The work upon which this publication is based was performed in part under Grant Agreement 118-G-00-99-00112 (WHO) and PASA 118-P-00-98-00165 (DHHS/CDC) funded by the U.S. Agency for International Development. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the U.S. Agency for International Development. Additional funding was provided by the World Health Organization and the Centers for Disease Control and Prevention. 2003 11 Patient Education Module 11 – Table of Contents 11.1 Introduction to Patient Education 1 11.2 Effective Communication Techniques 2 1121.1 Ask questions and listen. 3 11.2.2 Make interactions with the patient a positive experience. 6 11.2.3 Speak clearly and simply 6 11.2.4 Use the appropriate language level 7 11.2.5 Limit the amount of information given at any one time. 7 11.2.6 Discuss the most important topics first and last. 7 11.2.7 Repeat important information 7 11.2.8 Use concrete examples. 8 11.2.9 Encourage the patient to ask question. 8 11.2.10 Ask checking questions 8 11.3 Educating the TB Patient (First Meeting) 9 Exercise 1: Role Play – Initial Health Education about TB 13 11.4 Continue Patient Education Throughout Treatment 15 Exercise 2: Role Play – Continuing Health Education about TB 18 11.5 Facilitating Adherence to TB Treatment 20 1154.1 Reasons for Non-adherence 20 11.5.2 Explaining the Importance of Adherence 22 Exercise 3: Written Exercise and Discussion – Problem Solving 25 11.6 Summary 26 This page is left intentionally blank for double sided printing. 11 Patient Education 1 11.1 Introduction to Patient Education Education of the patient is a critical part of treating tuberculosis. The health worker must communicate with a patient clearly and supportively from the time of diagnosis, throughout the long treatment process, and until the patient is cured. The patient’s family will also need information, advice, and support. At the time of diagnosis, patients need basic information about tuberculosis and how it is spread. They may be afraid and need reassurance that TB can be cured. They need an explanation of the treatment process and the necessity of directly observed treatment. In some cases, health workers may have to persuade patients who feel that daily treatment will be too time-consuming and inconvenient. Daily or thrice-weekly interactions with patients for directly observed treatment offer many opportunities for health education. At every visit, health workers need to show a welcoming and supportive attitude so that patients will be willing to return for the next treatment. Patient education is very important in the intensive phase of treatment. However, it is vital to a successful treatment outcome that patient education be an ongoing process throughout the duration of treatment. Learning Objectives: This module describes the necessary steps health care workers must take to educate TB patients on their disease and course of treatment from diagnosis through completion of treatment. All training courses for health care workers should include instruction in patient education skills. The information, examples, and exercises in this module will assist the raion TB Coordinator in prioritizing and supervising the implementation of patient education at the raion level. At the end of the module, the raion TB Coordinator should be able to: • Identify effective communication skills useful for all health education • Effectively communicate important TB information to the patient throughout treatment • Explain the importance of adhering to the prescribed treatment • Identify issues that may affect patient adherence to treatment 11 Patient Education 2 11.2 Effective Communication Techniques Effective communication is more than just talking or giving advice. It involves asking questions, listening carefully, trying to understand a patient’s worries or needs, demonstrating a caring attitude, and helping to solve problems. Good communication begins when the health worker sees the patient promptly, addresses the patient by name, and offers a comfortable place for the patient to sit. It continues as the health worker makes eye contact, speaks in a respectful tone of voice, and encourages the patient to ask questions. Effective communication is not only needed to teach patients important messages about TB and its treatment. Effective communication is critical to encourage patients to return for the next treatment visit. This section of the module will describe effective communication skills that can be used when providing health education messages to patients and their families. Table 11.1 summarizes the communication skills described in this module. The right side of the table shows the purpose of each skill in the context of health education about TB. Table 11.1 Summary of Effective Communication Skills Communication Skill Purpose • Ask questions and listen • Encourage the patient to ask questions Understand the patient’s medical history Understand the patient’s current knowledge about TB Identify and help solve any problems the patient may have with treatment • Make the interaction with the patient a positive experience Motivate the patient to continue treatment • Speak clearly and simply • Use the appropriate language level • Limit the amount of information • Discuss the most important topics first and last • Repeat important information • Use concrete examples • Encourage the patient to ask questions • Ask checking questions Ensure that the patient understands and remembers important messages about TB and treatment Ensure that the patient knows exactly what to do next 11 Patient Education 3 The communication skills highlighted in Table 11. 1 above are discussed in further detail below. 11.2.1 Ask questions and listen. Asking questions and listening carefully to the responses are important skills to use to: • understand the patient’s medical history, • understand the patient’s current knowledge of TB, and • identify and help solve problems with treatment. Communication with the patient should always be two-way. Health care workers should ask questions and listen carefully to answers given by the patient. Open-Ended Questions An open-ended question is one that cannot be answered with a simple “yes” or “no.” Open-ended questions are designed to learn about the patient’s knowledge, feelings, and beliefs by beginning with words that elicit an explanation, such as “who,” “what,” “when,” “why,” and “how.” In addition, phrases that begin with “Tell me about” or “Explain to me” may be helpful in eliciting information from the patient. Such questions are used when a health care worker needs to explore complex issues that do not have a finite or predetermined set of responses. However, sometimes it may be necessary to ask a direct “yes” or “no” question. Throughout treatment, the health care worker should ask the patient about his or her concerns regarding TB and adherence to the prescribed regimen. Below are examples of questions that health care workers can use during the initial health assessment and subsequent interactions with the patient throughout the course of treatment. The questions below are merely a starting point. Whenever possible, the health care worker should adapt such questions according to the patient’s age, family situation, education level, and cultural background. The more the health care worker is aware of the patient’s ideas and concerns about TB and the needed treatment, the better prepared the health care worker will be to anticipate and resolve problems that can arise. 11 Patient Education 4 Examples of Questions to Ask to Understand the Patient’s Medical History The questions below are examples of questions that health care workers can use to learn more about the patient’s symptoms, family contacts, and previous treatments. Some of these questions may be used to find out whether a patient needs to have a sputum test. Others may be used after a TB patient has been diagnosed. • How are you feeling? • When did you first become sick? • What are the symptoms? Have you had fever? • What caused you to go to the doctor? • What medicines are you taking now? • How long have you had a cough? • How many people live with you? What ages? • Does anyone else in your household have a cough? Who? For how long? • Which of your symptoms, if any, have you had before? • What kinds of medicines did you take then? How long did you take them? • Have you ever been treated for tuberculosis? • (In areas where HIV is common) Do you know your HIV status? • (For women of childbearing age) Are you pregnant? Examples of Questions to Ask to Understand the Patient’s Current Knowledge About TB Before giving health education messages, health care workers can ask questions to determine what the patient already knows about TB, or what misconceptions the patient may have about TB disease and its treatment. • What do you think your illness might be? • What do you understand tuberculosis to be? • What do you think TB does to your body? • How serious do you think your illness is? • What do you think causes tuberculosis? How is it spread? • What do you fear about your illness? • How did you feel when you were told you had TB? • What do you think your family members and friends will think about your TB? • What have you heard about the sputum microscopy test for TB? • What do you know about the medicine used to treat TB? • What have you heard about curing TB? 11 Patient Education 5 By asking questions the health care worker can tailor the health education messages to the needs of the particular patient. Health care workers can build on accurate information that the patient already knows and believes, and concentrate on giving new information and correcting misconceptions. Examples of Questions to Ask to Identify and Help Solve Problems The following questions might be asked when arranging for directly observed treatment or identifying obstacles to treatment adherence: • How long do you think you need to take medicine to treat your illness? • How do you feel about taking your medicine? • How far away is your home? • How did you travel to the health center? • How long did it take you to come here today? • Where do you work? • What are your working hours? • What is your marital status? • Do you have any children? How many? How are they cared for? • Do your children go to school? Where? • Where do people usually go for health care in your village? • Are you likely to move? If so, when and where? How long will you stay? • Who is someone who always knows where to find you? Where does this person live? The following questions might be asked at daily visits to check for side effects of treatment: • How are you feeling? • Have you had any problems? Heath care workers should be trained to ask patients about side effects from the TB medicine they are taking. Health care workers should be able to distinguish between common and serious side effects, and should be able to assist patients in the management of side effects. For more information on side effects from TB medication, please see Module 3, Administering TB Treatment, Annex B. 11 Patient Education 6 11.2.2 Make interactions with the patient a positive experience. It’s not only what is said and done, but how it is said and done, that will help the patient understand health education messages and adhere to treatment. The health care worker should make interactions with patients a positive experience by being encouraging and supportive throughout the treatment process. By demonstrating a caring and respectful attitude toward the patient, the health care worker can make it more likely that the patient will return each day for treatment. A caring attitude can be demonstrated through actions, words, body language, tone of voice, and eye contact. When health care workers interact with patients, they should address the patient by name, and respect the patient’s time by attending to the patient as soon as possible. When a patient’s ideas are different from the health care worker’s, the health care worker should accept that the patient has different views, and then make sure the patient knows the health care worker’s point of view about TB. Health care workers can make it clear that even if they do not share the patient’s views, they respect them. Knowing and respecting the patient’s views will improve the working relationship and make the patient more likely to be adherent. The health care worker should keep in mind that judgments about the patient’s lifestyle, beliefs, and behaviors might be conveyed through nonverbal body language. This form of communication can also negatively affect the health care worker’s relationship with the patient. The health care worker should be objective and nonjudgmental. TB treatment is a long process. In order to motivate the patient to continue treatment, health care workers can provide praise and encouragement at every visit. They can say, for example, “I’m glad to see you. You are doing the right thing by coming for treatment every day.” 11.2.3 Speak clearly and simply. Simple, nonmedical terms should be used in explanations to the patient. Health care workers should be specific about the behaviors expected from the patient. For example, it is much more helpful to say, “This pill will help you get better,” than to say, “This drug, isoniazid, is a bactericidal agent that is highly active against Mycobacterium tuberculosis.” Using words that are familiar to patients can make the information relevant to them, therefore increasing the likelihood that the patient will comply with the prescribed treatment regimen. [...]... started on treatment for TB, or when the patient is registered in the TB Patient Register (TB 03) The initial meeting with the patient provides the opportunity to communicate essential information about TB and its treatment The first meeting with a patient also provides a good opportunity for the health care worker to gather information from the patient The health care worker should ask about the patient s... infected with TB; • begin an assessment of the patient s knowledge, attitudes, and beliefs about TB; • discuss the importance of adherence to the TB treatment regimen; 9 11 Patient Education In addition, the first meeting with the patients provides the opportunity to: • get to know the patient; • educate the patient about TB; • look for factors that may affect the patient s adherence to treatment; and... new patients and patients who have been treated for TB before (re-treatment patients) Re-treatment patients need a stronger treatment regimen to be cured Health care workers should provide general information about the patient s treatment, such as: • Length of treatment • Where the patient will receive treatment during the intensive phase • Where the patient will receive treatment during the continuation... treatment • What happens if the patient plans to moves while on treatment After the role-play, comment on what was done well and what could be improved 19 11 Patient Education 11.5 Facilitating Adherence to TB Treatment One of the main goals of the raion TB Coordinator is to ensure that health care workers within the raion are facilitating adherence to TB treatment among TB patients This section of the module... follow-up visit with the patient The health care worker’s relationship with the patient will develop over time as treatment progresses and the patient s health improves However, the initial meeting is often the patient s first encounter with the TB Specialized Services and therefore is very important The initial meeting marks the beginning of the health care worker’s relationship with a patient and therefore... lungs When TB damages the lungs, a person coughs up sputum and may not be able to breathe easily Without proper treatment, a person can die from TB 10 11 Patient Education TB Can Be Cured The patient should be reassured that with the right drug treatment, TB is a curable disease The patient must take all of the prescribed drugs for the entire treatment time in order to be cured Treatment of TB Treatments... continuation phase The patient does not want to have a sputum exam after 5 months’ treatment The patient says her husband, who has a cough, does not have time to be tested for TB The patient is afraid to tell her family that she has TB The patient feels the medicine is making him sick and wants to stop taking it The patient doesn’t have transportation to get to the health clinic 25 11 Patient Education 11.6... Adapt treatment to lifestyle, especially during the continuation phase Make social service referrals Treat the patient with dignity and respect Be consistent in what is done and told to the patient 23 11 Patient Education Issues Patient education • • • • • • • • • • • • Treatment Clinic operations • • • • • • • • • • • • • • 24 Improvement Methods Give vital information first in the initial patient meeting... instructions; the patient is likely to be anxious after hearing the diagnosis Follow oral instructions with written instructions Be clear from the start about the length of the regimen Don’t overload the patient with too much information at one time Speak simply and clearly Use educational materials that are culturally and linguistically appropriate for the patient Be alert for signs or indications that the patient. .. Treatment of TB • Necessity of directly observed treatment • How TB spreads • Symptoms of TB • How to prevent TB from spreading • Importance of completing treatment • What to expect; what to do next After the role-play, comment on what was done well and what could be improved 14 11 Patient Education 11.4 Continue Patient Education Throughout Treatment As discussed earlier, patient education is a continuous . 11 Patient Education 1 11.1 Introduction to Patient Education Education of the patient is a critical part of treating tuberculosis. The health worker must communicate with a patient. to know the patient; • educate the patient about TB; • look for factors that may affect the patient s adherence to treatment; and • arrange a follow-up visit with the patient. The health. entire treatment time in order to be cured. Treatment of TB Treatments differ between new patients and patients who have been treated for TB before (re-treatment patients). Re-treatment patients