Table 11.1 Summary of Effective Communication Skills • Ask questions and listen • Encourage the patient to ask questions Understand the patient’s medical history Understand the patient’
Trang 2The 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
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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
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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
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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
• 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
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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
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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?
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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
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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
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11.2.4 Use the appropriate language level
Written information should match the patient’s reading level Persons with a limited education may only be able to understand very basic materials, however highly educated patients may prefer more detailed information Visual cues are very useful, such as a calendar in which the patient has to mark off each day he ore she takes the medicine
11.2.5 Limit the amount of information given at any one time
A patient may not be able to remember the important components of the treatment plan if too much information is given at one time or if he or she is not prepared to receive detailed information The patient could possibly be overwhelmed and may
be experiencing fear over the diagnosis of TB disease It is possible that the patient could still be very sick and may be unable or unwilling to participate fully in an education session The health care worker should be aware of the patient’s ability
to pay attention and absorb health education messages and should schedule
follow-up education sessions with the patients as needed
11.2.6 Discuss the most important topics first and last
People remember information presented at the beginning and at the end of a session more easily than they do the information presented in the middle Health care workers should tell the patient what is expected of him or her before they explain test results, the expected outcome of a procedure, or treatment The health care worker should organize the topics to be discussed in the order of their importance
he most essential topics (such as the importance of completing the treatment or the importance of identifying side effects) should be discussed first and last For example, early in the first session the health care worker might say, “To get well, you must take four of these capsules every day.” This information should be reviewed again before leaving the patient
11.2.7 Repeat important information
Some people need to hear new information several times before they will remember
it Health care workers should repeat key messages throughout the session, have the patient repeat the information, and then in later sessions review material that was previously presented For example, topics can be introduced by saying, “As we discussed earlier (or last time) ”
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11.2.8 Use concrete examples
To make information easy to remember, concrete examples should be used For example, the health care worker can actually show the patient the pills while explaining what the course of treatment will be Likewise, the health care worker can demonstrate the steps of sputum collection for the patient instead of just explaining the steps
11.2.9 Encourage the patient to ask questions
Patients should feel comfortable asking questions about information they do not understand After giving instructions or an explanation, health care workers can pause and ask, “Do you have any questions? I know this is a lot of information at once.”
Patients may be timid and concerned about appearing uneducated Or they may be nervous and simply want to leave the health center in a hurry It may take courage for them to ask questions Patients should be praised for asking questions For example, health care workers can say:
• “I’m glad you asked that question ”
• “Good question ”
Health care workers should answer all questions thoughtfully and carefully
11.2.10 Ask checking questions
Checking questions are questions intended to find out what a person has learned, in order to provide more information or clarify instructions as needed Checking questions should be used at the end of an explanation to ensure that the patient understands the health education messages given Checking questions can also be used at the end of a visit to ensure that the patient understands what to do next
For example, to make sure that a patient knows what to do when instructed to bring back an early morning sputum for a follow-up sputum exam, a health care worker might ask the following checking questions:
• “When will you cough up the sputum?”
• “Where will you cough up the sputum?”
• “What container will you use?”
• “When will you bring the sample back to me?”
• “Why is this so important?”
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Asking checking questions requires patience A patient needs to be given time to think and answer If the patient is silent, the impulse of the health care worker may
be to answer the question or quickly ask a different question
The patient may know the answer but be slow to respond for several reasons The patient may be giving a wrong answer The patient may be timid The health care worker should wait for an answer and give encouragement
Sometimes the patient may give an incomplete or unclear answer to a checking question If this occurs, the follow-up questions can be used to see if the patient really understands
If the patient answers incorrectly or cannot remember, the patient should not be made to feel uncomfortable Misconceptions should be clarified and checking questions can be asked again
11.3 Educating the TB Patient (First Meeting)
The first meeting with a TB patient usually takes place when a patient receives the results of diagnostic tests and is 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 medical history, current knowledge about the disease, and personal circumstances in order to tailor health education messages to the patient’s needs
The first meeting with the patient is very important and should be used to
• establish the foundation for a good relationship with the patient based on mutual trust and understanding;
• confirm what the patient’s address will be after discharge and gather information on contacts who may have been 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;
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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
• arrange a 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 requires a certain amount of planning For the initial interview to be successful, a public health worker should:
• clearly understand aims of the meeting;
• plan the meeting properly so that sufficient time could be devoted to each topic discussed;
• listen to the patient’s concerns referring to TB and its treatment;
• share all the necessary information with the patient
During the initial contact with a patient it is important to provide essential information regarding TB Care should be taken not to overwhelm the patient
It is important to establish a level of comfort with the patient so that he or she feels comfortable enough to ask questions Continually asking the patient questions during the initial discussion, to ensure the information is being understood correctly, can help in this process More detailed information can be provided by the health care worker during subsequent visits with the patient
The topics to be discussed during the initial contact include, but are not limited to, the following:
What Is Tuberculosis?
The health care worker should explain in simple terms what TB is and what type of
TB the patient has (for example, TB of the lungs) TB is an illness caused by a germ TB germs can settle anywhere in the body One of the most common places for TB to develop is in the 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
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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 differ between 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 phase
Necessity of Directly Observed Treatment
Health care workers should explain the importance of directly observed treatment
as a standard of care for all patients The health worker must watch the patient swallow all the drugs This will ensure that the patient takes the correct drugs regularly for the required time If injections are needed, they will be given properly
For example, if the patient does not take all of the drugs, he or she will continue to spread TB to others, and his or her TB will not be cured It is dangerous to stop or interrupt treatment, because then the disease may become incurable
If the patient plans to move, they should inform the health worker so that appropriate measures can be taken to ensure continuation of treatment in the new location
How Tuberculosis Spreads
The health care worker should explain that anyone can get TB TB spreads when
an infected person coughs or sneezes, spraying TB germs into the air Others may breathe in these germs and become infected
Patients must also understand the importance of making sure all family members exposed to the disease (contacts) who have symptoms of TB go to the closest health care facility for screening of TB In particular, children under age 5 should be
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Symptoms of TB
Patients should be able to recognize symptoms of TB in family members, friends, and other contacts The main symptom is a cough which lasts for 3 or more weeks Usually, a person also has one or more of the symptoms listed below:
• Coughing up blood-stained sputum
How to Prevent Tuberculosis from Spreading
Health care workers should explain how to prevent TB from spreading Taking regular treatment for TB and being cured helps to prevent the spread to others in the family and community The patient should also
• cover the mouth and nose when coughing or sneezing, and
• open windows and doors to allow fresh air to flow through the home
There is no need to eat a special diet or to sterilize dishes or household items
Importance of Completing Treatment
Patients should understand that shortly after they begin treatment, they will most likely begin to feel better, but it is important to continue taking the medications The patient must understand that just because he or she feels better, it does not mean that the disease has been cured Health care workers should further explain that if the patient does not take all of the medicine, multidrug- resistant TB can develop, which is much more difficult to treat
What to Expect; What to Do Next
During the intensive phase of treatment, the patient may be hospitalized The health care worker should discuss what this means for the patient, and what the patient can expect as part of treatment
The patient should also be reminded to identify family members who may need to
be tested for TB, such as children under 5 years old and family members with a cough or other symptoms of TB