Three keys to boosting contacts’ completion
Capable staff, good morale, and Ninja Turtles
Good contact investigations without good completion rates for preventive therapy are like, well, you fill in the simile. While you’re thinking about it, consider that TB control programs are putting tons of creative energy into finding contacts. Evidence for that was abundant at this year’s TB Controllers’ Workshop in Atlanta, where participants testified about doing contact investigations in schools, crack dens, poultry plants, welfare hotels, transsexual networks, and nearly every other kind of situation imaginable.
Even so, completion rates for treatment of latent TB infection (LTBI) are just so-so, with the national average standing at about 70%, according to Patty Simone, MD, former chief of the field services branch at the Centers for Disease Control and Prevention’s Division of TB Elimination.
That falls short of the CDC’s 85% completion goal for LTBI contacts, she adds. Completion rates for other groups getting treatment for LTBI are nothing to brag about, either — around 60% for many programs, Simone says, compared with the CDC goal of 75%.
In Long Beach, CA, the TB control program does better than most. Here, completion rates for contacts in 1997, the last year CDC figures were available, stood at a very respectable 87%. Of the 807 other patients who began preventive therapy the same year, 79% managed to complete it.
It would be unfair to say that Long Beach, a gritty urban outpost of Los Angeles with a population of about 450,000, is doing well because it’s been dealt an easy hand. Clearly, that’s not the case. Demographics in Long Beach include the usual urban ills, plus a heavy sprinkling of foreign-born groups, principally Cambodians.
The program’s keys to success, though they may sound simple, aren’t necessarily easy to achieve. According to Barbara Taylor, RN, public health nurse for the Long Beach TB control program, two of the most important ingredients include keeping an enthusiastic and capable staff on board and using an imaginative array of incentives. Because so many contacts are kids, incentives have come to mean just about anything: dinosaur hand stamps, free toothbrushes, and a Ninja Turtle coloring contest that left the walls of the clinic plastered with images of the four cartoon heroes.
Encouraging the staff to keep things interesting by dreaming up new ways to keep kids happy and taking their meds has improved staff morale, Taylor adds. "We have a lot of fun here," she says. "Most people have been here for a long time, and that’s important, too, because it means continuity for patients. Patients can match a face to a name, and they can see the same people each time they come into the clinic."
Planting the seed of compliance
There’s also the fact that the staff works hard at staying in touch with contacts and letting them know just what’s expected of them.
"As soon as the contacts get their positive skin test, we plant the seed by telling them they’ll probably be contacted by someone here about starting preventive therapy," assuming that the chest X-ray is OK, she explains. A letter goes out a couple of weeks later, inviting the patients to come in, then a community worker calls (speaking Cambodian or whatever language is appropriate) to remind them of the appointment.
The first time in the clinic, the public health nurse meets with the contact in an educational session, explaining how preventive therapy works and what adverse events to watch for. Because clerical staff members speak several languages, there’s usually someone on hand who can translate if needed, Taylor adds.
Making it easier
Next, in a departure from procedure at many clinics, contacts are provided with a list of days and hours when they can return for refills, instead of being given a specific appointment to come back. "That way, if work or some other problem keeps people from coming back on a specific day, they don’t have to call us and reschedule," Taylor explains. Likewise, it’s OK if patients come in for refills a few days before their month’s supply of isoniazid actually runs out. "We try to stay flexible," she adds.
For problem patients, the TB clinic uses a variety of strategies. "Sometimes we get the sense that a mom is really struggling to get meds into her child, maybe because the child is the age where he wants control," says Taylor. "In those cases, we try to give the child some control: We tell him that if he takes his medicine, there’ll be a reward at the end of the month for good behavior."
Rewards run the gamut from coloring books to stuffed animals to toothbrushes. The incentives come from a variety of sources. "People donate things to our clinic from time to time," Taylor notes.
One woman brings in old copies of the magazine Highlights for Children. A former staff member who had business ties to a toothpaste manufacturer managed to get the supply of toothbrushes and toothpaste donated. The toothbrushes, incidentally, have turned out to be a huge hit. "We found that many of our families are so poor there’s no toothbrush, or maybe the whole family shares a single toothbrush," says Taylor. "So a free toothbrush is a really great incentive for some kids."
Other rewards cost virtually nothing. "We give out hand stamps to anyone who wants one," says Taylor with a laugh. The kids love the stamps, she adds. It’s not unusual to spot children leaving the clinic with their arms and hands gaily decorated with images of dinosaurs, sheep, kittens, and maybe a Mickey Mouse or two, and toting a couple of stickers for good measure. Adds Taylor: "We also try to be generous with praise," another free commodity in good supply around the clinic.
Teenagers, older kids, and even the occasional adult who’s having trouble with compliance sometimes get treats, as well. "We don’t do this for everyone, obviously, but on occasion we’ll give out free movie passes," Taylor says. "That’s a very effective motivator for teens and college students."
In what seems to be a growing trend in the state, the clinic added a social worker to its staff a few years ago. At times, simply knowing that Cynthia Brayboy, MSW, is on duty and available seems to be a good incentive for compliance, says Taylor. "Clients absolutely love Cynthia," she says. "They bring her food and other things, and they come in early if they know she’ll be here."
Usually Brayboy spends her time helping out with cases, not contacts, Taylor says. But if it looks like troubles with rent money or an empty pantry are interfering with adherence to LTBI, she’ll pitch in and do what’s needed for a contact, as well.
Finally, having the capability to translate information is important, Taylor says. Long Beach has a potpourri of foreign-born groups, with "more Cambodians than anyplace outside Phnom Penh, I’m told," she says. Knowing that it’s important for patients and contacts to get information in a language they can understand, Taylor has outfitted the office computer with a special program that translates letters into Cambodian.
The staff members who speak a foreign language are invaluable, Taylor says. "If you have staff who are knowledgeable about TB and can translate for you and explain your point of view, you can be sure information is flowing between you and the patient is accurate," she says. Without both those components, "it’s easy to lose control of the translation process."