAGING NONCOMPLIANT PATIENTS
There are a variety of strategies to deal with noncompliance, some of which are not very effective, because patients learn very quickly how to circumvent the system. The caregiver must continually evaluate compliance and be very flexible, so that changes can be made easily. The following strategies can be tried, but from the beginning of therapy, the caregiver must face the possibility that every patient who is noncompliant might eventually have to be switched to more aggressive methods such as directly observed therapy (DOT). Pill Counts
Pill counting is a method that can be used early in therapy. It is best done with the nurse making surprise home visits to determine whether or not the patient is actually removing the pills from the container. This method will not tell you whether the patient is actually taking them, only that they are gone from the container. Caution must be observed when using this method, because it is one of the easiest for the patient to circumvent. It can be effective with the elderly and for others who cannot remember to take medicines regularly. The use of a daily pill reminder container marked with the days of the week also helps the elderly and the forgetful. These containers are available from drug stores at a minimal cost. If there is any question at all that the patient may be removing pills from the container to coincide with the nurses visits, use of the pill counter must be stopped and DOT begun. Urine Testing for Drugs or Their Metabolites
There are several simple methods for testing the patient's urine for the presence of anti-TB drugs or their metabolites. This testing is accom-
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plished through the use of simple chemical tests or through a commercially prepared "dipstick." The CDC has published details for the purchase of these materials. 3 The effectiveness of these tests can be questionable because the amount of time elapsed since the medications were taken will affect the results of the test. Another method of monitoring compliance is to examine the color of the urine of patients who are taking rifampin. Rifampin turns the urine an orange col or, but again, this is affected by the amount of time elapsed since taking the medicines. Both these methods can be circumvented by patients if the tests are conducted at predictable times. Surprise home visits will prevent this from happening. Blood Testing for the Presence of Antituberculosis Drugs
Blood testing is available, but it is a very costly method for detecting the presence of anti-TB drugs in the blood. It is usually used to measure peaks and troughs of the drugs. Blood tests are performed by either the CDC or the National Center for Immunology and Respiratory Medicine in Denver, Colorado. Far more practical and dependable are other interventions mentioned in this article such as DOT. DOT
One of the earliest principles learned in medicine is that in order to make sure that the patient takes the medicine, you must watch him swallow it. Therefore, the most effective strategy to ensure compliance and subsequent cure is to consider DOT for all patients. This is now the standard of care in the United States. 2 DOT is most often done by health departments or by other outpatient clinics who provide TB services. It is preferable to have an experienced nurse do a professional patient assessment for DOT. (This can be done by calling the local health department or TB clinic.) Depending on the complexity of the case and the patient's physical status, the nurse may administer the DOT or it may be delegated to another health care worker such as an outreach worker. DOT is given two or three times a week, usually after an initial period of daily therapy. Its effectiveness has been repeatedly demonstrated in controlled research studies and is less costly and easier to administer than daily therapy.2 Physicians who are attempting to manage patients through their own offices should be alert to the realities of the number of patients who are truly noncompliant as is outlined in this article. To ensure compliance, the physician should refer the patient to either the health department or a clinic facility where DOT is provided. If the physician prefers to manage the case through his office staff, DOT can be handled by them as well. Before assuming the responsibility of monitoring therapy, any staff
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should be made aware of the prevalence of noncompliance and be taught to assess for it. They should be reminded that no matter who the patient is, the plan should always include being prepared to use DOT. It should be kept in mind that DOT is a positive intervention, not a punitive one. To give a TB patient his medicine is as positive an act as giving a patient with diabetes his insulin when he is unable to do it for himself. Many health care providers fail to use DOT because they feel some guilt at using this intervention, i.e., taking away the patient's rights. Much of their reluctance is having to explain to the patient why he is being placed on this closely supervised treatment. It is especially important to note that if the patient is allowed to take his own treatment initially, he should be properly prepared in case future developments require switching him to DOT. The patient can be told that in the future he may be moved to twice-weekly observed treatment to accelerate the completion of therapy. In addition, the patient can be told that this method of treatment will be given by a nurse who will monitor for side effects and the effectiveness of the new treatment plan. Or, it can be said that the treatment will be observed by an outreach worker who will report directly to the physician or nurse the patient's status. In this way, the treatment can move faster and patient progress be better monitored. The fact that the patient forgets to take his medicine shoul~ be mentioned, but in such a way that the patient does not feel punished. All efforts should be made to prevent animosity between the provider and the patient. The patient simply moves to a new phase in his treatment plan, for which he has been properly prepared. How to Do DOT
Believing in DOT. Many people are hesitant to do DOT because they do not know how to get started. The first and most essential component of doing DOT is believing in it! If the physician, the nurse, and the entire office team do not support the concept of DOT as a standard of care, then DOT is doomed from the start. Each staff member must share the enthusiasm that this is the only way to ensure compliance. A positive attitude, "This is the way we do it here," will give the patient confidence and assurance that the care givers are competent and that he is in good hands. Where to Give DOT. Picking the place to give DOT must be mutually agreed on by both patient and staff member. Don't ask the patient to meet at a place where it is impossible for him to be. In other words, don't make him come to the office or clinic if it is 20 miles away and he has no ride. Either arrange the ride for him by giving bus fare or money to pay someone to bring him. A larger issue is this: If the patient can't come in, someone must go out! That is a rule that must be observed in any good TB control program. Be flexible with the time to meet for the treatment. Don't ask the patient to meet you if he can't miss work during working hours. Make another arrangement with him, perhaps on his lunch hour or after work. When very difficult work schedules seem impossible to overcome, consider using other sources of medical care
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that are staffed around the clock, e.g., hospital emergency rooms, nursing homes, and urgent care facilities. Often "deals" can be worked out with these facilities to provide DOT as a community service at no charge. Confidentiality. The patient's confidentiality must be preserved. Provide the therapy where he feels secure. He may let you come to his house only if you don't wear a uniform or if you don't come in a county marked vehicle. The patient may have requests to preserve his confidentiality that are unusual. He may ask you to meet him in an elevator, in a supermarket, or on a street corner. Although the provider might think it ridiculous, it is best to do as the patient asks if you want to get him successfully treated. This is not a power struggle to see who comes out the winner! Maintaining Personal Safety. The provider should maintain his own personal safety and still preserve the patient's integrity. If the provider feels that the site chosen by the patient is unsafe, then negotiation should occur and another place should be chosen. If the patient lives in a high crime neighborhood, he should not be made to come all the way downtown to the clinic when he could be met two blocks away from his home in a safer place. It is important to remember that living in a poor neighborhood doesn't mean that this patient is a bad person or does bad things. It may just mean that he cannot afford to live in better surroundings. Delegating Others to Give Medicines. In the past it has been fairly standard for the provider to entrust family members with the responsibility of giving medicines to the patient. This concept also had extended over to persons who had other close relationships with the patient, e.g., girlfriends, neighbors, and friends. From vast experience, it has been found that this practice is undesirable in many cases. Emotional ties can be too close, and if the patient becomes difficult, the deputized caregiver may back off and not give all or part of the medications. An example might be the mother of a young child who gets especially exasperated when the child continuously spits out the medicine. The parent finally gives up because the child is feeling better. The parent wants to appear responsible to the physician or nurse, giving the impression that he or she has done the "right thing." Often, the truth is altered regarding how much medication got into the child. The same holds true for caregivers of adult patients who have been deputized to give medicines. Many experienced nurses will relate instances in which they have delegated responsibility to family members and instead of a positive experience have placed a heavy burden on the family's shoulders. Family relationships are important and should be strengthened not weakened by this delegation of responsibility. Because of the serious personal and public health consequences of TB, these experienced nurses now take this responsibility themselves. They have learned not to impose new stressors into often fragile family relationships, just to save themselves some time. There have been many very successful situations in which delegation of medication responsibility can be given to others. Persons such as teachers, school nurses, employee health nurses, law enforcement offi-
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cers, bosses, clergy, and others without emotional ties to the patient can make the completion of therapy happen. Other Problems Encountered in DOT (Dirty Tricks)
Providing DOT does give a measure of security that the patient is receiving his medicine. He may receive it, but not swallow it. Certain patients who are intent on not taking their medications will go through all sorts of antics to keep from swallowing their pills during DOT. It is for this reason that the observer must be attuned to some of these unusual patient "tricks." Probably the most common of these is to hide the pills under the tongue or in the cheek. Another is to never release the pills from the hand into the mouth, keeping them in the palm and then throwing them away. Spitting pills into an opaque drinking cup is another trick, as is faking a cough, then spitting the pills into the palm of the hand. Some patients fake a cough, then palm the pills and slide them into a shirt pocket or down into their pants. Most bizarre is the occasional patient who swallows the medicines and then when the nurse is out of sight, intentionally vomits them up. Other patients tell the nurse that they need to go to the bathroom and take the pills, then they spit them in the toilet. Obviously, there are probably many other methods that patients use to avoid swallowing medicines. The motivation for these dirty tricks is as hard to understand as the patient who comes to pick up bottles of medicine faithfully every month, then takes none of them. It is important to remember that just watching the patient put the pills in his mouth is not enough. There must be assurance that he has swallowed them, even if he must be made to open his mouth and allow the nurse to look inside. In the case of the patient who intentionally vomits, it may even be necessary to have the patient sit in the clinic for at least one half hour after he swallows the medicines to assure that he will not vomit. Although this discussion may be distasteful to some readers, it is a reality, and is necessary to keep in mind when patients fail to convert their sputum or improve clinically after all other possible reasons have been exhausted. USING INCENTIVES AND ENABLERS TO ENHANCE COMPLIANCE
One of the most successful programs used today in many TB control programs is the use of incentives and enablers to enhance completion of therapy.! Incentives are small rewards given to patients either to encourage them to take their own medicines or to entice them to maintain regular clinic visits or field visits for DOT. Enablers are those things that "enable" the patient to receive treatment. They may be bus tokens, driver's license fees, car batteries, a fan belt, or babysitting money so that the mother can go to the clinic.
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Incentives can be small or large, and can be food, goods, or services. What might be an incentive for one patient, might not be for another. Therefore, incentives must be specially tailored to the individual patient or they might not be successful. For example, a patient who is hungry will respond readily to certain foods. The patient who is cold will appreciate a pair of warm socks or a used sweater. A child might like an occasional tea party with the nurse, being read a story, an ice cream cone, or having her finger nails painted when the nurse comes. A mother may be motivated if gifts are brought for her children, such as notebook paper and pencils for school. A handful of flowers picked from a nurse's yard is a bright spot in the day of an elderly patient. The caregiver who is especially sensitive to the individual patient's needs is the one who will be successful in using incentives and enablers to help complete the patient's therapy. As many nurses, outreach workers, and other care givers have found, it is not what you give the patient, it is what you give of yourself. Taking the time to choose something that is meaningful and special to that person is easily understood by even the most hard-hearted patient. Many patients who fight for control of their treatment situation and give the staff a hard time have never had a meaningful relationship with anyone. Consequently, the use of incentives and the gift of self becomes a life-changing experience for the patient and the staff member as well. SUMMARY
The treatment experience in TB control can be a very rewarding time for both the patient and the provider. If the patient is made to feel that the provider cares for him as a person, a meaningful relationship can develop and can have a positive influence on the patient's behavior in taking medications and perhaps even in the direction of his lifeY Noncompliance with medications unfortunately has been a "given" in the TB control program. The successful program must be patient centered and include the following components: (1) fair and equal treatment of all patients, (2) patient involvement in the plan of care, (3) the most current patient treatment and services, including the availability of DOT for patients with TB infection and disease, and (4) rewards for patients and staff for positive behavior in the completion of treatment. Given current levels of staffing and other resources, some noncompliance will continue even in the best TB programs. Caring and knowledgeable staff members who support the patient-centered approach can make TB treatment a positive experience for both the patient and themselves. References 1. American Lung Association of South Carolina: Using Incentives and Enablers in the
Tuberculosis Control Program (booklet). Columbia, S.c., American Lung Association of South Carolina, 1989
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2. American Thoracic Society: Control of tuberculosis in the United States. Am Rev Respir Dis 146:1624, 1992 3. Centers for Disease Control: Improving Patient Compliance in Tuberculosis Treatment Programs. Division of Tuberculosis Elimination, CDC 20, 1989, P 20 4. Centers for Disease Control: National Action Plan to Combat Multi-Drug Resistant Tuberculosis. Division of Tuberculosis Elimination, CDC 1, 1992, P 91 5. Centers for Disease Control: National Action Plan to Combat Multi-Drug Resistant Tuberculosis. Division of Tuberculosis Elimination, CDC 19, 1992, P 19 6. Centers for Disease Control: Program Management Reports, United States. Division of Tuberculosis Elimination, CDC 1990 7. Chaulet P: Treatment of Tuberculosis: Case Holding Until Cure. WHO/TB/83.l41. Geneva, World Health Organization, 1983 8. Fox W: Compliance of patients and physicians: Experience and lessons from tuberculosis 1. Br Med J 287:101, 1983 9. International Union Against Tuberculosis Committee on Prophylaxis: Efficacy of various durations of isoniazid preventive therapy for tuberculosis: Five years of follow-up in the IUAT trial. Bull WHO 60:555,1982 10. Ley P: Communicating with Patients: Improving Communication, Satisfaction and Compliance. New York, Chapman and Hall, 1988, p 61 11. Miller B, Snider D: Physician noncompliance with tuberculosis preventive measures. Am Rev Respir Dis 135:1, 1987 12. Sbarbaro J: The patient-physician relationship: Compliance revisited. Annals of Allergy 64:325,1990 13. West C, Frankel RM: Miscommunication in medicine. In Coup land N, et al (eds): Miscommunication and Problematic Talk. Sage Publications, 1991, pp 167-194
Address reprint requests to Carol J. Pozsik, RN, MPH South Carolina Department of Health and Environmental Control Tuberculosis Control Division Michael D. Jarrett Building Box 101106 Columbia, SC 29211