TB Contact Investigation Interviewing Skills Course

(Title Slide).  Interviewing for TB Contact Investigation

After this session, participants will be able to:

Difference Between STD Interview and TB Interview

STD Interview

• Usually only 1 interview conducted
• Rapport building not so much a priority
• Only have to ask about one specific type of contact (sexual) so much less people you will need to follow up with
• Transmission period specific

TB Interview

• Multiple interviews required
• Building rapport is key since you need to ensure patient returns to clinic…and you will have multiple opportunities to re-interview
• Have to ask about multiple types of contacts (e.g., all sex partners, family, friends, co-workers, classmates)
• Transmission period may be vague, and for a long period of time

What is the Main Goal of a TB Interview?

• The main goal of a TB interview is to identify contacts.  Why?
• So you can assess them for TB disease and infection and get them on appropriate treatment.

[Image: Five stick figures.]

When Should the TB Interview Be Conducted?

• Initial interview should be conducted
  • Within 1 business day of reporting for infectious cases
  • Within 3 business days for others
• Second interview (re-interview) should be conducted 1 to 2 weeks later
• Additional interviews may be needed to gather more information and to build trust

Where Should the Interview Take Place?

• Interview should be conducted in person
  • Hospital
  • TB clinic
  • Case's home or living space
  • Other location convenient for the case
• At least one interview should be conducted in the case’s home or living space

[Image: A health care worker interviewing a TB case in the case’s home.]

What are the Objectives of the Initial Interview?

• Establish rapport
• Educate the case about TB and the CI process
• Verify and expand on information collected in the pre-interview phase
• Identify
  • Places WHERE they spent time
  • Persons with WHOM they spent time
  • Participation in activities and events (WHAT and WHEN)

What are the Objectives of the Re-Interview?

• Identify gaps in information
• Identify additional contacts
• Review/refine the infectious period
• Continue to build trust and rapport

[Image: A health care worker shaking hands with a TB case.]

Effective Interviewer Musts

• Build rapport
• Maintain confidentiality
• Arrange for privacy
• Listen actively
• Be objective and nonjudgmental
• Be creative
• Develop a style that works for you

The TB Interview: Video

[Image: A health care worker interviewing a TB case.]

(Title Slide). Interview Format

Interview Format

1. Introduction
2. Education
3. Information collection and confirmation
4. Contact identification
5. Conclusion of the interview

TB Interview Checklist

Refer to Appendix O

[Image: TB interview checklist.]

(Title Slide). Interview Format: Introduction

Interview Introduction (1)

• The first interaction with the case can influence the remainder of the interview
• Building trust and rapport early in the interview process is essential

[Image: A health care worker greeting a TB case at the case’s home. The case is holding her baby.]

Interview Introduction (2)

• Introduce yourself and shake hands if appropriate
• Provide a business card or other identification
• Explain your role in the TB program
• Ask the case how they are feeling
• Demonstrate respect towards the case

 [Image: A health care worker introducing herself to a TB case.]

Explain the Purpose of the Interview

Explain the purpose of the interview to the case

1. To identify contacts at risk of infection and refer them for medical assessment
2. To provide TB education

Discuss Confidentiality

• Explain that information will only be shared with persons who need to know
  • Health care providers who provide direct care
  • Public health authorities for the purpose of TB control
• Stress that confidentiality is reinforced by local program policies and state regulations

(Title Slide). Interview Format: Education.

Importance of  Education

  Increases knowledge of TB

• Influences desired behavior
  • Identification of contacts
  • Treatment adherence
  • Infection control activities
• Helps the case make informed decisions

 [Image: A health care worker providing education to a TB case.]

What Education Should be Provided to the Case?

 The case should be educated about the following:

1. Components of treatment and care plan
2. Infection control measures
3. Importance of maintaining medical care
4. Importance of the contact investigation

1. Treatment and Care Plan

• Explain that medications kill TB germs when taken properly
• Stress the importance of treatment adherence and follow-up medical care
• Establish a specific schedule for treatment

[Image: A health care worker talking to a TB case.]

2. Infection Control Measures

• Review the importance of the case using a mask or tissue to cover cough
• In some situations, the interviewer may need to wear a respirator to protect themselves from inhaling TB germs/bacteria
• Discuss the importance of ventilation
• Describe other topics as appropriate
  • Home isolation
  • Visitors to the home
  • Return to work or school

[Image: A TB case wearing a face mask.]

[Image: A health care worker wearing a respirator.]

3. Importance of Maintaining Medical Care

• Discuss the importance of:
• Adhering to all medical appointments and directly observed therapy (DOT)
• Sputum collection, chest x-rays, and medical evaluations

[Image: A health care worker providing DOT to a TB case.]

4. Importance of Contact Investigation

• Stress the importance and urgency of identification of all contacts
• Emphasize the role of the case in helping to protect family and friends from TB

What is Effective Education?

• Listening carefully
• Asking questions
• Understanding the case’s needs and concerns
• Demonstrating a caring attitude
• Helping to solve problems
• Clarifying misinformation

Tips for Providing Effective Education (1)

Use visuals

• Visuals can complement verbal and written information
  • Pictures
  • Calendars
  • Flipbooks
  • Real-life examples
  • Pills

[Image: A health care worker providing education to a TB case using a flipbook.]

Tips for Providing Effective Education (2)

Use culturally appropriate materials

[Image: A collage of culturally appropriate TB educational materials available from the CDC. There is a brochure specifically for TB contact investigations.]

Tips for Providing Effective Education (3)

• Speak clearly and simply
• Use simple non-medical terms
• Use familiar words the case will understand
  • Simple: “These pills will help you get better” 

vs.

Medical Terminology Exercise

Appendix P

The TB Interview: Video

[Image: A health care worker interviewing a TB case in an office.]

(Title Slide.) Interview Format: Information Collection and Confirmation

Information Collection and Confirmation

During the interview, information previously collected during the pre-interview phase should be reviewed and confirmed

• Personal information
• Medical information
• Infectious period

Confirm Personal Information

• Full name, aliases, and nicknames
• Date of birth
• Place of birth
• If born in another country, date arrived in United States
• Current address
• Telephone number
• Next of kin
• Emergency contact information
• Physical description
• Other locating information

[Image: A clipboard with pen and paper.]

Confirm Medical Information (1)

Obtain and/or confirm:

• Known exposure to TB (who, where, when)
• Recent hospitalization for TB (name of hospital, admission date, discharge date)
• Other medical conditions
• HIV status
• Substance use (frequency, type, how long)
• Medical provider for TB (private or public clinic, name, telephone number, address)
• DOT plan (where, when, by whom)
• Any barriers to adherence

Confirm Medical Information (2)

Review the following symptoms, including onset dates and duration:

• Cough
• Coughing up blood
• Hoarseness
• Unexplained weight loss
• Night sweats
• Chest pain
• Loss of appetite
• Fever
• Chills
• Fatigue

[Image: A woman with TB disease coughing into a tissue.]

Confirm Medical Information (3)

Discuss the case’s current diagnosis

• TST or IGRA results
• Site of disease
• Symptom history
• Radiographic and bacteriologic results

[Image: A health care worker interviewing a TB case.]

Review the Infectious Period

• Refine the previously established infectious period based on a medical record review
• Review the significance of the infectious period with the case and discuss its role in the contact identification

(Title Slide). Interview Process: Contact Identification

Contact Identification (1)

• Contact identification is the most important part of the initial interview with the case
• Get as much information as possible about contacts from the case during the interview
  • Talk to the case as if it is the last time you will see them

Contact Identification (2)

To help identify contacts, interviewers should collect and confirm information regarding:

• Places WHERE they spent time
• Persons with WHOM they spent time
• Participation in activities and events (WHAT and WHEN)

Identify Places WHERE Case Spent Time (1)

Ask the case where they spent time during the infectious period

• Residence
• Work, school, or volunteer sites
• Social, leisure, religious, or recreation sites
• Sites where illicit activities might have occurred
• Homeless shelters or jails

[A diagram split into three sections showing common locations where TB cases may spend time. These include locations of work/school, leisure/recreation, and household/residential.]

Identify Places WHERE the Case Spent Time (2)

After getting the list of places, ask the case about

• Amount of time spent at each
• Environmental characteristics
  • Number of rooms
  • Room size/square footage
  • Crowding
  • Ventilation
  • – Windows open or closed
  • – HVAC systems

[Image: Cartoon image of a house.]

Identify Places WHERE the Case Spent Time (3) – Residence

• Residence can include:
  • House
  • Apartment
  • Congregate settings
  • – Nursing home
  • –  Assisted living facilities
  • –Dormitory
  • –Correctional facility
  • –Shelters

[Image: Cartoon image of a house.]

Identify Places WHERE the Case Spent Time (4) – School

If attending school, collect information regarding:

• Name of school, address, telephone number
• Grade in school
• Hours per day/week
• Transportation type to and from school, length of commute

[Image: Students sitting on a staircase leading up to a high school.]

[Image: School buses.]

Identify Places WHERE the Case Spent Time (5) – Workplace

• If employed, collect information regarding:
  • Employer name, address, telephone number
  • Full or part-time, hours worked per day/week
  • How long employed
  • Transportation type to and from work, length of commute
  • Occupation/type of work
  • Indoor or outdoor work space, enclosed or open work space
• If unemployed
  • Source of income

Identify WHO the Case Spent Time With (1)

Ask the case who they spent time with during the infectious period, for example:

• Wife, husband, or partner
• Children
• Household members
• Other family members
• Friends
• Roommates
• Cellmates
• Coworkers

[Image: Stick figures.]

Identify WHO the Case Spent Time With (2)

• Ask for names and aliases of contacts
• Ask if contacts
  • Have TB symptoms
  • Have weakened immune systems
  • Are children younger than 5 years of age

[Image: Two women talking to each other.]

Identify WHEN and WHAT Activities or Events the Case Participated In (1)

• Ask about activities during  infectious period
  • Travel, vacations
  • Social events
  • Holidays
  • Ask the case to review calendar or appointment book
• Review cell phone logs and social networking sites (e.g., Facebook)

[Image: Cartoon image of an airplane.]

[Image: Cartoon image of a calendar.]

Identify WHEN and WHAT Activities or Events the Case Participated In (2)

• Examples of social/recreational places and activities
  • Hangouts, bars, clubs
  • Team sports
  • Community centers
  • Bands, choir
  • Places of worship
• Ask about the number of hours per day/week, and means of transportation

[Image: A glass of beer at a bar.]

[Image: Men playing basketball.]

What Information Should Be Collected About Contacts?

• Name/aliases/nicknames
• Relationship to the case
• Address, telephone number, and other locating information
• Hours of exposure per week and date of first and last exposure 
• Setting in which exposure took place
• Age, sex, race, and physical description

Process for Collecting Contact Information (1)

Contact and place information can be gathered using the following format:

1. Name
2. Relationship
3. Locating
4. Exposure time
5. Setting size
6. Description

Process for Collecting Contact Information (2)

1. Name

• Get a name and/or alias
• Ask the case to list as many contact names as possible before moving on

Process for Collecting Contact Information (3)

2. Relationship

• Ask the case what their relationship is to the contact
  • Spouse      
  • Boyfriend/Girlfriend
  • Child
  • Friend
  • Co-worker
  • Classmate
  • Roommate
  • Teammate
  • Any other “mate”

Process for Collecting Contact Information (4)

3. Locating Information

• Collect information on how to get in touch with the contact:
  • Address or map to home/living space
  • Phone number
  • Best time to contact
  • Email address

Process for Collecting Contact Information (5)

4. Exposure Time

• Gather exposure information for each contact:
  • First and last time the case saw the contact
  • Frequency of interaction
• Use significant dates (birthdays, holidays, etc.) to jog case’s memory

Process for Collecting Contact Information (6)

5. Setting Size

• Determine the size of the setting in which exposure took place:
  • Size of a bedroom?
  • Size of a car/van?
  • Size of a house?

Process for Collecting Contact Information (7)

6. Description

• Obtain a detailed physical description for each contact
  • Age
  • Hair color and length
  • Height
  • Weight
  • Complexion
  • Identifying features (e.g., tattoos, piercings)

Contact Identification Exercise

Refer to Appendix Q

[Image: A cartoon image of two people talking.]

(Title Slide.) Interview Process Conclusion of the Interview

Conclusion of the Interview (1)

1. Answer the case’s questions.
2. Review and reinforce all components of the adherence plan.
3. Evaluate the case’s remaining needs or potential adherence problems.
4. Confirm the date of the next medical appointment, if known.

Conclusion of the Interview (2)

1. Arrange for both a re-interview and home visit, if not already completed.
2. Confirm referral procedure of each contact.
3. Leave information on how the case can contact you.
4. If appropriate, shake the case’s hand, express appreciation, and close the interview.

(Title Slide.) Problem Solving During the Interview

Potential Interview Problems

The case:

• Does not believe or trust the health care worker
• Will not talk
• Is distracted or not paying attention
• Is hostile, abusive, or aggressive

Methods to Confront and Solve Problems

1. Provide Information
2. Direct Challenge
3. Self-Involvement
4. Withdrawal of Reinforcement

1. Provide Information

Use a factual statement to challenge what a case has told you.

For example:

• If the case says: “I knew I shouldn’t have shaken my neighbor’s hand when he offered it.”

How would you confront this statement by providing information?

2. Direct Challenge

A direct challenge is confronting a statement that is false. Use when the case says something which can lead to greater problems if not addressed.

For example:

• A case denies any contact with children. However, there are toys in the front yard and a picture of the case and a baby hanging on the wall.

How would you directly challenge this statement?

3. Self Involvement

Used to challenge information or commitments a case has made in interviewer’s presence.

For example:

• A case states that they don’t have a phone number for a contact. When looking through their cell phone address book, with permission, you notice a number for that contact.

How would you use self-involvement to address this statement?

4. Withdrawal of Reinforcement

Designed to appeal to a case’s need for positive reinforcement: the interviewer expresses disappointment with the case’s present behavior and/or withdraws positive feedback previously given. 

For example: 

• “You know, I thought you acted responsibly by coming into the clinic so quickly; however, by saying that you don’t care if your co-workers get examined for TB, that’s demonstrating little concern for their health.”

If You Continue to Have Challenges…

• Recognize the need to stop and reschedule a stalled interview.
• Assign another team member to conduct the interview at a later time if you are unable to gather necessary information.

The TB Interview: Video

[Image: A health care worker interviewing a TB case in an office.]

Review

1. What are the objectives of the initial case interview?
2. What are the steps of a TB interview?
3. What are some ways in which to confront and solve problems that may arise during the interview?