Finishing Preventive Tuberculosis Therapy by Phone: Final Report of a Nurse-Led Capstone Project
Student Name
Master of Science in Nursing Program, Aspen University
N599: Nursing Capstone
Instructor Name
Month Day, Year
Finishing Preventive Tuberculosis Therapy by Phone: Final Report of a Nurse-Led Capstone Project
People with latent tuberculosis infection carry the bacteria without symptoms, cannot spread them, and may never become ill; yet about one in ten will develop active disease at some point, and treatment can prevent most of those cases. In the tuberculosis program of one composite county health department, fewer than three in five patients who started preventive treatment ever finished it. This final report brings together the capstone project that set out to change that: why patients stopped, what the evidence offered, the theory that shaped the response, how the change was carried out and measured, what happened and what it means for nursing practice. It ends with a reflection on the master's program competencies the project required.
The Problem
In the twelve months before the project, 164 adults began treatment for latent infection at the clinic, and 95 completed it, a rate of 57.9%. Most were prescribed four months of daily rifampin and asked to return monthly. A chart review of the 69 unfinished courses found that most ended early, usually after a missed monthly appointment, among patients who worked hourly jobs, had arrived in the country recently or needed an interpreter. Nurses described losing contact for weeks at a time, with an outreach worker's calls often going unanswered. The problem, in short, was not that patients refused treatment but that a daily regimen supervised through monthly visits did not fit their lives.
What the Evidence Offered
Three bodies of evidence pointed toward a solution. First, shorter rifamycin regimens are finished more often than longer ones: in the trial that established the 12-dose weekly combination of isoniazid and rifapentine, 82.1% of the weekly group finished, against 69.0% of those given nine months of isoniazid (Sterling et al., 2011), and in a U.S. clinic cohort the weekly combination was completed more often than daily rifampin in both younger and older adults (Haas et al., 2021). Current national guidance lists both the weekly combination and daily rifampin as preferred options (Sterling et al., 2020).
Second, observing doses raises completion. In a large randomized trial, 87.2% of observed patients and 74.0% of those taking doses unobserved completed treatment, and automated text reminders added little (Belknap et al., 2017). Third, observation need not mean travel. In a London trial among patients with active disease and complex social needs, 70% of those using smartphone video observation completed at least four in five scheduled observations in the first two months, against 31% with in-person observation (Story et al., 2019). The gap in the literature was local and practical: little was known about how nurses running the weekly combination with video observation would perform in a U.S. county clinic serving newly arrived working adults.
Guiding Framework
The Health Belief Model, first developed to explain why people did not come forward for tuberculosis screening (Rosenstock, 1974), framed the project. Its constructs of perceived susceptibility, severity, benefits and barriers, cues to action and, in its later form, self-efficacy (Rosenstock et al., 1988) offered a vocabulary for why a person who feels well stops taking a preventive drug. A meta-analysis showing that benefits and barriers predict health behavior more strongly than perceived threat (Carpenter, 2010) led the project to concentrate on removing obstacles and building confidence rather than on warnings about disease. Each part of the intervention was matched to a construct: fewer doses and no travel to barriers, a nurse answering every video to cues to action and self-efficacy, and a picture showing lifetime risk with and without treatment to perceived benefit.
Methods
The project used a pre-post quality improvement design, reported according to SQUIRE 2.0 (Ogrinc et al., 2016), comparing six months of implementation with the preceding year. Every adult starting treatment was included whatever option they chose. Patients without a contraindication were offered the weekly combination and, if they had a smartphone, video observation through a secure application; others received weekly phone contact or continued on daily rifampin. A nurse reviewed each video within one business day, replied and followed up missed doses by message and then by phone. The primary outcome was completion, defined for the weekly combination as 11 doses within 16 weeks, and for rifampin by the clinic's existing standard. Secondary measures were uptake of each option, on-time videos, reasons for stopping, adverse events and nursing time. The health department classified the work as quality improvement. Analysis combined a chi-square comparison with the baseline, a confidence interval and a run chart of monthly cohorts.
Results
Eighty-four adults began treatment during the six months. Forty-nine chose video observation, 21 the weekly combination without video and 14 daily rifampin. The results below use composite figures constructed for teaching.
| Measure | Baseline year | Implementation, six months |
|---|---|---|
| Patients starting treatment | 164 | 84 |
| Patients completing treatment | 95 | 66 |
| Completion rate | 57.9% | 78.6% |
| Completion with video observation | Not offered | 87.8% (43 of 49) |
| Median nurse time per patient | About 40 minutes | About 14 minutes plus 5 minutes per video |
The rise in completion was statistically significant (chi-square = 10.40, p = .001), and every implementation month fell above the baseline median on the run chart, the signal of a sustained shift described by Benneyan et al. (2003). Ninety-one percent of weekly videos arrived on time. Three patients stopped because of adverse events, all mild and resolved. Those who completed treatment mostly credited the saved trips and the nurse's messages.
Discussion
The clinic's results sit close to what trials of observed weekly treatment would lead one to expect, which lends them plausibility, and they suggest that a phone video reviewed by a nurse can supply much of what in-person observation provides. The design, however, limits what can be claimed. Without a concurrent comparison group, changes over time other than the intervention cannot be ruled out, and because patients selected their own option, the high completion among video users reflects both the method and the kind of patient who chose it. The period was too short to count prevented cases of active disease. These limits argue for continued monitoring and a multisite evaluation, not for doubting that the clinic's patients were better served.
What Changed for Good
The project produced lasting changes in the clinic's practice. Nurses now propose phone-verified weekly dosing first, and daily rifampin remains available for those who need or prefer it. An early check-in call was added when patient surveys showed that early side effects were the most common reason for wanting to stop. The health department agreed to fund the video platform and a small stock of loaner phones, and the state tuberculosis program has asked the clinic to present the approach to other counties. Nurses now track completion monthly on the same run chart used in the project, which turns a one-time improvement into an ongoing measure.
Reflection on Program Competencies
The project drew on nearly every part of the master's program. Evidence-based practice skills were needed to judge trials of different designs and populations and to decide what could and could not be carried into a county clinic. Quality improvement methods, particularly the run chart and a pre-agreed outcome definition, made the results credible to physicians and administrators. Leadership was exercised less through authority than through persuasion: winning the medical director's support for a new default regimen, negotiating a budget line and working with interpreters as partners rather than as a service. Informatics knowledge mattered when choosing a video platform that met the department's privacy standards. Above all, the project reinforced that a public health nurse's greatest asset is a relationship with patients, and that technology is useful when it makes that relationship easier to keep.
Conclusion
Over six months at a county clinic, a nurse-led switch to a weekly preventive regimen observed by smartphone video was associated with a rise in the finishing rate from 57.9% to 78.6%. The approach rested on strong evidence, was shaped by a behavioral theory that pointed to barriers and confidence, and was measured with methods suited to local improvement. Its limits are real, but the clinic has adopted it, funded it and begun to share it. For patients who once drifted away after a missed appointment, finishing treatment is now the usual outcome rather than the exception.
References
Belknap, R., Holland, D., Feng, P.-J., Millet, J.-P., Caylà, J. A., Martinson, N. A., Wright, A., Chen, M. P., Moro, R. N., Scott, N. A., Arevalo, B., Miró, J. M., Villarino, M. E., Weiner, M., & Borisov, A. S. (2017). Self-administered versus directly observed once-weekly isoniazid and rifapentine treatment of latent tuberculosis infection: A randomized trial. Annals of Internal Medicine, 167(10), 689-697. https://doi.org/10.7326/M17-1150
Benneyan, J. C., Lloyd, R. C., & Plsek, P. E. (2003). Statistical process control as a tool for research and healthcare improvement. Quality and Safety in Health Care, 12(6), 458-464. https://doi.org/10.1136/qhc.12.6.458
Carpenter, C. J. (2010). A meta-analysis of the effectiveness of health belief model variables in predicting behavior. Health Communication, 25(8), 661-669. https://doi.org/10.1080/10410236.2010.521906
Haas, M. K., Aiona, K., Erlandson, K. M., & Belknap, R. W. (2021). Higher completion rates with self-administered once-weekly isoniazid-rifapentine versus daily rifampin in adults with latent tuberculosis. Clinical Infectious Diseases, 73(9), e3459-e3467. https://doi.org/10.1093/cid/ciaa1364
Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986-992. https://doi.org/10.1136/bmjqs-2015-004411
Rosenstock, I. M. (1974). Historical origins of the health belief model. Health Education Monographs, 2(4), 328-335. https://doi.org/10.1177/109019817400200403
Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the health belief model. Health Education Quarterly, 15(2), 175-183. https://doi.org/10.1177/109019818801500203
Sterling, T. R., Njie, G., Zenner, D., Cohn, D. L., Reves, R., Ahmed, A., Menzies, D., Horsburgh, C. R., Crane, C. M., Burgos, M., LoBue, P., Winston, C. A., & Belknap, R. (2020). Guidelines for the treatment of latent tuberculosis infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020. MMWR Recommendations and Reports, 69(1), 1-11. https://doi.org/10.15585/mmwr.rr6901a1
Sterling, T. R., Villarino, M. E., Borisov, A. S., Shang, N., Gordin, F., Bliven-Sizemore, E., Hackman, J., Hamilton, C. D., Menzies, D., Kerrigan, A., Weis, S. E., Weiner, M., Wing, D., Conde, M. B., Bozeman, L., Horsburgh, C. R., & Chaisson, R. E. (2011). Three months of rifapentine and isoniazid for latent tuberculosis infection. New England Journal of Medicine, 365(23), 2155-2166. https://doi.org/10.1056/NEJMoa1104875
Story, A., Aldridge, R. W., Smith, C. M., Garber, E., Hall, J., Ferenando, G., Possas, L., Hemming, S., Wurie, F., Luchenski, S., Abubakar, I., McHugh, T. D., White, P. J., Watson, J. M., Lipman, M., Garfein, R., & Hayward, A. C. (2019). Smartphone-enabled video-observed versus directly observed treatment for tuberculosis: A multicentre, analyst-blinded, randomised, controlled superiority trial. The Lancet, 393(10177), 1216-1224. https://doi.org/10.1016/S0140-6736(18)32993-3
How this N 599 Module 8 example is structured
Aspen does not publish N599 module prompts, so check your classroom and capstone guide for the exact instructions. This example integrates every earlier section into one report: problem, evidence, framework, methods, a results table, discussion with limitations, the practice changes that lasted, and a reflection on program competencies.
N599 Module 8 questions, answered
What does N599 Module 8 usually ask for?
The final module of Aspen's capstone typically requires the complete project report bringing together all earlier sections, often with a reflection on program outcomes. Check your capstone guide for the required structure and length.
Should the final paper repeat the earlier sections word for word?
No. The final report should integrate and condense them, revising earlier sections in light of the results and keeping the key evidence, methods and findings.
What goes in a reflection on program competencies?
Specific examples of how the project required skills from the program, such as appraising evidence, leading change, using data or informatics, linked to the program's stated outcomes.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Aspen University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.