Vietnamese face many barriers to treatment
Education can improve compliance, study finds
With the number of tuberculosis cases among Vietnamese refugees doubling in Georgia in the past three years, health officials recently began assessing why so many of their contacts have not adhered to therapy. What they found was an abundance of unhealthy attitudes and misconceptions that require intensive education to overcome.1
"Because so many were on preventive therapy and not completing, we had an incentive to look at their attitudes and see if we could adapt our practices more to encourage them to finish treatment," says Beverly DeVoe, MHS, an author of the unpublished study and director of the Georgia TB program.
Misinformation and misunderstanding
By reviewing medical charts of 118 Vietnamese refugees assigned to isoniazid (INH) preventive therapy, researchers determined that 48 or 40% were classified as "adherent" (picked up monthly medication within six weeks after receipt of the last supply), 53 or 44% as "low adherent" (picked up monthly medication six to 12 months after receipt), eight or 6% as "non-adherent" (picked up monthly medication more than 12 weeks after receipt, and 7% as "lost to follow-up."
After in-depth interviews with health care providers, two focus groups with 16 Vietnamese patients, and a self-administered survey, researchers made the following conclusions:
• 80% were unaware of how they became infected.
• 66% of patients’ families were worried about catching TB.
• 64% believed they were infectious.
• 65% feared losing their jobs.
• 50% were confused about the need for INH.
• 44% believed they could infect others by sharing eating utensils.
• 37% doubted the effectiveness of INH.
Additionally, researchers found several significant associations with patients with low adherence. They include: did not understand the need for INH; had difficulty getting to clinics; believed that medicine was too "strong;" reported inconvenient clinic hours; received home delivery of INH; and believed adherence would improve with longer clinic hours, and INH could be picked up on Saturdays.
Higher adherence was associated with patients realizing TB might develop if they didn’t take INH, establishing a pill-taking routine and believing communication with the provider was satisfactory.
The study found no significant associations between adherence behavior and age, gender, education, length of time in the country, and adjustment to living in the city.
Individually tailored response
Logistical problems, the shame and stigma associated with TB, and inconvenient services were among other issues raised during the study, the researchers note. Patients also mentioned that they would benefit from more TB education and encouragement from their providers throughout the long treatment period.
The researchers made the following recommendations for providers:
• Individually tailor patient education based on one’s level of understanding, and carefully explain expected results if treatment is completed.
• Help patients establish a routine for taking medicine, and encourage support from family members.
• Clearly explain the importance of completing medication even after symptoms have disappeared.
• Reassure the safety of the drug rather than emphasize its side effects.
• Confirm with patients that they understand the messages communicated.
• Send correspondence in appropriate language.
For health centers, the researchers recommend establishing more flexible clinic hours, decreasing waiting time, standardizing training of outreach workers so that assumptions are not made, and establishing a policy that patients receive periodic, direct contact so home delivery of medication is avoided.
Reference
1. Shrestha-Kuwahare R, Miner K, McBride A, et al. The knowledge, attitudes, and practices of Vietnamese refugees on preventive TB therapy summary report.
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