TUBERCULOSIS PREVENTION PROJ ECT Mary D. Barnwell, PhD, CHES, Rajinder Chitkara, MD, and Frank Lamberta, MD Jamaica, New York
This article reports the findings from a clinical study that examined the impact of health education and counseling on the decision of a patient infected with tuberculosis (TB) to complete a regimen of isoniazid (INH) chemoprophylaxis for 6 months to prevent TB. Forty patients were divided into two groups; both groups were administered a questionnaire to collect demographic data and medical history. One group received additional health education and counseling independent of clinic staff, and the other group only received health education and counseling from clinic staff. The proportion of patients in the first group who completed INH for 6 months (63.6%) was significantly greater than the proportion of patients in the second group (11.1%). These findings suggest that health education and counseling did make an impact on the decision of a patient infected with TB to conform with a rational choice when provided with information and a supportive relationship about the consequences of TB infection. (J NatI Med Assoc. 1992;84:1014-1018.) Key words * tuberculosis * isoniazid * health education The increase of tuberculosis in inner cities continues to
rise.'-7 In New York City, the rates have been rising since 1979, and in 1990, the rate was almost 50 per 100 000 From the Department of Health and Physical Education and
Gerontological Studies and Services, York College/City University of New York, Jamaica, New York. This research was supported in part by grant E 901498 from the American Lung Association of Queens. Requests for reprints should be addressed to Dr Mary D. Barnwell, Dept of Health and Physical Education and Gerontological Studies and Services, York College/City University of New York, Jamaica, NY 11451. 1014
population, and could be as much as five times the national rate. There were 3520 new cases of tuberculosis (TB) in 1990, representing a 38% increase over 1989 when reported new cases were 2545. Between 1989 and 1990, the incidence rate of TB for males of all ages increased 37% from about 56 to 70 cases per 100 000. Approximately 60% of all male cases were confined in 25 to 44 year olds. Black males had a higher TB incidence rate in 1990-188 per 100 000-than males in other racial/ethnic groups, and the next highest rate-98 for Latino males-was about half as large. Tuberculosis cases reported in New York City children younger than 15 years of age rose by 97% in 1990, up to 146 cases from 74 cases in 1989. Ninety-two percent of the entire increase was attributable to cases reported among children 4 years of age and younger. The magnitude of the increase of TB in 1990 was unprecedented, being the largest by far in New York City since the early 1980s after decades of steady decline.2 Despite the substantial body of evidence in the use of isoniazid (INH) to prevent TB,8-15 the disease is still a major public health problem. The extent to which individuals infected with TB complete INH chemoprophylaxis is disconcerting. The results of 76 reporting areas revealed that less than 68% of individuals infected with TB complete the regimen of treatment.6 Some explanations offered included: risk factors associated with INH such as hepatotoxic effects, difficulty in motivating individuals who are not ill to take INH daily,'6 lack of knowledge about TB infection, poor relationship with the health-care provider, long clinic waiting time, and lack of support from family and friends.'7 It is estimated that 90% of new TB cases in the United States will arise from a pool of approximately 10 million individuals infected with TB.6 This study was conducted to increase compliance of a 6-month regimen of INH chemoprophylaxis by providing additional health education and counseling JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
TUBERCULOSIS PREVENTION PROJECT
by a health educator independent of clinic staff. The intervention was provided on a one-to-one basis during a single clinic visit to patients at the chest clinic in a Queens municipal hospital in New York City.
both groups was compiled to determine the impact of health education and counseling, and histogram frequencies were used to assess prior TB knowledge and attitudes about completing INH chemoprophylaxis.
METHODS Study Population
RESULTS
The study population was comprised of 40 patients infected with TB who were registered in the chest clinic at a Queens municipal hospital in New York City between January 1989 and June 1989. All patients were recommended to complete a regimen of INH chemoprophylaxis for 6 months to prevent the progression of their TB infection to disease. The 40 patients were randomly assigned by odd and even numbers in the order of referral to the study. The patients were divided into two groups, Group A and Group B. Both groups were administered a questionnaire to collect demographic data and medical history. Patients in Group A (n = 22) received additional health education and counseling on a one-to-one basis during a single clinic visit, independent of clinic staff, while patients in Group B (n = 18) only received health education and counseling from clinic staff. Patients in both groups were asked to sign a medical release form.
Statistical Analyses Chi-square tests of homogeneity were used to determine any possible sociodemographic differences between the two groups. The dependent variables for this study were completion versus noncompletion of a 6-month regimen of INH chemoprophylaxis. A series of 70 questions were administered to both groups to collect demographic data and medical history. The health education instrument assessed prior TB knowledge before the provision of health education by the health educator. The counseling instrument assessed attitudes about completing the regimen for 6 months. The PRECEDE framework described by Green et al'8 was used as a basis for the design of the study. The PRECEDE model was found to be an appropriate tool for planning, implementing, and evaluating a health education program. We hypothesized that a greater proportion of patients in Group A would complete INH preventive TB therapy for 6 months than patients in Group B. The hypothesis was tested at the .05 level of significance. The Social Science SPPS-X'9 was used to compile, tabulate, and perform the frequency breakdown of the descriptive dimension, the crosstabular analysis, and the correlational analysis. A chi-square test of independence of JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
The sample of 40 patients infected with TB in Group A (n = 22) and Group B (n = 18) consisted of 21 males and 19 females. Patients' ages ranged from 18 to 54 years (mean: 31). The majority of the population was black, born in the United States and the Caribbean, with 62.5% having a high school education or less, residing in houses, apartments, rooms, and a drug residence. The median income for these patients was $5000 (Table 1). Major variables were compared by age, sex, place of birth, ethnic group, marital status, living arrangements, education, employment status, occupation, income, religion, and religious activity. The two groups did not differ significantly among these variables. Of the 40 patients, 13 reported working full-time, six reported working part-time, and 21 reported that they were unemployed. Fourteen had health insurance, and 26 had no health insurance, no Medicaid, and no Medicare. The health education instrument consisted of eight questions with 35 possible responses (Table 2). Responses ranged from 0 to 23, with a mean of 8.3 (SD =5.6) and a median of 8.5. These results suggest that patients had minimal prior TB knowledge. The counseling treatment reflected attitudes toward positive, negative, and poor responses (Table 3). Responses were 1 = positive through 3 = poor for nine items with possible scores across nine questions ranging from 9 to 27. Actual scores ranged from 9 to 13 with a mean of 9.8 (SD = 1.4) and a median of 9. These results were significant and indicated that counseling did make an impact on the attitudes of patients about completing the regimen for 6 months. These findings indicated that the proportion of patients in Group A (63.6%) who completed INH chemoprophylaxis for 6 months was significantly greater than the proportion of patients in Group B (11.1%) (x2=9.3, df= 1, P-.001) (Table 4).
DISCUSSION The data from this study suggest that additional health education and counseling provided by a health educator independent of clinic staff on a one-to-one basis during one clinic visit increased compliance to a 6-month regimen of INH chemoprophylaxis for TB patients attending a chest clinic at a Queens municipal hospital in New York City. 1015
TUBERCULOSIS PREVENTION PROJECT
TABLE 1. SOCIODEMOGRAPHIC VARIABLES OF TB-INFECTED PATIENTS, QUEENS MUNICIPAL HOSPITAL, NEW YORK CITY, JANUARY 1989 THROUGH JUNE 1989* DF GroupAt(%) Group B*(%) Chi-Square 2 1.69 Age 17 to 27 22.7 38.9 28 to 37 45.5 27.8 39 to 59 31.8 33.3 0.37 1 Sex 44.4 Male 59.1 Female 40.9 55.6 2 Place of birth 0.39 44.4 United States 36.4 36.4 Caribbean 27.8 Other 27.3 27.8 2 Ethnicity 0.04 36.4 African American 38.9 36.4 West Indian 33.3 27.3 Other 27.8 0.24 2 Marital Status Never married 45.5 38.9 Living together 31.8 38.9 22.2 22.2 Separated/divorced 2 Residence 5.1 House/room 63.6 27.8 Apartment 18.2 33.3 18.2 38.9 Drug rehabilitation center 1 Education 1.3 54.5 72.2 High school or less 45.5 27.8 College 2 2.6 Employment 22.2 Full-time 40.9 11.1 Part-time 18.2 40.9 66.7 Unemployed 2.12 1 Occupation 44.4 18.2 Semi-skilled/skilled Professional 81.8 55.6 Total income 1.41 1 31.8 55.6
This article reports the findings from a clinical study that examined the impact of health education and counseling on the decision of a patient infected with tuberculosis (TB) to complete a regimen of isoniazid (INH) chemoprophylaxis for 6 months to prevent TB. Forty patients were divided into two groups; both groups were administered a questionnaire to collect demographic data and medical history. One group received additional health education and counseling independent of clinic staff, and the other group only received health education and counseling from clinic staff. The proportion of patients in the first group who completed INH for 6 months (63.6%) was significantly greater than the proportion of patients in the second group (11.1%). These findings suggest that health education and counseling did make an impact on the decision of a patient infected with TB to conform with a rational choice when provided with information and a supportive relationship about the consequences of TB infection. (J NatI Med Assoc. 1992;84:1014-1018.) Key words * tuberculosis * isoniazid * health education The increase of tuberculosis in inner cities continues to
rise.'-7 In New York City, the rates have been rising since 1979, and in 1990, the rate was almost 50 per 100 000 From the Department of Health and Physical Education and
Gerontological Studies and Services, York College/City University of New York, Jamaica, New York. This research was supported in part by grant E 901498 from the American Lung Association of Queens. Requests for reprints should be addressed to Dr Mary D. Barnwell, Dept of Health and Physical Education and Gerontological Studies and Services, York College/City University of New York, Jamaica, NY 11451. 1014
population, and could be as much as five times the national rate. There were 3520 new cases of tuberculosis (TB) in 1990, representing a 38% increase over 1989 when reported new cases were 2545. Between 1989 and 1990, the incidence rate of TB for males of all ages increased 37% from about 56 to 70 cases per 100 000. Approximately 60% of all male cases were confined in 25 to 44 year olds. Black males had a higher TB incidence rate in 1990-188 per 100 000-than males in other racial/ethnic groups, and the next highest rate-98 for Latino males-was about half as large. Tuberculosis cases reported in New York City children younger than 15 years of age rose by 97% in 1990, up to 146 cases from 74 cases in 1989. Ninety-two percent of the entire increase was attributable to cases reported among children 4 years of age and younger. The magnitude of the increase of TB in 1990 was unprecedented, being the largest by far in New York City since the early 1980s after decades of steady decline.2 Despite the substantial body of evidence in the use of isoniazid (INH) to prevent TB,8-15 the disease is still a major public health problem. The extent to which individuals infected with TB complete INH chemoprophylaxis is disconcerting. The results of 76 reporting areas revealed that less than 68% of individuals infected with TB complete the regimen of treatment.6 Some explanations offered included: risk factors associated with INH such as hepatotoxic effects, difficulty in motivating individuals who are not ill to take INH daily,'6 lack of knowledge about TB infection, poor relationship with the health-care provider, long clinic waiting time, and lack of support from family and friends.'7 It is estimated that 90% of new TB cases in the United States will arise from a pool of approximately 10 million individuals infected with TB.6 This study was conducted to increase compliance of a 6-month regimen of INH chemoprophylaxis by providing additional health education and counseling JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
TUBERCULOSIS PREVENTION PROJECT
by a health educator independent of clinic staff. The intervention was provided on a one-to-one basis during a single clinic visit to patients at the chest clinic in a Queens municipal hospital in New York City.
both groups was compiled to determine the impact of health education and counseling, and histogram frequencies were used to assess prior TB knowledge and attitudes about completing INH chemoprophylaxis.
METHODS Study Population
RESULTS
The study population was comprised of 40 patients infected with TB who were registered in the chest clinic at a Queens municipal hospital in New York City between January 1989 and June 1989. All patients were recommended to complete a regimen of INH chemoprophylaxis for 6 months to prevent the progression of their TB infection to disease. The 40 patients were randomly assigned by odd and even numbers in the order of referral to the study. The patients were divided into two groups, Group A and Group B. Both groups were administered a questionnaire to collect demographic data and medical history. Patients in Group A (n = 22) received additional health education and counseling on a one-to-one basis during a single clinic visit, independent of clinic staff, while patients in Group B (n = 18) only received health education and counseling from clinic staff. Patients in both groups were asked to sign a medical release form.
Statistical Analyses Chi-square tests of homogeneity were used to determine any possible sociodemographic differences between the two groups. The dependent variables for this study were completion versus noncompletion of a 6-month regimen of INH chemoprophylaxis. A series of 70 questions were administered to both groups to collect demographic data and medical history. The health education instrument assessed prior TB knowledge before the provision of health education by the health educator. The counseling instrument assessed attitudes about completing the regimen for 6 months. The PRECEDE framework described by Green et al'8 was used as a basis for the design of the study. The PRECEDE model was found to be an appropriate tool for planning, implementing, and evaluating a health education program. We hypothesized that a greater proportion of patients in Group A would complete INH preventive TB therapy for 6 months than patients in Group B. The hypothesis was tested at the .05 level of significance. The Social Science SPPS-X'9 was used to compile, tabulate, and perform the frequency breakdown of the descriptive dimension, the crosstabular analysis, and the correlational analysis. A chi-square test of independence of JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
The sample of 40 patients infected with TB in Group A (n = 22) and Group B (n = 18) consisted of 21 males and 19 females. Patients' ages ranged from 18 to 54 years (mean: 31). The majority of the population was black, born in the United States and the Caribbean, with 62.5% having a high school education or less, residing in houses, apartments, rooms, and a drug residence. The median income for these patients was $5000 (Table 1). Major variables were compared by age, sex, place of birth, ethnic group, marital status, living arrangements, education, employment status, occupation, income, religion, and religious activity. The two groups did not differ significantly among these variables. Of the 40 patients, 13 reported working full-time, six reported working part-time, and 21 reported that they were unemployed. Fourteen had health insurance, and 26 had no health insurance, no Medicaid, and no Medicare. The health education instrument consisted of eight questions with 35 possible responses (Table 2). Responses ranged from 0 to 23, with a mean of 8.3 (SD =5.6) and a median of 8.5. These results suggest that patients had minimal prior TB knowledge. The counseling treatment reflected attitudes toward positive, negative, and poor responses (Table 3). Responses were 1 = positive through 3 = poor for nine items with possible scores across nine questions ranging from 9 to 27. Actual scores ranged from 9 to 13 with a mean of 9.8 (SD = 1.4) and a median of 9. These results were significant and indicated that counseling did make an impact on the attitudes of patients about completing the regimen for 6 months. These findings indicated that the proportion of patients in Group A (63.6%) who completed INH chemoprophylaxis for 6 months was significantly greater than the proportion of patients in Group B (11.1%) (x2=9.3, df= 1, P-.001) (Table 4).
DISCUSSION The data from this study suggest that additional health education and counseling provided by a health educator independent of clinic staff on a one-to-one basis during one clinic visit increased compliance to a 6-month regimen of INH chemoprophylaxis for TB patients attending a chest clinic at a Queens municipal hospital in New York City. 1015
TUBERCULOSIS PREVENTION PROJECT
TABLE 1. SOCIODEMOGRAPHIC VARIABLES OF TB-INFECTED PATIENTS, QUEENS MUNICIPAL HOSPITAL, NEW YORK CITY, JANUARY 1989 THROUGH JUNE 1989* DF GroupAt(%) Group B*(%) Chi-Square 2 1.69 Age 17 to 27 22.7 38.9 28 to 37 45.5 27.8 39 to 59 31.8 33.3 0.37 1 Sex 44.4 Male 59.1 Female 40.9 55.6 2 Place of birth 0.39 44.4 United States 36.4 36.4 Caribbean 27.8 Other 27.3 27.8 2 Ethnicity 0.04 36.4 African American 38.9 36.4 West Indian 33.3 27.3 Other 27.8 0.24 2 Marital Status Never married 45.5 38.9 Living together 31.8 38.9 22.2 22.2 Separated/divorced 2 Residence 5.1 House/room 63.6 27.8 Apartment 18.2 33.3 18.2 38.9 Drug rehabilitation center 1 Education 1.3 54.5 72.2 High school or less 45.5 27.8 College 2 2.6 Employment 22.2 Full-time 40.9 11.1 Part-time 18.2 40.9 66.7 Unemployed 2.12 1 Occupation 44.4 18.2 Semi-skilled/skilled Professional 81.8 55.6 Total income 1.41 1 31.8 55.6
