AIDERS

TB DOTS and IPCC Training

August 5-7, 2014

Dotties Place
Butuan City
Preliminaries
Prayer
National Anthem
Introduction
 Name
Age
Saang munisipyo/probinsya galing
Area of Assignment
Ka look-alike na artista o sikat na tao
Expectations Check
 Green - Facilitator
Blue – Content
Red – Co-Participants
 Training Objectives
 Gained understanding on the GF Project and AIDERS
Component and the roles of AIDERS in TB Service
Provision for GIDA
 Gained knowledge the basic facts of TB and the updated
NTP Protocols on Case-finding and Case Holding
 Understood the concept of Interpersonal
Communication in Facilitating Behavior Change
 Demonstrated Basic competence in IPCC
 Understood the GF Reporting Protocols, Forms and
Reporting Schedules
 House Rules

 Please come on time.

 Put your phone on silent mode. If you need to take
an important call, please answer your call outside
the training room.
 Please keep the copy of your modules aside for now
and kindly give your attention to the speaker.

 Please feel free to share your “mini-meetings”
with the bigger group.
Game?
 About Us
(PBSP/Global Fund/AIDERS)
 About PBSP

 Philippine Business for Social Progress (PBSP) is

the largest corporate-led social development foundation
in the Philippines
 More than 260 large, medium-scale and small businesses
comprise PBSP
 PBSP operates nationwide, with programs in Health,
Education, Environment and Livelihood implemented
with partners and communities as empowered players in
development
 PBSP and Health
 Introduced workplace-based health programs like
HIV/AIDS, TB-DOTS, Avian Influenza, Family Health
and Quit Smoking Support Program

 Developed models for business sector participation in

community TB control

 Currently implementing the IMPACT Project funded by

USAID and the Global Fund TB Project, both supporting
the National TB Control Program.
 The Global Fund

 The Global Fund to Fight AIDS, Tuberculosis and Malaria

 Created in 2002
 International financing institution that fights AIDS,
tuberculosis and malaria with a 21st century approach:

partnership,
transparency,
constant learning and
results-based funding.
 The Global Fund
 Partnerships with
government,
civil society,
the private sector and
communities.
 The Global Fund does not manage or implement
programs on the ground, relying instead on local experts.
 It works with partners to ensure that funding serves
beneficiaries affected by these diseases in the most
effective way.
 GF TB Project Objectives

 Assist NTP in the achievement of its enhanced PhilPACT

targets in case finding and case holding, and in securing
an enabling environment for TB control
 GF Support to the NTP

COMPONENTS

1. ITIS (Integrated TB Information System)

2. TB-HIV Collaboration

3. DOTS – Hospital DOTS, AIDERS, New Technologies

4. MDR – TB Diagnosis and Treatment and Patient

Support

5. Program Management and Operational Researches

 AIDERS

(Accelerating Implementation of DOTS Enhancements

to Reach Special populations)
 AIDERS
 Initiative of the DOH-National TB Control Program
 Adapted from the DOH Nurse Deployment Program and RN
Heals
 Implemented by the DOH Regional Offices
 Supported by PBSP-GF NFM
 Rationale for AIDERS
Component
 TB services are not adequately available in the poor areas,
(urban and rural poor) GIDA, and conflict areas
 There are regional variation in accessing TB services
 high population per health worker ratio
 poverty incidence
 geographical characteristics
 2103 National TB Program Joint Program Review
identified lack of manpower to support local DOTS
implementation
Support to the PhilPACT’s key
strategy no. 5

To address MDR-TB, TB HIV and needs of

the vulnerable population

Improve access to quality TB care by the poor,

Strengthen the capacity of the RHUs to provide
diagnostic, treatment and TB education services
Enhance service delivery
Capability building of the CHTs and volunteers,
community TB education and;
System improvement.
 AIDERS
 Nurses (Licensed)
 Screened and selected by the DOH-ROs
 Deployed to selected GIDA and/or municipalities with poor
and vulnerable population
 Help augment the need for additional health personnel,
 Help improve DOTS performance and implementation.
 Priority Sites
 Nationwide (all 17 regions)

 335 Select Municipalities with:

o GIDA (Geographically Isolated and
Disadvantaged Areas)
o Vulnerable Populations (urban/rural poor, IPs)
o Conflict areas

 Sites needing improvement in TB

Performance (CDR/TSR)
 Support from DOH-ROs and GF
Salary

Capacity-building

• Basic DOTS
• PMDT Referral
• Interpersonal Communication and Counseling
• Other trainings as needed

Mentoring Activities
Program Monitoring
 Performance Indicators

Indicators 2014 2015 2016

1. Number of Cases (All

Forms) Notified by 3000 3600 4000
AIDERS

• Number of Cases - confirmed TB case

• Notified - recorded into the TB registry
 Roles and
Responsibilities
 AIDERS’ Responsibilities
1. Assist the RHU and NTP Staff in:
 Providing TB Services
 Conducting of TB Education Sessions
 Case Finding and Referrals
 Case Holding and Patient Management
 Tracing of patients lost to follow-up
 Proper referral of presumptive MDR-TB for screening
2. Prepare and submit monthly performance reports to MHO/RHU for
submission to DOH-RO
3. Ensure compliance to DOH-RO/RHU and GF Project policies and
guidelines;
4. Provide administrative and logistics backstopping to RHU;
NTP Updates and Regional
NTP Performance
NTP Medical Coordinator Report
 Module 1:
Tuberculosis and the National TB Control Program
(NTP)
Pre Test
 Session 1
Understanding the Basic Facts
of Tuberculosis
What is Tuberculosis?
 A disease caused by a bacteria called
Mycobacterium tuberculosis
 Discovered by Robert Koch in March 24, 1882
 Affects the lungs most often (pulmonary); other
parts of the body such as bones, intestines,
kidney, meninges of the brain, liver, etc., may
also be affected (extra-pulmonary)
 A Pulmonary TB patient whose sputum is
positive for TB bacilli may spread the disease to
about 10-20 persons in two years.
Mycobacterium Tuberculosis

 Opportunistic bacteria
 Very sensitive to direct sunlight (can be
killed in 5 minutes), may survive in the
dark for years
 Can be destroyed in 20 minutes at 60
degrees and 5 minutes at 70 degrees Celsius
How is TB spread to other people?

 Through air
 Transmitted by aerosol / droplet, inhalation
through coughing/sneezing a person with TB
 Droplets inhaled by susceptible people
Who are affected by Tuberculosis?

 Affects all ages but is most common among the

productive years 25-55 and is found to be more
prevalent in men more than women
 TB is high among the malnourished and diabetic
group.
 The prevalence rate is twice higher among the urban
poor in Metro Manila compared to that of the general
population.
TB Cases Detected by Gender, DOH; 2004-
2008
70,000

60,000

50,000

40,000

30,000

20,000

10,000

0
2004 2005 2006 2007 2008
Male Female
New Sm(+)’s By Gender and Age Groups
(DOH 2004 to 2008)
0-14 15-24 25-34 35-44 45-54 55-64 >65
Female
Male 2008

Female
Male
2007

Female
Male
2006

Female
2005
Male

Female 2004
Male

0 10000 20000 30000 40000 50000 60000 70000

Signs and Symptoms
 COUGH, productive or not, of two weeks or more, with or
without:
 Unintended weight loss and loss of appetite
 Chest and/or backpain
 Fever
 Blood streaked sputum
 Body weakness/malaise

There are cases of asymptomatic TB

Diagnosis
 Direct Sputum Smear Microscopy (DSSM) – primary tool
for TB diagnosis

 2 specimens within 2 days (1st specimen at the time of first

consultation, 2nd specimen after an hour of the first
specimen or early morning of the following day)

Chest X-Ray can be done after a negative sputum exam.

 WHO endorsed molecular diagnostic test:
 Xpert MTB/RIF assay is a rapid test that detects
presumptive MDRTB or HIV-associated TB.
 Line-Probe Assay (LPA) for first line drugs

 TB Culture and drug susceptibility test (DST)  

 Tuberculin skin test (TST) is a basic
screening tool for TB infection among children
How to prevent TB transmission?

 Ensuring good ventilation

 Maintaining a clean environment
 Consulting a physician regularly
 Eating healthy food
 Exercising regularly
 Practicing the right way to cough using the
UBOkabularyo guide
BCG
 Given at birth
 Can give 80% protection for 15 years if given
before first infection
How is TB treated?
 Using standard drug regimen composed of
4 to 5 anti TB drugs
 With standard treatment regiment ranging from
6 to 8 months
 Coupled with a healthy lifestyle
What is MDR-TB?
 MDR TB stands for Multi- Drug Resistant TB
 TB caused by the Mycobacterium tuberculosis
organism resistant to at least Isoniazid and
Rifampicin, the two most powerful anti-TB drugs
 MDR-TB strain can be resistant to more than
these two antibiotics
 What Causes MDR-TB?
 Inadequate regimens
 Inadequate drug supply or quality
 Inadequate drug intake
Who are the Presumptive MDR-
TB Cases?
 All re-treatment cases including Category II non-
converter.
 TB cases who are in contact with confirmed DR-TB cases
and also the non-converters of Category I treatment.
 People living with HIV (PLWHIV) who are presumptive
TB cases.
 Current Status: (DOH)
Philippines
• 9th among the 22 high burdened countries (HBCs) worldwide – National
Tuberculosis Control Program. Manila, Department of Health, 2011

• 4th in Case Notification Rate (TB all forms) amongst the WPRO countries –
TB Control in the Western Pacific Region, 2009 Report

• 8th among 27 priority countries with highest number of MDR-TB cases

• TB is 6th in mortality and morbidity – FHSIS Report 2010

 TB Situation
75 Filipinos die of TB each day

 One third of the Filipinos are infected with the

TB Bacilli
Common Misconception
Is TB hereditary?
Is TB hereditary?
 TB is not hereditary. Bacteria causing TB come
from air droplets from a person with TB when
he/she coughs, sneezes or spit.
 However, it is infectious such that household
members of TB patients are at risk of acquiring
the disease.
Can a person die of TB?
 Can a person die of TB?
 Yes, if treatment is not started early enough and if a
patient does not finish the treatment regimen.
Does TB afflict only the thin, the elderly,
or the poor people?
 Does TB afflict only the thin, the
elderly, or the poor people?

 No. Everybody is at risk of getting TB. Those with higher

risk are the malnourished, immuno-compromised (HIV-
infected, diabetic, cancer patients), and those in contact
with patients who are sputum smear-positive.
Can one contract TB from doing
heavy work?
Can one contract TB from doing
heavy work?

 No. However, if heavy work leads to a lowering of

body resistance, a person becomes susceptible to
the disease.
Can one contract TB from too much
drinking or smoking?
Can a person contract TB from too
much drinking or smoking?

 No, but excessive drinking or smoking may

weaken a person’s body resistance, making
him/her susceptible to the disease.
Is there a need to separate the
personal belongings, especially
utensils, of the TB patient?
Is there a need to separate the personal belongings,
especially utensils, of the TB patient?

 There is no need to do so, because TB in

transmitted through inhalation (not ingestion) of
aerosol.
Can a patient breastfeed
while on treatment?
Can a patient breastfeed while on
treatment?

 A woman taking anti-TB drugs can continue to

breastfeed. All anti-TB drugs are compatible with
breastfeeding.
 A breastfeeding woman with TB should receive a
full course of anti-TB treatment.
 BCG vaccination should be given to the infant
immediately at birth.
Can pregnant women take anti-TB
drugs?
Can pregnant women take anti-TB
drugs?

 Most anti-TB drugs are safe for pregnant women,

except Streptomycin, which can cause ototoxicity
(deafness) to the fetus.
Is it alright for a patient on pills
to take anti-TB drugs?
 Is it alright for a patient on pills to
take anti-TB drugs?

 A woman taking anti-TB drugs while on pills/oral

contraceptives has two options:
1) Take an oral contraceptive pill containing a higher dose of
estrogen, following consultation with a clinician;
2) Use another form of contraception.

Rifampicin may decrease oral contraceptive’s protective

efficacy against pregnancy.
Can a cured TB patient contract
TB again?
Can a cured TB patient contract TB
again?

 Yes, if he/she inhales TB bacilli when the body

resistance is low.
Can a TB patient engage in sex?
Can a TB patient engage in sex?

 Yes. In most cases, a patient is no longer

infectious after two weeks of proper medication.
Can a TB patient go back
to work?
Can a TB patient go back to work?

 Yes, after 2-3 weeks of treatment, patient is

usually non-infectious. It is advised that before
patient reports back to work, he/she should
undergo sputum examination and is smear
negative.
 LEARNING ASSESSMENT ACTIVITY

Grab a pen and paper then answer the following items in 10

minutes:
 Give at least 2 parts of the body that can be infected
by mycobacterium tuberculosis aside from the
lungs.
 Give 3 signs and symptoms for a presumptive case
of TB.
 Give 2 reasons for acquiring Multi-drug resistant
TB (MDR-TB).
 Session 2
NTP 101
Realizing the Importance of the National
TB Control Program
What is NTP?
 It stands for National Tuberculosis Program
 It is the Government's commitment to address the TB
problem in the country. 
 The NTP is being implemented nationwide in all
government health centers, government hospitals and
selected private institution. 
 Its objectives are to detect all forms of TB cases (at  least
90%) and to treat them (more than 90%). 
 Achieving and sustaining targets will eventually result to
the decline of the TB problem in the Philippines.

http://www.doh.gov.ph/ncdpc_tb/11
 Vision, Mission and Goal of NTP

• A TB-free • To reduce TB mortality and

Philippines prevalence by half
compared to 1990 data

Vision Goal

Manual of Procedure for the National TB Control Program, 2013

 NTP Targets (90/90)
• Case Detection Rate all
Increase forms to 90 % or more
Effective
• Treatment Success Rate
Increase to 90% or more
TB Control
Efforts
• Notification Rate of 62% through
Increase among estimated MDR DOTS
TB cases Strategy
Increase • MDR TB Treatment
Success Rate of 75%
5 (five) Elements of DOTS Strategy
•Sustainability of quality-assured TB sputum
microscopy
•Uninterrupted supply of quality-assured drugs
•Supervised treatment
•Patient and program monitoring
•Political will
Major Components of NTP
I. Case Finding
II. Case Holding
Major Components of NTP
I. Case Finding
I. Case Finding
• is the identification and diagnosis of TB
cases among individuals with suspected signs
and symptoms of TB
 It is the basic step in TB control.

• Objective – to identify & diagnose TB cases early

•Types of case finding:

 Passive case finding – finding TB cases among presumptive

TB cases consulting at the TB DOTS facility
 Active case finding – purposive action/effort to find TB
cases who do not consult TB DOTS facility
 Intensified case finding – active case finding among individuals
belonging to special or defined populations: 
 Close contact –a person who shared an enclosed space, such as the
household, a social gathering place, workplace or facility, for extended periods
with a TB patient

 High-risk Clinical groups –individuals with clinical conditions that puts

them at risk of contracting TB disease

 High-risk populations – inmates, elderly, Indigenous People, urban/rural

poor.
 Let’s be familiar with:
 Contact investigation - process to identify undiagnosed cases of TB
among the contacts of an index case.

 Index Case - initially identified case of TB in a specific household or

other comparable setting in which others may have been exposed.

 Presumptive TB case - person with signs and/or symptoms

suggestive of TB

 Presumptive Drug Resistant-TB (DRTB) case - person who

belongs to any of the DR-TB high-risk groups
 TB infection or latent TB infection (LTBI) - an
individual with no signs and symptoms but has a (+) TST
reaction.

 TB disease - A presumptive TB case who after clinical

and diagnostic evaluation is confirmed to have TB.
 Flow of NTP Activities
IDENTIFY AND REFER:
COMMUNITY Identification of presumptive TB and MDR TB cases
Chest X-ray findings suggestive of TB
Case Finding

Verify history of anti-TB treatment, exposure, clinical or high-risk factors

DOTS FACILITY 2 Sputum specimens with NTP Laboratory Request Form For Direct
Sputum Smear Microscopy (DSSM)

MICROSCOPY CENTER
Diagnosis

Recording into
Presumptive TB TBDC recommended for EVALUATE & RECOMMEND referred
case master list treatment of (-) DSSM w/ (+) TBDC DSSM smear negative with chest x-
X-ray ray suggestive of PTB
(+) DSSM
Initiation of Treatment
Case Holding

One sputum specimen with Laboratory Request

Form for DSSM every 2 months (as scheduled)

MICROSCOPY CENTER
Treatment Completion Results (DSSM for follow-up)

Report Treatment Outcome /

Request Supplies

Monitoring and Supervision

I. Case Finding
 Presumptive TB case – any person with cough for 2
or more weeks with or without the following
symptoms
 Fever
 Chest and/back pains not referable to any
musculoskeletal disorders
 Hemoptysis or recurrent blood-streaked sputum
 Significant weight loss
 Other symptoms
o Sweating, fatigue, body malaise, shortness of breath
For below 15 years old

at least three (3) of the following clinical criteria:

 Coughing/wheezing of 2 weeks or more
 Unexplained fever of 2 weeks or more
 Loss of weight/ failure to gain weight/ weight faltering/
loss of appetite;
 Failure to respond to 2 weeks of appropriate antibiotic
therapy
 Failure to regain previous state of health 2 weeks after a
viral infection
 Fatigue, reduced playfulness, or lethargy (child has lost
his/her normal energy)
For below 15 years old

 Any of the above in a child who is a close

contact of a known active TB case

 Chest x-ray findings suggestive of PTB,

with or without symptoms
Unexplained Cough of any duration in:
 a close contact of a known active TB case;
 high-risk clinical groups (HIV/AIDS, diabetes,
end-stage renal disease, cancer, connective
tissue diseases, autoimmune diseases,
silicosis, patients who underwent gastrectomy
or solid organ transplantation and patients on
prolonged systemic steroids);
 high risk populations (elderly, urban poor,
inmates and other congregate settings).
NTP 101 Challenge:
“TRUTH or LIE”
Direct sputum smear microscopy is
the basic test needed in diagnosing
pulmonary TB.

TRUTH or LIE?
FACTS
• Direct Sputum Smear Microscopy (DSSM)
 Principal diagnostic method/tool in NTP case finding because :
 It provides a definitive diagnosis of active TB
 The procedure is simple
 It is economical
 A microscopy center could be put up even in remote areas

 Only trained medtechs or microscopists shall

perform DSSM. However, in far flung areas, BHWs or
other community health volunteers may be allowed to do
smearing and fixing specimens, as long as they have been
trained and are supervised by their respective NTP
MedTech/microscopist
Presumptive TB Case should be referred
to any laboratory for direct sputum
smear microscopy.

TRUTH or LIE?
FACTS
 All presumptive TB cases identified shall be
asked to undergo DSSM for diagnosis
before start of treatment, regardless of whether
or not they have available x-ray results or whether or not
they are suspected of having Extrapulmonary TB

 The only contraindication for sputum collection is

hemoptysis; in which case, DSSM will be requested
after control of hemoptysis
 All Chest X-ray procedures should be done within six
(6) months from the time of consultation
Direct sputum smear microscopy
requires three early morning
specimens.

TRUTH or LIE?
FACTS
 For Diagnosis: 2 sputum specimens taken/collected
w/in 2 days
 1st specimen – “spot specimen” – collected at the time of consultation
in TB DOTS facility
 2nd specimen – an hour after collection “spot-spot” of the first
specimen or at early morning of the following day “spot-early
morning”
 If patient fails to complete the 2 specimen collection
within three days from the first specimen, another set of 2
should be collected unless the first already tested positive
FACTS
 For Diagnosis: 2 sputum specimens taken/collected w/in 2 days
 Sputum cup for sputum specimen collection provided by TB DOTS facility
 “QUALITY sputum specimen” – phlegm, mucoid
 Prepare the sputum cup and accomplish NTP lab request form
 Instruction how to collect/produce quality sputum
1. Rinse mouth with water
2. Breath deeply , hold breath for a second or two, then exhale slowly thru the mouth (Done
twice)
3. Cough strongly after inhaling deeply for the third time and bring up sputum from deep
within the lungs
4. Expectorate the sputum into a container with a well fitted cap; collect at least 1 teaspoon
full and examine the specimen for quality
 Label body of sputum cup indicating patient’s complete name and order
of specimen (1st and 2nd)
 Observe precautions against infection during the demonstration. Stay
behind the patient. Collect specimen outside the facility.
DSSM positive cases should be referred
to a physician primarily
for close contacts investigation
in their household.

TRUTH or LIE?
FACTS
 DSSM Smear (+) cases (bacteriologically
confirmed PTB)
 DSSM results serve as bases for:
 categorizing TB cases according to standard case definition
 Proper treatment regimen
 Monitoring progress of patients with sputum smear (+) TB while
on anti-TB treatment
 Confirming cure at the end of anti – TB treatment
 Smear (+) cases are the basis for tracing TB illness among
children and other family members (Household contact
investigation)
 Smear negative PTB cases are routinely
treated with anti-TB drugs immediately after
the DSSM result.

TRUTH or LIE?
 FACTS
 DSSM Smear (-) cases
 Presumptive TB case (not eligible for Xpert MTB testing) shall
be asked to undergo chest x-ray and / or culture
 If the chest x-ray result is suggestive of Pulmonary TB, the TB
DOTS facility will refer the patient’s case and submit necessary
documents (complete case history, DSSM results and chest x-
ray film of the patient) to the TBDC for further evaluation
 If (-) DSSM among a) PLHIV, b) presumptive DR-TB case, c)
high-risk clinical groups or high-risk populations, then they
shall be asked to undergo Xpert MTB testing
 If Xpert MTB/RIF is positive for MTB, patient is classified as
bacteriologically-confirmed PTB.
 If Xpert MTB/RIF is negative for MTB, investigate further or refer to a
specialist.
 Referral to TBDC would reduce
over-diagnosis and over-
treatment of symptomatic smear
positive cases.

TRUTH or LIE?
FACTS
 TBDC
 Evaluates the results of the chest x-ray film reading
together with the complete history and findings ( Smear
negative with x-ray suggestive of Pulmonary TB cases only)
 Recommends to TB DOTS facility whether or not the case
will be started on treatment within 2 weeks
 Composition
 NTP Medical Coordinator
 Radiologist
 Clinician/Internist/Pulmonologist
 NTP Nurse Coordinator
How to confirm TB cases?
 Ask the symptoms
 TB Symptomatic – presence of chronic cough lasting of 2 or more
than 2 weeks
 TB Asymptomatic– absence of cough with or without associated
other symptoms
 Common among workers and applicants with accidental finding on Chest
X-ray

 Collect sputum specimen for

 Direct Sputum Smear Microscopy(DSSM)
 Sputum Culture & Drug Sensitivity Testing for M. Tuberculosis

 Refer cases for chest X-ray, if negative for DSSM

 FLOW CHART FOR THE DSSM Positive
DIAGNOSIS OF SMEAR Positive
TB

Manual of Procedure for the National TB Control

Program, 2013
FLOW CHART FOR
THE DIAGNOSIS OF
ELIGIBLE FOR XPERT
SMEAR Negative TB MTB/Rif

Modified from Manual of

Procedure for the National TB
Control Program, 4th ed 2005
FLOW CHART FOR NOT ELIGIBLE
THE DIAGNOSIS OF FOR XPERT
SMEAR Negative TB

Modified from Manual of

Procedure for the National TB
Control Program, 4th ed 2005
 LEARNING ASSESSMENT ACTIVITY

Discuss the following cases with your group mates and be ready
to present your answers in 15 minutes.
 CASE 1

Sara is a factory worker and availed free chest x-ray

services provided by the RHU. When she got the
chest x-ray findings, she is positive for suspicious
infiltrates. As a health care provider, how do you
handle this situation?
CASE 2

Maria is a 30-year old mother of 4 children. She has

been coughing for more than two weeks now. She
went to the DOTS center. If you are the NTP nurse,
what will you tell her?
I. Case Finding Summary

 Fundamental to case finding is the detection of infectious cases

through DSSM - Sputum smear (+)
 The most common symptoms of pulmonary TB is cough of 2
or more weeks with or without other signs/symptoms.
 The associated symptoms can be remembered as FEWBANS for
fever, easy fatigability, weight loss, blood –tinged phlegm/back
pain, anorexia, night sweating and shortness of breath.
 Advise all presumptive TB cases to submit 2 QUALITY sputum
specimens for DSSM for diagnosis.
 Smear negative PTB should be assessed if eligible for XPERT
MTB/Rif Testing.
 Household members of identified TB cases should be
encouraged to undergo DSSM.
Major Components of NTP
II. Case Holding
 Flow of NTP Activities
IDENTIFY AND REFER:
COMMUNITY Presumptive TB Case case
Asymptomatic PTB with abnormal Chest X-ray Finding
Case Finding

DOTS FACILITY 3 Sputum specimens with NTP Laboratory Request Form For Direct
Sputum Smear Microscopy (DSSM)

MICROSCOPY CENTER
Diagnosis

EVALUATE & RECOMMEND referred

(+) DSSM
TBDC recommended for
treatment of (-) DSSM w/
TBDC DSSM smear negative with chest x-
ray suggestive of PTB
(+) X-ray

Initiation of Treatment
One sputum specimen with Laboratory Request
Holding

Form for DSSM every 2 months (as scheduled)

Case

MICROSCOPY CENTER
Results (DSSM for follow-up)

Treatment Completion

Report Treatment Outcome / Request Supplies

Monitoring and Supervision

NTP 101 Challenge:
“TRUTH or LIE”
 The aim of case holding is to cure
TB cases after six months of treatment.

TRUTH or LIE?
Case holding
 is the set of procedures which ensures that patients
complete their treatment
 involves 1) assignment of the appropriate treatment
regimen, 2) supervised drug intake with support to
patients and 3) monitoring response to treatment
through follow-up sputum smear microscopy

Objective: To ensure effective and complete treatment of

all TB cases for both adults and children.
Diagnosing and Classifying TB
cases
 TB Cases are classified according to:
1. History of anti-TB treatment – previous treatment
outcome
2. Anatomical site - based on the location of lesions
(Pulmonary or Extra Pulmonary TB)
3. Bacteriologic confirmation – DSSM result and Xpert
MTB Rif Result

*Note: The correct classification of TB cases is necessary in

determining the correct treatment regimen.
1. Classification of TB disease based
on history of previous TB treatment

 New case – a patient who has never had treatment for TB or who has taken
anti-TB drugs for less than one (<1) month. Isoniazid preventive therapy or
other preventive regimens are not considered as previous TB treatment.

 Retreatment case –a patient who has been previously treated with anti-
TB drugs for at least 1 month in the past. retreatment cases are classified
according to subtypes:
a) relapse
b) Treatment after failure
c) Treatment After lost to follow-up (TALF)
d) Previous Treatment outcome unknown (PTOU)
 Definition of Terms (TB Disease Registration Group)
Registration Group Definition
never had treatment for TB* or less than one (<1)
New
month intake

• Previously cured or treatment completed in

their most recent treatment
Relapse
• presently diagnosed with bacteriologically-
confirmed or clinically-diagnosed TB.
Retreatment

A previously treated for TB and whose treatment

failed at the end of their most recent course
Treatment OR
After Failure
A patient for whom sputum examination cannot be
done and who does not show clinical
improvement anytime during treatment.
 Retreatment Subtypes
Registration Group Definition
• previously treated
Treatment After • lost to follow-up for two months or more in their
Lost to Follow-up most recent course of treatment
Retreatment

(TALF) • currently diagnosed with bacteriologically-

confirmed or clinically-diagnosed TB.
 
Previous Treatment •  previously treated
Outcome Unknown • outcome after their most recent course of
treatment is unknown or undocumented.
(PTOU)

Patients who do not fit into any of the categories

Other listed above.
• registered in a DOTS facility
*Note: All retreatment patients should be referred to a PMDT treatment facility
for MDR-TB screening before transferred
• initiating to another
Category II DOTSregimen.
treatment facility with proper
Transfer-in referral slip to continue the current treatment
regimen.
2. Classification of TB Disease
based on anatomical site
 Pulmonary TB (PTB) - refers to a case of tuberculosis
involving the lung parenchyma.

 Extrapulmonary TB (EPTB) - refers to a case of

tuberculosis involv­ing organs other than the lungs (e.g.
larynx, pleura, lymph nodes, abdomen, genitourinary
tract, skin, joints and bones, meninges).
 
3. Classification of TB Disease based on
bacteriological confirmation

 Bacteriologically confirmed - A TB patient

from whom a biological specimen is positive by
smear microscopy, culture or rapid diagnostic tests
(such as Xpert MTB/RIF).

 Clinically diagnosed – A PTB patient who has

negative sputum smear result but has been
diagnosed with active TB by a clinician or other
medical practitioner who has decided to give the
patient a full course of TB treatment (TBDC).
Anatomical/ DSSM
Diagnostic
Location of Result Definition
criteria
Lesion

A patient with at least one (1) sputum specimen positive for AFB,
Smear
with or without radiographic abnormalities consistent with active
(+)
TB

Bacteriologic Culture- A patient with positive sputum culture for MTB complex, with or
ally positive without radiographic abnormalities consistent with active TB
confirmed
Rapid A patient with sputum positive for MTB complex using rapid
Diagnost
ic test- diagnostic modalities such as Xpert MTB/RIF, with or without
positive radiographic abnormalities consistent with active TB
A patient with two (2) sputum specimens (-) for AFB or MTB or with
smear not done but with radiographic abnormalities consistent with
Pulmonary active TB; and with no response to a course of medications; and
TB (PTB) who has been decided (either by the TBDC and/or physician) to have
TB disease requiring a full course of anti-TB chemotherapy
 
A child (less than 15 years old) with two (2) sputum specimens
(-) for AFB or with smear not done, with 3/5 criteria for disease
Clinically Diagnosed activity: signs and symptoms of TB, exposure, positive TST, chest
radiograph suggestive of TB, and other laboratory findings
suggestive of TB
 
A patient with laboratory or strong clinical evidence for HIV/AIDS
with two (2) sputum specimens (-) for AFB or MTB or with smear
not done regardless of radiographic results, has been decided (either
by physician and/or TBDC) to have TB disease activity requiring a
full course of anti-TB chemotherapy.
Anatomical/
Diagnostic
Location of Definition
criteria
Lesion

A patient with a smear/culture/new diagnostic test from a

Bacteriologically
biological specimen in an extra-pulmonary site (i.e., organs
confirmed
other than the lungs) positive for AFB or MTB complex

Extra-
pulmonary
(EPTB)

A patient with histological and/or clinical or radiologic

Clinically evidence consistent with active extra-pulmonary TB and
Diagnosed there is a decision by a physician to treat the patient with
anti-TB drugs
 Classification of TB disease based on drug-
susceptibility testing

Pan-susceptible TB – a form of TB wherein the tubercle bacilli is susceptible to all

the first-line anti-TB drugs: isoniazid (H), rifampicin (R), pyrazinamide (Z),
ethambutol (E), and streptomycin (S).
Mono-resistant TB- resistant to only one first-line anti-TB drug  
Poly-resistant TB- resistant to more than one first-line anti-TB drug (other than
both H and R).
Multidrug-resistant TB (MDR-TB)- resistant to at least both H and R.
Extensively drug-resistant TB (XDR-TB)- MDR-TB plus resistance to any
fluoroquinolone and to at least one second-line injectable drugs (kanamycin,
amikacin or capreomycin)
Rifampicin resistance (RR-TB) - resistance to rifampicin with or without
resistance to other anti-TB drugs. It includes any resistance to rifampicin, whether
monoresistance, multidrug resistance, polydrug resistance or extensive drug
resistance.
 All TB cases registered for
anti-TB treatment comply with
at least 6 months regimen
TRUTH or LIE?
FACTS

• National TB Prevalence (NPS) Survey (2007)

 Only 49.5% are able to complete six months of treatment or
longer
 Default rate is 21.2% among females and 18.8% among males
 Reasons for defaulting:
 Long duration of treatment (6 or more months)
 “feeling of wellness” experienced by the patient while taking the
anti-TB drugs during the 2nd or more months of treatment
 Patient experiences side effects
 If a treatment partner is not available,
it is okay for the TB DOTS facility to start
the TB patient on anti-TB treatment.
TRUTH or LIE?
FACTS

 All patients undergoing treatment shall be supervised

(DOT).
 Directly Observed Treatment (DOT) - DOT is a
method developed to ensure treatment compliance by
providing constant and motivational supervision to TB
patients
 DOT works by having a responsible person, referred to as
treatment partner, watch the TB patient take medicines every
day during the whole course of treatment
A physician can start a registered TB
case on anti-TB drugs of his/her
choice
TRUTH or LIE?
 FACTS
 A patient’s anti-TB regimen shall be comprised of at least
four (4) first-line drugs in fixed-dose combination (FDC)
– except in children unable to take tablet formulations.
 Drug Formulations:
1. Fixed–dose combination (FDCs) – Two or more first-line anti-TB drugs
are combined in one tablet. There are 2-, 3-, or 4-drug fixed-dose
combinations, namely: HR, HRE and HRZE. These are usually provided in
kits with boxes of blister packs corresponding to treatment phases of an
average-weight patient.

2. Single drug formulation (SDF) – Each drug is prepared individually,

either as tablet, capsule, syrup or injectable (Streptomycin) form.

Legend: R-Rifampicin, H-Isoniazid, Z-Pyrazinamide, E-Ethambutol, S-Streptomycin

FACTS
 Treatment shall be based on a Standardized
Treatment Regimen
Treatment Type of TB Patient Regimen
Regimen
 Pulmonary TB, new (whether bacteriologically
confirmed or clinically diagnosed)
Category I   2HRZE/4HR
Extra-pulmonary TB, new (except CNS/ bones
or joints)
Category Ia 2HRZE*/10HR
 
Extra-pulmonary TB, new (CNS*/ bones or
*Note:For TB meningitis in adults,
joints)
ethambutol should be replaced by
streptomycin (WHO tx guidelines)

Legend: R-Rifampicin, H-Isoniazid, Z-Pyrazinamide, E-Ethambutol, S-Streptomycin

Treatment Type of TB Patient Regimen
Regimen
Previously treated drug susceptible TB
 Relapse
 Treatment After Failure
 Treatment After Lost to Follow-up (TALF)
2HRZES/1HRZE
Category II  PTOU
/5HRE
 Others
 EPTB (except CNS, bones or joints)
 

Previously treated drug susceptible TB 2HRZES/1HRZE

Category IIa EPTB –CNS/bones or joints
 /9HRE

Standard
ZKmLfxPtoCs
Regimen Drug
Confirmed cases of MDR- or XDR-TB Individualized once DST result is available
Resistant
 Treatment duration for at least 18 months
(SRDR)

Regimen for Individualized based on DST result and history of

XDR-TB
XDR previous treatment

Legend: R-Rifampicin, H-Isoniazid, Z-Pyrazinamide, E-Ethambutol, S-Streptomycin

Reminder
 Streptomycin intramuscular injections are
to be administered only by trained and
authorized health personnel.
All TB patients who completed their
course of treatment are considered
cured?

TRUTH or LIE?
FACTS

• A patient’s (+) DSSM result from the time of his

diagnosis must be converted to (-) DSSM during the
continuation phase of his treatment up to the completion
of the whole treatment course for him to be considered
as cured.
• Types of treatment outcome:
 Cured
 Treatment completed
 Treatment failed
 Died
 Lost to follow-up
 Not Evaluated
A. Treatment Outcomes for
susceptible TB cases
 Treatment Outcomes
Outcome Definition

• bacteriologically-confirmed TB at the beginning of

treatment
Cured • smear- or culture-negative in the last month of
treatment and on at least one previous occasion in the
continuation phase.

• A patient who completes treatment

• without evidence of failure

Treatment
completed • but with no record to show that sputum smear or
culture results in the last month of treatment and on at
least one previous occasion were negative
(either because tests were not done or because results
are unavailable)  
 Treatment Outcomes
Outcome Definition

• A patient whose sputum smear or culture is

positive at 5 months or later during treatment.
Treatment
failed • A clinically diagnosed patient for whom sputum
examination cannot be done and who does not
show clinical improvement anytime during
treatment.

• A patient who dies for any reason during the

Died course of treatment.
 Treatment Outcomes
Outcome Definition

Lost to • A patient whose treatment was interrupted for 2

consecutive months or more.
follow-up

• A patient for whom no treatment outcome is

assigned. (This includes cases transferred to
Not another DOTS facility and whose treatment
Evaluated outcome is unknown.)

Treatment • The sum of cured and treatment completed

Success
 A. Treatment Outcomes for RR-
TB/MDR-TB/ XDR-TB patients
Outcome Definition
Treatment completed as recommended by the national policy without evidence of failure AND
Cured three or more consecutive cultures taken at least 30 days apart are negative after the intensive
phase
Treatment completed as recommended by the national policy without evidence of failure BUT
Treatment
no record that three or more consecutive cultures taken at least 30 days apart are negative after
completed
the intensive phase. 
Treatment terminated or need for permanent regimen change of at least two anti-TB drugs
because of:
 lack of conversion** by the end of the intensive phase*, or
Treatment
 bacteriological reversion** in the continuation phase after conversion to negative, or
failed
 evidence of additional acquired resistance to fluoroquinolones or second-line injectable
drugs, or
 adverse drug reactions (ADRs).
Died A patient who dies for any reason during the course of treatment. 
Lost to follow-
A patient whose treatment was interrupted for 2 consecutive months or more. 
up

A patient for whom no treatment outcome is assigned. (This includes cases “transferred out” to
Not Evaluated
another treatment unit and whose treatment outcome is unknown)  

Treatment
The sum of cured and treatment completed  
Success
TB cases must comply with three follow-
up DSSM during the course of treatment.

TRUTH or LIE?
FACTS
Schedule of DSSM Follow-Up
1st Sputum 2nd Sputum 3rd Sputum
Category Follow-up Exam Follow-up Exam Follow-up Exam

Towards end of Towards end of

I 2nd month 5th month End of 6th month

Towards end of Towards end of

II 3rd month 5th month End of 8th month
 Anti-TB drugs can cause minor
side effects that could be corrected by symptomatic
treatment.

TRUTH or LIE?
 Possible Side-Effects of Anti-TB Drugs

Side Effects Drug(s) Responsible What To Do?

Major Side Effects: Discontinue taking medicines and refer to MHO/CHO/Physician

immediately

Severe skin rash Any kind of drug (esp. Discontinue and refer
streptomycin)

Jaundice due to hepa Any kind of drug (esp. Discontinue and refer. If
HRZ) symptoms subside, resume
treatment and monitor.

Impairment of visual acuity and Ethambutol Discontinue and refer to

color vision opthalmologist

Hearing impairment Steptomycin Discontinue strep and refer

 NTP Recording Forms

 Form 1. Presumptive TB Case Masterlist

 Form 2. Laboratory Request Form
 Form 3. Laboratory Register
 Form 4. TB Treatment/IPT Card
 Form 5. NTP ID card
 Form 6a. DS TB register
 Form 6b. DR TB Register
 Form 7. NTP referral form
 Form 8. Hospital TB referral register
Form 1. Presumptive TB Case Masterlist
Form 2. NTP
Lab Request
Form
Form 3. Laboratory Register
Form 4. TB treatment card
Form 4. TB Treatment/IPT Card
Form 5. NTP ID card
Form 5. NTP ID card
Form 6a. DS TB Register
Form 6b. DR TB Register
Form 7. NTP referral form
 Summary of procedures for
Case Holding
 Initiation of treatment and registration- Physician or nurse
 Inform the patient that he/she has TB disease and motivate
him/her to undergo treatment.
 Do pre-treatment evaluation. Address all pertinent health issues
appropriately then assign the corresponding treatment regimen
based on the patient’s disease site and registration group.
 Open and accomplish the NTP Treatment Card and two (2) NTP
ID Cards – one for the patient and the other for the treatment
partner.
  Discuss with the patient and decide who will be the most
appropriate treatment partner and where the treatment will be
administered.
 DOTshould be carried out in facilities that are most accessible
and acceptable to the patient. Exert all efforts to decentralize
MDR-TB patients as soon as possible to a treatment facility
most accessible to the patient.
 Register the patient in the TB register. Assign a TB case
number.
  Monitoring Response to Treatment by follow-up DSSM for CAT
I and CAT II and For EPTB patients and patients where DSSM was not
done, treatment response will be assessed clinically (e.g. weight gain,
resolution of symptoms).
Summary
 Case holding requires 6-8 months of treatment through
DOTS Strategy using 4-5 drugs
 TB cases can be classified as Pulmonary TB (PTB) if located in
the lungs or Extra Pulmonary TB (EPTB) if found in other organs.
 Category of treatment is based on WHO
recommendation
 All TB cases who developed side effects should be referred
to the health service provider for advise, reassurance or
treatment.
 DSSM follow-up must be done regularly as scheduled.
Summary
 Chemotherapy is currently the only way to stop the
transmission of TB
 Effective anti-TB drugs are available in TB DOTS facility
 Once a TB patient is registered for treatment in a TB DOTS facility
he/she has a complete anti-TB drug supplies provided from the start
of treatment
 Poor treatment compliance may lead to worst outcomes
 DOT (Directly Observed Treatment) is a strategy to
ensure treatment compliance of TB patient
 DOT works by assigning a responsible person to observe or
watch the patient take the correct medications daily during
the whole course of treatment
Post Test
 Module 2:
Interpersonal Communication and
Counseling
 Session Objectives

By the end of this training, the AIDERS will have:

1. Understood the importance of interpersonal
communication and counseling (IPCC) in
facilitating behavior change
2. Related the importance of IPCC to TB service
provision
3. Demonstrated basic competence in
interpersonal communication and counseling
 Training approach
The three Ds:

1. Describe the skills – Explain what the skill

is, why it is important, when it should be
used
2. Demonstrate the skills – Let the trainees
see an expert (the trainer) perform the skill
3. Drills – Allow/arrange practice sessions
 Course content

This course is divided into 3 sessions:

Session 1: Introduction to IPCC

Session 2: One-on-one IPCC
Session 3: Group IPCC
What is your role as
AIDERS in TB
health service
provision?
 Roles of AIDERS

 TB Educator
 Counselor
 Conducts intensified case-finding activities
 Conducts case-holding activities
 Does referral
 Roles of AIDERS

• Implementer
• Community Mobilizer
• Advocate
• Documenter
• Logistic Support to RHU / MHO / PHN
 What are the
qualities of an
effective TB health
service provider?
 Attributes of effective Health Service Providers

1.Sufficient knowledge
2.Attitudes
 warm
 cheerful
 respectful
 friendly
 committed to service
 accessible
 approachable
 Attributes of effective Health Service Providers

3.Skills
 Good interpersonal communication
 Competent
 Credible
 Resourceful
 Creative
 Culturally sensitive
 Session 1:
Introduction to IPCC
 Contents

1. Definition of communication
2. Elements of communication
3. Definition of IPC
4. Levels of IPC
5. Types of IPC
Game muna tayo
Reverse Charades
Hanapbuhay
MAGSASAKA
MACHO DANCER
DUKTOR
FLIGHT ATTENDANT
BOLD STAR
SEPULTURERO
AIDER
Communication
 What is Communication?

 the process of sharing information, ideas, values,

beliefs and attitudes.

 expressing, listening, reflecting on information that

convey facts, ideas, values, and beliefs
Elements of communication
Sender and Audience
 Audience

 Sender
 Receiver

 They go through stages of behavior change

 It is important to know their stages to know how to
communicate to them
Message and Feedback
 Messages and feedback

 Key health facts and messages on TB

 They flow in a circular or cyclical fashion to and
from the sender and receiver creating spirals to
bigger and bigger cycles as communication
progresses
Channel
 Channels

1. Mass media
2. Community channels
3. Interpersonal communication
a) One-to-one communication
b) Group communication
Environment
 Environment

 Condition or context of communication that may

facilitate or impede on the process
 Environment may be:
 Barrier
 Motivation
 Barriers in Communication

 Ano ang mga magiging

“barriers” sa trabaho
nyo bilang AIDER?
Some examples of “Barriers”
Mga hadlang sa pakikipag-ugnayan

1. Pagka-abala sa ibang bagay

2. Inis o galit
3. Karisma ng kausap
4. Makasariling interes
5. Paglipad ng isip
6. Personal na problema
7. Magkaibang paniniwala
 Barriers

 Ano ang dapat gawin

upang di makasagabal
ang “noise or barrier” sa
inyong pakikipag-usap
sa mga pasyente o
kliyente?
Interpersonal Communication
 What is Interpersonal
Communication?
1. IPC is the face-to-face, verbal and non-verbal
exchange of information between two or more people

2. Through IPC, we learn from others and find out their

opinions/ feelings / knowledge, and life situation

3. Through IPC, we share our opinions/ feelings and

knowledge to others
 Levels of Interpersonal
Communication
 Health Provider with client (examples:
information-giving and counseling)

 Health Provider with group (examples: group

discussions, health education sessions)

 Health Provider with community leaders and

influential people (examples: advocacy, social
mobilization)
 Types of Interpersonal
Communication
 Verbal Communication
 Non-verbal Communication
 What is Verbal
Communication?
 Communication using the “verbal” meaning
“concerned with words”

 refers to communication through sounds, words,

speaking, vocabulary and language.
What is Non-verbal Communication?

 Communicating messages without using words

 Body language

 Often more accurate in communicating a

person’s true feelings (Actions speak louder than
words.)
Forms of Non-verbal Communication
 Ang ganda ganda
Exercise
(gwapo gwapo) mo!
 Kung ikaw ang pasyente, alin sa mga
sumusunod ang gusto mong makita sa isang
health worker?
 Non-verbal Communication

REMEMBER!
 A message is received according to this
proportion
 Words: 7%
 Tone of Voice: 38%
 Body Language or non-verbal: 55%
 Session 2
One-on-One Interpersonal Communication and Counseling
 What is Counseling?

 An interpersonal process that assures that each

client is guided to make a well-informed and
voluntary choice of action that is best suited to
address his or her individual health need(s)

 A person-to-person interaction in which the

health service provider gives adequate
information which will enable a client to make an
informed decision about his/her health.
The importance of Counseling

 Counseling helps the client understand and deal

with his/her specific, personal health concerns

 Effective counseling empowers a client to make

his/her own decisions about a particular health
concern.
 TB counseling

 Probably more difficult than for other health

programs because of:
 Stigma
 Fear of infection
 Difficulty of diagnosis
 Length of treatment
Counseling in TB Case Finding and
Case Holding

 Counselling is the link between health provider and

the client—strengthening the partnership in care

 Counselling will help address barriers that prevent

clients from completing the 6 steps in the Cough to
Cure pathway
 Cough to Cure Pathway (C2C) to Ideal
Behavior in TB Control
1. Seek early care
 Recognizing and accepting early signs and symptoms
2. Go to DOTS facility
 Choosing to seek TB care from DOTS facility
3. Complete diagnosis
 Complying with diagnostic procedures
4. Start treatment
 Agreeing to undergo treatment
5. Continue treatment
 Committing to complete treatment
6. Complete treatment
 Seeking confirmation as cured TB patient
 IPCC is a 5-phase process
 Phase 1: Establishing rapport (pakikipagpalagayang-loob)
 Phase 2: Correct assessment of the health problem
 Phase 3: Recommendation of options for solving the
assessed health problem.
 Phase 4: Discussing alternatives or negotiation for the
client to immediately perform the required actions
 Phase 5: Summarizing
Phase 1. Establishing & maintaining
rapport
 Good rapport sets the tone for a positive and
productive one-on-one session

 Bad vibes could result in

 withdrawal of trust
 withholding key information
 being hostile or antagonistic
RAPPORT = pakikipagpalagayang-
loob
 Good rapport starts with…

 A warm, enthusiastic and genuine greeting

 Giving your full attention
 Introducing yourself, asking for the client’s nickname
 Telling the client that s/he has done right in going to
the health center
 If necessary, assuring her/him that anything that is
discussed during the session will be kept confidential
The purpose of asking
Phase 2. Assessment: Ask questions

1. What is the health issue which prompted the visit to the

health facility?

2. What s/he is doing or has done about the health issue?

Pointers on how to ask questions

DOs

 Use open- and closed-ended questions to arrive at the

collection of basic facts.
 Try to find out what the person believes and does, what
she or he does not know about the subject and what this
all means to her/him.
 Ask questions that allow people to inform you about
their needs and desires for information.
 Ask in a natural, easy, casual, and friendly manner.
Open –ended and closed questions

Activity: What questions do you usually ask clients?

Make sure the client understands
what you mean
Identify what the client already knows about
a subject or her/his experience on the topic
Understand the whole context of the
client’s situation
Help the client talk about a difficult
topic
To get more specific
information
 Pointers on how to ask questions
DON’Ts

 Don’t ask leading questions, e.g., “Nahihiya ka ba na mayroon

kang TB kaya hindi ka nagpupunta ng Health Center?”
 Don’t ask questions simply because you’re curious.
 Avoid the use of technical terms, very complicated
questions, or too many questions at one time as this
would confuse the person being asked.
 Distortion
 Distortion is the degradation or alteration of
messages in the process of communication.
 In counseling, messages may be distorted when
asking questions: There are many factors in the
environment that distort the message (both in
delivering the message and in receiving the
message).
 Distortions can occur for both the listener and
the receiver and may happen at any phase in
IPC/C.
Ano ang mararamdaman mo sa
ganitong pagtatanong?
Phase 2. Assessment: Listen

Listen to what the person is SAYING (verbal) and

what s/he is NOT SAYING (non-verbal)…
 Tips for active listening
 Be ATTENTIVE

 ACKNOWLEDGE views and ideas

 Be ALERT and listen to facts, feelings, attitudes,

and emotions

 Show RESPECT

 Don’t interrupt unless absolutely necessary.

Phase 2. Assessment: Discuss/clarify
 Avoid premature diagnosis and haphazardly
recommending a solution or treatment
 Summarize and present your understanding of
the health concern based on client’s answers. Ask
your client if your summary is accurate.
Example:

Based on what we have talked about, you said that you have been
coughing for about two weeks now and that your children are also
sick with cough and fever. You have taken medications but nothing
works so far. Am i correct?
Phase 2. Assessment: Discuss/clarify

 Ensure that the health need is clear to BOTH you

and your client

 When you and the client are in agreement about

the health problem, you are ready to move to the
next stage

 Clarifying is a good technique in addressing

Distortions.
 In asking, listening, and clarifying,
your goal is to …

Accurately assess your CLIENT’s health needs

 Plenary Activity
(provider-client scenario)

Health provider: Find out how s/he can help a first-time

visitor-client using rapport and assessing skills

Client: She is new in the community and have been

coughing for a couple of days. She is a single mother
and a fish vendor with one child. She is ashamed to
visit the center because she thinks she might have TB,
but she fears she could infect her family. She was just
forced by her mother to visit the center.
 Plenary Activity
(provider-client scenario)

Client: Only provide information that the provider

asks for and never volunteer information

Observers (Audience) : Observe rapport and, in

particular, assessing skills using IPCC checklist
 Phase 3. Recommendation

 Provide medically correct Information that could

help client take action
 What is medically-correct &
responsive information?

 Medically-correct information is unbiased,

evidence-based, updated and accurate.

 Responsive information is
 relevant to the health concern only
 in a tone that is appropriate
 using language that avoids technical terms and is easy to
understand
Stages of Behavior Change
Applying behavior change theory in providing
precision, need-based information
PRE-CONTEMPLATION
• People do not intend to take action within the next 6
months
• Possible causes:
– Lack information
– Have inadequate information about the consequences of
current behavior
– Have tried to change a number of times but failed
CONTEMPLATION
• People intend to change in the next 6 months
• Aware of pros and cons of changing behavior
(benefits vs. costs)
• Balance between pros and cons can cause prolonged
inaction
PREPARATION
• People intend to take action in the immediate future
(usually within the next month)
• Have a mental plan of action
ACTION
• People have made specific, observable changes in
behavior the past 6 months
• Vigilance against relapse to a previous stage is
important
ACTION
• People have made specific, observable changes in
behavior the past 6 months
• Vigilance against relapse to a previous stage is
important
ACTION
• People have made specific, observable changes in
behavior the past 6 months
• Vigilance against relapse to a previous stage is
important
MAINTENANCE
• People are working to prevent a relapse to a
previous stage
• People are more confident that they can continue
performing the behavior
 Stages of Change

 Precontemplation
 Contemplation
 Preparation for
Action
 Action
 Maintenance
 So What?

What are the implications of this model on how we do

provide health services?
Implications of this model on IPC/C

 Individuals will have varying information needs

depending on what stage they are in the change
continuum

 Because we know that individuals are not in the same

stage of change

 We develop custom messages and provide

recommendations that fit the current behavior change
stage of individuals or groups
Pre-Contemplation
• Possible IPC/C interventions:
• Information & education
• about consequences of behavior
• Other alternatives or options for individuals
Contemplation (to action)
• Possible IPC/C interventions:
• Information & education about consequences of behavior
(increase motivations)
• Information & education that address barriers
• Persuasive messages
Preparation
• Possible IPC/C interventions:
• Practical info on how to correctly perform behavior
• Persuasive messages and encouragement
• Suggestions to action; other options
• Negotiate to immediately take action or “improved behaviors”
Action
• Possible IPC/C interventions:
• Support and encouragement
• Discuss benefits of positive behavior
• Discuss how to overcome barriers to maintaining positive behavior
• If encountering difficulties, negotiate to slide to a less complex, more
feasible behavior
Maintenance
• Possible IPC/C interventions:
• Positive reinforcement and social support (praise and rewards)
• Regular small-group discussions on benefits of behavior change
• Encourage to tell others (accountability)
Pre-Contemplation

“Ang TB ay Nagagamot”
Contemplation (to action)
• Panatilihing malusog ang sarili para hindi mahawa ng
TB.”
• Libre ang gamot sa health center
Preparation

Persuasive: “Iwasan mong mahawaan ang iyong anak.”

Practical: “Takpan ang bibig at ilong kapag umuubo at
bumabahing.”
Alternatives: “Gamitin ang manggas o loob ng kuwelyo kung
walang panyo pag umuubo.”
Action

“Pumunta na sa pinakamalapit na health center at maagapan

agad ang iyong sakit.“
Maintenance

“Huwag itigil ang pag inom ng gamot kahit ilang araw pa

lang at nakakaramdam na ng ginhawa. Masisiguro ang
iyong paggaling kapat nakumpleto mo ang gamutan.”
What information to provide

 Explain what the medical problem / issue is

 Tactfully correct misconceptions about the health issue

(if you detect any)

 If needed and there is time, explain how the remedial

action works. If done correctly, this will help eliminate
or reduce the spread of rumors and misconceptions
What information to provide

 If client has taken action that is not medically-correct

(as in self-medication), explain
 why it is wrong
 the possible adverse effects of such action
 the correct action

 If client has taken action that is partially correct, explain

 What s/he did right
 What s/he did incorrectly
 what else s/he might do to complete the health action
What information to provide

 If there is only one prescribed course of action to

address the medical problem / issue:
 Explain the benefits of implementing the prescribed course of action
 Explain the negative results of not implementing the prescribed course of
action
 If there are several remedial actions to choose
from:
 Explain the applicable options, and the advantages / disadvantages of each
option
 If client asks about what you think, give your professional opinion of the
best course of action. But be clear that it is up to the client to choose.
What information to provide

 If needed and there is time, explain how the

remedial action works. If done correctly, this will
help eliminate or reduce the spread of rumors and
misconceptions

 Explain how to perform the remedial action.

Tips in providing information
Use simple language and Speak
clearly
Demonstrate how to perform
essential actions
Use reminder material for client to take home and
use to remember undertaking the essential actions
Provide information using job aids
 How provide to information

 Give out appropriate

IEC materials as
reference for discussion
with family members or
spouse
Using Visual AIDS
 What is a visual aid?

 Visual aid is any tool or instrument being used to

facilitate learning.
 It can be a whiteboard, flip chart, overhead projector
(OHP), PowerPoint presentation, video, props,
handouts, yourselves demonstrating an action or in a
role play
 Aim: To effectively transfer the information being
communicated or presented. o your presentation and
ideas
 Phase 4. Discussing alternatives for
client action or behavior

 Health providers need to negotiate for the client to

perform actions or behaviors that will lead to the
solution of the health issue
 Merely imposing your authority often results in clients
who say they will do what you want them to do but turn
out not doing anything
 Or they perform aspects of the health behavior that is
acceptable to them and not perform those that they are
opposed to or find not doable for some reason
 Discussing alternatives or
Negotiation can be used for…

 Prescribed treatment regimens (ex. Malaria, TB

DOTS)

 Multiple options (ex. Family Planning,

Nutrition)
 What are behaviors?
 Behaviors are concrete actions; A combination of four
components
 Action
 Target
 Context
 Time
 Sample description of a behavior:
Always (time) cover (action) your (target) mouth
and nose when coughing or sneezing (context)
 Motivations

 an internal state or condition in an individual that

serves to activate or energize behavior

 sometimes described as “want”, “need”, or “desire”

 The strength of the motivation determines the

intensity and direction of the behavior.
 Barriers

 factors that prevent individuals or large segments

of a population from performing the ideal or
feasible behavior.

 Also called “resistance”

Seek Early Care

Presumptive TB Case recognizes/accepts presence of TB symptoms

Poor knowledge of TB symptoms, susceptibility, and

consequences of TB
Presumptive TB Case decides to seek
care:

 Low knowledge of potential TB consequences to

self/family
 Lack of sense of urgency to seek early are
 Inadequate financial capacity to seek care
Presumptive TB Case decides to seek
care:

 Lack of support from relatives/ friends

 Fear of stigma associated with TB
 Lack of knowledge on appropriate people to consult
2. Go to DOTS Facility

Presumptive TB Case chooses DOTS over

non-DOTS provider

 Low awareness of DOTS services and providers

 Poor accessibility of DOTS providers
 Non-acceptability of DOTS providers and services
 Direct and indirect costs are not affordable for the
patient
3. Complete Diagnosis

Presumptive TB Case complies with diagnostic procedures particularly sputum

examination

 Client does not believe in examination’s importance

 Examination is not acceptable and/or affordable
 Procedure is inconvenient
 Long turnaround time
4. TB patient agrees to undergo TB
treatment after diagnosis is made

 Patient is not convinced of the urgent need for

treatment
 Treatment is not acceptable, affordable, or accessible
 4. TB patient agrees to undergo TB
treatment after diagnosis is made

 Providers are not acceptable to the patient

 Treatment interferes with lifestyle or routine
activities
 Lack of social support from family or friends
5. TB patient adheres to treatment

 Patient is unaware of the value of completing

treatment
 False sense of cure due to feeling of well being
 Treatment is no longer acceptable, affordable or
accessible
5. TB patient adheres to treatment

 Lack of support from family and friends

 Presence of competing priorities
 Lack of support from health providers
6. Patient is cured

 Patient is unaware of the importance of being

declared cured (Submit to sputum exam towards end
of treatment)
 Barriers Vs. Motivations

 When the strengths of the motivation and barrier

are equal, the individual stays in a prolonged state
of inaction (behavioral procrastination)
How to negotiate for desired/feasible
behavior?
 People change when they believe that the benefits of
adopting the new behavior exceed the disadvantages

 Behavior change can occur if the person has a strong,

positive intention or commitment to perform the
new behavior

 People are likely to adopt a new behavior when they

believe that others will approve it
 Negotiating for desired/feasible
behaviors
 Increase motivations / supports
 Eliminate / reduce the effect of barriers
 When Discussing alternatives or
Negotiating, Remember…

 People always act according to what they think is:

 their best interest and/or
 the best interest of the people they love
 In many instances, we may know they are wrong
but People will still perform a behavior in pursuit
of this “best interest”
 Discussing alternatives or
Negotiation steps, simplified

1. Subukan
2. Gawin palagi, hanggang… (so that the client will
see the benefit of doing the behavior)
3. …Makasanayan
 Phase 5. Summarizing

 Summarize main points of the interaction

 Highlight the key messages
 Pose a call to action
 Solicit client’s commitment

MAKE A LASTING IMPRESSION!

The Cough to Cure Counseling Chart ( C2C C2 )

 Identifies:
 What health provider needs to say and do for each step
 Ideal outcomes for each step
 Enables health provider to save time in counselling
and give only information required to prevent
overload
The cough to cure matrix handout
Identifying stage in the pathway

 Usually very evident specially if you have been

counseling the patient in the past

 Let’s practice…
 Role play

 Participants to divide into triads or small groups

 Each member of the groups will shift roles in every
scenario to act as health provider, TB patient,
observer
 Situation 1

Gina is an AIDER who she notices her

suking fish vendor Gloria, 25 years old,
coughing. Gloria asked to be excused for her
cough. But she can’t explain where she got
it. Gloria lives in a small house with 3 other
families with small children. What should
Gina do?
 Situation 2

Martin, 52, has been diagnosed with TB. His

whole family are presumptive TB patients.
He wants to keep the knowledge away from
his family as he doesn’t want to burden
them. He doesn’t want a treatment partner to
go to his house because there will be
questions. He says that he would rather not
begin treatment.
 Situation 3

Susan, 25, is married to Ronnie, 26, a TB patient

taking anti-TB drugs for the past two months.
Susan visits the health center to consult about what
she feels is very strange behaviour of her husband.
“Since taking TB medicines,” Susan says, “Ronnie
has started acting like a “maniac,” always
demanding “you know”. Bakit ganoon? Is his
behaviour a side effect of anti-TB drugs?” She
wants Ronnie to stop taking the TB medication.
 Situation 4

Noynoy, 48, has been showing symptoms

of TB and has been advised by his doctor
to undergo DSSM for diagnosis. At the
DOTS center, he is required to produce
two sputum specimens. How do you
advise Nonoy to produce quality sputum
and in what quantity?
 Processing of Scenarios:

 What do you think are the most powerful

motivations that will help to address behavioral
barriers that contribute to low case finding and
poor treatment compliance in your areas
 Suggest ways that will improve the service
providers’ attitudes to TB and TB clients.
 Summary

 There are behavioral barriers in both clients and

service providers
 Positive behaviors of service providers have a strong
impact/influence on clients
 The C2C C2 provides a clear framework and guide to
service providers to care for TB patients
 Give only the information/message that is relevant for
each step
Thank you!
 Session 3
IPCC in Groups
Who among you are comfortable talking
in front of many people?
Who are anxious or afraid to do so?
What do you feel?
What techniques did you try to overcome
your nervousness
Phases of group health education

Every group health education session involves 3

phases:

 Planning & Preparation (Before)

 Delivery (During)
 Post Activity (After)
Bus Stop Exercise
 Planning & Preparation

 What are your communication objectives?

 Session Outline:
 structure of the topic presentation?
 sequence of sub-topics?

 Duration?

 Visual aids?
Presentation Skills

344
 Topic Outline

 Hook
(energizers, imagination, position statement, self-rating, associations)

 Orient
(objectives, benefits, show and tell, display, flowchart, teeing up)

 Input
(example, interviews, right-left comparison, synonyms, check understanding, press
conference, temperature check)

 Summarize
(Q and A, Quiz, Statements, Cases, Exercises)

 Challenge
(implications, applications, Insights, lead to next step)
 Planning & Preparation

 Check materials, supplies, equipment

 Setup a conducive physical environment
 Rehearse your session
 Be CREATIVE! A PowerPoint presentation is not
always the best tool to facilitate adult learning.
 Delivery

 Physical appearance
 Rapport with the group members
 Voice
 Posture and body movements
 Job aids
 Culturally-appropriate humor
 Post Session

 Course Evaluation
 Debriefing
 Monitoring (referrals, peer educators, etc.)
 Recording & Reporting
 7 Tips in conducting group
presentations
1. Know your audience: their interests and issues
2. Be sensitive and respectful
3. Learn a relaxation technique to counter nervousness
4. Avoid turning your back to the audience
5. Pause or maintain a moment after stressing an
important point
6. Always maintain eye contact with one member of the
group
7. Practice breeds confidence
3 Minutes of Fame
As health service providers, how can we
promote health in our communities?
 What did you observe?
 How was the activity done?
 What was my role?
 What tools did I use?
Facilitating a group discussion

A Facilitator…
 Ensure effective flow of communication within a
group of participants to share their thoughts and
arrive at a decision
 Is sensitive to both verbal and non-verbal
communications that occur in the group
 Your Role in facilitating a group
discussion
 Pose challenging questions
 Bring out opinions
 Encourage to think critically, leading to group
analysis
 Help everyone to participate
 Stay neutral
 Keep discussion relevant and on-topic
 Keep track of time and remind time lapse
 Importance of Listening and
Observing
 Lets you know when to ask appropriate and
sensitive questions

 Listen and observe for:

 Cues indicating one’s desire to speak
 Cues for boredom and withdrawal
 Signs of suppressed anger or hostility
 Cues for shyness
Facilitating problem participants

 Disinterested type
 Argumentative type
 Overly talkative type
 Rambling type
 Controversial type
 Handling A Difficult Audience

 House rules should be given at the start of the training.

 Move closer to participants who are constantly in
private conversation.
 Address a heckler directly or tell him politely that he
will have his own turn.
 Call another participant or shift to a new topic.
 Raise the volume of your voice and call participant’s
attention or make a pause until everybody’s attention is
in him.
 Handling A Difficult Audience

Disinterested Type
 Stress personal benefits to be gained
 Direct questions to the individual to get involvement
 Seat the person in the middle of the discussion flow

Argumentative Type
 Direct questions raised by others back to him/her
 Direct the person's questions to the team for answering
 Avoid being drawn to an argument - let the group settle issues
 Seat the person at your immediate right or left
 Handling A Difficult Audience

Overly Talkative Type

 Direct questions away from the person to other members
 Talk to the individual privately and suggest value of letting others
participate
 Seat the person to your immediate right/left

Rambling Type
 Suggest listing the points raised to lead them to organize their ideas
 Briefly summarize all important points so far - bring them into focus
 Point out the need to stay in schedule to curtail rambling
 Handling A Difficult Audience

Controversial Type
 Try to see point of controversy and plan answers to them
 Defer points for later report
 Defer points for private discussions
Exercise in facilitating groups
Thank You!
 Module 3:
Reporting Accomplishments
 Performance Indicators

Reportable to NTP and Global Fund;

anchored on the enhanced PhilPACT
targets
 Performance Indicators

Indicators 2014 2015 2016

1. Number of Cases Notified

3000 3600 4000
by AIDERS (all sites)

• No of Cases - confirmed TB case

• Notified - recorded into the TB registry
 Performance is measured

 To monitor and evaluate accomplishments against

targets
 To establish performance gaps which may need
additional support (mentoring sessions)
 In the GF context, performance is measured as
condition for funding (performance-based funding)
AIDER Performance is also measured to
establish:

 Number and Percent of cases contributed by

AIDER in the overall number of cases of the facility
where the AIDER is assigned and;

 Increase in the TB Performance of the facility

within the period of AIDER deployment compared
to the same period prior the AIDER initiative.
Familiarization on
GF Report Forms
AIDER Monthly Consolidated Report
 Reporting Flow
NTP Nurse
AIDERS RO PBSP DOH
MHO

Maintains Submits Endorses

NTP nurse Prepares
record of Monthly approval of
validates/certi quarterly
confirmed & Consolidated PUDR to
fies AIDERs consolidated
referred TB Report (every Global Fund
report reports;
cases 15th of the twice a year
Conducts
following (Aug. 15 for
quarterly
month) to Jan to June
MHO OSDV
PBSP report & Feb
approves and 15 for July to
Submits: 1) endorses to Dec report)
Monthly RO for Submits Submits
AIDER Report approval Quarterly quarterly *Technical Working
2) Masterlist (every 5th day Accomplishm report to DOH Group for TB & Phil.
(every 3rd of of the ent Report to (TWG & CCM) Country
the following following PBSP every Coordinating
and semestral
10th day ff. Mechanism
month) month) report to
end of Global Fund
quarter
 Reporting Requirements
Prepared/ Primary Form Supporting Approved by Submit to Due Date
Submitted Forms
by
AIDER AIDER MHO/Physician or DOH-RO Every 3rd of
Monthly Masterlist Authorized (Technical the following
Report or Logbook Representative Staff*) month
AIDER
*Renz

Monthly AIDER Regional Director or PBSP Every 5th of

Consolidated Monthly Authorized the following
Report Report Representative *Cyril month
(ARD/Cluster
Head/NTP
Coordinator)
DOH-RO
(c/o TS)
Quarterly Regional Director or PBSP Every 10th of
Consolidated Authorized the month
Report Representative *Cyril following end
(ARD/Cluster of quarter
Head/NTP
Coordinator)
 On-Site Data Validation

Ensures that data describing programmatic

achievements are of high quality and performed
quarterly by PBSP
 Documents for Validation of Report

 AIDER TB Case Masterlist

 Return Slip of Referral form (if applicable)
 DS TB Registry
 Lab Registry
 Treatment Card
 Reporting Schedule

 AIDER Monthly Report for MHO approval (on or

before the 3rd of the following month)
 Approved AIDER Report to RO (on or before 5th of
the following month)
Planning/Next Steps
DOH-RO Admin
& Other Concerns
Graduation