Self-Study Modules on Tuberculosis
Module 9: Patient Adherence to Tuberculosis Treatment
Using Incentives and Enablers to Improve Adherence
Incentives and Enablers
Just offering a DOT program is not enough. Patients must agree
to participate in taking their medicine and stick with it. Incentives
and enablers may help them do this. Incentives
are small rewards given to patients to encourage them to either
take their own medicines or keep their clinic or field DOT appointments.
Enablers are those things that make it possible
or easier for the patients to receive treatment by overcoming barriers
such as transportation difficulties. Incentives and enablers are
widely used in facilities providing TB services; they help patients
stay with and complete treatment. Table 9.4 is a list of examples
of incentives and enablers, and Figure 9.6 shows examples of incentives.
Incentives and enablers should be chosen according to the patients'
special needs and interests, or the patients may not care if they
receive them. For example, if the health care worker knows that
transportation is a problem, he or she could offer bus tokens, bus
fare, or taxi fare as an enabler. If transportation is not a problem,
then he or she should offer something that is needed. Learning as
much as possible about patients will help to identify their needs
and interests and better motivate them to complete treatment. The
best time to begin using incentives is after a good relationship
has been established with a patient. Enablers, however, may be vital
to the initiation of treatment and should be provided as soon as
Examples of Incentives and Enablers
- Fast food
- Canned food
- Food vouchers
- Applesauce or pudding (to mix medicine in)
- Homemade cakes and cookies
- Ice cream
- Soft drinks
- Nutritional supplements
Social service referrals
Help in obtaining housing, social security, food stamps
Help in obtaining drug treatment
Help in paying rent
Help in obtaining other medicines
Help in obtaining birth certificate
Washing patient's clothes
Help in obtaining driver's license
Paying rent or mortgage
Fuel oil for heat
Bus and subway fare
Paying friend for transportation
Transportation provided by staff
Special seasonal treats
Homemade Valentine cookies
Birthday cakes and cards
Contraceptives (e.g., condoms)
Painting child's nails
Charts with stars and stickers
Grab bag with assorted treats
Crossword puzzle books
Source: Adapted from Using Incentives and Enablers in the Tuberculosis
Control Program. Columbia: American Lung Association of South
Carolina and South Carolina Department of Health and Environmental
Control, Division of Tuberculosis Control, 1989.
Figure 9.6 This is a picture of different
incentives and enablers.
Sources of Incentives and Enablers
Programs can obtain incentives and enablers from many different
sources. Possible resources for obtaining incentives and enablers
- The state or local American Lung Association chapter
- Community organizations, such as church groups
- Businesses that can donate items such as food or food coupons
- Volunteers who can contribute goods and services, such as baked
goods or childcare
- TB program staff who are willing to devote extra time and attention
For example, one TB clinic asked for donations from area businesses
to add to their existing program. Some of the popular donations
were recently or soon-to-be expired dietary supplements, pillows
and blankets from a hospital, food coupons from area restaurants,
and athletic shoes and clothes from an area manufacturer. Another
TB control program paid the rent for a family's house for one month
to avoid eviction and possible disruption of therapy.
Barriers to Using Incentives
Some health care workers disagree about whether or not incentives
should be used. The attitude one has about incentives is important.
Some health care workers do not like using incentives because they
think patients should want to get well and should consider it their
duty to take their medicine. They believe that incentives are bribes.
At times, patients may also feel that the health care worker is
trying to bribe them into accepting treatment. This is more likely
to happen if the health care worker has not gained the patient's
trust, and has offered incentives before getting to know him or
her. When incentives are used with an attitude of caring and concern
for the patient, the patient will be less inclined to question the
health care worker's motives. The reason for using incentives is
to motivate the patient to complete treatment. Above all, incentives
and enablers are not a substitute for a high-quality relationship
with patients based on trust, effective communication, and mutual
respect. Many programs have shown success using incentives and enablers.
|Study Questions 9.21-9.23
9.21. What are incentives and enablers, and what
are their purposes?
9.22. How does a health care worker determine which
incentives and enablers to use for each patient?
9.23. What are some sources of incentives and enablers?
|Case Study 9.7
Mrs. Chan has active pulmonary TB and is very reluctant
to participate in the DOT program. She is afraid she will
die from her disease, and is very anxious. Because of difficulties
she had when she immigrated 5 years ago, Mrs. Chan doesn't
trust health department staff or any other government employee.
A health care worker is assigned Mrs. Chan's case while
she is hospitalized. During a visit to the hospital, the
health care worker explains to Mrs. Chan that she is being
offered DOT so that she will never forget to take her medicine.
If she follows all the health care worker's instructions,
Mrs. Chan will receive a supply of dietary supplements at
each meeting and $100 at the end of treatment. Mrs. Chan
smiles and nods.
The health care worker is very surprised when Mrs. Chan
doesn't show up for her first DOT appointment.
- What can happen if a health care worker offers Mrs.
Chan incentives before gaining the patient's trust?
- How might the health care worker have done a better
assessment interview with Mrs. Chan?
Improving Adherence with Children and Adolescents
Working with Parents and Caregivers
To improve adherence in children and adolescents, the health care
worker should work with the parents or caregivers. The health care
worker cannot assume that parents will give medications to their
children as prescribed; sometimes they do not. The health care worker
should do everything possible to make sure that parents support
their children's TB treatment, including
- Educate parents
- Warn parents of possible problems
- Give DOT
- Use incentives and enablers
- Give TB drugs in easy-to-take preparations
Educate parents of children and adolescents with
TB disease. By assessing their knowledge and beliefs about TB, the
health care worker can address concerns and needs, correct misconceptions,
and help parents understand their child's disease. If both the patient
and his or her parents are knowledgeable about TB, the patient is
more likely to successfully complete a regimen.
Warn parents about the problems their children
might have during TB treatment. Children may resist taking medications,
may have adverse reactions to the medications, and may have problems
swallowing pills and capsules (the common form of TB medications).
When parents know in advance about problems that can come up during
their child's treatment, they can cope with and help solve problems
as they arise.
Give DOT to children with TB when parents' or
caregivers' compliance with giving medications as prescribed cannot
Use incentives and enablers, such as coloring
books and toys, to encourage a child to take medicine. Giving incentives
to parents and caregivers should be considered, too; this will encourage
and reward their participation.
Give TB drugs in easy-to-take preparations. Rifampin
can be made into a liquid suspension. Isoniazid can also be prepared
as a suspension, although its stability varies. The health care
worker can discuss the use of liquid medications with the patient's
clinician. Isoniazid and pyrazinamide pills can be crushed and given
with small amounts of food.
Although adolescents can be responsible for taking their own medications,
they are also frequently nonadherent. They may be embarrassed about
having to take TB medications because they are concerned about what
their friends think. Also, they may not feel threatened by TB and
may not take the condition seriously. For these reasons, adolescents
are a high priority group for DOT.
Individualized treatment plans are needed for children and adolescents.
Health care workers should be watchful in monitoring adherence and
creative in finding ways to ensure adherence.
|Study Questions 9.24-9.25
are five ways the health care worker can help parents improve
adherence in children?
9.25. Why are adolescents at high risk for nonadherence?