Effective TB Interviewing 

for Contact Investigation: 

Self-Study Modules 

Developed in partnership with The New Jersey Medical 

School Global Tuberculosis Institute 

2006 

Department of Health and Human Services 

Centers for Disease Control and Prevention 

Division of Tuberculosis Elimination 

Atlanta, Georgia 

Self Study

Page i 

Introduction 

The TB Interview 

The TB interview for contact investigation is one of the most important components of a TB 

control program. As a result of TB interviews, individuals with latent TB infection, active 

and future TB cases, and source cases of TB disease can be identified and medically 

evaluated. 

The TB interview is an interaction with an index patient or a person with suspected or 

confirmed TB disease who is the initial case reported to the health department. The index 

patient might not be the source case. The interview interaction involves the basic principles 

of effective communication and mutual information exchange. The goal of the interview is 

to elicit information on contacts for contact investigation purposes. This process requires 

practice and a commitment to realizing the interview goal while respecting the patient’s 

need for confidentiality and understanding the importance of his or her role in the contact 

investigation. 

TB interviewing entails a partnership between the index patient and the interviewer. 

Information is shared and exchanged. The TB interview offers an opportunity for 

investigators to 

• Build trust and rapport with the patient; 

• Provide TB education; 

• Engage the patient in the contact investigation process; 

• Identify contacts; and 

• Address the patient’s questions and concerns. 
Self Study

Introduction 

Format of the Self-Study Modules for Effective TB interviewing 

This resource will offer guidance to both new and experienced TB interviewers about how 

to communicate clearly with patients under various circumstances. The self-study format 

offers a self-paced framework for healthcare workers to follow to learn how to conduct TB 

interviews. Effective TB Interviewing for Contact Investigation: Self-Study Modules

describe the steps and information to be conveyed to the patient during the interview, 

including what the patient should expect after the interview process is completed. 

The modules in this resource include: 

Module Topic 

1 The TB Interview for Contact Investigation 

2 Basics of Communication and Patient Education 

3 Cultural Competency in TB Interviewing 

4 Special Interview Circumstances 

Each module will begin with a list of learning objectives and will end with review questions. 

Case presentations are included throughout the modules to illustrate important concepts. 

Prerequisite 

Prior to reading these materials, it is recommended that one read the Centers for Disease 

Control and Prevention’s (CDC) Self-Study Modules on Tuberculosis, Modules 1-9, which 

provide essential clinical and TB control information. If there is not adequate time to 

complete this prerequisite, at a minimum, Module 3, Transmission and Pathogenesis, 

Module 6, Contact Investigation, and Module 7, Confidentiality, should be read. In addition, 

the Core Curriculum on Tuberculosis is also a valuable resource for participants. 

Using this Resource 

Although this resource is most useful when read in its entirety, Modules 1 and 2 should be 

read in consecutive order before other modules are read. Modules 3 and 4 may be read 

independently if each of the individual module’s content needs to be referred to or reviewed. 

Although this material is presented in a self-study format, a supervisor should review each 

module’s concepts and answer any questions the reader may have. For those without the 

benefit of a personalized review, the questions at the end of this manual are accompanied by 

detailed explanations. In addition, a supervisor should also review health department 

protocols and relevant forms for contact investigation and patient interviewing. 
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Introduction 

Additional TB Interviewing Training and Resources 

In addition to reading these self-study materials, viewing the Effective TB Interviewing for 

Contact Investigation videotape and participating in a facilitator-led group training on TB 

interviewing is highly recommended. The video and facilitator-led training manual are both 

available from CDC. A list of additional resources is included at the end of these modules. 

New interviewers should also supplement their learning by observing experienced 

colleagues conducting interviews in a variety of settings. Engaging in role-playing scenarios 

prior to conducting actual patient interviews can also provide an opportunity for reviewing 

interview techniques and experiencing various interview scenarios. 

This resource is not meant to substitute for the learning gained from observation of 

experienced interviewers and, of course, from conducting actual interviews. However, 

understanding the fundamental concepts in Effective TB Interviewing for Contact 

Investigations: Self-Study Modules can help the interviewer become successful in the art of 

TB interviewing. 

Self Study

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Module 1. The TB Interview for Contact Investigation 

Table of Contents 

Module 1. The TB Interview for Contact Investigation ..................................... 1

Objectives ................................................................................................... 1

Introduction ................................................................................................. 1

Interview Strategy ....................................................................................... 1

The TB Interview ..................................................................................... 3

Prioritizing Interviews .................................................................................. 3

Infectious Period ......................................................................................... 4

Use of Respiratory Protection ...................................................................... 5

Structure of the Interview ............................................................................ 7

I. Pre-Interview Activities ............................................................................. 8

II. Introduction ............................................................................................. 9

III. Information and Education Exchange ..................................................... 9

IV. Contact Identification ........................................................................... 13

V. Conclusion ............................................................................................ 17

Re-interviewing ......................................................................................... 18

Summary ............................................................................................... 20

Case Presentations ............................................................................... 21

Case 1....................................................................................................... 21

Case 2....................................................................................................... 23

TB Interview Checklist ........................................................................... 25

Review Questions .................................................................................. 27

Review Questions Answer Key .............................................................. 29

Glossary ................................................................................................ 31

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Module 1. The TB Interview for Contact Investigation 

Objectives 

After reading through this module, you will be able to 

• Define a TB interview; 

• Formulate a TB interview strategy; 

• Identify who requires a TB interview and for what reasons; 

• Prioritize TB interviews based on various factors; 

• Determine an infectious period for contact identification; 

• Conduct a TB interview in a logical and productive manner; and 

• Conduct a re-interview asking the appropriate follow-up questions. 

Introduction 

An interview is a formal, individualized exchange of information. The TB interview is an 

interaction with a patient that involves the basic principles of effective communication and 

patient education. The objectives of the TB interview are to 

• Build trust and rapport with the patient; 

• Provide TB education; 

• Engage the patient in the contact investigation process; 

• Identify priority contacts; and 

• Address patients’ questions and concerns. 

The interview requires skills, commitment to the interview objectives, respect for the 

patient’s need for confidentiality, and understanding of the patient’s role in the contact 

investigation process. 

Interview Strategy 

To formulate a strategy prior to an interview, the interviewer should 

• Understand the purpose of the interview and what should be accomplished; 

• Analyze the interview situation by asking: 

– Where will the interview take place? 

– What is the condition (mental and physical state) of the interviewee? 

– Is there already an established relationship with the interviewee? 

• Anticipate and prepare to deal with resistance. 
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Module 1. The TB Interview for Contact Investigation 

To meet the interview objectives, the interviewer’s strategy should include methods for 

• Building trust and rapport with the patient; 

• Collecting the patient’s personal and medical information and asking for verification, 

clarification, and additional information; 

• Determining what information the patient understands and his or her level of 

comprehension prior to providing education; 

• Continuously clarifying information given verbally or messages conveyed through 

verbal and nonverbal cues; 

• Reinforcing the health and medical regimen during discussion; and 

• Promoting a dialogue by intermittently allowing time for patient questions. 

Completing these tasks does not occur simply by asking standard questions, but by asking 

questions purposefully and in an understandable and sensitive manner. Module 2, “Basics 

of Communication and Patient Education,” will address the skills of asking questions and 

assessing patients for a tailored discussion. 
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Module 1. The TB Interview for Contact Investigation 

The TB Interview 

The TB interview is initiated to identify contacts at risk of exposure to refer for medical 

evaluation for TB infection or disease. Because of this goal, only certain patients need to be 

interviewed. These include patients who 

• Have been diagnosed with verified TB (excluding most forms of extrapulmonary TB, 

but including pleural effusion or miliary TB with cough and laryngeal TB); 

• Are suspected of having pulmonary, laryngeal, or pleural TB; 

• Have been diagnosed with any form of verified TB, abnormal chest x-ray, positive 

tuberculin skin test which indicates recent TB transmission (for example, a documented 

converter who has developed disease or a young child). 

The TB interview is conducted with individuals who may have put others at risk of 

contracting TB. In addition, if there is evidence of recent TB transmission, a source case 

investigation may be initiated. Like a contact investigation, this process attempts to locate a 

patient’s contacts, referred to as associates. In this case, the associate is viewed as the 

“source,” or the person who transmitted TB infection and not the recipient of TB infection 

due to prolonged exposure to the index case. For this reason, it is recommended that 

interviews be conducted with the following groups: parents or guardians of children 2 years 

of age and younger who have TB infection, and children 4 years of age and younger with 

TB disease or chest x-ray findings consistent with TB-related abnormalities. Guidelines for 

interviews for source case investigations are covered in Module 4. 

Prioritizing Interviews 

Once it has been determined who will be interviewed, priority must be assigned to the 

interviews. All interviews should be initiated within 72 hours of TB suspect/case report. 

Follow-up interviews may occur to obtain additional information. A second complete 

interview or re-interview should be done within 2 weeks of initial interview to determine 

additional information that the patient may not have shared for various reasons and to 

confirm previously obtained information. The infectiousness of a patient and his or her 

ability to transmit disease is the main consideration for prioritizing the interview. 

Infectiousness is determined by 

• Site of disease (pulmonary, pleural effusion, miliary TB with cough, or laryngeal TB); 

• Presence of cavitary disease; 

• Positive acid-fast bacilli (AFB) sputum smear; 

• Positive TB culture; 

• Presence of cough or hoarseness; 

• No treatment, recently started treatment, or inadequate treatment; and 

• Length of time of symptoms. 
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Module 1. The TB Interview for Contact Investigation 

Source case interviews take lower priority than interviews with infectious cases. However, 

this may change if the number of skin test conversions or occurrence of new TB cases is 

high in a particular setting. This will be covered in Module 4. Other considerations, which 

may also influence priority of interviews, are location of the patient, ability to locate the 

patient in the field, the patient’s history of nonadherence, and number of interviewers 

available. 

Infectious Period 

In order to bring focus to the interview process, the infectious period must be determined. 

This period is a time frame in which potential exposure to others may have occurred while 

the patient was infectious or able to transmit TB. Often, the beginning of the infectious 

period is when the onset of symptoms occurs, especially coughing. Local or state standards 

should be used to determine the beginning of the infectious period. Some health department 

guidelines denote a specified period prior to the patient recollection of the onset of 

symptoms, particularly coughing. 

For the purpose of the contact investigation, the end of the infectious period is determined 

by the existence of all of the following criteria 

• Symptoms, such as frequency and intensity of cough, have improved 

• Patient has been receiving adequate treatment for at least 2 weeks 

• Patient has shown some evidence of a bacteriological response, such as the reduction of 

the grade of the AFB sputum smear or negative sputum smears 

or 

• Exposure to contacts has ended 

The infectious period should be stated in the form of start date to end date. The infectious 

period provides a timeframe for the patient when identifying information on contacts. 

The determination of the infectious period is based on several factors and should result from 

a collection of all relevant information from both the patient and the patient’s medical 

record. The infectious period may exceed 6 months; however, the patient’s memory of 

details beyond that time frame may be unreliable. Regardless, if review of the patient’s 

medical record or other source indicates that the patient has had signs and symptoms of 

pulmonary or laryngeal TB for more than 6 months, collection of contact and congregate 

setting information prior to that time should be done. Using a retrospective timeline, the 

results of contact evaluations will help determine when to stop identifying more contacts. 

This timeline should start with the date of the interview and work its way back in time. 
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Module 1. The TB Interview for Contact Investigation 

A patient will most likely not be able to provide you with exact onset dates for symptoms. 

Asking the patient to associate symptoms with events may assist. For example, a patient can 

be asked if he or she remembers coughing around a major event or holiday (e.g., his or her 

birthday, Christmas). 

In a source case investigation for a child, the infectious period generally begins 3 months 

prior to the date of the interview. The infectious period end date is the interview date. The 

factors regarding treatment and sputum conversion for ending the infectious period in source 

case investigations do not apply because most young children, as well as persons with latent 

TB infection, are not usually infectious. 

Use of Respiratory Protection 

The infectiousness or potential infectiousness of a patient should be taken into consideration 

by the interviewer, not only for the purpose of eliciting contacts, but also for assessing the 

need for respiratory protection. Appropriate respiratory protection should be used when 

interviewing an infectious or potentially infectious patient. However, the use of respiratory 

protection may cause difficulty in establishing rapport with a patient, as some patients may 

be offended. If respiratory protection is used, the interviewer should explain to the patient 

why its use is necessary. For additional information regarding the infectiousness of patients, 

please consult the CDC resource, Self-Study Module on Tuberculosis #5: Infectiousness and 

Infection Control. 

There are two basic types of respiratory protection that may be utilized during contact 

investigation: 

• Personal Respirators – There are a variety of personal respirators available. The most 

commonly used personal respirator in a healthcare setting is the disposable N-95 

respirator. Research has shown that use of a surgical mask is not adequate in capturing 

all TB bacteria. Some surgical masks fit poorly and, therefore, provide very little 

protection from any airborne hazards. Personal respirators should be used by the 

interviewer around an infectious patient. Different varieties of personal respirators are 

available. Staff should be trained on the appropriate method of wearing respirators and 

be fit tested according to their institutional policy. A personal respirator should not be 

worn by a patient, since it may result in increased difficulty in breathing for the patient 

and is generally more expensive than a surgical mask. 

• Surgical Mask – These masks should be used by the infectious patient and may prevent 

M. tuberculosis bacteria from spreading. However, surgical masks can be loose fitting 

and, depending on the proximity of an individual to the patient, may not be an adequate 

barrier for all M. tuberculosis bacilli. 
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Module 1. The TB Interview for Contact Investigation 

In situations involving infectious or potentially infectious patients, personal respirators 

should always be worn by interviewers and surgical masks should only be worn by patients. 

There are a number of different factors that affect the use of respiratory protection by the 

interviewer and patient. Detailed below are several common contact investigation scenarios 

with infectious patients, and the correct use of respiratory protection for each scenario: 

• Interview in an infectious patient’s home – While many infectious patients are 

hospitalized, this is not always the case. The patient should be wearing a surgical mask 

at home if he or she is living with others. In this situation, after entering the home, the 

interviewer should wear a personal respirator. The interviewer should not put on a 

respirator outside the patient’s home because it may draw attention from outsiders. Even 

though the patient’s mouth and nose are to be covered by a mask at all times, the 

interviewer cannot assume that the patient is always masked and should take adequate 

precautions. 

• Interview in an airborne infection isolation (negative pressure) room (AIIR) in a 

hospital – In this case, the patient is considered infectious. The patient should not be 

asked to wear a mask in this situation, but should be instructed to cover his or her mouth 

with disposable tissue while coughing. Any person entering the room should wear a 

personal respirator (e.g., N-95).

• Interview in a clinic setting in both AIIR and non-AIIR – A patient can arrive at a clinic 

setting and be deemed infectious or potentially infectious based on symptoms, 

particularly a productive cough. In this case, the patient should be immediately triaged 

into an isolation room, that is, away from other patients. A surgical mask should be 

given to the patient for use as he or she proceeds through the clinic, and the patient 

should be instructed to cover his or her mouth with disposable tissue while coughing. 

– In an AIIR – As above, the patient may remove the surgical mask, but the interviewer 

should wear a personal respirator. 

– In a non-AIIR – The patient should wear a surgical mask and the interviewer should 

wear a personal respirator. 

As noted above, the use of a surgical mask or a personal respirator may affect the rapport 

between interviewer and patient. Explaining the need for protection and acknowledging that 

surgical masks or respirators may be uncomfortable can help in re-establishing rapport. Out 

of respect to the infectious patient at home, an interviewer should not put on a respirator 

prior to entering the home, in sight of neighbors or passers-by. The respirator should be 

worn upon entering the home. The interviewer can say to the patient, “I hope you don’t 

mind, but I need to wear my respirator while I am here visiting you today.” If the patient 

questions the reasons, particularly if he or she is already wearing a surgical mask, the 

interviewer can explain, “I am glad that you are wearing your mask. However, it may not 

prevent all TB germs from spreading. That is why I need to take precautions. If, in a few 

weeks, you are no longer spreading germs, I will not need to wear this respirator.” 
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Module 1. The TB Interview for Contact Investigation 

Structure of the Interview 

The interview has five components, which are presented in detail in pages 8-17. The 

components are as follows: 

I. Pre-Interview Activities 

II. Introduction 

III. Information and Education Exchange 

IV. Contact Identification 

V. Conclusion 

At the end of this module is a checklist that summarizes the elements of the interview 

(page 25). This checklist can be used during the interview as a prompt and after the 

interview to evaluate whether the interview was complete. Note that some interview 

elements may vary depending on what information is required by the local health 

department. Information the interviewer provides to the patient may depend on the job 

responsibilities of the interviewer, including a combination of medical care, directly 

observed therapy, and congregate setting investigation. 
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Module 1. The TB Interview for Contact Investigation 

I. Pre-Interview Activities 

Before conducting the interview, the interviewer should organize and prepare for it by 

obtaining background information on the patient. This will assist the interviewer in forming 

a preliminary infectious period and developing an interview strategy. 

1. Review medical record – The record may contain information from hospital staff, 

infection control practitioners, or social workers. 

• Review and note medical record information related to the diagnosis (site of disease, 

symptom history, bacteriologic and chest x-ray results, treatment, and recent or past 

known exposure to TB, including skin test results)

• Review and record social history, language and cultural barriers, and other medical 

conditions 

• Note previous hospital admissions and any history of previous treatment, substance 

abuse, mental illness, or inability or unwillingness to communicate with other 

healthcare staff who may have interacted with the patient 

• Assess the need for respiratory protection during the interview for both the 

interviewer and patient

• Obtain and record index patient locating information:

– Record name, address, telephone number, and additional locating information 

– Collect and record next of kin, emergency contact, employer 

2. Establish a preliminary infectious period based on medical record review and local 

health department guidelines. This will be refined during the interview based on the 

patient’s verification of information. 

3. Develop a strategy for the interview process by analyzing information collected thus far. 

This should include looking for any unusual factors about the patient that will need to be 

considered, such as any other medical conditions, mental status, housing or money, 

transport, and social support needs. 

4. If possible, arrange an interview place and time convenient to the patient and satisfactory 

to the local health department time frame for the completion of interviews. 

5. Arrange and ensure privacy by seeking an interview time and place with minimal 

distractions and interruptions. Note: When a patient is hospitalized, the initial interview 

should take place in this setting. 
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Module 1. The TB Interview for Contact Investigation 

II. Introduction 

As discussed later in Module 2, “Basics of Communication and Patient Education,” the very 

first interaction with the patient can influence the remainder of the interview. It is important 

from the beginning for the interviewer to provide an explanation of who he or she is and 

present a clear picture of the importance of the TB interview.

1. Begin by building trust and rapport, as well as demonstrating respect. Introduce yourself 

and provide a business card or identification. If appropriate, shake the patient’s hand. 

Greet the patient using Mr./Ms. and family name and then ask the patient what he or she 

would prefer to be called. Explain your role in the tuberculosis control program. This 

includes your responsibility to protect the health of the public. 

2. Explain that the purposes of the interview are 

• To provide TB information and answer any patient questions, and 

• To identify people who have been exposed to TB so that they can be referred for 

medical evaluation. 

3. Emphasize confidentiality, yet inform the patient that relevant information may need to 

be shared with other health department staff or other people who may assist in 

congregate settings to most efficiently ascertain which contacts need to be evaluated. 

Also, note local laws regarding confidentiality when interviewing minors. 

III. Information and Education Exchange 

As the interview progresses, the interviewer should educate the patient on TB and the 

contact investigation process. As this occurs, the interviewer should continuously assess 

whether the patient understands the information being exchanged and appears invested in 

the interview process.

1. Throughout the interview, determine the extent of trust and rapport being developed 

while observing the patient and assessing responses. 

2. Observe the patient’s body language and speech for comfort level and comprehension of 

information provided. 

• Make note of any physical signs or behavior indicative of alcohol or substance 

abuse, nutritional status, lifestyle, and other conditions which may influence the 

patient’s level of cooperation

• Assess the patient’s communication skills, attitudes, concerns, and needs. As 

necessary, refine the interview strategy. This may include accomplishing less during 

the initial interview session and scheduling a follow-up interview
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Module 1. The TB Interview for Contact Investigation 

3. Personal information – Explain that it is important to obtain and confirm the patient’s 

personal information. The following patient information should be collected and 

verified:1

• Full name 

• Alias(es)/nickname(s) 

• Date of birth 

• Place of birth (city, state/province, country) 

• If born in a foreign country, date arrived in USA 

• Travel destinations (when last there and for how long) 

• Physical description (height, weight, race, other identifying characteristics) 

• Current address and post office (PO) box or place of residence, including directions, 

if necessary 

• Telephone number 

• Length of stay at current address 

• Marital status 

• Next of kin (name, address, telephone number, other locating information) 

• Emergency contact (name, address, telephone number, other locating information) 

• Employer or school (name, address, telephone number, other locating information) 

4. Medical information and problem indicators 

• Explain the importance of collecting accurate medical information 

• Obtain and document the following patient information: 

– Known exposure to TB (who, where, when) or knowledge of anyone with similar 

symptoms 

– Past hospitalization(s) for TB (name, admission and discharge date[s]) 

– Other medical conditions, including HIV test results, if available 

– Substance abuse (including frequency, type, how long) 

– Medical provider for TB (private or clinic, name, address, telephone) 

– Transportation availability to/from medical provider 

– Directly observed therapy (DOT) plan, if known (where, when, by whom) 

– Barriers to adherence 

 

1

 This information may vary by individual health department requirements. 
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Module 1. The TB Interview for Contact Investigation 

• Disease comprehension

– Use open-ended questions to determine the patient’s TB knowledge 

– Reinforce the patient’s TB knowledge and correct any misconceptions. Explain 

mode of transmission and how TB affects the body, using language the patient 

can understand. Avoid using medical terms and recognize when to defer 

questions to appropriate personnel (see Module 2, “Basics of Communication 

and Patient Education”). Provide appropriate patient education materials. 

• Symptom history – Review with the patient the following TB-related symptoms, 

including onset dates and duration:

– Cough 

– Hemoptysis (coughing up blood) 

– Hoarseness or laryngitis 

– Unexplained weight loss 

– Night sweats 

– Chest pain 

– Loss of appetite 

– Fever 

– Chills 

– Fatigue 

Recall of symptom onset can generally be poor. Mentioning prominent dates and 

major holidays can help the patient recall symptom onset. Cough, if present, is 

the most critical symptom in determining the infectious period. 

• Discuss the elements of patient’s current diagnosis, including 

– Tuberculin skin test results 

– Site of disease 

– Symptom history 

– Chest x-ray and bacteriologic results 
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Module 1. The TB Interview for Contact Investigation 

5. Disease intervention behaviors – Explain the importance of the following interventions: 

• Treatment regimen

– Explain that the patient’s medications kill TB germs when taken as prescribed. 

Reinforce the personal and public health benefits of taking the medicine. 

– If trained to do so, identify and explain each prescribed drug and discuss 

potential side effects. 

– Establish a specific schedule or reinforce existing schedule for outpatient 

treatment, including DOT. 

– Review the local/state regulations mandating treatment adherence (if applicable). 

• Infection control measures

– If the patient is infectious, review the importance of cough hygiene, e.g., using a 

mask or a tissue to cover the mouth and nose if coughing and sneezing. Explain 

proper disposal technique. Emphasize that covering the mouth and nose is an 

important measure the patient can take to protect others. 

– Discuss the importance of adequate ventilation to protect others. 

– Describe other measures as appropriate, i.e., home isolation, visitors to the home, 

and return to work or school. 

• Maintaining medical care – Discuss the importance of

– Adherence to therapy while reemphasizing the significance of continuity of 

therapy; 

– Sputum collection, chest x-rays, and physician evaluations; 

– Adherence to all medical appointments and DOT, if ordered; and 

– Adherence-enhancing strategies, e.g., available incentives, pill boxes, and 

reminder notes.

6. Infectious period 

• Based on the information collected thus far, refine previously established infectious 

period. 

• Review significance of infectious period with patient and discuss its role in contact 

identification. 
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Module 1. The TB Interview for Contact Investigation 

IV. Contact Identification 

While a brief explanation of a contact investigation should be provided at the beginning of 

the interview, a reemphasis prior to the elicitation of contacts is necessary. This reassures 

the patient of the importance of providing contacts’ names. It is also important at this time 

to reinforce confidentiality and to educate the patient on TB transmission. 

• Introduce the contact identification process by reviewing the patient’s understanding 

of TB transmission. Stress the importance and urgency of the rapid and accurate 

identification of all priority contacts during the infectious period. Reinforce the 

importance of identifying contacts in order to protect family and friends from getting 

TB. 

• Explain the difference between priority and nonpriority contacts. This should 

include a discussion of how TB is spread. It should be emphasized that transmission 

increases with duration and frequency of exposure and with exposure in closed 

spaces. These concepts should be explored with each named contact. 

• Inform the patient that a congregate-setting investigation may be done in any place in 

which the patient reveals having spent prolonged time during the infectious period. 

The patient should be made aware that an appropriate site manager (e.g., supervisor, 

school principal) may be called in to assist in identifying persons in this setting, but 

that an emphasis on confidentiality will be maintained. With other medical 

conditions, the patient’s illness and identity are held in strict confidence. For an 

infectious disease such as TB, working with a third party in a congregate setting may 

be appropriate. The patient should know that if he or she chooses to tell others about 

his or her illness, or if others already know about the diagnosis, the health 

department will continue to maintain confidentiality and not reveal or confirm any 

patient information. 

• Collect information about the patient’s contacts in the household/residence, 

workplace/school, other congregate settings, and social/recreational environments. If 

the patient’s responses contain conflicting information, ask about these 

inconsistencies in a nonconfrontational manner. Be aware that patients are being 

asked to recall detailed information over an extended period of time and may not 

remember information very clearly. Some patients, however, may intentionally 

provide vague or inconsistent information. In this case, the interviewer should reemphasize the importance of contact identification and confidentiality (see Module 4 

for additional strategies). 
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Module 1. The TB Interview for Contact Investigation 

Contact tracing information – Obtain the following information as relevant to the patient’s 

infectious period (some information will require a field visit for confirmation): 

• Type of housing (e.g., house, apartment, shelter, nursing home) 

• Description of housing, including size of rooms, ceiling height (low or high), number 

of rooms, method of ventilation, and source of heating and cooling 

• Additional addresses where patient spent time 

• If employed: employer name, address, telephone number, full or part-time, hours per 

day/week, how long employed, transportation type to/from work, length of commute, 

occupation/type of work, indoor or outdoor work space, and enclosed or open work 

space 

• If unemployed: source of income 

• If attending school: name of school, address, telephone number, grade/year, hours 

per day/week, transportation type to and from school, and length of commute 

• Social and recreational activities (e.g., hangouts, bars, team sports, community 

centers, band, choir, place of worship), including hours per day/week, and means of 

transportation 

• Other congregate settings (e.g., armed services, hospital, nursing home, drug 

treatment center, detoxification center, shelter, group-living home, hotel, prison or 

jail), including name and dates of attendance

• Travel history (where, with whom, mode of transportation, person visited)

Eliciting Contacts 

Contacts’ information should include locating and physical identifying details. Explain to 

the patient that the reason for collecting detailed information on each contact is to be able to 

locate these individuals as easily and quickly as possible and not to mistake them for others. 

Information should be gathered in three spheres: 

• Household or living situation 

• Workplace or school 

• Social and recreational 

The patient may not be able to provide full names or any names for some contacts, so the 

investigator who must locate the contacts in the field may need to rely on nicknames or 

physical descriptions, or both. Note that the patient may not be able to supply all of the 

details listed below and that the interviewer should decide how much information is needed 

based on what has already been collected. 
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Module 1. The TB Interview for Contact Investigation 

Obtain the following information for activities occurring within the patient’s infectious 

period about all persons in each sphere. Information should include 

name/alias(es)/nickname(s), relationship to patient, age, sex, physical description, 

employer/school, and other locating information (include current address if no longer living 

in the household). Also, include hours of exposure per week and date(s) of first and last 

exposure. Include, with identified contacts, persons regularly socialized with and 

social/recreational establishments, including

– Close friends 

– Sex partners 

– Overnight guests and regular visitors to patient’s residence (e.g., neighbors, 

friends, and relatives) 

– Persons with whom drugs are used 

– Overnight visits to any other location(s) (obtain address[es]) 

– Specifically ask about time spent with young children or immunocompromised 

individuals 

• Congregate setting assessment 

– Ask for a description of identified congregate settings, including size of rooms, 

ceiling height (low or high), number of rooms, method of ventilation, source of 

heating and cooling. 

– Inform the patient that it will be necessary to make site visits to the home, workplace 

or school, and leisure establishments to assess the shared air environment to 

accurately structure the contact investigation. 

– Stress patient confidentiality as well as the necessity of sharing information on a 

need-to-know basis with appropriate site management. Discuss the importance of a 

medical evaluation for each contact.

• Methods of referral 

– Inform the patient that referrals and verified contacts’ medical evaluations should be 

carried out immediately 

– Explain contact referral options (options may vary by state): 

Patient should be given a choice of whether to inform contacts of their risk of 

exposure prior to the health department referral process. Discuss the referral options 

with the patient, deciding which contacts are appropriate for health department 

referral and for patient referral. Review with the patient how and when contact 

referrals will be made and where the contacts will be referred. 

Health Department Referral: While protecting the patient’s right to privacy, the 

healthcare worker assumes full responsibility for locating and informing the contact 

about exposure and the need for a medical evaluation. 
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Module 1. The TB Interview for Contact Investigation 

Patient Referral: The patient agrees to inform the contacts about exposure and the 

importance of speaking with the healthcare worker regarding the need for a medical 

evaluation. Remind the patient that this method will not protect his or her 

confidentiality. If necessary, rehearse with the patient how to inform contacts and 

what instructions they should be given regarding their medical evaluations. Inform 

the patient that the health department will follow up on anyone who does not respond 

within an agreed upon timeframe. 

Explain that the index patient’s identity will be held in confidence during the 

investigation, and the same is true for all contacts’ confidentiality. The health 

department cannot reveal the results of medical evaluations (e.g., how many people 

are tuberculin positive, how many people have TB disease, who has been started on 

treatment) of contacts to the index patient, other contacts, or staff of congregate 

settings. 

– Discuss re-interview time frame: 

Explain that you will be visiting the patient again upon discharge from hospital, or 

within 10-14 days if the initial interview is at home, to obtain further information and 

answer additional questions. 
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Module 1. The TB Interview for Contact Investigation 

V. Conclusion 

Conclude the interview in a positive manner. Recognize the index patient’s participation in 

the interview, and make the patient feel that you are trustworthy and can be consulted with 

concerns as they arise, even after the interview. 

• Request and answer the patient’s questions. 

• Review and reinforce all components of the treatment plan. 

• Evaluate the patient’s remaining needs or potential adherence problems. 

• Restate the date of the next medical appointment, if known. 

• Arrange for both a re-interview and home visit, if not already completed. 

• Reinforce the procedures for referral of each contact. 

• Provide information on how the patient can contact you. 

• If appropriate, shake the patient’s hand, express thanks and appreciation, and close 

the interview. 

While it is important for the interviewer to follow a systematic process to achieve the 

interview objectives, it is also important for the interviewer to demonstrate flexibility and 

respond to the patient’s needs. The patient may have questions, show signs of fatigue, or 

need assistance in some way, which may lead to a deviation from the interview agenda. 

Addressing these needs through recognition of concerns, problem solving, and referral to 

appropriate resources may be a minor set-back, but can eventually allow the interview to 

progress. For strategies on dealing with patient needs, see Module 4, “Special 

Circumstances.” 
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Module 1. The TB Interview for Contact Investigation 

Re-interviewing 

It is possible that not all information will be collected in the first interview with the patient. 

Even if the interviewer conducts a comprehensive first interview, a second interview 

should be completed. A second interview will allow the patient to recall any further 

information that may assist in the contact investigation and may facilitate additional 

questions for the interviewer. If the first interview was conducted in the hospital or health 

department, the second interview should be done in the patient’s living space, such as a 

home, apartment, shelter, or correctional facility. Observations made in a patient’s living 

space can provide additional information about contacts, as well as identify or confirm any 

environmental information that can aid in decisions about transmission and testing. The 

patient may also feel more comfortable participating in an interview in a familiar 

environment, and may provide information more readily. In between interviews, the 

interviewer should ask the patient to make notes of questions, concerns, additional contacts, 

and other topics to be addressed at the time of the re-interview. In addition, the interviewer’s 

contact information should be provided to the patient so that the patient can contact the 

interviewer with any additional information or questions. 

Before a re-interview, do the following: 

• Review original interview documentation 

• Identify gaps in first interview that need clarification 

• Review infectious period to ensure all time is accounted for in collected information from 

the patient 

• Formulate a strategy as was done for the first interview 

• Clarify known contact information to plan additional questions. 

Assessing for Additional Contacts and Risk of Transmission 

While conducting a re-interview, the interviewer can evaluate environmental characteristics 

of the place in which exposure occurred, and may be able to obtain additional information 

about identified contacts, as well as identify additional contacts. 

During a re-interview, the interviewer should 

• Continue building trust and rapport; 

• Provide additional TB education, as needed; 

• Observe environmental characteristics such as room size, crowding, and ventilation, to 

estimate the risk of TB transmission; 

• Identify additional contacts, especially children and immunocompromised persons; 

collect their locating and identifying information, such as phone numbers, addresses, and 

physical descriptions; 
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Module 1. The TB Interview for Contact Investigation 

• Look for evidence of other contacts who may not be present at the time of the visit. 

Evidence may include photographs, toys, extra jackets, and shoes. In addition, take 

notice of trophies or plaques, as well as other items that may suggest outside leisure 

activities in which the index patient participates;

• Verify previously identified contact information by observing characteristics of who is 

present; 

• Follow up on contact referrals already made; and 

• Discuss any problems with locating previously identified contacts. 
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Module 1. The TB Interview for Contact Investigation 

Summary 

This module covered the components of the TB interview for contact investigation. It stated 

the objectives of the interview, the first and most important of which is contact 

identification. Additional points included 

• Explanation of the interview as an individualized exchange of information; 

• Importance of formulating a strategy prior to conducting an interview; 

• Identifying who should be interviewed; 

• Determining an infectious period as a framework for the index patient in identifying 

contacts; 

• Determining circumstances under which to use respiratory protection with an infectious 

index patient; 

• The elements of the interview process, including: 

– Pre-interview activities 

– Introduction 

– Information and education exchange 

– Contact identification 

– Conclusion; and 

• Utilizing the re-interview process to confirm information and obtain additional 

information. 

The TB interview process can be challenging, even for the most experienced interviewer. 

The interviewer should be prepared to complete the objectives, but should anticipate a 

number of circumstances that can hinder this process. The patient should receive education, 

and an emphasis should be placed on confidentiality at the beginning of the interview, 

during the contact elicitation process, and as needed. Careful planning and ongoing 

assessment during the interview process can ease any challenges. 
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Module 1. The TB Interview for Contact Investigation 

Case Presentations 

The following case presentations apply concepts from this module. You may review them 

with your supervisor if you have questions. 

Case 1 

Part 1 – Melvin is a 38-year-old man who needs to be interviewed in the hospital. He was 

admitted 2 days ago with a diagnosis of pulmonary TB and is highly infectious. You walk 

into the room, wearing appropriate respiratory protection, to meet Melvin. He is awake but 

looks very tired and is coughing frequently. You introduce yourself and he acknowledges 

your presence. When you offer your hand, Melvin shakes it weakly. 

Under circumstances like this, should you start the interview process? Why or why not? 

If so, what information should you include in your introduction? 

Explanation: The patient may not be able to fully complete the interview process due to his 

physical condition. However, since it is required that you initiate the TB interview within 3 

days of the report of a TB suspect, you should 

• Introduce yourself as a representative of the TB control program or health department 

• State that you are there to answer any of the patient’s questions and concerns and find 

out to whom he may have transmitted TB 

• Explain that the reason you are wearing respiratory protection is that he is infectious and 

that this will not be necessary once his symptoms improve and he starts to feel better 

Part 2 – You introduce yourself to Melvin and acknowledge that he is not feeling well, and 

you will try to make this process as comfortable for him as you can. Melvin states that it is 

all right to speak with him. So, you proceed with the interviewing process. 

Melvin coughs throughout the interview. What should you do while this occurs? 

Explanation: See if Melvin is covering his mouth while coughing. This is a good time to 

provide education about infection control. If the patient covers his mouth as he coughs, 

provide positive feedback by saying, “Thanks for covering your mouth while coughing. 

Even though this is a hospital room, it is good to get into the habit of covering your mouth. 

That’s a good way to prevent the spread of TB.” If Melvin does not cover his mouth, gently 

remind him, “I understand that you don’t feel very well, but it is a good idea to get into the 

habit of covering your mouth when you cough. This is the best way to prevent spreading 

TB germs to others.” While Melvin coughs, wait before proceeding with any discussion or 

questions. You should also ask if he needs anything to make him feel more comfortable, 

such as a glass of water. 
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Module 1. The TB Interview for Contact Investigation 

Part 3 – You and Melvin are having a productive discussion. While you are eliciting 

contacts’ names, he begins to lose eye contact with you. He seems to be nodding his head 

but does not say much. 

What may Melvin’s behavior indicate? What should you do? 

Explanation: Melvin may be becoming tired and his interest in the interview could be 

dwindling. You should ask open-ended questions, which require more than one-word 

answers to determine how much Melvin can answer. If he continues to not say much or 

responds to questions inappropriately, you should address this possible fatigue and lack of 

interest. Ask, “You seem to be getting tired. Is it all right if we continue, or shall we try 

again tomorrow?” If he states that he cannot continue the interview, determine a time to 

come back and continue the following day. 
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Module 1. The TB Interview for Contact Investigation 

Case 2 

Part 1 – Jane is a 35-year-old woman who has been hospitalized with pulmonary TB. You 

conducted a TB interview during her stay. During the interview, Jane mentioned that she 

lives with her husband and 13-year-old daughter. She also told you about her workplace and 

social contacts. At the end of her interview, you told Jane that you would visit her at home 

after her discharge to talk with her further. Jane has asked you why you need to talk with 

her again, because she feels she has given you adequate information. 

How should you explain to Jane the importance of a re-interview? 

Explanation: Explain to Jane, “Sometimes patients may remember other information after 

leaving the hospital. That is why it is routine to interview a patient at home after 

discharge.” You can also tell her, “It will help me to see your home to decide further steps 

to take in testing your contacts.” This can include confirming the details of her home’s 

environment. Jane can also be told that you can answer any additional questions while you 

are there. 

Part 2 – Jane was discharged 2 weeks later. You go to her home to conduct a re-interview. 

What should you look for in the home upon entry and while you are inside regarding 

additional contacts and formulating a testing plan?

Explanation: When you walk into the home, you should be aware of anything that may 

indicate the presence of the people who live there. Begin by looking at the type and number 

of personal items around the house. For instance, this may include the type and number of 

shoes, coats, pictures, trophies, and plaques. You may find evidence that additional people 

are present or visit the home. Regarding the testing plan, your health department resources 

and standards of practice may influence the plan for evaluating household contacts. 

Part 3 – As you walk into the home, you notice a pair of shoes that seem to be too small for 

any of the household members. Inside the house, you see a picture on the fireplace mantle 

of a woman and a small child. You also see a teddy bear. 

Since you suspect there may be other unnamed contacts, how do you ask Jane about other 

people? 

Explanation: You should proceed with the re-interview process as you would in any other 

situation. Ask Jane about any information she might have forgotten to give you, including 

people who spent time at her house during her infectious period. If she does not mention 

anything about a child, you can start by talking about the picture by saying, “By the way, I
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Module 1. The TB Interview for Contact Investigation 

noticed the picture on the mantle. Who is the child in the picture?” Once the child’s 

identity has been established, you can ask, “Oh, that’s your sister’s child? Are you lucky 

enough to see her often?” If the line of questioning does not yield helpful information, you 

should be more direct. Simply ask about the shoes by saying, “I also noticed a pair of small 

child’s shoes in the front and was wondering if they belong to a child who comes to visit 

frequently. It is important that we know, since children can become seriously ill if infected 

with TB.”
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Module 1. The TB Interview for Contact Investigation 

TB Interview Checklist

 Pre-Interview Activities 

• Review medical record 

• Establish preliminary infectious period 

• Develop an interview strategy 

• Arrange interview time and place 

 Introduction 

• Introduce self 

– Provide identification 

– Explain role in TB control 

– Build trust and rapport 

• Explain purpose of interview 

• Ensure confidentiality 

 Information and Education Exchange 

• Observe patient’s physical and mental state and evaluate communication skills 

• Collect and confirm the following information: 

– Name 

– Alias(es) or nickname(s) 

– Date of birth 

– Address 

– Telephone number 

– Next of kin 

– Other locating information 

– Physical description 

– Known exposure to TB 

– Recent hospitalization(s) for TB 

– Medical provider for TB 

– Transportation availability 

– Other medical conditions 

– Outpatient/DOT plan 

– Barriers to adherence 

• Assess TB disease comprehension and provide TB education 

• Obtain and confirm TB symptom history 

• Discuss basis of patient’s current diagnosis 

• Discuss disease intervention behaviors (treatment, infection control, medical 

appointments) 

• Refine infectious period and review significance with patient 
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Module 1. The TB Interview for Contact Investigation 

 Contact Identification 

• Focus on infectious period 

• Explain priority and casual exposure 

• Stress importance of identification of all priority contacts 

• Collect information on patient’s contacts in the household/residence, workplace, school, 

other congregate settings, and social/recreational environments during the infectious 

period, including 

– Name 

– Alias(es) or nickname(s) 

– Age, race, sex 

– Address/telephone number 

– Other locating information 

– Physical description 

– Hours of exposure per week 

– Dates of first and last exposure 

• Discuss site visits and the sharing of information on a need-to-know basis; reinforce 

confidentiality 

• Discuss patient vs. health department referrals 

 Conclusion 

• Request and answer patient’s questions 

• Review and reinforce adherence plan 

• Restate next appointment (if known) 

• Arrange re-interview and home visit (if not already completed) 

• Leave name and telephone number 

• Thank patient and close interview 
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Module 1. The TB Interview for Contact Investigation 

Review Questions 

Complete these questions to review important concepts from this module. The answers are 

on page 29. 

1. What must be in place for a communication process to be considered an interview? 

a. Two-way communication 

b. Objectives 

c. A strategy 

d. All of the above 

2. In order to develop an interview strategy prior to conducting the TB interview, what or 

whom should the interviewer consult for information first? 

a. Co-workers 

b. Supervisor 

c. Medical record 

d. A nurse 

3. Identify which type of patient requires a TB interview, based on infectiousness: 

a. Patient with lymphatic TB 

b. Patient with pulmonary TB 

c. Patient with latent TB infection 

d. Patient with old, healed TB as revealed by chest x-ray findings 

4. Prioritize the interviews of the following five patients by number, 1 being the highest 

priority. Use ‘0’ if you would not interview the patient. 

__ 4-year-old, with latent TB infection and no TB disease 

__ 45-year-old, cavitary disease 

__ 45-year-old, non-cavitary disease 

__ 60-year-old, with abnormal chest X-ray, but findings not consistent with active 

disease 

__ 30-year-old, with lymphatic TB, no pulmonary involvement 
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Module 1. The TB Interview for Contact Investigation 

5. When eliciting contacts, how far back should you ask the index patient to recall? 

a. 6 months 

b. 3 months 

c. The designated time of the infectious period based on local or state standards 

d. When medications were initiated 

6. What factor(s) should be in place in order to end the infectious period (circle one 

answer)? 

a. Symptoms have improved 

b. Patient has been receiving adequate treatment for at least 2 weeks 

c. Patient has had improvement on sputum smears 

d. Only a and c 

e. Must have all three factors (a, b, c) 

7. Under what circumstances may the interviewer reveal the index patient’s identity during 

a contact investigation? 

a. To congregate setting management during a congregate setting investigation when 

written consent is given by the patient 

b. To congregate setting management during a congregate setting investigation when 

written consent is not given by the patient, but revealing the patient’s identity is 

critical to conducting a quality public health investigation 

c. When interviewing a proxy 

d. All of the above. 

8. In what three environmental settings should the index patient be asked about priority 

contacts? 

1._____________________________________________________ 

2._____________________________________________________ 

3._____________________________________________________ 

9. Which of the following is true of re-interviews? 

a. They should always be conducted even if the initial interview was completed 

b. They do not need to be done if the patient completes the first interview 

c. They do not need to be done if the first interview was in the index patient’s home 

d. None of the above 
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Module 1. The TB Interview for Contact Investigation 

Review Questions Answer Key 

Answers are in bold. 

1. What must be in place for a communication process to be considered an 

interview? 

a. Two-way communication 

b. Objectives 

c. A strategy 

d. All of the above 

2. In order to develop an interview strategy prior to conducting the TB 

interview, what or whom should the interviewer consult for information 

first? 

a. Co-workers 

b. Supervisor 

c. Medical record 

d. A nurse 

3. Identify which type of patient requires a TB interview, based on 

infectiousness: 

a. Patient with lymphatic TB 

b. Patient with pulmonary TB 

c. Patient with latent TB infection 

d. Patient with old, healed TB as revealed by chest x-ray findings 

4. Prioritize the interviews of the following five patients by number, 1 being 

the highest. Use ‘0’ if you would not interview the patient. (ND: check 

this) 

 3 4-year-old, with latent TB infection and no TB disease 

 1 45-year-old, cavitary disease 

 2 45-year-old, non-cavitary disease 

 0 60-year-old, with abnormal chest X-ray, but findings not consistent with active 

disease 

 0 30-year-old, with lymphatic TB, no pulmonary involvement 
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Module 1. The TB Interview for Contact Investigation 

5. When eliciting contacts, how far back should you ask the index patient to 

recall? 

a. 6 months 

b. 3 months 

c. The designated time of the infectious period based on local and state standards 

d. Back to when medications were started 

6. What factor(s) should be in place in order to end the infectious period 

(circle one answer)? 

a. Symptoms have improved 

b. Patient has been receiving adequate treatment for at least 2 weeks 

c. Patient has had improvement on sputum smears 

d. Only a and c 

e. Must have all three factors (a, b, c) 

7. Under what circumstances may the interviewer reveal the index patient’s 

identity during a contact investigation? 

a. To congregate setting management during a congregate setting investigation when 

written consent is given by the patient 

b. To congregate setting management during a congregate setting investigation when 

written consent is not given by the patient but revealing the patient’s identity is 

critical to conducting a quality public health investigation 

c. When interviewing a proxy 

d. All of the above. 

8. In what three environmental settings should the index patient be asked 

about priority contacts? 

a. household or residential 

b. workplace or school 

c. social and recreational 

9. Which of the following is true of re-interviews? 

a. They should always be conducted even if the initial interview was completed 

b. They do not need to be done if the patient completes the first interview 

c. They do not need to be done if the first interview was in the index patient’s home 

d. None of the above 
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Module 1. The TB Interview for Contact Investigation 

Glossary 

Contacts – persons exposed to M. tuberculosis organism by sharing air space with a person 

with infectious TB disease. Contacts can include family members, roommates or 

housemates, friends, coworkers, classmates, and others classified as priority or nonpriority. 

Exposure to TB – time spent with or near someone who has infectious TB disease. 

Health department referral – the process of a public healthcare worker informing contacts 

to an index case of the need for medical evaluation due to exposure. 

Index patient – a person suspected or confirmed TB disease is the initial case reported to 

the health department. 

Infectious period – the time frame during which a person with TB disease is capable of 

spreading M. tuberculosis. The beginning of the infectious period is usually estimated by 

determining the date of onset of the patient's symptoms (especially coughing); it ends when 

contact with others is broken, smears improve, treatment is adequate, and symptoms have 

improved. 

Latent TB infection (LTBI) – also referred to as TB infection. Persons with latent TB 

infection carry the organisms that cause TB but do not have TB disease, are without 

symptoms, and are not infectious. Such persons usually have a positive reaction to the 

tuberculin skin test or a positive QuantiFERON-TB Gold test result. 

Mantoux tuberculin skin test – a test used to determine if a person has been infected with 

M. tuberculosis. Tuberculin, a substance derived from dead tubercle bacilli, is injected under 

the skin. If the person has TB infection, the immune system will recognize the tuberculin 

and, in most cases, form a reaction. 

Patient referral – the process by which an index patient informs his or her contacts of TB 

exposure and the need for medical evaluation. 

QuantiFERON-TB Gold test (QFT) - a blood test used to detect TB infection. It 

measures a person’s immune reactivity to M. tuberculosis. 

Re-interview – a second interview within 2 weeks of the initial interview to determine 

additional information which the patient may not have shared for various reasons and to 

confirm previously obtained information. 
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Module 1. The TB Interview for Contact Investigation 

Source case investigation – the process of conducting a public health investigation to 

determine who may have transmitted M. tuberculosis to a patient when recent 

transmission is reported. Source case investigations can be applied to both recent 

transmission in infected adults and children and for disease in very young children. 

TB interview – an interview of a TB patient by a health department staff to identify priority 

contacts, build trust with the patient, and provide TB education. Interactions with a patient 

involve the basic principles of effective communication and patient education. 
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Module 2. Basics of Communication and Patient Education 

Table of Contents 

Module 2. Basics of Communication and Patient Education ............................ 1

Objectives ................................................................................................... 1

Introduction ................................................................................................. 1

Patient Education .................................................................................... 2

The Importance of Patient Education .......................................................... 2

Patient Education During the TB Interview .............................................. 3

Effective Communication ............................................................................. 3

Information Sharing ..................................................................................... 4

Verbal and Nonverbal Communication ........................................................ 7

Asking Questions ...................................................................................... 11

Active Listening ..................................................................................... 14

Barriers to Communication .................................................................... 15

Overcoming Barriers ................................................................................. 15

Understanding the Patient ......................................................................... 16

Working with Interpreters ....................................................................... 19

When Is an Interpreter Required? ............................................................. 19

Choosing an Interpreter ............................................................................. 19

Types of Interpretation .............................................................................. 20

How to Communicate Through an Interpreter ............................................ 20

Summary ............................................................................................... 22

Case Presentations ............................................................................... 23

Case 1....................................................................................................... 23

Case 2....................................................................................................... 25

Review Questions .................................................................................. 27

Review Questions Answer Key .............................................................. 30

Glossary ................................................................................................ 33

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Module 2. Basics of Communication and Patient Education 

Objectives 

After reading through this module, you will be able to 

• Explain why patient education is important in the TB interview process; 

• Define communication; 

• Identify verbal and nonverbal patient cues and their meanings; 

• Use closed, open-ended, and focused questions to gather descriptive, yet 

targeted information; 

• Utilize the techniques of reflection, paraphrasing, and summarizing to affect 

the course of the interview; 

• Address and overcome communication barriers; 

• Select, and communicate through, an appropriate interpreter; and 

• Apply effective communication concepts to patient education. 

Introduction 

In order to accomplish the objectives of the TB interview, the interviewer must provide 

accurate and tailored patient education and utilize effective communication skills. These 

skills, from the outset, will help provide the foundation of what will be an important 

relationship. Ultimately, gaining trust, building rapport, and providing patient education 

will lead to the important TB interview objective of contact identification. 
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Module 2. Basics of Communication and Patient Education 

Patient Education

A well-informed patient is more likely to cooperate if the patient understands that it is 

important to identify priority contacts so that those individuals may be medically evaluated 

and prevent the spread of TB. The patient may also have additional questions about the TB 

diagnosis and treatment. Thus, it is important that patient education be continued 

throughout the TB interview process. 

The Importance of Patient Education 

Often, patient education is overlooked for various reasons including time constraints, 

communication barriers, cultural differences, poor rapport with the patient, and the 

interviewer’s discomfort with certain topics. However, ensuring patient understanding is 

extremely important and is a vital part of the TB interview for the following reasons: 

• The patient who understands his or her illness is more likely to be invested in his or her 

treatment 

• The patient-interviewer relationship becomes more trusting as information is shared and 

made specific to the patient’s level of understanding 

• An educated patient may feel more involved and accountable for his or her health care 

decisions 

• The patient becomes part of the health department team when the patient understands the 

investigation processes and the reasons they are occurring 

The following principles of learning help summarize the methods for an effective patient 

education process: 

• Information provided must be relevant to the patient’s existing knowledge, condition, 

and life circumstances 

• Educational techniques must be individualized 

• The interviewer must constantly look for feedback through verbal and nonverbal 

language to gauge the patient’s understanding 

• Messages should always be reinforced through active listening techniques

• Education should be provided through multiple methods (e.g., discussion, print 

materials) to reinforce messages
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Module 2. Basics of Communication and Patient Education 

Patient Education During the TB Interview 

The main objective of the TB interview is to identify the correct priority contacts as quickly 

as possible. This can be done more easily if patient education covers the following points: 

• How TB is transmitted 

• The difference between TB infection and disease 

• TB disease can be prevented by treating those with latent TB infection 

• TB is curable 

• The importance and purpose of contact investigation

• Contacts are at great risk for infection and disease 

• Potential consequences of not initiating TB treatment 

• The patient could have been prevented from getting TB if the person who infected 

him/her had given his or her name as a contact 

• Contacts will not be told by the health department who identified them 

• Confidentiality will be maintained by the interviewer and the health department 

• A public health worker will be available to the patient to address any questions or 

concerns throughout the contact investigation process 

• Role, responsibility, and authority of the health department to protect the public’s health 

Patient education is best provided through effective communication techniques, which take 

into consideration how to best convey messages to the patient and receive feedback on how 

these messages are understood. Interviewers should continually encourage the patient to 

express any concerns and ask questions. This enhances the interviewer-patient partnership. 

Effective Communication 

Communication is the exchange of information by words, symbols, signs, or actions. It is an 

interactive process, which involves feedback. Communication revolves around asking 

questions, listening actively, understanding a patient’s concerns or needs, and demonstrating 

a caring attitude, while helping to solve problems. Communication begins when the 

interviewer first sees the patient, addresses the patient by name, and sits down to talk. 

Effective communication continues as the healthcare worker makes eye contact, speaks in a 

respectful tone of voice, and encourages the patient to ask questions. 
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Module 2. Basics of Communication and Patient Education 

Information Sharing 

When two individuals communicate, there is a sharing of ideas, beliefs, values, goals, 

sincerity, and level of trust. These characteristics can be conveyed verbally, nonverbally, or 

both. All verbal and nonverbal cues provide vital information between the interacting 

individuals. For the purposes of TB interviewing, understanding and utilizing 

communication skills will assist in establishing trust and rapport with the patient. Both the 

interviewer’s and the patient’s styles of communication can set the groundwork for the 

success of the interview process. 

Table 1 summarizes communication skills described in this module. The left side of the 

table lists each communication skill. The right side of the table shows the purpose of each 

skill in the context of health education about TB. 

Table 1. Summary of Effective Communication Skills 

Communication Skill Purpose 

• Ask questions and listen 

• Encourage the patient to ask questions 

Understand the patient’s history 

Understand the patient’s current 

knowledge about TB 

Identify and help solve any problems 

the patient may be facing 

• Make the interaction with the patient a 

positive experience 

• Assess and display appropriate verbal and 

nonverbal language 

Motivate the patient by emphasizing 

his or her important role in the 

interview process 

Emphasize that a healthcare worker is a 

partner in working through the contact 

investigation process with the patient 

• Use the appropriate language level 

• Limit the amount of information 

• Summarize the information being provided 

• Repeat important information, as needed 

• Ask additional probing questions and listen 

Ensure that the patient understands and 

remembers the TB education and 

contact investigation information 

Obtain relevant contact investigation 

information 

The communication skills highlighted in Table 1 are discussed in further detail in this 

module. 
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Module 2. Basics of Communication and Patient Education 

Make interactions with the patient a positive experience. 

How the interviewer expresses himself or herself is as important as the content of the 

messages. The interviewer should make the patient interaction a positive experience by 

providing encouragement and support. By demonstrating a caring and respectful attitude, 

the patient may be more likely to provide the necessary information and not hesitate to ask 

questions. A caring attitude is demonstrated through the interviewer’s actions, words, body 

language, tone of voice, and eye contact. 

When an interviewer interacts with a patient, the interviewer should address the patient by 

name and respect the patient’s time by attending to the patient as soon as possible. The 

interviewer should not appear judgmental about the patient’s lifestyle, beliefs, and 

behaviors. Such judgments might be conveyed through nonverbal body language. 

Judgment-laden communication can negatively impact the interviewer’s relationship with 

the patient and possibly compromise interview goals. The interviewer should also 

acknowledge the patient’s competing issues and priorities by demonstrating empathy. 

The TB interview process involves asking questions about whom a patient has spent time 

with and where this time was spent. It also is based on the fact that the patient may have 

spread TB infection to others. In order to motivate a patient’s participation in the interview 

process, the interviewer should acknowledge and thank the patient for providing information 

despite its personal nature and the fact that the patient may be quite ill. 

Use the appropriate verbal and written language. 

Using words that are familiar to patients can make information relevant and understandable. 

Prior to imparting any education, the interviewer should be aware of the patient’s level of 

TB knowledge. Some patients may readily ask questions, which may provide some 

indication of the patient TB knowledge. Others may require probes from the interviewer 

such as 

• “Tell me what you know about TB.” 

• “What did they tell you in the hospital about this interview?” 

• “What do you know about how TB is spread?” 

Evaluation of the patient’s knowledge and understanding is a continual process, since the 

patient may not understand all aspects of the information exchanged throughout the 

interview. It is the interviewer’s responsibility to look for verbal and nonverbal patient cues 

to see how well the information being shared is processed or if the patient is hesitating to ask 

questions. The interviewer should look for any signs in the patient’s body language that 

may suggest confusion (see Table 2). 
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Module 2. Basics of Communication and Patient Education 

The language used to deliver information is very important. Medical jargon should be 

avoided in most cases, but if it is used, it must be followed by an explanation. Simple, 

nonmedical terms should be used in explanations to the patient. For example, when 

explaining TB transmission, it is much more helpful to say, “The TB germs are spread 

through the air,” than “TB bacilli are transmitted via an airborne route.” The interviewer 

should also be aware that TB may be referred to by different terms such as “consumption” 

or “weak lungs.” 

Printed materials can also be helpful in providing patient education. The language used in 

education materials should match the patient’s level of comprehension and be culturally 

appropriate. Effective educational materials generally assume no more than a sixth-grade 

reading level. For patients below that level, the interviewer should review materials verbally 

with the patient (See Resource List for information on patient education materials). 

Information about the patient’s level of understanding should be included in the patient’s 

interview notes for follow-up. 

Limit the amount of information given at any one time. 

A patient may not be able to remember the important components of the interview if too 

much information is given at one time or if they are not prepared to receive detailed 

information. The patient may be overwhelmed and experiencing fear over the diagnosis of 

TB disease. In addition, illness may make it difficult for the patient to fully participate. The 

interviewer should be aware of the limits of the patient’s ability to pay attention and to 

absorb relevant information. The duration and intensity of the interview should be adjusted 

accordingly. 

Provide an overview of the interview at the beginning and upon conclusion. 

People remember information presented at the beginning and at the end of a session more 

easily than the information presented in the middle. The interviewer should inform the 

patient about the purpose of the interview, with an emphasis on confidentiality, and the 

importance of contact identification at the beginning of the interview. Important 

information should be summarized at the end of the interview. 

 

Repeat important information. 

Some people need to hear new information several times before they remember it. Key 

messages should be reviewed throughout the interviews. These messages should include the 

purpose of the TB interview and the fact that the collected information will be used to locate 

contacts for evaluation and, perhaps, treatment. 
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Module 2. Basics of Communication and Patient Education 

Encourage the patient to ask questions. 

Patients should feel comfortable asking questions about information they do not understand. 

After giving instructions or an explanation, healthcare workers can pause and ask, “I know 

we are discussing a lot of information at once. What questions do you have?” 

Patients may be timid and concerned about appearing uneducated or they may be nervous or 

not feeling well and simply want to complete the interview quickly. It may take courage for 

them to ask questions. Patients should be praised for asking questions. For example, an 

interviewer can say: 

• “I’m glad you asked that question.” 

• “Good question.” 

All questions should be answered thoughtfully and carefully. Interviewers should also be 

aware of what questions can be answered within the scope of their job responsibilities and 

knowledge. If an interviewer does not know the answer to a question, it is acceptable for 

him or her to say, “I don’t know the answer to that...” or “That isn’t an area that I have 

experience with, but I will be glad to find out the answer and get back to you.” 

Verbal and Nonverbal Communication 

How something is said conveys meaning in addition to what is actually said. Characteristics 

of how something is said can convey many meanings particularly when viewed in 

conjunction with nonverbal cues. Nonverbal communication, or “body language,” can 

provide more additional meaning than speech alone. 

The key to effective communication is to be aware of verbal and nonverbal cues. The 

interviewer should be observant of how the patient portrays these cues. In turn, the 

interviewer should display the appropriate body language indicated in Tables 2 and 3 while 

speaking to or listening to the patient. 
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Module 2. Basics of Communication and Patient Education 

Table 2. Building Rapport through Nonverbal Communication 

Communication Through Body Language 

Builds Rapport Does Not Build Rapport 

Eye Contact 

• Meeting the patient’s eye without 

aggressively forcing eye contact 

• Looking at other objects 

• Looking down 

• Looking defiantly 

• Shifting eyes from object to object 

• Looking away when the client looks at you 

or verbally responds to you 

Facial Expressions 

• Pleasant expression 

• Brow relaxed 

• Sincerity 

• Frown 

• Scowl 

• Grin 

• Pained look 

Posture 

• Leaning slightly toward the client 

• Sitting in a relaxed but attentive 

manner 

• Facing the client 

• Consideration of personal space 

• Sitting sideways or away from the client 

• Slouching 

• Crossing arms in front as if to protect self 

• Taking an aggressive stance 

• Standing over the client 

Gestures 

• Demonstrating with hands to show 

sizes 

• Nodding in recognition or agreement 

• Flailing arms 

• Tapping feet 

• Fidgeting 

• Shrugging shoulders noting disapproval 

• Winking 

• Tending to other tasks during the interview 

Touching 

• In most cultures, touching someone you have not developed a rapport with is not 

acceptable. However, a handshake is usually acceptable upon greeting. 
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Module 2. Basics of Communication and Patient Education 

Table 2. Building Rapport through Nonverbal Communication, continued 

Nonverbal Behavior Using the Environment 

Builds Rapport Does Not Build Rapport 

Distance 

• Interviewer moves in relation to 

movement initiated by client 

• Interviewer moves away from client as 

client moves toward interviewer 

• Interviewer takes the initiative in 

establishing distance instead of client taking 

the initiative 

Arrangement of Physical Setting 

Builds Rapport Does Not Build Rapport 

• Tidy, organized 

• Warm, soft 

• Casual, cheerful 

• Quiet 

• Well lit 

• Private 

• Untidy, disorganized 

• Cold, formal 

• Cheerless, no color 

• Filled with distractions 

• Dark 

• Crowded with other patients, healthcare 

workers, or others 
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Module 2. Basics of Communication and Patient Education 

Table 3. Interviewer Verbal and Nonverbal Cues 

Cue Display 

Eye contact Consistent eye contact; eyes should not move around, as this may 

indicate disinterest and distraction

Posture Natural and comfortable, not overly rigid or slouching

Voice Natural volume and tone; if voice is loud, the patient may be intimidated 

and if too soft, the message may be inaudible or sound hesitant

Speech Regular pace; excess speed can indicate a feeling of being rushed, while 

slow speech can sound tentative

Hand motion Although quite common and acceptable, it should not be distracting to 

the patient

Interruptions Kept to a minimum; however, they can be used to move the conversation 

back into a useful direction if it diverts from the topic 

Arms Not crossed during an interview; use relaxed, open posture

Silence While uncomfortable, may be an indication of a thought process 

occurring; silence may reflect thinking both on the part of the interviewer 

and patient, particularly if there is an unexpected question or statement

Listening Done while offering eye contact in conjunction with affirmative head 

nodding or reactive emotions (e.g., smile or empathy); this displays 

engagement in and acknowledges the value of what is being 

communicated

Although the cues described in Table 3 pertain to the interviewer, these cues can also pertain 

to the patient and indicate similar meaning to what is mentioned above. Signs of problems 

occurring with communication, as indicated from the patient, are included in Table 4. 
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Table 4. Patient’s Nonverbal Language 

Nonverbal Cue Possible Meaning 

Faltering eye contact Boredom, fatigue, disengagement 

Intense eye contact Fear, surprise, confrontation or anger 

Rocking Fear, nervousness, preoccupation 

Stiff posture Discomfort, nervousness 

Elevated voice tone Confrontation/anger 

Prolonged and frequent periods of 

silence 

Disinterest, loss of train of thought, inability to

understand, fatigue 

Fidgeting Discomfort, disinterest, nervousness, possible 

drug use 

Distress on the patient’s part needs to be addressed immediately or the interview will be 

unproductive. When communication becomes strained, the interviewer should ask how the 

patient feels and if it is permissible to continue. Acknowledging the amount of information 

being exchanged and its personal nature may put the patient at ease. The patient may simply 

not feel well and may need to take a break or continue the interview at another time. 

Making an appointment for the next day, if possible, may be the best intervention if an 

interviewer perceives distress. The interviewer should attempt to obtain as much 

information as possible, as there is a chance that the interviewer may not see the patient 

again. However, an interviewer should recognize a patient’s limits. 

Asking Questions 

In order to keep focused on the objectives of obtaining accurate and complete information 

from the patient and building trust, the use of closed and open-ended and focused questions

is very important. These concepts are explained below. 

Closed-ended questions require a one-word or briefly phrased response, such as “yes” or 

“no.” While not appropriate in obtaining the most information from the patient, closedended questions can be useful in confirming information received and quickly summarizing 

information that was obtained previously. Closed-ended questions can also move a 

conversation in a more productive direction if the information that is being sought is not 

being obtained. 

Open-ended questions require more than a one-word response, such as a description or an 

explanation. Open-ended questions prompt the interviewee to provide information without 

interviewer biases. These types of questions generally begin with who, what, where, when, 

why, and how. A statement may also begin with “Tell me about...,” “Describe for me...,” or 

“Explain to me...” 
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Module 2. Basics of Communication and Patient Education 

Table 5. Examples of Closed- and Open-Ended Questions 

Examples of closed-ended and of open-ended questions 

Closed-Ended Questions: Open-Ended Questions: 

Do you live alone? 

Have you had a cough? 

Do you work in a large area? 

Is your dad’s name spelled J-O-H-N DO-E? 

Did the doctor talk to you about TB? 

Who lives with you? 

What symptoms have you had? 

What is your work environment like? 

How is your dad’s name spelled? 

What did the doctor tell you about TB? 

Examples of closed-ended and open-ended question used in combination 

Example 1: Determining the infectious period 

Open-ended question: What symptoms have you had? 

Patient: Well, I have been kind of run down. Stuff like that. 

Open-ended question: What other symptoms have you had besides being tired? 

Patient: I don’t really remember. I’ve been on medications, so I’m feeling better now. 

Closed-ended question: Have you had a cough? 

Patient: Yes. 

Open-ended question: For how long did you cough? 

Patient: For about a month. 

Example 2: Determining basic congregate setting exposure information 

Opening interviewer statement: Please describe your work environment. 

Patient: I work in a factory. 

Open-ended question: How is it set up? 

Patient: Well, it’s kind of an assembly line. 

Closed-ended: Is it a large factory? 

Patient: Yeah, it’s pretty big. 

Open-ended: How big would you say? 

Patient: Oh, I couldn’t really say. 

Closed-Ended: Is it the size of this room? 

Patient: No, it’s about three times the size of this room. 
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Module 2. Basics of Communication and Patient Education 

Examples of closed-ended and open-ended question used in combination 

Example 3: Physical descriptions 

Open-ended question: You said you hang out with Ralph. How would you describe him? 

Patient: He’s a little guy; doesn’t say much. 

Open-ended question: When you say little...how tall is he? 

Patient: Oh, I don’t know his exact height. 

Closed-ended question: Is he my height, taller, or shorter? 

Patient: About your height. 

Focused questions are used if the respondent makes a vague statement or one requiring 

more specific information. The question may provide limits or boundaries (e.g., time) to 

direct an answer. Focused questions are not closed-ended questions. 

Table 6. Examples of the use of combined open-ended and focused questions 

Example 1 

Open-ended question: Where do you spend most of your time? 

Patient: You know, it’s really hard to say where I spend most of my time. 

Focused question: Okay, let’s take yesterday. How did yesterday compare to an average 

day for you? 

Patient: It was pretty much the same. 

Focused question: So, what did you do in the morning? 

Example 2 

Open-ended question: Where do you spend most of your time? 

Patient: I guess I spend the most time with some people over at the shelter and then some 

other people I meet for drinks now and then. 

Focused question: Whom do you spend time with over at the shelter? 

Patient: Well, there’s this guy Larry... 

Example 3 

Open-ended question: What is your mailing address? 

Patient: I don’t really have a fixed address. I’m living here and there. 

Focused question: Can you tell me a little bit more what you mean by here and there? 
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Module 2. Basics of Communication and Patient Education 

Active Listening 

Active listening is an effective component of communication and is an essential 

communication technique that should be used when conducting a TB interview. Active 

listening is not only hearing what people say, but paying attention to how it is said as well 

so that further dialogue can be adjusted to elicit the needed responses. 

Active listening will 

• Provide insight into problems the patient has that might impede his or her adherence; 

• Provide insight into how the patient may behave in future situations; 

• Help to gain information; and 

• Convey to the patient a sense of concern and care. 

Active listening allows the patient to speak without interruption and allows the interviewer 

to 

• Absorb information to respond to the patient’s questions and concerns; 

• Follow the patient’s train of thought; 

• Pay attention to nonverbal clues; 

• Validate unspoken feelings; and 

• Verify the patient’s understanding of the interview questions. 
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Barriers to Communication 

During an interview, various barriers to communication may occur that can potentially 

hinder the interview process if not quickly resolved. Some of these barriers may occur due 

to the patient’s actions, while some may occur in part due to the interviewer. Barriers can be 

physical or nonphysical. 

Table 7. Examples of Communication Barriers

Physical Nonphysical

• Desk or table between interviewer and 

patient 

• A person wearing sunglasses 

• Noise 

• People actively moving about the interview 

room 

• Body language suggestive of insecurity, 

poor listening, or disinterest 

• Lack of privacy 

• Uncomfortable room temperature 

• Time pressure 

• Language 

• Interruptions 

• Judgmental attitude 

• Education level 

• Insecurity 

• Selective listening or failure to listen 

• Lack of cultural competency 

Overcoming Barriers 

Noting that some barriers are difficult to overcome, an interviewer can minimize the 

occurrence of barriers and their effects by 

• Scheduling interviews at a time convenient to both the patient and interviewer, keeping 

in mind health department interview completion deadlines; 

• Conducting interviews in quiet, private areas, whenever possible; 

• Following appropriate verbal and non-verbal cues; 

• Engaging in active listening; 

• Utilizing an interpreter as needed; 

• Using terminology the patient understands; and 

• Consistently assessing the need for a proxy (a person who knows the patient well and is 

able to provide interview information when the patient is unwilling, or mentally or 

physically unable, to participate in the interview; see Module 4). 
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Understanding the Patient 

Another way to overcome barriers is for the interviewer to ensure that he or she completely 

understands the information that the patient is conveying. It is also important for the patient 

to see that the interviewer is actively listening to what is being stated and is sincere in 

addressing the emotions and concerns the patient may be having throughout the interview. 

This can be accomplished through a combination of three communication techniques: 

paraphrasing, reflection, and summarizing. 

Paraphrasing is the rewording of a patient’s response in order to verify information and 

display that the interviewer is actively listening.

Examples of Paraphrasing Techniques 

Example 1 

Patient: I don’t know how I got TB. I eat well and I don’t smoke. 

Paraphrase: So, you don’t understand how you got TB since you take good care of 

yourself. 

Example 2 

Patient: I am feeling very tired these days and the meds mess up my drug use. I don’t know 

if it’s all worth it. 

Paraphrase: It sounds like you are considering not taking your medications anymore. 

Example 3 

Patient: I have not always been positive for TB. I think my first exposure was when I lived 

in shelters and a lot of the people who lived there coughed. That was about 3 or 4 years ago.

Paraphrase: So you think that you got exposed to TB about 3 or 4 years ago when you 

were staying in a shelter. 
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Module 2. Basics of Communication and Patient Education 

Reflection is the rewording of a patient’s emotional reactions by acknowledging the 

displayed feeling(s) and its cause. A reflection should be followed by the interviewer’s next 

statement, which should help resolve what is causing the feeling. 

Examples of Reflecting Techniques 

Example 1 

Patient: I don’t want to get the HIV test. What’s the use anyway, it doesn’t make much 

difference. I would rather not know I have AIDS. 

Reflection: It sounds like the HIV-testing process may be scary for you...

Example 2 

Patient: I don’t see any reason why people need to see me take my medicines. I am not a 

child anymore. 

Reflection: It seems like you feel unhappy about being on DOT... 

Example 3 

Patient: (makes statement with a trembling voice) Sure, I’ll answer your questions. 

Reflection: You seem a bit nervous... 

Example 4 

Patient: You have asked me all sorts of questions already. I have answered them all, but 

I’m not going to give you the names of my friends. We don’t like snitches. 

Reflection: So you’re feeling like you’ve been very cooperative but feel offended by the 

request to reveal the names of your friends... 

Example 5 

Patient: You’re telling me that I might have given TB to the people I work with! They’ll be 

so mad at me if they find out it’s me. 

Reflection: It sounds as though you are anxious about others’ involvement in this contact 

investigation... 
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Module 2. Basics of Communication and Patient Education 

Summarizing is the rephrasing of a series of statements that have occurred through a 

dialogue in order to verify information and display that the interviewer is actively listening. 

Examples of Summarizing Techniques 

Example 1 

Patient: Actually, I know very little about TB. Like I said, I thought I had the virus ’cause I 

started feeling weak and tired. I lost my appetite. I don’t know much about it, thought you 

could catch it overnight. I didn’t realize that you had to be exposed for a long time. I think I 

got it from working on ships. A lot of the workers came from places where they have a lot of 

TB so I think I got it from one of them. 

Summary: So you think that TB is a virus and that you got it while working with people 

who came from places with a lot of TB. You also know that it takes exposure over a long 

time to become infected and that tiredness and loss of appetite are symptoms of TB.

Example 2 

Patient: You’ll have trouble approaching the people I use drugs with about TB. They know 

we never discuss that ‘cause it’s sort of common knowledge. The only reason they go to 

take an AIDS test or TB test is because someone is paying them and a lot of them come out 

positive and they don’t even bother to do anything about it. Most people have other things to 

worry about like money and food. 

Summary: You think that the people you use drugs with do not have to be educated about 

TB because they already know about it. But if I would want to get them in for testing, I 

would have to offer them money as an incentive.
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Module 2. Basics of Communication and Patient Education 

Working with Interpreters 

One of the barriers to communication is language difference. In this case, a patient may 

have little or no proficiency in the language in which the interviewer is speaking. This is 

when an interpreter should be used. An interpreter is any individual who orally conveys 

speech for another individual who has little or no proficiency in the language in which the 

interviewer is speaking. 

When Is an Interpreter Required? 

The interviewer must gauge when an interpreter is needed. In some cases this is very 

obvious, while in others it is not. The patient’s medical record may mention a language 

barrier so an interpreter can be arranged prior to meeting the patient. A patient may 

demonstrate language comprehension by nodding his or her head affirmatively or verbally 

indicate understanding by saying “yes” or “no” when answering questions. However, in this 

case, the interviewer must be watchful. Even though the patient may have some proficiency 

in the interviewer’s language, the patient may not have an adequate understanding of the 

interviewing messages. This is where open-ended questions play a key role. The responses 

to open-ended questions require more than a word or two and can assist the interviewer in 

judging how much is understood by the answer given. If the patient understands very little 

of the conversation, despite the interviewer’s simplifying of the language used and basing 

questions on the patient’s level of understanding, it is time to engage an interpreter. 

Choosing an Interpreter 

If possible, a professionally trained or certified medical interpreter should be used for patient 

interviewing. Interviewers should be aware of resources available to provide appropriate 

interpretation and make all attempts to acquire an interpreter. One should utilize a third 

party who is unknown to the patient. A third party can provide unbiased communication 

and preserve confidentiality.1 However, in some cases, individuals may feel more

comfortable and trusting of people they know. In such instances, reiterate confidentiality 

issues, especially in small communities or settings where a TB diagnosis may be easily 

found out. If using an interpreter the patient knows, the patient must state that he or she is 

comfortable with this person in this role. 

Often, a client will bring in a family member or friend to interpret. This can be challenging, 

especially if sensitive questions are being asked and confidentiality is a concern. Family 

members, especially children, should not be used as interpreters. Despite this general rule, 

there are some exceptions when family members may be a good source of interpretation, 

 

1 Interviewers should adhere to policies regarding the provision of appropriate interpretation and any legal 

statements or contracts, which should be binding upon the interpreter and interviewer. These policies and 

contracts may include protection of confidentiality and methods for interpretation. 
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Module 2. Basics of Communication and Patient Education 

such as when the index patient is a young child. Urgency is also key. If an appropriate 

interpreter cannot be found in time to complete the interview as recommended, an available 

healthcare worker may serve this purpose. Asking a healthcare worker to serve as an 

interpreter may also be necessary if a patient is at risk of leaving an interview setting prior to 

a more appropriate interpreter being located. 

Types of Interpretation 

There are two styles of interpretation in TB interviewing that can be used: consecutive and 

simultaneous. Consecutive is when one speaker says a few phrases or sentences and then 

awaits the interpreter to interpret. In the simultaneous style, the interpreter speaks as the 

dialogue occurs without pause. With both styles of interpretation, the interaction is face-toface. However, there are times when a trained interpreter is not available in person. In these 

cases, a telephone interpretation service can be used. This may involve an interpretation in a 

remote location by use of a speaker phone. However, if a speaker phone is unavailable, the 

phone may be passed back and forth between the patient and interviewer, allowing the 

interpreter to know to whom he or she is speaking. 

How to Communicate Through an Interpreter 

There are some essential points to keep in mind when working with an interpreter. The 

interviewer should assess verbal and nonverbal indicators to gauge how well the message is 

being understood and the patient’s comfort level. Note that communication through an 

interpreter will take more time than a noninterpreted interview and, as such, the interviewer 

and interpreter should plan accordingly. 

Introduction 

Explain to the interpreter that the interviewer will be talking to the patient directly and that 

the interpreter is to convey exactly what was said. In turn, the interpreter should be 

instructed to state exactly what the patient has said back to the interviewer and not 

paraphrase or summarize the discussion. This is important so that all key facts are 

communicated. 

Confidentiality 

Ensure that the interpreter is aware that all communication is confidential and cannot be 

shared with anyone outside of the interview. 

Addressing the Patient 

The interviewer should address the patient directly, using first- and second- person 

terminology (“I” and “you”). In general, in is best to look directly at the patient when 

speaking to the patient. Also, when the patient is responding, the interviewer should make 

eye contact as well. It is acceptable to look at the interpreter when he or she is conveying 

the patient’s statements. 
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Use of Language 

Avoid slang terminology, as many local words and phrases may not translate accurately into 

other languages. Also, do not use healthcare jargon. If the interpreter is a layperson, he or 

she may not know how to state medical terms accurately. Use simple language. Short, 

precise questions and sentences work well. 

Rate of Speech 

Speak slowly and clearly. Gauge the pace at which the interpreter can convey messages back 

and forth. Ask the interpreter at the beginning of the interview to inform the interviewer at 

anytime if the conversation is proceeding too quickly. Also, take breaks as needed to 

counter fatigue and to give the interpreter a chance to interpret what has been said. 

Acknowledge Beliefs 

If the patient offers views or ideas counter to your training and knowledge, acknowledge 

what is being said and attempt to work within the patient’s explanation without jeopardizing 

the message that needs to be conveyed (see Module 3, “Cultural Competency”). 

Assess Patient Understanding 

At the end of the interaction, review the material with the client to ensure nothing has 

been missed or misunderstood. Ask if the patient has any questions. 

Although working with interpreters is a challenge, it is often essential for effective 

communication of appropriate messages. Much of the interview will be the same as when 

working with a patient speaking the same language as the interviewer. However, additional 

time should be allowed, and there should be a greater reliance on observing nonverbal cues. 
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Module 2. Basics of Communication and Patient Education 

Summary 

This module covered the basics of communication and patient education. Main points 

included 

• The importance of patient education in the TB interview process; 

• Communication as an exchange of information involving asking questions and active 

listening; 

• Assessment of verbal and nonverbal cues to assist in determining the level of the 

patient’s comfort, understanding, and sincerity; 

• Eliciting information through open-ended, closed-ended, and focused questions; 

• Demonstrating active listening through reflection, paraphrasing, and summarizing; 

• Addressing and overcoming communication barriers by eliminating physical barriers, 

actively listening, interviewing in patient-focused circumstances, and engaging a proxy, 

if needed; and 

• Choosing an effective interpreter who keeps in mind that the patient is the primary 

source of information. 

An understanding and application of these essential components will enhance the TB 

interview. These components will also allow the communication and education to proceed 

more smoothly, meeting the objectives of the interview process. 
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Case Presentations 

The following case presentations demonstrate concepts from this module. You may review 

them with your supervisor if you have questions. 

Case 1 

Part 1 – Tony is a 56-year-old homeless man. He was diagnosed with TB, and you are 

interviewing him in the hospital. He is very talkative and friendly. You have completed 

your introduction and provided TB education. However, as you move through the 

interview, Tony moves off topic frequently. He talks about his fear of being “kicked out” of 

the shelter he lives in and his concern about not getting his monthly disability check. You 

haven’t been able to obtain much information regarding the contact investigation from him. 

How can you accomplish the interview objectives when the interview is taking a different 

direction as it progresses? 

Explanation: While it is important to accomplish certain objectives during an interview, 

these objectives may not be of importance to Tony if he has other pressing concerns. By 

using the communication methods of reflection and paraphrasing, you should be able to 

uncover and validate Tony’s primary life concerns at the same time. You can say, “It 

sounds like you are very concerned about where you will be living,” and “You seem worried 

about receiving your money.” By doing this, you are communicating that you are listening 

and are concerned for Tony’s well being. 

Part 2 – Upon hearing you acknowledge his concerns, Tony immediately asks if you can 

help him. 

How should you now proceed with moving the interview in a useful direction? 

Explanation: The interview objectives will not be accomplished unless Tony is reassured 

that his other concerns will be addressed. Acknowledging his concerns is the first step. You 

can talk to Tony about referring him to a case manager or others within the health 

department who can work with him on housing and financial issues. Mentioning this 

possible resolution may not prompt Tony to answer all of your questions immediately, but it 

may ease his worries so that you can move on with the interview. 

Part 3 – Since you have eased some of Tony’s concerns, he seems eager to proceed with 

answering the rest of your questions. You begin to ask Tony open-ended questions about 

where and with whom he spends time. As Tony shares information with you, you realize 

that his answers are not precise. For example, if you ask him what he does each day, he 

gives a variety of answers. He also names many contacts that you are not sure are truly 

priority contacts. 
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Module 2. Basics of Communication and Patient Education 

How can you ask Tony questions in such a way that you will obtain more specific 

information about places he frequents and individuals with whom he spends prolonged 

periods of time? 

Explanation: A combination of open-ended and focused questions would be appropriate in 

this situation. While you have assessed that Tony spends time in various places, you are 

mostly concerned with where he regularly spends time. You can ask him where he spends 

time, but provide a specific time frame. Regarding with whom he spends his time, a time 

frame is also appropriate to determine if these individuals are priority contacts. Since 

various methods for identifying contacts are required, you should ask for specific pieces of 

information including physical descriptions and nicknames. These can be posed as closedended questions. 

Part 4 – As you progress further through the contact elicitation, Tony’s answers become 

shorter and less detailed. His eye contact begins to falter. 

What seems to be occurring based on what has transpired so far during the interview and 

your assessment of Tony’s body language? What can be done to resolve this situation? 

Explanation: Based on what you know and are observing, Tony appears to be growing tired 

and is therefore unable to concentrate on the interview process. Tony is a newly diagnosed 

TB patient who has participated in a lengthy interview thus far, and you must be sensitive to 

the fatigue that may occur. At this point, you can tell Tony, “It appears as though you are 

getting tired. We can continue this interview at a later time when you may be more up to 

talking.” You should end the interview on a positive note, thanking Tony for his time and 

shaking his hand. 
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Module 2. Basics of Communication and Patient Education 

Case 2 

Part 1 – May Lee is a 67-year-old woman from China who is a TB suspect and requires a 

TB interview. You looked at her medical record, in which you found out that you will need 

an interpreter to complete the interview in her home. You talk this over with a colleague, 

who says that he is proficient in Mandarin and would be happy to attend the interview as an 

interpreter. 

Should you take up your colleague’s offer to interpret? 

Explanation: While it is tempting to bring along a person you know and are comfortable 

with, another healthcare worker is not always an appropriate choice for interpretation. An 

interpreter should be trained or certified in medical interpretation. 

Part 2 – You thank your colleague for his offer to interpret, but tell him that you will try to 

locate a medical interpreter through your health department listings. You tell your colleague 

that if you cannot locate an interpreter, you will have him come along. However, you are 

able to get an interpreter and set up a time for the interview at May Lee’s home. You plan to 

pick the interpreter up in your car so you can both arrive together. 

 

In your health department, the general practice is not to make appointments with patients for 

TB interviews, but rather to simply arrive unannounced at their homes. However, since you 

need to ensure that the patient is home and schedule an interpreter to come with you, you 

ask your Mandarin-speaking coworker to call the patient to make sure she will be home 

when you are scheduled to arrive. 

What should you do on the day of the interview, just prior to entering the patient’s home? 

Explanation: While in the car with the interpreter, you should set up some ground rules. 

These rules should address keeping all communications confidential, interpreting all 

communications precisely without editing, adding, or deleting information, and stopping the 

interaction if clarification is needed or if more time is required to complete the 

interpretation. 

Part 3 – The interpreter agrees with your ground rules. You then knock on the patient’s 

door and enter her home. You explain to her that the interview will be through a trained 

interpreter and that all communications will be confidential. You also let her know that the 

interpreter will be stating all communications exactly as they occur in both English and 

Mandarin. 
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Module 2. Basics of Communication and Patient Education 

As the discussion progresses, you notice that the interpreter is struggling a bit with the 

discussion and seems to be slowing down. The interpreter tells you that though he is trained 

in Mandarin, he has not worked with the dialect for a while. Therefore, it is taking him a 

little longer than expected to interpret. 

What can you do to ease the communication? 

Explanation: In addition to slowing your rate of speech and speaking in shorter sentences, 

you can stop the conversation occasionally to ask the interpreter if the process is progressing 

well or if he needs a break or assistance. The interpreter may be tired after a while and in 

need of a short break. 

Part 4 – As the conversation proceeds, you notice the interpreter’s sentences seem to be 

getting shorter than what they had been thus far. He is also not interpreting after each pause 

in your conversation, but does so after you provide several opportunities. 

How do you address this apparent communication gap with the interpreter? 

Explanation: The interpreter may be paraphrasing the conversation. While you do not know 

Mandarin to make a definite determination about this, the fact that the pattern of the 

interpreter’s speech has changed is a good indicator. You should therefore stop the 

interview and tell the interpreter that you sense that the entire conversation may not be 

interpreted exactly as you indicated in your ground rules. Again, ask if the interpreter needs 

a break or assistance, and how you can make this an easier process. 
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Module 2. Basics of Communication and Patient Education 

Review Questions 

Complete these questions to review concepts from this module. The answers are on 

page 30. 

1. What two conditions must be present for a patient education message to be most 

effective? 

a. Information provided must be relevant to the patient’s condition and life 

circumstances. 

b. The message must be presented by a certified health educator. 

c. Educational techniques must be individualized for each patient. 

d. The interviewer must present information in its entirety and then ask the patient for 

questions. 

2. How should the interviewer maintain eye contact when interviewing a patient and using 

an interpreter? 

a. The interviewer should always look at the patient. 

b. The interviewer should always look at the interpreter. 

c. The interviewer should look at the patient when talking to him or her. 

d. The interviewer should not look at anyone. 

3. Who is the best choice to use as an interpreter? 

a. A family member 

b. A friend 

c. A trained or certified medical interpreter 

d. Another health-care worker 

4. When is it appropriate to use closed-ended questions when interviewing a patient? 

a. To confirm information when first interacting with patient 

b. Never 

c. To confirm information after having received it from the patient during the interview 

d. To confront the patient when he or she is inconsistent 
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Module 2. Basics of Communication and Patient Education 

5. Match the interviewing technique and its definition. 

___ Paraphrasing A. The provision of limits or boundaries if the patient makes 

a vague statement or one requiring more specific 

information 

___ Reflection B. The rephrasing of a series of statements that have occurred 

through a dialogue in order to verify information and 

display that the interviewer is actively listening 

___ Focused Question C. The rewording of a patient’s emotional reactions by 

acknowledging the displayed feeling(s) and its cause 

___ Summarizing D. The rewording of a patient’s response in order to verify 

information and show that the interviewer is actively 

listening 

6. Match the following verbal and nonverbal cues exhibited by a patient with one emotion 

they may suggest (answers may be used more than once and each cue may have more 

than one answer). 

_______ Intense eye contact 

_______ Rocking 

_______ Stiff posture 

_______ Elevated voice tone 

_______ Prolonged and frequent periods of silence 

_______ Fidgeting 

A. Boredom 

B. Fatigue 

C. Fear 

D. Surprise 

E. Confrontation 

F. Nervousness 

G. Preoccupation 

H. Inability to concentrate 

I. Disinterest 

J. Loss of train of thought 

K. Inability to understand 

L. Anger 

M. Discomfort 
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Module 2. Basics of Communication and Patient Education 

7. When can medical jargon be used with a patient during an interview? 

a. If it is followed by a layperson’s explanation 

b. If the patient has already been seen by a doctor 

c. If the patient is a healthcare worker 

d. Never 
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Module 2. Basics of Communication and Patient Education 

Review Questions Answer Key 

Answers are in bold. 

1. What two conditions must be present for a patient education message to be most 

effective? 

a. Information provided must be relevant to the patient’s condition and life 

circumstances. 

b. The message must be presented by a certified health educator. 

c. Educational techniques must be individualized for each patient. 

d. The interviewer must present information in its entirety and then ask the patient for 

questions. 

2. How should the interviewer maintain eye contact when interviewing a patient and using 

an interpreter? 

a. The interviewer should always look at the patient. 

b. The interviewer should always look at the interpreter. 

c. The interviewer should look at the patient when talking to him or her. 

d. The interviewer should not look at anyone. 

3. Who is the best choice to use as an interpreter? 

a. A family member 

b. A friend 

c. A trained or certified medical interpreter 

d. Another health care worker 

4. When is it appropriate to use closed-ended questions when interviewing a patient? 

a. To confirm information when first interacting with patient 

b. Never 

c. To confirm information after having received it from the patient during the 

interview 

d. To confront the patient when he or she is inconsistent 
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Module 2. Basics of Communication and Patient Education 

5. Match the interviewing technique and its definition. 

 D Paraphrasing A. The provision of limits or boundaries if the patient makes a 

vague statement or one requiring more specific 

information. 

 C Reflection B. The rephrasing of a series of statements that have occurred 

through a dialogue in order to verify information and 

display that the interviewer is actively listening.

 A Focused Question C. The rewording of a patient’s emotional reactions through 

acknowledging the displayed feeling(s) and its cause. 

 B Summarizing D. The rewording of a patient’s response in order to verify 

information and show that the interviewer is actively 

listening. 

6. Match the following verbal and non-verbal cues exhibited by a patient with one emotion 

they may suggest (answers may be used more than once and each cue may have more 

than one answer). 

C,D,E Intense eye contact 

C,F,E Rocking 

F,M Stiff posture 

E,L Elevated voice tone 

B,I,J,K Prolonged and frequent periods of silence 

F,M Fidgeting 

A. Boredom 

B. Fatigue 

C. Fear 

D. Surprise 

E. Confrontation 

F. Nervousness 

G. Preoccupation 

H. Inability to concentrate 

I. Disinterest 

J. Loss of train of thought 

K. Inability to understand 

L. Anger 

M. Discomfort 
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Module 2. Basics of Communication and Patient Education 

7. When can medical jargon be used with a patient during an interview? 

a. If it is followed by a layperson explanation 

b. If the patient has already been seen by a doctor 

c. If the patient is a health care worker 

d. Never 
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Module 2. Basics of Communication and Patient Education 

Glossary 

Active listening – the process of hearing what is said and paying attention to how it is said 

so that further dialogue can be adjusted to elicit the needed responses. Active listening 

utilizes various verbal and nonverbal techniques. 

Barrier – physical or nonphysical obstacles or hindrances that can slow or stop 

communication. 

Closed-ended questions – require one-word or briefly-phrased responses, such as “yes” or 

“no.” Closed-ended questions can move a conversation in a more productive direction if the 

information that is being sought is not being obtained. 

Communication – the exchange of information by symbols, words, signs, or actions. It is 

an interactive process, which involves feedback. Communication revolves around asking 

questions, listening actively, understanding a patient’s concerns or needs, and demonstrating 

a caring attitude while helping to solve problems. 

Interpreter – an individual who orally conveys the exact communication for another 

individual who has little or no proficiency in the language in which the interviewer is 

speaking. Ideally, an interpreter should be professionally trained or certified. 

Focused questions – used if the respondent makes a vague statement or one requiring more 

specific information. The question may provide limits or boundaries to direct an answer. 

Open-ended questions – used to promote dialogue; these questions require more than a 

one-word answer and usually begin with who, where, what, why, or how. 

Nonverbal communication – conveying messages through body language, such as eye 

contact, facial expression, posture, gestures, and touching. 

Paraphrasing –the rewording of a patient’s response in order to verify information and 

display that the interviewer is effectively listening. 

Patient education – the process of providing information to a patient on his or her medical 

condition, treatment regimen, or processes in which he or she becomes involved with 

healthcare staff (e.g., contact investigation). Information is based on patient’s level of 

understanding, existing knowledge, and feedback (e.g., body language or questions) he or 

she provides. 

Reflection – an interviewer’s rewording of a patient’s reactions through acknowledging a 

patient’s feeling(s) and its cause. 
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Module 2. Basics of Communication and Patient Education 

Summarizing – the rephrasing of a series of statements that have occurred through a 

dialogue in order to verify information and demonstrate that the interviewer is listening 

carefully. 

Verbal communication – how something is said conveys meaning in addition to what is 

actually said. Verbal communication includes sound, words, and language. 
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Module 3. Cultural Competency 

Table of Contents 

Module 3. Cultural Competency ...................................................................... 1

Objectives ................................................................................................... 1

Introduction ................................................................................................. 1

The Concept of Culture ........................................................................... 2

Culture and the Individual ............................................................................ 3

Role of the Interviewer ................................................................................ 3

Health Beliefs .............................................................................................. 4

Appropriate Communication ........................................................................ 5

Eliciting Contacts ..................................................................................... 8

Summary ................................................................................................. 9

Case Presentations ............................................................................... 10

Case 1....................................................................................................... 10

Case 2....................................................................................................... 12

Review Questions .................................................................................. 14

Review Questions Answer Key .............................................................. 16

Glossary ................................................................................................ 18

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Module 3. Cultural Competency 

Objectives 

After reading through this module, you will be able to 

• Describe the concepts of culture and cultural competency; 

• Identify various factors that contribute to an individual’s culture; 

• Understand why cultural competency is essential in TB interviewing; 

• Assess the communication process based on a patient’s verbal and nonverbal cues; 

and 

• Limit the barriers of language, dialect, lifestyle, and belief differences during an 

interview. 

Introduction 

Culture is shaped by experiences and life events that contribute to a person’s beliefs, values, 

attitudes, and behaviors. Culture may also affect the ways in which a person communicates, 

both verbally and nonverbally, and understands information. Interviewers should be aware 

of the diversity of all individuals they encounter and how cultural factors may affect the 

course of the interview. 

Cultural competency is the sensitivity to and awareness of the various factors that shape a 

person’s identity. It is an important skill for a TB interviewer and encompasses the ability to 

work with and care for diverse individuals to meet their cultural needs without 

compromising their health or that of the public. 

The populations affected by TB are very diverse. TB affects a disproportionate number of 

nonUS-born individuals, migrants, people who travel extensively to and from TB-endemic 

countries, racial and ethnic minorities, the elderly, and other distinct groups. While local TB 

epidemiology varies greatly from area to area, cultural competency is important in TB 

interviewing in all geographic locations. 
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Module 3. Cultural Competency 

The Concept of Culture 

What we refer to as culture often consists of numerous variables for an individual, including 

but not limited to 

• Age 

• Gender 

• Race 

• Ethnicity 

• Geographic origin or location 

• Spirituality, religion, or faith 

• Sexual orientation 

• Nationality 

• Language or dialect 

• Disability 

Specific life events and factors can influence the way in which the above variables for the 

person or his or her family are integrated into one’s life. These factors can include 

• Political values and affiliation; 

• History of oppression; 

• Experience of discrimination; 

• Socioeconomic status; 

• Language and the arts; 

• Religious practices; 

• Upbringing; 

• Family roles and structure; 

• Degree of opposition to acculturation; 

• Settlement in outside environments through immigration and migration; 

• Education and employment history; and 

• Military experience. 
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Module 3. Cultural Competency 

Culture and the Individual 

Culture is individual, and information about it should be obtained directly from the patient. 

While a variety of information exists on various races, ethnicities, religions, and other 

categories of cultural groups, it is important to note that not all persons identified by the 

same label have the same beliefs and behaviors. For example, a person who identifies 

himself or herself by a particular ethnicity may not behave similarly to all others in that 

ethnic group. This person may have lived away from members of this ethnic group or may 

have been raised by someone from another ethnic group. The person’s own identification, 

name, or physical characteristics could suggest an ethnicity even though the person’s beliefs 

and behaviors do not fit the accepted image of that group. 

Despite the fact that cultural characteristics are specific to a patient, it is valuable to learn 

about different cultures to develop a general understanding of how a person’s perceptions, 

beliefs, and values may vary. While these characteristics will not always pertain to the 

individuals who are deemed a part of a certain culture, it is important for interviewers to be 

aware of differences. For example, noting that particular hand gestures may have negative 

connotations in certain cultures can indicate that one should use care when using any hand 

gestures in communications with patients. 

Role of the Interviewer

The interviewer should communicate respect for the patient, both verbally and non-verbally. 

This is best achieved by being observant of and sensitive to the many variables that can 

affect the interaction between the interviewer and the patient. A patient’s reaction to the 

interviewer may be a reflection of the patient’s values or views of certain relationships. For 

example, the gender of the interviewer may affect the patient’s comfort level. If the 

interviewer senses a patient’s discomfort, changing to an interviewer of the same gender 

would be preferable, if possible. 

Interviewer’s Culture 

The interviewer’s culture (e.g., race or ethnicity) can also affect the interaction between the 

interviewer and the patient. However, each patient’s preference is individual. A patient 

may prefer an interaction with someone of the same culture, while for others this is 

undesirable. The interviewer should be aware of how comfortable the patient is by noting 

verbal and non-verbal cues. 
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Module 3. Cultural Competency 

Nature of the Interviewer’s Job 

It is important to keep in mind that the role of an interviewer may have some inherent 

negative connotation, especially since he or she is asking personal questions. A patient may 

have had negative experiences with the healthcare system or government authorities in the 

past. The interviewer, representing both of these entities, should remain sensitive to this 

connotation and clarify that his or her role is to protect the public’s health and the health of 

the patient and the people close to the patient. 

Observing Customs and Practices 

While conducting an interview, the interviewer should honor customs observed by the 

patient. For example, if the interview takes place in the patient’s home and it is observed 

that shoes are kept outside the home, the interviewer should remove his or her shoes prior to 

entering. Seating arrangements are also important. An interviewer should wait to be asked 

to sit in a certain location, to make the patient feel more comfortable. In some cultures, a 

male may be the spokesperson for the family. If an interview is being conducted with a 

female patient, but a male in the home is speaking for her, respect for this practice should be 

given. It is important, however, to maintain rapport with both the patient and spokesperson 

and to explain that you wish to gain information exclusive to the patient, from her 

viewpoint. If the interviewer is uncomfortable, another interview can be suggested with just 

the female patient. 

Health Beliefs 

A patient’s understanding of or beliefs about TB may differ from the medical model in 

which most healthcare workers are trained. This may include how to treat TB, how TB is 

transmitted, and the specific significance the disease has for the affected person. It is 

important to respect different health beliefs, and provide the correct information in nonjudgmental fashion. As with any TB interview, the provision of education and an emphasis 

on reasons for contact identification are important. In regard to other health beliefs, the 

interviewer should refer any treatment or diagnostic concerns to the patient’s clinician or 

case manager for further follow-up.

Stigma 

The diagnosis of TB may carry a particular stigma or negative connotation in some cultures. 

The patient may even deny that he or she has TB or that the treatment offered is curative. 

The interviewer should always acknowledge the fact that a patient may feel ashamed or 

fearful of the diagnosis of TB. In a contact investigation, having to probe for information 

about persons to whom the patient may have spread TB may cause even further distress. 

Again, it is important to acknowledge the patient’s stress, explain why it is important to 

conduct the TB interview, and emphasize its confidential nature. For example, an elderly 

person with TB may recall many cases of TB in the past among friends and family members. 

These cases were treated differently than today’s cases, due to the fact that medical regimens 

were limited in the past 
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Module 3. Cultural Competency 

and many people eventually died. The current TB patient may fear having TB and have 

trouble accepting the way disease is being treated because of his or her past experiences. 

The interviewer should be sensitive to these issues. 

Health Seeking Behaviors and Beliefs 

Cultural attitudes about illness may complicate determination of a patient’s infectious 

period. A patient may have been symptomatic for longer than he or she may acknowledge. 

TB symptoms may have been attributed to other illnesses for which various remedies or care 

were sought. The interviewer should attempt to discover any and all instances of TB 

symptoms, especially coughing, to accurately determine the infectious period. Asking about 

specific symptoms can be helpful. Also, asking what remedies were sought to resolve 

symptoms can assist in remembering when symptoms may have occurred. 

Source, Treatment, and Cure of Illness 

Beliefs about how TB is spread and its causative agents can vary. The long history of TB 

has created various theories about its cause, including beliefs that certain behaviors such as 

smoking, breathing polluted air, and hard labor may cause TB and contribute to its 

progression. Furthermore, remedies for symptom relief and cure of the disease can vary. If 

discussion about treatment occurs, the interviewer should keep in mind that traditional or 

folk medicine can be complementary to Western medicine, but should be overseen by the 

treating clinician. It is also important to be sure of the patient’s understanding of 

terminology. For example, for some, the word “infection” may suggest something much 

more serious than the word “disease.” Effectively communicated patient education can help 

resolve these issues. 

Appropriate Communication 

Communication with the patient can be affected by many different factors, of which the 

interviewer must be observant. This is covered further in Module 2, “Communication and 

Patient Education.” However, cultural differences can also influence this communication. 

The interviewer should be mindful of the following cultural factors that may affect the 

patient interview. 

Interviewer Introduction 

When greeting a patient, even if unsure of the pronunciation of a patient’s name, an attempt 

should be made to pronounce it. The patient should then be asked for the correct 

pronunciation. Making this sincere attempt demonstrates respect and assists in rapport 

building. Asking for clarification on pronunciation and not being able to pronounce all 

names is not a bad reflection on the interviewer. Also, sometimes learning a common 

greeting, such as, “Hello” or “How are you?” in a patient’s language, can ease any tension 

and show the interviewer’s sensitivity to culture. 
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Module 3. Cultural Competency 

Accent and Dialect 

The presence of a foreign accent or of dialect differences can cause difficulty in 

understanding for both the patient and interviewer. If the patient’s language is limited, then 

an interpreter is necessary. 

If conducting an interview in which the interviewer or the patient is having difficulty in 

understanding the discussion because of accent or dialect, some of the following techniques 

may be used: 

• Speak slowly and clearly. 

If the pace of the interview is slowed, then the patient may also slow his or her speech to 

make the information more understandable. 

• Use nontechnical words and phrases. 

Many individuals who speak more than one language will internally translate phrases 

into the language with which they are most comfortable. Some phrases, especially 

“sayings” with figurative meanings, change in meaning when translated. When working 

with an interpreter, avoiding local jargon and excessive medical language will ease 

communication. 

• Ask the patient if anything is not understood. 

Even if a patient affirms information by nodding his or her head or verbally 

acknowledging information, the interviewer should encourage the patient to ask 

questions and summarize what he or she has heard. If the interviewer has trouble 

understanding the patient, he or she should politely ask for clarification. Conversely, the 

interviewer may not always be understood and may be asked for a rewording of what 

was said. 

• Use written information. 

While English may not be the primary spoken language for many people, it may be easy 

for them to write. If the patient cannot write in English, the interviewer should obtain 

phonetic spellings of names and addresses of contacts based on what the patient states. 

That is, the interviewer should write items in the closest way to which the patient 

pronounces them. This can assist the interviewer during the re-interview, if he or she 

must ask additional details about certain contacts. This can also provide assistance to the 

healthcare worker who must go into the field and interact with any named contacts later. 
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Module 3. Cultural Competency 

Presence of Additional Individual(s) During the Interview 

During the interview, there may also be another family member present. Often times, a 

patient, while proficient in the language in which the interview is being conducted, feels 

more comfortable communicating through a family member or having this member speak 

for him or her. The interviewer should explain to the patient and the family member that 

direct communication with the patient would be most accurate and questions would be best 

answered if they came directly from the patient. While this is not preferred, interviewers 

can collect baseline information (names, phone numbers, or addresses) can be collected 

from a family member. If the family member is present throughout the interview, a reinterview should be scheduled at a time when the family member is not present to ensure 

privacy. If either party is uncomfortable with this arrangement, then the interview should 

proceed under circumstances with which all parties are comfortable. 
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Module 3. Cultural Competency 

Eliciting Contacts

The most important part of the TB interview is identifying priority contacts and obtaining 

information about congregate settings in which transmission may have occurred. While 

seemingly straightforward, patients do not always readily do this, particularly if lifestyle 

characteristics are different from the local culture. 

• Nontraditional Living Circumstances 

– If the patient has contacts within a living arrangement that is different from a 

“mainstream” situation, he or she may be less willing to share this information. For 

example, a patient who lives in a joint family (e.g., multiple families living in the 

same household), may not want to reveal this information. It is up to the interviewer 

to restate the importance of identifying all priority contacts to protect their health. 

To obtain information about all household contacts, the interviewer must ask about 

all people who live in the house, whether these are nonimmediate family members, 

distant relatives, or friends. 

– A patient’s “partner” or “significant other” may not be someone the person is 

married to, even if he or she lives in the same household. A partner or significant 

other may also be of the same sex as the patient. The interviewer should be sensitive 

to a variety of living arrangements and sexual orientations and ask questions with 

this in mind. The interviewer should ask about a “spouse or partner” when eliciting 

priority contacts, not assuming the sex or marital status of these individuals. 

• Non-United States Resident Contacts 

Information about contacts exposed during the entire infectious period should be 

collected, even if the contacts are not in the country during the time of the interview. The 

health department protocols for follow-up of contacts outside the United States should 

be followed in this case. 

• Cultural Organizations 

Contacts associated with cultural organizations (e.g., places of worship, fine arts groups, 

or ethnic- or language-based organizations) may be difficult to identify. Often cultural 

groups are support systems, and naming contacts from these groups may promote a 

patient’s fear of losing this support. The interviewer should emphasize why contact 

identification is important and that confidentiality will be maintained. The interviewer 

should also try to obtain the name of an individual within the cultural group who can 

assist with information collection about contacts and the exposure setting itself. The 

patient can tell the interviewer who this person would be. In some circles, a prominent 

or leading member of the community may need to be consulted for permission to 

conduct a contact investigation within that group. The patient should be consulted to 

determine the best approach, and if the patient wants formal permission to be obtained, 

this should be respected. 
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Module 3. Cultural Competency 

Summary 

This module provided an overview of the principles of cultural competency needed for TB 

interviewing. It included 

• A definition of culture as the variables and life events that contribute to a person’s 

beliefs, values, attitudes, and behaviors; 

• A definition of cultural competency as the sensitivity to and awareness of various factors 

that may shape a person’s identity; 

• The variables that comprise culture, such as race, gender, ethnicity, geographical origin 

or location, spirituality/religion/faith, sexual orientation, age, nationality, 

language/dialect, and disability; 

• How the interviewer’s own culture, communication style, language, and attention to 

differences in behaviors and beliefs can contribute to the interactive process with the 

patient; and 

• How observing and respecting nontraditional living, working, and social circumstances 

may play a role in eliciting appropriate contacts. 

Cultural competency cannot be learned only by reading and absorbing generic information 

about various groups. Cultural competency is a set of skills developed by remaining aware 

of patient diversity through verbal and nonverbal cues and engaging the patient in 

information exchange while demonstrating respect, objectivity, and willingness to learn 

about the patient’s culture. Developing these skills is the best way to conduct an effective 

interview and build rapport with patients from diverse backgrounds. 
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Module 3. Cultural Competency 

Case Presentations 

The following case presentations demonstrate concepts from this module. You may review 

them with your supervisor if you have questions. 

Case 1 

Part 1 – You have been asked to conduct an interview in the home of Sona, a 27-year-old 

woman who has been diagnosed with smear-positive suspected pulmonary TB. According 

to her medical record, she arrived in this country 3 months ago and has been told by her 

doctor to stay at home until she is noninfectious. She speaks English fluently. You go to 

her home, introduce yourself, and are ushered inside by a man who introduces himself as 

Sona’s husband. He asks you to sit down. Sona goes into the kitchen and returns with a 

drink for you. The husband sits down, as you are about to start your interview. 

Should you proceed with the interview in this situation? If so, how? 

Explanation: It is important to let both individuals know that you are there to share 

information with Sona. However, the acceptable way of interviewing for this patient may be 

for another individual to speak for her. 

You should first professionally and respectfully indicate to Sona and her husband that you 

are from the health department to discuss an important health matter. If and when, in private, 

Sona agrees that it is all right to speak openly about her TB with her husband present, the 

three-way discussion may occur. Stressing confidentiality procedures and respectfully 

thanking Sona and her husband for their understanding will also exemplify your 

commitment to privacy. 

During the interview, speak directly to Sona even if answers to your questions are coming 

from another person. However, if the husband is speaking to you, maintain eye contact with 

him. Try to schedule a re-interview at a later date with only Sona present. 

Part 2 – The husband answers the questions for Sona and asks TB-related questions. He is 

very cooperative and lets Sona answer questions for which he is unsure of the answer. As 

you build rapport, Sona also begins to speak directly to you but does not maintain eye 

contact. She also keeps her hands in her lap and speaks softly and briefly. 
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Module 3. Cultural Competency 

How can you be sure that Sona is engaged in the discussion? 

Explanation: Sona may be uncomfortable with direct eye contact or even speaking with her 

husband present. You should use open-ended questions for broader answers. You should 

also ask Sona throughout the interview if she is feeling all right, and if she has any 

questions. She may need to hear you state that it is acceptable to interrupt you if she has 

questions or remembers anything she or her husband forgot to tell you. 

Part 3 –When you begin eliciting contact names, the husband explains to you that he is 

afraid of telling you the names of any contacts as they will be very upset. While he trusts 

that you will keep Sona’s identity confidential, he fears that the contacts will be very upset, 

since TB is a “killer” disease in his country of origin. 

What can you say to address the fears of Sona and her husband?

Explanation: Reassure them that you are conducting this interview so that you can 1) help 

prevent the further spread of TB, 2) provide education on the status of Sona’s treatment, 3) 

answer any questions she may have about her disease, and 4) refer priority contacts for 

medical evaluation, treatment if infected, and cure if found to have disease. Let her know 

that you will find out the answers to any of her questions for which you do not know the 

answers. 
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Module 3. Cultural Competency 

Case 2 

Part 1 – You are conducting an interview of Razia, a 21-year-old woman who is a TB 

suspect. This interview is in the patient’s apartment. She is a recent immigrant to the United 

States, but speaks fluent English. You note from her medical record that she is a 

homemaker and lives with her husband. He is at work during the interview. The record 

states that Razia has only listed her husband as an emergency contact and has no children. 

As you walk to her home, you notice that she lives on the third floor of a multifamily house. 

There are two other apartments, and you hear people inside. 

As you proceed with the interview, Razia appears to understand the purpose of the interview 

and the information you are providing about her diagnosis and treatment. When you begin 

to elicit contacts, Razia states no one else lives in her home, a small 3-room apartment. 

However, when she gives this information is given to you, Razia’s eye contact begins to 

waiver and her voice tone is quieter. Upon questioning whether she has visitors or 

employment within her home, she insists that no one else besides her husband is in her 

home. 

Since it is obvious that Razia is not confidently providing this information, how should 

you proceed? 

Explanation: Since you must elicit all contacts, ask your questions in other ways such as 

“Whom do you spend time with regularly?” Razia’s priority contacts may not all be in her 

home. You can also touch upon her interactions with the other apartment dwellers by 

asking, “How much time do you spend with your neighbors?” These are just the 

preliminary questions you should ask before looking into other spheres of her life such as 

work, school, and social activities. 

Part 2 – When you ask Razia a general question about whom she spends a lot of time with, 

she still insists that she spends time at home all day until her husband arrives. When you ask 

about other contacts, she mentions some other friends whom she rarely saw during the 

infectious period. A few minutes later, an elderly woman walks into the apartment without 

knocking. The woman speaks to Razia in her native language and is carrying food that she 

leaves on a table. Razia says something to the woman, who then leaves. 

How do you approach the topic of others who spend time in Razia’s home in light of 

observing the visitor who just arrived? 

Explanation: It is obvious that the visitor is familiar enough to be someone with whom 

Razia spends a lot of time. This visitor is also someone who may not live with Razia, but 

probably lives nearby, perhaps even in one of the other apartments in the house. 
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Module 3. Cultural Competency 

Part 3 – You reiterate the importance of identifying priority contacts and tell Razia that she 

needs to be candid about all people with whom she spends prolonged periods of time. You 

then directly ask Razia about the woman who walked into her home. Razia hesitates, but 

then tells you it is her mother-in-law who lives downstairs. She came to bring some food for 

her and her husband. She then mentions that her husband’s family lives in the other two 

apartments. She spends considerable time with them while she watches her sister-in-law’s 

two small children 2 days a week. Razia states that she was too embarrassed to tell you this, 

and that none of the family members know that she has TB. 

How should you react to Razia’s admission? 

Explanation: In a nonjudgmental tone of voice, you should thank Razia for sharing the 

information and tell her it must have been hard for her to tell you this. However, it was 

important that she told you about other people she spends time with, especially any elderly 

or very young contacts. You now need to ask Razia some very specific questions about who 

lives in the other two apartments, how much time she spends with them, and if there are 

other visitors who come to those homes while she is there. As needed, reassure the patient 

that she is doing the right thing by sharing the names of other contacts with you. It will 

make the contact investigation go more smoothly and may allow these persons to be more 

supportive of her. You tell her that perhaps her husband and even you can be there while 

she tells them; however, this is her choice. 
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Module 3. Cultural Competency 

Review Questions 

Complete these questions to review concepts from this module. The answers are on 

page 16. 

1. What is cultural competency? 

a. Having specific knowledge of customs of many groups 

b. The sensitivity to and awareness of various factors that shape a person’s identity 

c. Providing education to foreign-born patients 

d. Knowing many languages 

2. What is usually the best source of information about a patient’s culture? 

a. An encyclopedia 

b. A relevant cultural organization 

c. Another healthcare worker from the same cultural group 

d. The patient 

3. What strategy would not be expected to ease communication between an interviewer and 

patient who speaks the same language but cannot be understood because of a different 

accent? 

a. Speaking slowly 

b. Writing things down phonetically 

c. Using an interpreter 

d. Asking for clarifications 

4. When eliciting household contacts, what is an appropriate first question to ask a male 

patient if obtaining information about a spouse or domestic partner? 

a. “What is your wife’s name?” 

b. “Do you have a girlfriend?” 

c. “Do you have a significant other?” 

d. “Who lives with you?” 
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Module 3. Cultural Competency 

5. If a patient appears uncomfortable with a particular interviewer, what is a good initial 

problem-solving approach? 

a. Change interviewers 

b. Find out what is making the patient uncomfortable 

c. Explain why this interview is important and move forward with questions 

d. Discuss an unrelated topic 

6. If a patient reveals during a TB interview that he does not believe in his TB treatment, 

but in an alternative herbal regimen, what should the interviewer do? 

a. Tell the patient he can continue with his alternative herbal regimen 

b. Ask the patient to talk to his doctor about this alternative herbal regimen and that 

there is a possibility that he can continue with his alternative herbal regimen as long 

as he continues his TB drugs 

c. Tell the patient to stop the alternative herbal regimen and take only his TB pills 

d. Tell the patient to adhere to the regimen that makes him feel best 
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Module 3. Cultural Competency 

Review Questions Answer Key 

Answers are in bold. 

1. What is cultural competency? 

a. Having specific knowledge of customs of many groups

b. The sensitivity to and awareness of various factors that shape a person’s identity

c. Providing education to foreign-born patients 

d. Knowing many languages 

2. What is usually the best source of information about a patient’s culture? 

a. An encyclopedia 

b. A relevant cultural organization 

c. Another healthcare worker from the same cultural group 

d. The patient 

3. What strategy would not be expected to ease communication between an interviewer and 

patient who speaks the same language but cannot be understood because of a different 

accent? 

a. Speaking slowly 

b. Writing things down phonetically 

c. Using an interpreter 

d. Asking for clarifications 

4. When eliciting household contacts, what is an appropriate first question to ask a male 

patient if obtaining information about a spouse or domestic partner? 

a. “What is your wife’s name?” 

b. “Do you have a girlfriend?” 

c. “Do you have a significant other?” 

d. “Who lives with you?” 
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Module 3. Cultural Competency 

5. If a patient appears uncomfortable with a particular interviewer, what is a good initial 

problem-solving approach? 

a. Change interviewers 

b. Find out what is making the patient uncomfortable 

c. Explain why this interview is important and move forward with questions 

d. Discuss an unrelated topic 

6. If a patient reveals during a TB interview that he does not believe in his TB treatment, 

but in an alternative herbal regimen, what should the interviewer do? 

a. Tell the patient he can continue with his alternative herbal regimen 

b. Ask the patient to talk to his doctor about this alternative herbal regimen and that 

there is a possibility that he can continue with his alternative herbal regimen as 

long as he continues his TB drugs 

c. Tell the patient to stop the alternative herbal regimen and take only his TB pills 

d. Tell the patient to adhere to the regimen that makes him feel best 
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Module 3. Cultural Competency 

Glossary 

Culture – the variables and life events that contribute to a person’s beliefs, values, attitudes, 

and behaviors. 

Cultural competency – the sensitivity to, and awareness of, various factors that shape a 

person’s identity. 

Epidemiology – the study of the distribution and causes of disease and other health 

problems in different groups of people. 

Health beliefs – one’s attitude or understanding of the cause or cure of an illness or 

condition. 

Joint family – two or more families living in the same household. 

Significant other – a person of extreme importance to a patient, usually a love interest or 

spouse. Person may live in the same household or live in another household but spend a 

great deal of time with the index patient. 
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Module 4. Special Circumstances 

Table of Contents 

Module 4. Special Circumstances................................................................... 1

Objectives ................................................................................................... 1

Introduction ................................................................................................. 1

Challenges During the TB interview ........................................................ 2

Overcoming Challenges .......................................................................... 4

Proxy Interviews ...................................................................................... 6

Deciding to Use a Proxy .............................................................................. 6

Appropriate Proxies ..................................................................................... 6

Confidentiality and Sensitivity ...................................................................... 7

Source Case Investigation ....................................................................... 8

The Purpose of Source Case Investigation ................................................. 8

Identifying Associates .................................................................................. 8

Outbreak Investigation Interviewing ....................................................... 10

What Is an Outbreak? ............................................................................... 10

Identifying an Outbreak ............................................................................. 10

Outbreak Interviewing Challenges ............................................................. 10

Conducting the Outbreak Interview ........................................................... 11

Congregate-Setting Investigations and Interviews ..................................... 11

Interviewing Priority Contacts .................................................................... 12

Social Networks ..................................................................................... 13

Identifying Social Networks ....................................................................... 13

Outbreak Interviewing Skills .................................................................. 15

Summary ............................................................................................... 16

Case Presentations ............................................................................... 17

Case 1....................................................................................................... 17

Case 2....................................................................................................... 19

Case 3....................................................................................................... 20

Review Questions .................................................................................. 22

Review Questions Answer Key .............................................................. 24

Glossary ................................................................................................ 26

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Module 4. Special Circumstances 

Objectives 

After reading this module, you will be able to 

• Describe how TB interviews may vary depending on the patient’s life circumstances; 

• Decide when to use, how to choose, and how to interview a proxy; 

• Conduct a source case interview by selecting an appropriate interviewee and eliciting 

appropriate contact and exposure setting information; 

• Conduct interviews in outbreak circumstances; and 

• Understand social network analysis and the role the interviewer plays. 

Introduction 

While the objectives of TB interviewing and the skills involved are the same for all patients, 

there are instances in which traditional approaches for obtaining information may need to be 

altered. All patients, regardless of their health status and their circumstances, should be held 

to the same expectations for completing an interview. However, it is important to be 

prepared for challenges that may occur during an interview and to understand why these 

challenges occur. 

An interviewer should use information gleaned from the medical record review to develop a 

preliminary strategy for working with all patients. If the record indicates that the patient has 

a pre-existing medical condition, unmet needs, a history of nonadherence, or behavior that 

may make the interview process difficult, the interviewer should be prepared to deal with 

these issues in a concerned and nonjudgmental manner. Other circumstances may also 

include the need to utilize someone other than the patient to identify contacts. 
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Module 4. Special Circumstances 

Challenges During the TB interview 

If the medical record review does not suggest the existence of any special circumstances, or 

if no medical record is accessible, it is the interviewer’s responsibility to interpret verbal and 

nonverbal cues that may influence the successful exchange of information. The following 

circumstances may cause challenges to conducting a TB interview: 

• Unlikelihood of Follow-up Interviews 

Some patients may be difficult to locate for more than one interview, making the initial 

interview most important for collecting information. To the extent possible, all 

objectives of the TB interview must be accomplished during this one interaction. For 

example, patients who are homeless or have a history of migration can be difficult to 

locate for follow-up interviews. 

• Distrust of Authority 

Past negative experiences with government or healthcare agencies may cause a patient to 

refuse interview requests or to provide little or no information during the TB interview. 

• Fear of Legal Consequences or Moral Judgments 

Anything alluding to the legality or morality of patient actions can frighten a patient who 

is involved in illicit or illegal activities such as drug use, undocumented immigration 

status, commercial sex work, or previous negative experiences with the law. 

A patient can be reluctant to reveal participation in behaviors that are illegal, perceived 

as immoral, or different from that of mainstream society (e.g., drug use, unreported 

work, or alternative lifestyle). The patient can also fear the consequences of revealing 

that contacts are involved in illicit activities. This fear can outweigh the perceived 

responsibility to identify priority contacts exposed while engaging in these activities. 

• Inability to Provide Identifying and Locating Information 

An index patient may make sincere attempts to identify priority contacts. However, due 

to the nature of the patient’s or contacts’ lifestyles (e.g., homelessness or substance 

abuse) or the setting(s) (e.g., drug den, bar, or social club) in which the contacts were 

exposed, the patient may not be able to provide the names or locating information of the 

contacts. 

• Undocumented Immigration Status of Contacts 

If contacts are in the country illegally or were exposed in a work setting and do not have 

valid work permits, a patient may hesitate to name them for fear of jeopardizing their 

status in the country and at the work site. 
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Module 4. Special Circumstances 

• Unmet Personal Needs and Coexisting Medical Conditions 

A patient may consider health, housing, family, occupational, or financial concerns as 

being of higher priority than completing TB treatment or participating in the contact 

investigation process. Persons who are homeless, HIV infected, primary caregivers, or 

on public assistance may not be entirely engaged in the interview process due to other 

concerns. 

• Physical or Mentally Inability to Adequately Communicate 

Some patients may not be competent or able to understand or communicate effectively 

because of a physical or mental disability. 
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Module 4. Special Circumstances 

Overcoming Challenges 

All TB interviews should be guided by the same principles and skills. In all cases, the TB 

interviewer’s initial introduction and self-identification is crucial. While being identified as 

a member of the health department, the TB interviewer should emphasize protection of the 

public good and the health of those the patient knows or has come into contact with as the 

reason for initiating the TB interview. Also, reiteration of confidentiality and provision of 

education, with many opportunities for patient questions, should be ongoing. 

Patient concerns may surface throughout the interview, necessitating various approaches to 

address the unique nature and circumstances of each patient. 

• Patient Reluctance 

A patient may hesitate to reveal information about illicit activities or contacts. The 

interviewer must emphasize that the interview is being conducted for the purpose of 

identifying and evaluating priority contacts, and not to implicate or pass judgment. It is 

important that the interviewer safeguard patient information and assure the patient that 

this information will not be shared with authorities or prevent the patient from receiving 

services. This should be reiterated each time a patient shares concerns or shows 

evidence of reluctance to provide information. 

• Vague or No Contact Information 

If a patient cannot give names or addresses of priority contacts, the patient should be 

asked for nicknames, physical descriptions, and descriptions of locations in which 

exposures have occurred. However, descriptions can be difficult to specify. When 

gathering descriptive information, the interviewer should provide reference points for the 

patient to use such as: “How tall is John? Is he about my height?” The same is true for 

exposure setting descriptions. For example, “Where is the diner? What is the nearest 

store or landmark? Tell me how to get there from the shelter where you live.” 

• Undocumented Immigration Status 

Since the goal of the TB interview is to provide education and identify contacts, the 

patient’s immigration/visa status and standing with the law is not relevant. Interviewers 

should not ask about immigration/visa status or legal standing. If the patient volunteers 

this information or reveals it in an effort to determine how this may affect the contact 

investigation, the interviewer should reinforce that the health department is only 

concerned about preventing transmission and medically evaluating exposed contacts. 
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Module 4. Special Circumstances 

• Other Pressing Life Concerns 

A patient may display disinterest in the interview process as evidenced by body language 

or frequent diversions to other topics. The interviewer should address this to discover 

what concerns the patient has and how they can be resolved, if possible, and should 

make referrals according to health department policy. A case manager or other 

personnel within the health department can address overwhelming social and medical 

needs and other concerns. Discussing patient concerns can assist the patient in 

completing TB treatment and provide information for the TB interview process. 

• Uncooperative Behavior 

Some patients may not want to participate in the contact investigation process. They 

may feel that questions about contacts and exposure sites are too personal. Also, the 

patient may state a lack of concern for his or her contacts. While not easy to do, it 

should be explained that, in the patient’s case, someone spread TB to him or her and that 

the same could happen to others if contacts are not identified. Or, there may be contacts 

who have developed active cases of TB and will spread the germs to others. The 

patient’s role is very important in this regard. The patient should also be reassured about 

confidentiality, as this may also be a worry on the patient’s part. If all attempts to 

engage the patient fail, another healthcare worker may attempt to conduct the interview. 

Often, cues from the patient may be subtle; the interviewer should look for verbal and 

nonverbal cues to assess fear, discomfort, hesitance, and lack of understanding. Use of 

problem identification and problem-solving strategies such as patient assessment, review of 

the interview objectives, emphasis on confidentiality, and prompting for locating and 

descriptive information should be employed as often as necessary. These are used to 

educate the patient about the purposes and importance of the TB interview as well as to 

inform him or her of how any collected information will be used. 
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Module 4. Special Circumstances 

Proxy Interviews

A proxy is a person who is interviewed in the place of the index patient. Proxies are used 

based on local standards of practice when the index patient is unable to be interviewed. For 

example, a proxy could be used if the patient is 

• Deceased 

• Physically or mentally unable to adequately communicate or provide information 

• A child 

• Unable to be located 

A proxy should not be engaged simply because the patient is unwilling to be interviewed. 

This is also true for a patient who does not speak the same language as the interviewer. In 

this case, instead of using a proxy, an interpreter should be used. 

Deciding to use a Proxy 

Prior to the interview, the interviewer will decide whether to use a proxy or not. Whenever it 

is not possible to interview the index patient due to death or medical or mental condition, the 

interviewer should interview one or more persons who are likely to know the patient’s 

practices, habits, and behaviors and are able to identify persons with whom the patient has 

been in contact. Any notes in the medical record from a social worker can also be helpful. 

Obviously, in the case of a deceased or very young patient, the need to use a proxy is very 

clear. If the interviewer decides to interview the actual patient, a decision to introduce a 

proxy can be made at any time during the interview.

Appropriate Proxies 

A proxy can be a family member or close friend, and should be who knows the patient and 

his or her routine well. Family members who visit the patient in the hospital or at home 

regularly or are designated as next of kin or emergency contacts are the best choice. In a 

congregate setting, the proxy may not have clear personal knowledge of the patient, but may 

have access to documentation in the form of schedules or records, which provide data on the 

patient’s exposure setting(s). For example, in a correctional setting, if an index patient has 

been released and cannot be located, a worker within the setting may be able to provide 

information on the patient’s contacts based on records of the inmate’s locations during 

incarceration and his or her documented routine. There may be more than one proxy used 

for an interview. However, this should only be done if additional useful information can be 

derived from interviewing others. 
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Module 4. Special Circumstances 

Confidentiality and Sensitivity 

Though a proxy is not the index patient, confidentiality is just as important. The interviewer 

should educate the proxy about the health department’s policy of protection of 

confidentiality. The proxy should also be informed about his or her responsibility in 

keeping information about the index patient confidential. Even though in most states 

information about deceased patients need not remain confidential, respect and sensitivity are 

required, especially if the proxy is a family member or close friend of the index patient. 
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Module 4. Special Circumstances 

Source Case Investigation 

In some cases a contact investigation will be done with patients, especially young children 

with TB infection or noninfectious disease. This is called a source case investigation. The 

source is a person with infectious TB disease who transmits M. tuberculosis to another 

person or persons. The patient is identified through a contact or source case investigation 

and may or may not be the index patient. 

The Purpose of Source Case Investigations 

Source case investigations are recommended for young children age 2 and under with latent 

TB infection and age 4 and under with active TB disease.

1

 This is because TB in young 

children indicates recent transmission, so the ability to locate an infectious source case is 

more likely. Not all source case investigations result in potentially infected contacts being 

identified. The ultimate goal of a source case investigation is to determine who transmitted

M. tuberculosis to a child, index patient, or persons in a cluster of skin test conversions and 

whether this person 

• Is still infectious; 

• Was reported to the health department as a TB case or suspect; or 

• Has infected others. 

Even though not routinely recommended for adults, source case investigations for adults 

may also be conducted in some health departments, especially when there is 

• A group of documented recent tuberculin skin test conversions in a high-risk institution; 

or 

• A severely immunosuppressed person who does not have a known history of latent TB 

infection found to have TB disease. 

Identifying Associates 

In source case investigations, the names the interviewer elicits are called associates. For 

child source case investigations, emphasis is placed on adults or adolescents with whom the 

child spends or has spent great amounts of time. In such a scenario, there is no infectious 

period, since children rarely spread TB. Health department guidelines should be followed 

for establishing a time frame to guide the elicitation process. A time frame of greater than 6 

months can make it difficult for individuals to recall exposure sites and people they have had 

contact with. 

 

1

 Conducting source case investigations is also driven by resources and pending work in a health department. 

Therefore, the patients for whom source case investigations are conducted, and even whether they are 

conducted, vary on a local basis. 
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Module 4. Special Circumstances 

Since young children may not be the best source of information, the parent, guardian, or 

someone who knows the child’s lifestyle well should be interviewed. A source case 

interview should match the format of a standard TB interview, with the exception of 

symptom elicitation to verify an exposure time frame. Questions for source case 

investigations regarding children should be asked about associates in the following areas: 

• Household (those living in the household, frequent visitors, other homes where the index 

patient has lived) 

• School 

• Regular child care (both inside the home and outside the home) 

• Car pools 

• Play groups 

• Recreational activities 

• Extended family and friends 

• Places of recent travel 

The interviewee should also be reminded of confidentiality and the contact referral process. 

Education must be provided, particularly on transmission and the difference between latent 

TB infection and TB disease. 
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Module 4. Special Circumstances 

Outbreak Investigation Interviewing

Conducting TB interviews under outbreak circumstances provides a special challenge. 

While the objectives and communication skills remain the same for all TB interviews, the 

situations under which outbreak interviews occur are different. 

What Is an Outbreak?

An outbreak is a greater-than-normal or greater-than-expected number of individuals 

infected or diagnosed with suspected or verified TB in a given period of time, or a particular 

place, or both. This can occur in a community or larger geographic area or as part of a single 

contact investigation. In the first situation, routine surveillance provides an opportunity to 

identify outbreaks, since the greater-than-expected number of cases may not be readily 

available. Delays in reporting, cases occurring in multiple communities or TB control 

jurisdictions, and the new occurrence of a large number of latent TB infections, which are 

not reportable in many areas, make outbreak identification a difficult task. 

Identifying an Outbreak 

Outbreaks may be identified by detecting 

• A greater-than-expected rate of M. tuberculosis transmission, as defined by health 

department or institutional standards, e.g., from one index case, through routine 

interviewing and evaluation of contacts; 

• A greater-than-normal rate of skin test conversions as indicated by institutional 

standards; 

• An increase in TB cases noted through surveillance via required reporting of TB 

suspects and verified cases, and in some instances, latent TB infection; or 

• The same strain of TB detected in various locations through analysis of the genetic 

structure of specific bacteria from multiple patients (restriction fragment length 

polymorphism [RFLP] analysis). 

Outbreak Interviewing Challenges 

In any contact investigation, the TB interview is the first step in identifying all contacts at 

risk of exposure and transmission to others. However, unique challenges in outbreaks can 

slow this process, including a greater number of interviews and numerous follow-up 

interviews of the same index patients to gain additional information. Other issues include 

• Having multiple index patients; however, these links may not be evident at first as 

infected patients who are linked to each other; 
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Module 4. Special Circumstances 

• Contacts not being linked through the “obvious” and usual settings such as home, work, 

or school; 

• Links that are difficult to establish due to illicit activities; 

• Occurrence of TB disease in individuals not required to be interviewed (e.g., 

extrapulmonary cases). Subsequently, links to a source case and his or her infected 

contacts may not occur; or 

• Index patients’ inability or unwillingness to name contacts and where they can be 

located. 

Conducting the Outbreak Interview 

Most outbreaks are identified after routine TB interview data have been collected. The 

analysis of the routine interview data to conduct subsequent interviews and re-interviews 

requires a different approach. However, comparisons of named contacts and places that 

patients frequent can yield similar data. For example, several persons with TB or infected 

contacts may commonly mention one person as a priority contact; this individual may be the 

source case. A follow-up interview with this individual should be done to determine if there 

are other contacts who have not been identified. Use of a common place to focus the nature 

of contact identification can assist in identifying other possible priority contacts. Follow-up 

interviews can occur as information becomes available and is analyzed. The focus of these 

interviews, however, may be more specific than previous interviews. 

Interviewers should be prepared to provide extensive education about outbreaks in a 

congregate setting. If an outbreak has been detected and additional patients are being 

interviewed, the interviewer should explain to these patients, as appropriate, about possible 

media and press attention that may occur in connection with this outbreak. There may also 

need to be explanations about possible negative attitudes of those being tested, particularly 

in a workplace, where speculation about the source case (i.e., the index patient) will occur. 

The interviewer should acknowledge that a breach in confidentiality by others may occur; 

however, the health department’s dedication to maintaining confidentiality under all 

circumstances will be maintained. 

Congregate-Setting Investigations and Interviews 

Commonly identified places should be prioritized and investigated further through a 

congregate-setting investigation per health department guidelines. Key to these on-site 

investigations is the identification of additional priority contacts. This is also the procedure 

in a standard contact investigation in which a congregate-setting investigation would take 

place. Prioritization entails looking for places having the likelihood of the highest chances 

for transmission, i.e., where the index patient(s) spent the most time, and where high priority 

contacts may be. 
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Module 4. Special Circumstances 

Interviewing Priority Contacts 

In an outbreak scenario, individuals identified as priority contacts may also become the 

subjects of interviews due the high rate of transmission. This will routinely occur if the 

contact has developed active TB. However, if transmission is high or seems to be unusual 

for the identified circumstances in the congregate setting, even with infection, not disease, 

contacts should be interviewed. Interviews of an infected contact should include 

• Review of tuberculin skin test result, latent TB infection, and TB disease history. This 

history will assist in determining whether the contact has been recently infected or not; 

• Places in which, and persons with whom, he or she spends prolonged periods of time. 

This may eventually lead to determining if the contact has been infected by the identified 

index case or another case; 

• Asking who the contact knows who has TB or TB-like symptoms; listing the symptoms 

should help identify others with TB. If the contact names the index patient, further 

questioning about the index patient’s whereabouts, lifestyle, and other potential contacts 

can be explored. However, it is important that this be done without confirming the 

identity of the index patient. The interviewer can also inquire about any other persons’ 

whereabouts, symptoms, and lifestyle mentioned during the interview so as not to appear 

to focus on the index patient; and 

• Discussion with the contact about people with whom he or she shares drugs and alcohol, 

and where, if applicable. Acknowledging the sensitivity of this line of questioning and 

reiterating confidentiality can assist in obtaining this information. 

The purpose of this type of interviewing is to further identify contacts and other places that 

the index case has not previously mentioned that can provide information for further 

investigation. This needs to be done without revealing the name of the index patient(s). In 

order to find out the most accurate information about where transmission occurred, it is 

critical that both skin test positive and negative contacts be interviewed, if possible. 

Deciding which contacts should be interviewed can be facilitated through network analysis, 

discussed in the next section.
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Module 4. Special Circumstances 

Social Networks 

Outbreak investigations may focus on congregate settings as sites for transmission. 

Investigations must also look at other common links between multiple index patients and 

places. The social network is a linkage of persons and places where M. tuberculosis is 

spread via shared air space. The analysis of the network can help identify important 

contacts, (i.e., those most likely to be infected). Social network analysis is best 

accomplished by someone who has access to multiple pieces of data collected in TB 

interviews of cases and contacts. Once links are established, including analysis of all 

priority contacts’ skin test results and medical examinations, additional interviews can be 

prioritized. For example, if a group of priority contacts were identified as having been 

exposed under similar circumstances, only a particular segment of the network may have 

skin test conversions. These contacts would be considered high priority for further, more 

extensive interviewing. In this situation, the re-interview should concentrate on any other 

exposure factors that may have caused additional risk for infection (e.g., substance abuse). 

In another example, a place where drug use takes place is an exposure environment. 

However, this environment is one that neither the contacts nor the index patient may 

mention during an interview. With further probing in a re-interview, this place may be 

mentioned if the contact realizes that the interviewer knows of the place and what occurs 

there. 

Identifying Social Networks

Determining that M. tuberculosis has been transmitted to others can occur several months or 

longer after an index case is reported. The report of a case may be postponed due to a delay 

in seeking medical care until months after the patient becomes symptomatic. The 

interviewer should keep in mind the need to evaluate contacts exposed during the infectious 

period and all of the ways in which outbreaks can be uncovered. In this way, common 

exposure settings should be identified as follows:

• Analyzing the data collection forms from various interviews should note common 

locations of exposure including work, school, and social settings. The data should also 

be analyzed for commonly named contacts (i.e., persons named by multiple cases). 

Actual names may not all be the same, as some patients may identify contacts by 

nicknames, a first name, or by physical description. Sort cases by first name and look for 

persons who may be mentioned several times (e.g., Dave, David, Davey or Rich, Richie, 

Ricco, Richard, Dick). 

• Re-interviewing the index case(s) involved and appropriate congregate setting personnel; 

if the index case is deceased, an appropriate proxy should be identified. 

• Contacting other health departments from areas in which index cases, contacts, or both 

may spend time. 
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Module 4. Special Circumstances 

Further details can be noted and field visits made to common exposure sites. The field visits 

should be done per health department guidelines on congregate-setting investigations. 

However, if the congregate setting is social in nature, it may take the interviewer several 

visits to determine the pattern of social mixing, who frequents the setting, and who are the 

appropriate individuals from whom to gain additional information. Again, this process 

should be completed while only revealing the name of the index patient per health 

department standards of practice. In most cases, this is done when the patient’s identity will 

help to focus the investigation appropriately. 
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Module 4. Special Circumstances 

Outbreak Interviewing Skills 

During outbreak interviewing, it is imperative for the interviewer to 

• Clearly educate the index patient on the importance of describing exposure settings; 

• Reiterate to the index patient that his or her confidentiality will be maintained by the 

health department personnel and those involved in the locations of investigation; 

• Probe for nontraditional exposure settings in addition to the traditional ones; these 

should include living quarters, work (both paid and voluntary), school, social and 

recreational settings (e.g., bars, “hang-outs,” clubs, sporting events, areas of drug use, if 

substance abuse history is probable), and regular travel locations; 

• Question the patient about who frequents exposure settings, and gain as much 

identifying information about the priority contacts as possible, even if this does not 

include names, but merely physical descriptions. Questions should also include inquiries 

about where the patient stays or sleeps, if not at the mailing address, sex partners, and 

people with whom drugs are used; and 

• Ask the index case about who may provide further information about priority contacts. 

RFLP analysis may also be part of the investigation. This is because TB bacteria have a 

unique genetic pattern that can be traced to the one or more persons who carry the same 

strain of bacteria. Access to this type of information is very helpful in finding related cases. 

These contacts may not know or identify each other in an interview, but may have a 

common link through a person or place. 
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Module 4. Special Circumstances 

Summary 

While all TB interviews have the same objectives, a different strategy may be required for 

each patient. The patient’s lifestyle and the cues the patient provides can assist the 

interviewer in determining how to modify the approach for each patient. The circumstances 

under which interviews occur should also be considered when formulating an interviewing 

strategy. These patient and interview circumstances can be addressed through 

• Providing continuous patient education and asking for patient questions; 

• Reinforcing confidentiality; 

• Addressing pressing life concerns; 

• Assessing verbal and nonverbal cues; 

• Identifying and using an appropriate proxy; and 

• Using social networks to identify additional index patients and contacts. 
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Module 4. Special Circumstances 

Case Presentations 

The following case presentations demonstrate concepts from this module. You may review 

them with your supervisor if you have questions. 

Case 1 

Part 1 – Barbara is a 41-year-old woman who was diagnosed with TB while in jail. You 

need to interview her in the hospital to which she was transferred. The medical record 

review indicates that Barbara has a history of crack and cocaine use. The interview is 

difficult to conduct as Barbara appears tired and has little eye contact with you. Also, as 

indicated in her record, she is experiencing withdrawal symptoms. While Barbara does not 

have many questions about TB, she verifies most of the medical and personal information 

you provide. When you try to elicit contacts, Barbara becomes defensive and asks why you 

need to know all of this information. 

How do you deal with Barbara’s concern about contact identification? 

Explanation: Even though Barbara has been cooperative thus far, you have come to a 

critical and difficult point in the interview. Although the explanation of the purpose of the 

TB interview for identifying contacts should come at the beginning of the interview, this 

purpose should be reiterated once again prior to asking about contacts. You should also 

acknowledge to Barbara, through the use of reflection, that she seems tired and worried 

about her confidentiality. You should also acknowledge that the interview has been a long 

process for her. 

Part 2 – Once you explain to Barbara again about the reason for identifying contacts, she 

states that she is willing to continue with the interview. As you ask questions, Barbara 

offers very little information about her contacts. She provides no names or just first names 

and little or no address information. She fidgets in her chair and has not mentioned where 

exposure has occurred. 

Is the contact information you have received enough to work with? If not, how can you 

obtain more detailed information? 

Explanation: Barbara appears nervous. She has not given enough information to allow you 

to end the contact identification process. At this point, you should mention to Barbara that 

while it is difficult to name people she may have exposed to TB, you need their names and 

where to find them so that they can be tested for TB and be evaluated by a doctor. Barbara 

may also be fearful of you finding out about illicit activities she was involved in during the 

infectious period. Even though she may not have stated her fear directly, you should 

reassure her that you are only concerned about the well-being of those individuals that may 

have been exposed to TB and not the nature of the activities in which they are involved. 
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Module 4. Special Circumstances 

Part 3 – After you explain the process and importance of contact identification again to 

Barbara, she agrees to give you some more contact information. However, she still claims 

to only know first names or nicknames of many of her contacts, and states that she has no 

mailing addresses. The contacts Barbara names outside of her household are individuals she 

has been involved with during drug use or transactions. 

How should you proceed with the contact elicitation process from here? What other 

information may help you? 

Explanation: Asking as much information as possible about the contacts will assist the 

healthcare worker who will go into the field to locate them. You should ask Barbara for 

physical descriptions and distinguishing characteristics of her contacts and descriptions of 

the locations in which she meets them, including times when she meets them. 
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Module 4. Special Circumstances 

Case 2 

Part 1 – Joey is a 3-year-old boy who was diagnosed with pulmonary TB. You were asked 

to interview his mother, Ms. Jones, as part of a source case investigation. Joey is under the 

care of a private doctor who referred him to the health department. Ms. Jones is confused 

about why you are only looking for who transmitted TB to her son. She also wants to know 

why Joey should not be isolated so that he will not infect others. The doctor seemed 

unconcerned about this and she is worried, as there is another child at home. 

What should you say to Ms. Jones regarding her concerns? 

Explanation: Part of the interview process is to educate the patient on the reasons for the 

TB interview and answer any TB-related questions the patient may have. Ms. Jones should 

be told why a source case investigation is being conducted and why you are trying to find 

out who may have transmitted TB to her son. It is important that Ms. Jones understand that 

young children with TB are not usually able to spread infection and, therefore, do not need 

to be isolated. Also, she should understand that evidence of TB disease in a young child 

suggests that he has been infected recently and that you can potentially find the source of her 

son’s disease, who needs to be treated as well. Reassure Ms. Jones that you are conducting 

this investigation not to lay blame on anyone, but to provide medical attention to the source 

case so that he or she can get well and not infect others, including anyone else close to her or 

to Joey. 

Part 2 – After Ms. Jones has understood the purpose of the interview and its outcomes, she 

is willing to provide you with information that you need. Your review of the patient’s 

record shows that Ms. Jones and her other child have negative tuberculin skin test results 

and are asymptomatic. 

In order to assess where exposure to TB disease may have occurred, what types of 

locations and people would you want to ask Joey’s mother about? 

Explanation: You should ask Ms. Jones where Joey spends time. To assist her with 

thinking of places, ask her about daycare centers, play or activity groups, and relatives’ and 

friends’ homes. You should ask about people Joey spends time with, including parents or 

guardians and relatives or friends who come to the house. Also, ask who has come to the 

house and stayed for prolonged periods of time in the past few months. In addition to 

regular visitors, this should also include those who have had extended contact with Joey. 

Finally, ask Ms. Jones about any people she knows who have had TB or TB symptoms, 

particularly cough. Giving Ms. Jones a time frame would provide a reference to guide her in 

answering this question. Consult your health department guidelines for a time frame used to 

elicit contacts for source case investigations. 
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Module 4. Special Circumstances 

Case 3

Part 1 – A small local hospital has contacted your health department. Four nurses, who 

undergo annual tuberculin skin testing, have tested positive this year. This is a highly 

unusual number of skin test conversions in this facility. The hospital reports that none of the 

nurses have TB disease. There have also not been any known TB cases in the hospital in the 

past several years. 

What should you do as the TB interviewer in this situation? 

Explanation: Even though these nurses are not infectious, the fact of their recent skin test 

conversions in a high-risk setting makes it important to do an interview with each of them. 

You also need to ask two questions: 1) Have the skin testing protocols and methods in the 

hospital changed recently? 2) Has there been a change in the hospital staff who are regularly 

tested? 

Part 2 – After finding out that the skin testing procedures and staff have not changed, you 

decide to interview each of the nurses separately. You have confirmed that they have indeed 

recently tested positive for latent TB infection (LTBI) and do not have TB disease. You 

have also obtained documentation of the nurses’ previously negative skin test results. 

Since these are healthcare workers, what kind of information should you provide 

regarding TB and this interview? 

Explanation: Even though the nurses are healthcare workers, you should still determine 

their level of TB knowledge. If needed, you should explain the difference between latent 

TB infection and TB disease and why completing treatment is important. Each nurse should 

also understand why these interviews are being conducted. The reason is that the hospital 

had observed an unusually high rate of new skin test conversions, indicative of TB 

transmission, and wants to 1) find the probable source case, 2) see if all of the people being 

interviewed are linked in some way, and 3) prevent further TB transmission. 

Part 3 – After the nurses receive the education, you are ready to identify associates and 

exposure settings. 

What questions should you ask to gather contact information? 

Explanation: You should ask about anyone that they know who has TB or may have been 

ill with symptoms consistent with TB. You should also ask about with whom and where 

they spend time frequently, including home, work, school, social, and congregate settings. 
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Module 4. Special Circumstances 

Part 4 – After all of the interviews are completed, you analyze your interview data. You see 

that none of the nurses name the same associates nor know anyone likely to have TB. All 

four nurses do “moonlighting” work at the same nursing home. However, they all work 

different shifts and on different days. 

What should be done with this information, what additional questions should be asked, 

and should further interviews be done? 

Explanation: Since a substantial amount of information was collected from the nurses, you 

may not want to re-interview them at this time, but may need to do so later. You should 

conduct an investigation in the commonly named nursing home, since it may be the place of 

common exposure to a source case, who remains untreated. Further interviews may arise 

from this setting, if a case of infectious TB is discovered. In the congregate setting you 

should find out 1) what the nurses’ routines are, 2) which patients they care for, and 3) the 

locations in which they work. 
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Module 4. Special Circumstances 

Review Questions 

Complete these questions to review concepts from this module. The answers are on 

page 24. 

1. During an interviewer’s discussion about a work site investigation, the interviewer 

should tell the patient that limited information may be shared about the TB exposure 

with whom? 

a. No one 

b. The patient’s co-workers 

c. His or her contacts 

d. A high-level site manager, if necessary to focus the investigation 

2. If a patient reveals that he or she does not hold a valid visa for being in the country, what 

should the interviewer do? 

a. Continue the interview and, later, report the patient to the appropriate authorities 

b. Tell the patient you will refer him/her to a lawyer for assistance 

c. Tell the patient about the consequences of his illegal status 

d. Tell the patient that his visa status is not important for the purpose of the interview 

and that it is not the health department’s concern; identifying contacts is the concern 

3. What will assist the interviewer to assess the patient’s fear, discomfort, hesitance, and 

lack of understanding? 

a. Nonverbal cues 

b. Proxy 

c. Interpreter 

d. Medical record 

4. If a patient frequently discusses other priorities during the interview, what should the 

interviewer do? 

a. Stop the interview and try to resolve the issue 

b. Ignore the patient’s diversions and move ahead with the interview 

c. Acknowledge the issue and state that nothing can be done about it 

d. Acknowledge the issue, work through to a solution, and resume the interview 
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Module 4. Special Circumstances 

5. In which of these circumstances should a proxy not be used? 

Patient is: 

a. Deceased 

b. Unable to speak the language of the interviewer 

c. Physically unable to adequately communicate 

d. Very young 

6. In which circumstance would a contact or source case investigation not be conducted? 

a. 2-year-old child with latent TB infection 

b. Adult with an abnormal chest x-ray 

c. Adult with cavitary TB 

d. Prison in which 25% of employees have had recent skin test conversions 

7. What piece of information, routinely collected on the TB interview data form, can be 

analyzed to find links between index patients and infected contacts? 

a. Exposure settings 

b. Names of priority contacts 

c. Address information 

d. All of the above 

8. Why may an infected contact be interviewed in a contact investigation? 

a. To find out to whom the infected contact may have transmitted M. tuberculosis

b. To identify a common exposure setting between the infected contact and the index 

case 

c. Because it is recommended that ALL infected contacts are interviewed 

d. To convince the infected contact not to reveal information about index case 
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Module 4. Special Circumstances 

Review Questions Answer Key 

Answers are in bold. 

1. During an interviewer’s discussion about a work site investigation, the interviewer 

should tell the patient that limited information may be shared about the TB exposure 

with whom? 

a. No one 

b. The patient’s co-workers 

c. His or her contacts 

d. A high-level site manager, if necessary to focus the investigation 

2. If a patient reveals that he or she does not hold a valid visa for being in the country, what 

should the interviewer do? 

a. Continue the interview and, later, report the patient to the appropriate authorities 

b. Tell the patient you will refer him or her to a lawyer for assistance 

c. Tell the patient about the consequences of his illegal status 

d. Tell the patient that his or her visa status is not important for the purpose of the 

interview and that it is not the health department’s concern; identifying contacts is 

the concern 

3. What will assist the interviewer to assess the patient’s fear, discomfort, hesitance, and 

lack of understanding? 

a. Nonverbal cues 

b. Proxy 

c. Interpreter 

d. Medical record 

4. If a patient frequently discusses other priorities during the interview, what should the 

interviewer do? 

a. Stop the interview and try to resolve the issue 

b. Ignore the patient’s diversions and move ahead with the interview 

c. Acknowledge the issue and state that nothing can be done about it 

d. Acknowledge the issue, work through to a solution, and resume the interview 
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Module 4. Special Circumstances 

5. In which circumstance should a proxy not be used? 

Patient is: 

a. Deceased 

b. Unable to speak the language of the interviewer 

c. Physically unable to adequately communicate 

d. Very young 

6. In which circumstance would a contact or source case investigation not be conducted? 

a. 2-year-old child with latent TB infection 

b. Adult with an abnormal chest x-ray 

c. Adult with cavitary TB 

d. Prison in which 25% of employees have had recent skin test conversions 

7. What piece of information, routinely collected on the TB interview data form, can be 

analyzed to find links between index patients and infected contacts? 

a. Exposure settings 

b. Names of priority contacts 

c. Address information 

d. All of the above 

8. Why may an infected contact be interviewed in a contact investigation? 

a. To find out to whom the infected contact may have transmitted M. tuberculosis 

b. To identify a common exposure setting between the infected contact and the index 

case 

c. Because it is recommended that ALL infected contacts are interviewed 

d. To convince the infected contact not to reveal information about index case 
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Module 4. Special Circumstances 

Glossary 

Associate – a person who has been identified by the index patient in a source case 

investigation as someone with whom he or she spends prolonged, frequent time. A person 

who is somehow affiliated with a patient who has noninfectious tuberculosis or another 

contact, often used in connection with source-case investigations. 

Outbreak – a greater-than-normal or greater-than-expected number of individuals infected 

or diagnosed with suspected or verified TB in a given period of time or a particular place. 

Proxy – a person who is interviewed in the place of the index patient; proxies can be family 

members or close friends. A proxy is used if the patient is deceased, physically or mentally 

hindered, very young, uncooperative, or unable to be located. 

Restriction fragment length polymorphism (RFLP) analysis – A method of DNA 

fingerprinting, which can be used to identify specific strains of M. tuberculosis and, thus, 

track TB transmission during outbreaks. 

Social network – linkage of persons or places where TB is spread through shared air space 

and common ties (e.g., social) amongst the persons and settings involved. 

Social network analysis – looking at routinely collected interview data to find common 

links amongst both cases and infected persons; these links may be persons or places. 

Source case – a person with infectious TB disease who is responsible for spreading 

M. tuberculosis to another person or persons. 

Source case investigation – the process of conducting a public health investigation to 

determine who may have transmitted M. tuberculosis to a patient when recent 

transmission is reported. Source case investigations can be applied to both recent 

transmissions in infected adults and children and for disease in very young children. 

Undocumented – the term used to describe a person who is not in the country on a valid 

visa. 
Self Study

Acknowledgments 

Page 1 

The following individuals have contributed to development of the TB interviewing 

resources: 

Nisha Ahamed, Rajita Bhavaraju, 

Eileen Napolitano, and Mark Wolman 

New Jersey Medical School National 

Tuberculosis Center 

Suzanne Banda Zaw 

Department of Health Services, State of 

Oregon 

David Berger 

Francis J. Curry National Tuberculosis Center 

Bill Bower 

Charles P. Felton National Tuberculosis 

Center 

J. Todd Braun 

Texas Center for Infectious Diseases 

Judi Bulmer 

New York State Department of Health 

Bill Cissell 

Texas/Oklahoma AIDS Education and 

Training Center 

Al Cortes, Pete Fantasia, and Karen 

Galanowsky 

New Jersey Department of Health and Senior 

Ward Services 

Nickolas DeLuca, Maria Fraire, Michael 

Iademarco, Peter McElroy, Zach Taylor, and 

Wanda Walton 

Centers for Disease Control and Prevention 

Maureen Donovan 

Maryland Department of Health and Social 

Hygiene 

Andrew Eke 

Fulton County Department of Health and 

Wellness 

Genevieve Greeley 

New Mexico Department of Health 

Joy Hardacre and Barbara Weber 

Indiana State Department of Health 

Marty Huber 

Arizona Department of Health 

Kathleen Hursen 

Massachusetts Department of Public 

Health 

Ann Jackson and Pam Kreyling 

Mississippi State Department of Health 

Lorena Jeske 

Washington State Department of Health 

Jennifer Johnson 

Greenwich Department of Health 

Michael Joseph and Tambi Shaw 

California Department of Health Services 

Lisa Koffler and Manni Lee 

New York City Department of Health 

Rachelle Kotrba 

Health and Human Services Agency, 

County of San Diego 

Linnette McElroy 

Vancouver Island Health Authority TB 

Clinic 
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Acknowledgments 

Page 2 

Mark Miner 

Baltimore City Department of Health 

Kathleen Overholt 

Elkhart County Health Department 

Ann Poole 

Georgia Department of Human Resources 

Judy Proctor and Elizabeth Talbot 

New Hampshire Department of Health and 

Human Services 

Margaret Marek Rohter 

Suburban Cook County Tuberculosis District 

Ricardo Silva 

Hawaii Tuberculosis Control Program 

Lois Smith 

Grant County Health District 

Ann Tyree 

Texas Department of Health 

Krissy Vinnup 

Santa Clara County TB Prevention and 

Control Program 
Self Study

Acknowledgments 

Page 3 

The following resources were used or adapted in developing the TB interviewing 

educational materials: 

American Lung Association 

Curriculum: Extended Disease Control Investigator Training (Trainer’s Manual) 

California Department of Health Services 

TB Interviewing Course Materials 

Centers for Disease Control and Prevention, Division of Tuberculosis Elimination 

Conducting a TB Interview (Videotape) 

Centers for Disease Control and Prevention, Division of Tuberculosis Elimination 

Effective Tuberculosis Interviews: A Course on Communication Skills (Trainer’s and 

Participant’s Manuals) 

Centers for Disease Control and Prevention. Guidelines for the investigation of contacts of 

persons with infectious tuberculosis. Recommendations from the National Tuberculosis 

Controllers Association and CDC. MMWR 2005. 

Centers for Disease Control and Prevention, Division of Tuberculosis Elimination 

Self-Study Modules on Tuberculosis: Module 6 – Contact Investigations for Tuberculosis 

Centers for Disease Control and Prevention, National Network of STD/HIV Prevention 

Training Centers, Core Training Programs: Partner Services and Program Support 

Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention 

Training Guide for HIV Partner Counseling and Referral Services 

Emory University 

Lost and Found: The Case of Mr. Norwood - A Video to Build Communication Skills for 

Healthcare Providers (Videotape and Trainer’s Manual) 

Francis J. Curry National Tuberculosis Center 

Effective TB Interviewing Course (Training materials) 

Francis J. Curry National Tuberculosis Center 

Making the Connection: An Introduction to Interpretation Skills for TB Control 

Massachusetts Department of Public Health 

Contact Tracing and Investigation of Tuberculosis (Slide set) 

New Jersey Medical School National Tuberculosis Center 
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Acknowledgments 

Page 4 

Performance Guidelines for Contact Investigation: The TB Interview 

New Jersey Medical School National Tuberculosis Center 

TB Interviewing for Contact Investigation: A Practical Resource for the Healthcare Worker 

New Jersey Medical School National Tuberculosis Center 

TB Simulated Patients: A Training Resource for the Contact Investigation Interview 

New York City Department of Health 

Contact Investigation Communication Skills Workshop (Exercises) 

Texas Center for Infectious Diseases/Texas Department of Health 

Contact Investigation (Policy handbook) 

Wisconsin Department of Public Health 

Conducting Comprehensive Contact and Source Case Investigation (Procedure manual) 
Self Study

Resource List 

Page 5 

The following resources and organizations can provide additional education and training 

information related to TB and other topics addressed in the TB interviewing educational 

materials: 

Centers for Disease Control and Prevention (CDC) 

Division of Tuberculosis Elimination (DTBE) 

1600 Clifton Rd., NE 

Mail Stop E-10 

Atlanta, Georgia 30333 

1-800-CDC-INFO (1-800-232-4636) 

http://www.cdc.gov/tb

The mission of the Division of Tuberculosis Elimination (DTBE) is to provide leadership in 

preventing, controlling, and eventually eliminating tuberculosis (TB) from the United States, 

in collaboration with partners at the community, state, and international levels. 

Division of HIV/AIDS Prevention 

1600 Clifton Rd., NE 

Mail Stop E-49 

Atlanta, Georgia 30333 

1-800-CDC-INFO (1-800-232-4636) 

http://www.cdc.gov/hiv CDC's HIV mission is to prevent HIV infection and reduce the 

incidence of HIV-related illness and death, in collaboration with community, state, national, 

and international partners. 

Division of Sexually Transmitted Diseases 

1600 Clifton Rd., NE 

Mail Stop E-02 

Atlanta, Georgia 30329 

1-800-CDC-INFO (1-800-232-4636) 

http://www.cdc.gov/std

The Division of STD Prevention provides national leadership through research, policy 

development, and support of effective services to prevent sexually transmitted diseases 

(including HIV infection) and their complications such as enhanced HIV transmission, 

infertility, adverse outcomes of pregnancy, and reproductive tract cancer. 
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Resource List 

Page 6 

Centers for Disease Control and Prevention (CDC) National Prevention Information 

Network (NPIN) 

P.O. Box 6003 

Rockville, MD 20849-6003 

1-800-458-5231 

http://www.cdcnpin.org/scripts/index.asp

The CDC National Prevention Information Network (NPIN) is the U.S. reference, referral, 

and distribution service for information on HIV/AIDS, sexually transmitted diseases (STDs), 

and tuberculosis (TB). NPIN produces, collects, catalogs, processes, stocks, and 

disseminates materials and information on HIV/AIDS, STDs, and TB to organizations and 

people working in those disease fields in local, state, national, and international settings. 

Centers for Disease Control and Prevention (CDC) National Prevention Information 

Network (NPIN) Tuberculosis and Education and Training Resource Guide 

http://www.cdcnpin.org/scripts/tb/guide/toc.asp

The Tuberculosis Education and Training Resource Guide was developed as a cooperative 

effort between the Centers for Disease Control and Prevention (CDC) National Prevention 

Information Network (NPIN) and the CDC Division of Tuberculosis Elimination (DTBE). 

TB Education and Training Resources Website 

http://www.findtbresources.org

Sponsored by the Centers for Disease Control and Prevention (CDC), the TB Education and 

Training Resources Website includes a searchable, comprehensive database of materials 

from numerous national and international organizations. At this “one-stop” site of TB 

education and training resources, you can find materials to suit your needs by selecting 

parameters such as language, target audience, and format. 

Regional Training and Medical Consultation Centers 

The Centers for Disease Control and Prevention, Division of Tuberculosis Elimination funds 

four Regional Training and Medical Consultation Centers (RTMCCs). The primary purpose 

of each RTMCC is to 

• provide training and technical assistance to increase human resource development in TB 

programs 

• develop TB educational materials, and 

• provide medical consultation to TB programs and medical providers.
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Resource List 

Page 7 

Francis J. Curry National Tuberculosis Center 

3180 18th Street, Suite 101 

San Francisco, CA 94110-2028 

415-502-4600 (Phone) 

415-502-4620 (Fax) 

tbcenter@nationaltbcenter.edu (E-mail) 

www.nationaltbcenter.edu (website)

Heartland National Tuberculosis Center 

2303 SE Military Drive, 

San Antonio, TX 78223-3542 

800-TEX-LUNG (800-839-5864) (Phone) 

210-531-4500 (Fax) 

http://www.heartlandntbc.org (website) 

Northeastern Regional Training and Medical Consultation Consortium 

225 Warren Street 

Second Floor East Wing 

Newark, NJ 07103 

973-972-3270 (Phone) 

800-482-3627 (Toll-Free) 

973-972-3268 (Fax) 

www.umdnj.edu/globaltb (website) 

Southeastern National Tuberculosis Center 

1329 SW 16th Street 

Room 5187 

Gainesville, FL 32608 

Mailing Address: 

PO Box 103600 

Gainesville, FL 32610-3600 

352-265-7682 (Phone) 

352-265-7683 (Fax) 

http://sntc.medicine.ufl.edu/ (website) 
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Resource List 

Page 8 

Special Populations Resources

EthnoMed

http://www.ethnomed.org

EthnoMed is a joint project of the University of Washington Health Sciences Library and the 

Harborview Medical Center's Community House Calls Program. EthnoMed is a website 

containing medical and cultural information on immigrant and refugee groups. It contains 

information specific to groups in the Seattle area, but much of the cultural and health 

information is of interest and applicable to other geographic areas as well. 

Office of Minority Health Resource Center 

P.O. Box 37337 

Washington, D.C. 20013-7337 

800-444-6472 

http://www.omhrc.gov

The mission of the Office of Minority Health is to improve and protect the health of racial 

and ethnic minority populations through the development of health policies and programs 

that will eliminate health disparities. 

Health Resources and Services Administration 

http://www.hrsa.gov/culturalcompetence/ 

This Health Resources and Services Administration site exists to provide culturally and 

linguistically appropriate, high-quality, comprehensive, and coordinated primary and 

preventive care developed and implemented at the community level. This site provides tools 

and resources aimed at cultural competency. 

The François-Xavier Bagnoud Center 

AIDS Education and Training Centers (AETC) National Resource Center 

30 Bergen Street 

PO Box 1709 

Newark, NJ 07101-1709 

973-972-0410 / 1-800-362-0071 

http://www.aidsetc.org/

The AIDS Education and Training Centers National Resource Center works to increases the 

number of healthcare providers who are effectively educated and motivated to counsel, 

diagnose, treat, and medically manage individuals with HIV infection, and prevent high-risk 

behaviors that lead to HIV transmission. 
Self Study

Resource List 

Page 9 

The Migrant Clinicians Network (MCN) Clinical Education Program 

P.O. Box 164285 

Austin, TX 78716 

(512) 327-2017 

http://www.migrantclinician.org 

The Migrant Clinicians Network is committed to providing high-quality continuing 

education to healthcare providers serving migrant farmworkers. MCN's comprehensive 

clinical education program helps to develop excellence in practice, clinical leadership, and 

dissemination of best models and practices.