A Patient Education Program to Improve Adherence Rates with Antituberculosis Drug Regimens

Abstract

The design, logic, and results of a two-year health education study directed at im proving rates of patient adherence to antituberculosis medical regimens are presented. An incentive scheme to reward positive health behaviors plus targeted educational coun seling sessions was implemented in a randomized clinical controlled trial. The 205 subjects who participated in the study are categorized according to patients with active tuberculosis ( n = 88) or preventive patients with no evidence of active disease ( n = 117). Patients in each of these groups were randomly assigned to a special intervention (SI) group or a usual care (UC) control group and were followed monthly throughout their treatment program. While SI patients with active tuberculosis demonstrated higher levels of ap pointment-keeping behavior and mean percent of medication taken compared to UC patients, no statistically significant differences between the two groups were found. Pre ventive therapy patients assigned to the SI group, however, were significantly more likely than UC patients to remain in care during their 12-month regimen (64% vs 47%; p = .003). Furthermore, SI patients had significantly higher levels of adherence to their medical regimen compared to UC patients (68% vs 38%; p < .001). These results demonstrate the positive effects of a structured health education program on the im provement of continuity of care and adherence behavior among patients with tuberculosis. This study was funded by the Centers for Disease Control through contract #200-85-0835. The assistance of the Project Clerk, Sook Hee Treadwell, the Project Health Educators, Magda Fischer, Jennifer Adams, Nancy Murray, Fred Dominguez, and the clinic staff and patients who participated in this project are gratefully acknowledged. 1. US Department of Health and Human Services, Public Health Service: The 1990 Health Objectives for the Nation: A Midcourse Review. Office of Disease Prevention and Health Promotion, 1986. 2. Centers for Disease Control. Tuberculosis—Provisional data—United States, 1986. MMWR 36: 254-255, 1987. 3. Centers for Disease Control. Tuberculosis. Final Data—United States, 1986. MMWR 36: 817-820, 1988. 4. County of Los Angeles, Department of Health Services, Public Health Programs: Communicable Disease Morbidity Report, County of Los Angeles, 1986. 5. Kopanoff DE, Snider DE, Johnson M: Recurrent tuberculosis: Why do patients develop disease again? A United States Public Health Service Cooperative Survey. Am J Public Health 78: 30-33, 1988. 6. American Thoracic Society: Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis 134: 355-363, 1986. 7. Haynes RB: Introduction, in RB Haynes, DW Taylor, DL Sackett. (eds): Compliance in Health Care. Baltimore, Johns Hopkins University Press, 1979, pp 1-7. 8. Sackett DL, Haynes RB, editor: Compliance with Therapeutic Regimens. Baltimore, Johns Hopkins University Press, 1976. 9. Haynes RB, Taylor DW, Sackett DL, ed: Compliance in Health Care. Baltimore, Johns Hopkins University Press, 1979. 10. Meichenbaum D, Turk DC: Facilitating Treatment Adherence: A Practitioner's Guidebook. Plenum Press, New York, 1987. 11. Addington WW: Patient compliance: The most serious remaining problem in the control of tuberculosis in the United States. Chest 76 (supp):741-743, 1979. 12. Report of the Committee: A Strategic Plan for the Elimination of Tuberculosis in the United States. US Department of Health and Human Services, Centers for Disease Control, May 1988. 13. Comstock GW: New data on preventive treatment with isoniazid. Annals of Internal Medicine 98:663-665, 1983. 14. Cross FS, Long MW, Banner AS, Snider DE Jr: Rifampin-isoniazid therapy of alcoholics and nonalcoholic tuberculosis patients in a U.S. Public Health Service cooperative trial. Am Rev Respir Dis 122:349-353, 1980. 15. Snider DE Jr,. Improving Patient Compliance in Tuberculosis Treatment Programs. Atlanta, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, 1985. 16. Green LW, Kreuter MW, Deeds SG, Partridge KB: Health Education Planning: A Diagnostic Approach. Palo Alto, CA, Mayfield Publishing Company, 1980. 17. Hochbaum GM, Public Participation in Medical Science Programs: A Sociopsy chological Study. Washington, DC, United States Government Printing Office, PHS Publication No. 572, 1958. 18. Rosenstock IM: What research in motivation suggests for public health. Am J Public Health 50:295-302, 1960. 19. Becker MH: The health belief model and personal health behavior. Health Educ Monographs 2:324-473, 1974. 20. Becker MH: Sociobehavioral determinants of compliance, in DL Sackett, RB Haynes (eds): Compliance with Therapeutic Regimens. Baltimore, Johns Hopkins University Press, 1976, pp 40-50. 21. Janz NK, Becker MH: The health belief model: A decade later. Health Education Quarterly 11:1-47, 1984. 22. Sackett DL: Priorities and methods for future research, in DL Sackett, RB Haynes (eds): Compliance with Therapeutic Regimens. Baltimore, Johns Hopkins University Press, 1976, pp 169-189. 23. Dunbar JM, Stunkard AJ: Adherence to diet and drug regimen, in Levy RI, Rifkind B, Dennis B, Ernst N (eds): Nutrition, Lipids, and Coronary Heart Disease. New York, Raven Press, 1979, pp 391-423. 24. Svarstad BL: Physician-patient communication and patient conformity with medical advice, in Mechanie D (ed): The Growth of Bureaucratic Medicine. New York, John Wiley and Sons, 1976, pp 220-238. 25. Colcher IS, Bass JW: Penicillin treatment of streptococcal pharyngitis: A comparison of schedules and the role of specific counselling. JAMA 222:657-659, 1972. 26. Sharpe TR, Mikeal RL: Patient compliance with antibiotic regimens. Am J Hospital Pharm 31:479-484, 1974. 27. Swain MA, Steckel SB: Influencing adherence among hypertensives. Res Nursing and Health 4:213-222, 1981. 28. Levine DM, Green LW, Russell RP, Morisky DE, Chwalow J, Benson P: Compliance in hypertension management: What the physician can do. Practical Cardiology 5:151- 160, 1979. 29. DiMatteo MR, DiNicola DD, Achieving Patient Compliance: The Psychology of the Medical Practitioner's Role. New York, Pergamon Press, 1982. 30. Eraker SA, Kirscht JP, Becker MH: Understanding and improving patient compli ance. Ann Intern Med 100:258-268, 1984. 31. Waitzkin H, Stoeckle JD: Information control and the micro-politics of health care. Soc Sci Med 10:263-276, 1976. 32. Minkler M: The use of incentives in family planning programmes: A study of com peting theories regarding their influence on attitude change. Int J Health Educ 19 (supplement):1-11, 1976. 33. Sbarbaro JA: Compliance: Inducements and enforcements. Chest 76 (supp): 750- 756, 1979. 34. Snider DE Jr, Anders HM, Pozsik CJ: Incentives to take up health services. Lancet 2:812, 1986. 35. Hull CH, Nie NH. Survival: Life Table Analysis. SPSS Update 7-9, McGraw-Hill, New York, 1981.