Operational Handbooks

The basic principle of a health behaviour change is that people hold a range of beliefs about their problems and behaviours. They range between those who do not acknowledge that there is a problem, those who acknowledge that there is a problem but are not ready to act and those who understand and make efforts to act but are unable to persist with desired actions. A careful assessment of an individual’s readiness or preparedness to change can help a healthcare provider plan further intervention.

In cases where the healthcare providers feel that the person does not understand the nature of undernutrition, potential harm and need for diet modification or nutritional supplements, the healthcare providers should follow the principles of ‘health education and counselling’ described in chapter 3 to educate the person.

An assessment of the cause of undernutrition is essential. If the cause is primarily poverty or food insecurity related, these socioeconomic issues will need to be addressed. If underlying medical causes are suspected, then an appropriate medical referral should be considered. In cases of co-morbid medical (e.g., diabetes) or psychiatric conditions (e.g., alcohol use), again the individual should be referred appropriately.

In view of a strong bidirectional causal link between TB and undernutrition, WHO recommends that all persons with active TB should receive appropriate counselling based on their nutritional status at diagnosis and throughout treatment (21).

If a mental health condition is suspected or identified, refer the patient to appropriate mental health services.

It is important to realize how stressful it can be to care for people with TB and how important the caregiver is in helping the patient to recover completely from TB. Caregivers need to be respected even if they find it difficult to support the patient with TB; if the patient allows, the caregiver should be involved in making decisions about treatment. Providing support to the caregivers is an important psychosocial element of treatment for chronic conditions (45)

Some areas that may help assess the stress in caregivers are:

Stress can affect a patient’s ability to respond well to problems. Patients may feel helpless or lack confidence in managing their problems, or possibly their feelings of anxiety or grief will get in the way of managing their day-to-day problems well. Problem-solving is a step-by-step strategy that may help distressed patients to solve and manage their problems (55).

In general, direct advice should not be offered. Instead, patients should be helped to explore their own solutions (see Box 2).

Strengthening social support is important to reduce the many of the harmful effects of stress (45).]

Basic psychological support tries to help people deal with emotional distress and help them recover from stress responses (53). In addition to following the principles of effective communication in Section 5.2, these guidelines should be followed:

Section 3.2.2 describes factors that can affect a person’s psychological health, cause distress, decrease their quality of life, prevent them from following their treatment plan and cause them not to be able to complete a course of treatment.

Being diagnosed with TB and worrying about its impact on what a patient needs to do daily – employment, income, family and taking treatment as prescribed – can be an extremely stressful experience. A stress response can manifest in psychological symptoms, physical symptoms and changes in behaviour (see Table 4).