Risk Communication Intervention Of Pulmonary Tuberculosis And Effect Assessment

China is one of the22countries with higher-burden tuberculosis (TB) disease, that ranked second in the world. Today, floating tuberculosis population, untimely detection of TB case sand cross-regional transferred TB case are considered big obstacles in TB control of China, despite comparatively high TB cure rate has achieved.Risk communication is an interactive process of risk information exchange among individuals, communities and institutions; In the field of clinical medicine, risk communication is referred to that doctors share and discuss with patients about the pros and cons of medical services or health behavior, and help patients choose a medical service or change unhealthy behaviors on the basis of individual risk information.In this research, based on the informed decision-making mode of risk communication (as used in the field of clinic medicine), we executed several trials in Nanshan District, Shenzhen city. Intervention such as strengthened counsel, intercommunication, well informed consent, reminder and incentives were adopted to increase the self-efficacy and self-initiative of TB patients, thus to promote the TB cases finding and to achieve continuous of treatment among cross-regionally transferred TB patients.Part Ⅰ Risk perception and stigma of TB among residentsObjective:Risk perception is the subjective judgment of the nature and severity of risk, which is an important driving force for people to change health behavior. And TB stigma is patient’s sense (also a social process) of be excluded, rejected, blamed, belittled and of shame and guilt, arising from negative treatment they have experienced or anticipated, which is one of the important factors causing patients’treatment delay and non-compliance. In this part, we tried to grasp the residents’risk perception of TB and stigma, thus to provide scientific evidences for developing effective intervention to change health behaviors of TB patients (i.e, contact screening, visit doctors and medication, etc).Methods:Totally,492non-tuberculosis patients were investigated by questionnaire in the community health service centers, using stratified sampling method.Results:The results showed that the awareness rate of TB knowledge was82.0%; the perceived severity of TB was6.9(scale1-10), which was at the intermediate level of the eight diseases/conditions surveyed; the perceived vulnerability was3.1(scale1-10), ranked last third within those diseases/conditions; and the perceived threat (severity*vulnerability) was2.1(scale1-5), which was similar to that of all other diseases/conditions. There was an optimistic bias towards TB among the residents, as54.9%of the residents thought that the possibility of getting tuberculosis was lower than others. The survey showed that the score of external TB stigma was22.6(scale0-50), of which the most situation was keeping their distance from patients with tuberculosis. The internal TB stigma was20.8(scale0-50), of which "others will avoid me","spouse or boy/girl friends will not live with me","others will look down upon me" and "it is very difficult to find job even after being cured" were the first four situations. And the composite score of the negative emotion (stress, fear and worry) was3.6(scale1-5).We found that the respondents’TB knowledge was positively related to internal stigma and perceived severity (r=0.11and0.13), and had no correlation with perceived vulnerability, perceived threat and external stigma. The external stigma was positively related to perceived severity (r=0.14), and was negatively correlated with perceived vulnerability and threat (r=-0.21,-0.13, respectively), while internal stigma was only related to perceived severity (r=0.18). And all negative emotions were moderate positive correlated with both of internal and external stigmas (r varied between0.37and0.43), and weak positive correlated with perceived severity (r varied from0.12to0.16). Conclusion:The awareness rate of TB knowledge by the surveyed residents has achieved the goal set by the Ministry of Health in the "Eleventh Five-Year" TB control program. TB risk perception of the residents was the same as that of common chronic diseases (AIDS, heat attack, hypertension, diabetes) and acute diseases or conditions (avian influenza, colds, food poisoning). And tuberculosis-related stigma and negative emotions exist among them.Part II Risk communication intervention on close contact investigation of patients with infectious TBObjective:Contact investigation (CI) is considered one of the effective case finding strategies, however set low priority in China. In this part, we will appraise the effects of risk communication intervention on improving patients’adherence, close contacts’acceptation of clinic screen, and promoting TB case findings.Methods:We adopted an un-random controlled intervention on CI of patients who were15year old and above and with infectious TB (smear positive TB, culture positive TB or TB with cavity on chest X-ray) registered in Nanshan District, Shenzhen City, China. The patients were clustered grouped, based on their registered month. A total of285patients had received either a routine CI (135patients)-queried by the clinic doctors, or a combined intervention (150patients) of health education, prompt mobile message reminder, and symbolic incentives. Meanwhile, we executed a questionnaires survey on patients’ willingness and obstacles to refer their close contact(s).Results:Totally,623close contacts were identified during patients’ interview in the intervention group, namely an average of4.6close contacts per index case which was higher than three expected by the National Guideline (P=0.009). The proportion of patients who referred their close contacts and at least one received TB clinic screen were36.7%(55patients) in the intervention group and9.6%(13patients) in the control group (P=0.001). After being referred by TB patients,109close contacts in the intervention group and19in the control group had received TB screening, and most were household members. The number of close contacts screened per index case in the intervention group was higher than that in the control group (0.7VS.0.1, P<0.0001). Finally,31TB cases (29latent TB infections (LTBI) and two active TB cases) were found in the intervention group, and7LTBI in the control group (TB cases detected per index case:0.2VS.0.1, P<0.0001). The willingness of patients to refer close contacts was72.3%, and they were more likely to refer their household members (91.7%); while anticipating job lost, others’ avoidance behavior and lowing salary were the first three obstacles.Conclusion:The comprehensive risk communication interventions have encouraged patients to refer their close contacts to receive TB screening. Furthermore, this intervention has promoted close contacts identification and TB cases detection. Internal stigma is the one of the big obstacles hindering close contact referring by patients. How to guarantee patients’work right, and to balance patients’ privacy rights and others’health rights need to be further researched. More direct interventions should be adopted in future specifically for close contacts to improve their compliance.Part Ⅲ Risk communication intervention on cross-regional transferred TB patients among floating populationObjective:Cross-regional transference often occurs among the diagnosed floating TB patients, causing irregular medication or even discontinuation of treatment, thus brought great difficulties for TB control. This section will assess the effect of risk communication interventions on the treatment continuity and outcomes of TB disease among floating TB patients.Methods:From October2007to September2008(Phase before the intervention), we managed transferred patients according to the program of "cross-regional tuberculosis patient management" by Global Fund fighting TB; and from October2008to September 2009(risk communication intervention Phase Ⅰ), we used interventions consisting of standardized health education and patient-doctor communication, strengthened supervision of treatment, cross-regional referral assistance, timely patient tracking, and cooperation with other TB dispensaries; from October2009to September2011(risk communication intervention Phase Ⅱ), we added new interventions to establish more cooperation between TB dispensaries, besides of measures in Phase I:QQ contact platform were established with almost all of TB dispensaries at the county or city level in China, achieving real-time contact (i.e., to remind tracing of transferred patients, to share the experiences of how to operate the subsystem of management of TB cross-regional transference in national disease prevention and control system, and so on); also economic incentives for TB dispensaries were adopted to award the behavior of non-reregistering of transferred TB patients.Results:Within the four years,2244floating TB patients were registered in Nanshan District. The total transfer-out rate was17.1%, and it was17.5%(94) at the phase before the intervention,18.5%(110) and16.1%(179) at the phase I and phase II (P=0.439). The rate of patients who informed doctors before transferred-out was only39.4%, and it raised to61.8%at phase Ⅰ, and to86.5%at phase II, with an average annual increase of30.0%(P <0.001); The successful transfer-out rate increased from51.1%at pre-intervention phase to85.5%at phase Ⅱ, with an average annual increase of18.7%; the absolute value of re-register rate decreased by69.0percentage points within four years, which meant an average annual decline of32.1%; and the cured rate of the transferred-out patients increased from4.3%to59.8%, but less than that of whole TB patients (86.0%).Conclusion:The intervention improves patients’adherence and enhances collaboration between TB dispensaries, establishes more practical mechanisms, which could be useful for TB control in China. However, more efforts should be directed towards improvement of TB control among floating population, especially advocating the economic perspective.Innovation:1. We quantitatively measured the risk perception and stigma related to TB disease by a scale, and analyzed their relationships; 2. We adopted comprehensive risk communication interventions on two big obstacles of TB control-untimely detected TB case and cross-regional transference of floating TB patients, and we achieved some ice-breaks, such as promoted contact investigation of patients with infectious TB in the result of earlier TB case finding, and continuous treatment of transferred floating TB patients.