Ch 32: Counselling the TB patients

Awareness should be generated in the community for promoting various health programmes, health seeking behaviours, screening of TB cases etc. by involving and sensitizing community influencers including PRI members and treatment support groups.

Figure: Activities for awareness generation in community

Counselling before initiating treatment for a patient. is an important component of the National TB Elimination Programme (NTEP). The patient is counselled along with his family by the health staff.

Counselling is done on the following points:

• Health education on TB and its symptoms
• Mechanism of TB transmission
• Infection control measures, like cough etiquette and sputum disposal
• Nature and duration of treatment
• Importance of adherence to treatment and the need for complete and regular treatment
• Possible side effects of drugs
• Consequences of irregular treatment or premature cessation of treatment
• Nutritious diet
• Nikshay Poshan Yojna

Communication tools

1. Communication is provided through interpersonal communication in one-to-one sessions and by use of Information, Education and Communication (IEC) materials like posters, pamphlets, flip charts, etc.

2. Arogya Sathi App: The app empowers TB patients to proactively increase their awareness of TB by addressing Frequently Asked Questions (FAQs) regarding TB and information on the symptoms of TB and side-effects of anti-TB drugs. It also helps them in accessing their treatment details, DBT details and adherence calendar. 

3. Nikshay Sampark: National TB call centre "Nikshay Sampark" toll-free helpline number 1800-11-6666 can be contacted anytime by patients and their families to resolve concerns and issues faced by TB patients.

Resources

1. Training Modules (1-4) for Programme Managers and Medical Officers, NTEP, 2020.
2. Guidelines for PMDT in India, NTEP, 2021.

Assessment

The continuum of counselling and care is essential to constantly motivate TB patients to take their full drug regimen and complete it in due course.  

Counselling is regularly given by counsellors, treatment supporters and all those involved with patient care and treatment.  

Counselling should start at the initial point of contact as soon as the diagnosis is established and continued during all visits: 

• By the patient to a health facility  
• By healthcare workers’ visit to the patients’ home  
• Through the national TB call centre (Nikshay Sampark) 

Key Points for Counsellors:

1. Counsellors must inform patients that regular monthly follow-up during their treatment is important to understand their TB treatment response and to determine if they have been cured. 
2. During these monthly follow-up visits, TB patients should be screened for any clinical symptoms and/or cough. If found positive on screening, then sputum microscopy and/or culture should be considered. This is important to detect recurrence of TB as early as possible. 
3. Counsellors should inform patients of the follow-up schedule, and follow up, via physical visits or telephone calls, with patients to verify that they have gone for their follow-up visits at these times: 

a. Clinical evaluation at the end of every 4 weeks of treatment 

b. Sputum examination at the end of each treatment phase i.e., intensive and continuation phase 

c. Long-term post-treatment follow up: Sputum examination, at an interval of 6 months, 12 months, 18 months and 24 months, and if suspected, referred for testing again.​ 

A counselling register is maintained for all patients for recording information about the patients’ situation and counselling services provided from the time of diagnosis till post-treatment follow-up period. 

Information to be Provided to Patients During Regular Monthly Follow-up 

• Nature and duration of treatment 
• Need for regular treatment/adherence 
• Information on the lab results, and the reliability of lab results  
• Consequences of irregular treatment or pre-mature cessation of treatment 
• Possible side effects of anti-TB drugs and management of side effects 
• Nutritional counselling (Nikshay Poshan Yojna) 
• Services under National TB Elimination Program (NTEP) and linkage to social protection schemes 
• Infection control precautions that are necessary, and re-assurance to the family against panic or unnecessary stigmatization of the patient 

Resources 

Guidelines for PMDT in India, 2021 

Assessment 

Confidential dialogue between a health care provider and a patient that helps a patient to define his/her feelings, cope with stress, and to make informed decisions regarding treatment.

The patient should be counselled at all the three phases i.e.,

Objectives of TB Counselling:

• Prevention of TB transmission.
• Provision of emotional support to TB patients.
• Motivation of TB clients to complete treatment.
• Helping patients make their own informed decisions about their behaviour and supporting them in carrying out their decisions.

Figure: Characteristics of effective counselling

Do’s

• Active listening, emphatic gestures and expressions
• Ensure the confidentiality of the conversation done with the patient
• Ensure Minimum interruption during the conversation with patient
• Ensuring availability of IEC materials such as posters, videos, pamphlets etc. to dispel myths and misconceptions.

Don'ts

• Do not use any negative stereotypes
• Do not have any physical wall or glass between patient and yourself
• Do not breach the trust and confidentiality of the TB patient
• Do not make threats or use coercive language
• Do not exaggerate dangers or risk of TB
• Do not blame or shame TB patients

Nutritional Counselling begins with the nutritional assessment of TB patients by

• Nutritional Status: Assessing the height, weight and BMI of the TB patient

• Diet and Preference food for TB patients

• Current appetite and food intake of TB patients

Based on the nutritional assessment, following information can be conveyed to TB Patients

• Patients with TB should be encouraged to have frequent food intake in the form of three meals and three snacks.

• Attempts should be made to increase the energy and protein content in the meals and snacks without increasing its volume.

• The addition of oil, butter or ghee to the chapati or rice can increase the energy content of the diet.

• Pulses in other forms, e.g. sprouts, roasted Chana, groundnuts, can be taken as snacks in either fried or in roasted form. Milk and eggs to be included in the diet.

• The use of easily available nutritious foods based on vegetarian/non-vegetarian preferences of the patients must be emphasized.

• Information about NFSA (National Food Security Act) and Poshan abhiyan should be given.

Figure: Healthy diet for TB Patients

Resources:

• Guidance Document: Nutritional care and support for patients with Tuberculosis in India

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