摘要：Objectives. We sought to determine the efficacy of coaching Latino adolescents with latent tuberculosis infection to adhere to isoniazid treatment. Methods. Participants (n = 286) were randomly assigned to adherence coaching, attention control, or usual care groups. Adherence was measured via interviews and validated with urine assays. Results. Coaching resulted in significant increases in adherence compared with attention and usual care groups. Bicultural adolescents were more likely to be adherent than those most or least acculturated. Age and risk behavior were negatively related to adherence. Conclusions. Coaching can increase Latino adolescents’ adherence to treatment for latent tuberculosis infection and should contribute to tuberculosis control for adolescents at high risk of contracting the disease. Education, screening, and treatment for tuberculosis (TB) declined from 1985 to 1991, 1 contributing to an epidemic of 26 283 new US cases of Mycobacterium tuberculosis in 1992. 2 Reduced TB control resources, inadequate medication adherence, and AIDS contributed to the resurgence 3, 4 and emergence of multidrug-resistant TB. 5– 7 The increased incidence of the multidrugresistant form of the disease in the United States 8 has led to a need to ensure adherence to treatment regimens. Although TB rates in the United States have decreased as a result of renewed aggressive treatment of active cases, goals for reduced incidence have not been realized in ethnic minorities and foreign-born individuals. 9, 10 The 2010 national goal calls for an overall case rate of less than 1 per 100 000. 11 In 1998, the overall case rate in the United States was 6.8 per 100 000, with Asians/Pacific Islanders having the highest rate (34.9 per 100 000), followed by African Americans/Blacks (17.4 per 100 000), Latinos/Hispanics (13.6 per 100 000), and Whites (3.8 per 100 000). 12 Progression from latent TB infection (LTBI) to the active form of the disease accounts for most cases, and about 10% of infected individuals develop active TB. 13, 14 This suggests that LTBI treatment is important for populations at high risk of developing active TB. 15 Since about 50% of active and LTBI cases occur among immigrants to the United States and other developed nations, 16 and the San Diego–Tijuana border (the area of focus in the present study) is the busiest in the world 17 with about 9 million crossings per month, 18 TB control efforts along the US–Mexico border should include screening and treatment of LTBI and adherence support. LTBI treatment requires balancing possible risks of developing disease versus medication side effects. 19 Because completed LTBI treatment conveys nearly (90%) lifetime prevention of active TB, 20 and because adolescents face the lowest risk of isoniazid (INH) side effects, 21 adolescence is the optimal period for treatment in terms of safety and number of “protected” years of life. Another important reason for directing treatment toward this group is that the distribution of active TB cases has shifted toward individuals of younger ages. 22 Across all categories of disease, both adults and children demonstrate poor adherence with medication regimens. Depending on the regimen, nonadherence rates have been shown to range from 20% to 80%, 23 and adolescents have exhibited more difficulties than those in other age groups in terms of adhering to various regimens. 24 Low adherence is a significant barrier to TB control. 25, 26 Healthy People 2010 calls for 90% of LTBI patients to complete treatment. 27 However, across a variety of measures (e.g., self-report, chart review, pill count, electronic monitor) rates of reported adherence to self-administered LTBI treatment for usual care participants range from 5% to 50% in adults 20, 28– 38 and 50% to 72% for adolescents. 39– 42 Observed treatment completion rates as low as 5% among adults and 50% among adolescents suggest that the nation’s objectives will not be met without specific interventions. A number of interventions aimed at increasing adherence to LTBI treatment have been reported. They have generally focused on adult high-risk populations including drug users, 28, 29, 43, 44 foreign-born immigrants, 37, 45 homeless people, 46 recently released inmates, 34, 35 HIV-positive individuals, 47, 48 and contacts of active cases. 48, 49 Discerning the effectiveness of these interventions is complicated by significant variation in adherence measures and definitions of adherence. Nonetheless, postintervention studies primarily using patient education have reported adherence rates between 23% and 68% 34, 38 ; those using peer counseling, rates between 60% and 78% 28, 37, 43 ; those using incentives such as cash, clothing, or transportation or food vouchers, rates between 71% and 89% 28, 29, 34, 46, 50 ; and those using directly observed preventive therapy, rates between 54% and 94%. 29, 38, 46, 48, 51 Limited data are available on adherence interventions targeting adolescents with LTBI. Kohn et al. 42 demonstrated a significant increase in INH adherence in a twice-weekly directly-observed preventive therapy group (88%) compared to a self-administered daily INH treatment group (50%). Morisky et al. 40 assessed the effects of peer counseling, contingency contracts, and a combination of peer counseling and contingency contracting. Participants in the combined intervention group showed the highest (80%) treatment completion rate, followed by the peer counseling group (74%) and those in usual care (72%). Following Sumartojo’s recommendations to use a theoretical model and multiple and reliable measures, 26 we designed an experimental intervention based on learning theory and our Behavioral Ecological Model. 52– 54 These approaches assume that adherence is influenced by interactions between an individual and his or her social and physical environment. 55– 57 The present study was designed to determine whether counseling/coaching, compared to attention control or usual medical care, could increase adherence to INH treatment regimens among Latino adolescents with LTBI.
