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TB Notes 1, 2000
Where We've Been and Where We're Going: Perspectives from CDC's Partners in TB Control
Changes I've Seen
TB Control in New York City: A Recent History
Not by DOT Alone
Baltimore at the New Millennium
From Crickets to Condoms and Beyond
The Denver TB Program: Opportunity, Creativity, Persistence, and Luck
National Jewish: The 100-Year War Against TB
Earthquakes, Population Growth, and TB in Los Angeles County
TB in Alaska
CDC and the American Lung Association/ American Thoracic Society: an Enduring Public/Private Partnership
The Unusual Suspects
The Model TB Prevention and Control Centers: History and Purpose
My Perspective on TB Control over the Past Two to Three Decades
History of the IUATLD
Thoughts about the Future of TB Control in the United States
Where We've Been and Where We're Going: Perspectives from CDC
Early History of the CDC TB Division, 1944-1985
CDC Funding for TB Prevention and Control
Managed Care and TB Control - A New Era
Early Research Activities of the TB Control Division
The First TB Drug Clinical Trials
Current TB Drug Trials: The Tuberculosis Trials Consortium (TBTC)
TB Communications and Education
TB Control in the Information Age
Field Services Activities
TB's Public Health Heroes
Infection Control Issues
A Decade of Notable TB Outbreaks: A Selected Review
International Activities
The Role of CDC's Division of Quarantine in the Fight Against TB in the U.S.
The STOP TB Initiative, A Global Partnership
Seize the Moment - Personal Reflections
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TB Notes 1, 2000

From Crickets to Condoms and Beyond

by Carol Pozsik, RN, MPH
South Carolina TB Controller

It's history now but people still chuckle about the story of the man who was given crickets for fishing as an incentive when he couldn't be located to take his TB medications. Clearly, fishing was more important that his TB treatment. His public health nurse recognized that it was going to take an unusual motivator to get him to meet her for directly observed therapy, and thus was born the story of the crickets given to the fisherman. It wasn't the first time that nurses or other health care workers had given incentives to encourage patients to comply and it certainly wasn't going to be the last. For TB nurses in South Carolina, incentives and enablers became something that they could not do without. The concept has spread nationwide, and is now an accepted intervention in the treatment of TB infection and disease.

Image 1: Graphic of a fisherman - An example of a creative use of incentives and enablers is the man who was given crickets for fishing as a motivation to take his TB medications.

For many years the American Lung Association of South Carolina (ALASC) had given money for patient needs to the State Tuberculosis Sanatorium. As the sanatorium population dwindled in 1981, the Executive Director of the Lung Association began to wonder how the Patient Needs Funds could be used to help TB patients who were not in the hospital. It was at that time that the fisherman's TB nurse approached the ALASC and appealed for funds to provide incentives to more patients who needed them. That was the beginning of the use of incentives and enablers in the South Carolina TB Program.

At first some of the nursing staff resisted the idea of using incentives. Change was difficult to accept; about that same time, the program was also starting what was then called SIT (supervised intermittent therapy), and is now called DOT (directly observed therapy). Some nurses could be heard griping about "spoon-feeding" the patients. (Translated, this meant that they felt that the patients should take total responsibility for their treatment, and that the nurses shouldn't have to give them anything to get them to be responsible.) For some staff, it was all too much: asking them to not only watch patients take their medicines, but then, asking them to give the patients small gifts as well it was just more than they could bear! However, as time wore on, these same nurses became zealous about doing DOT and giving incentives. (In fact, one nurse fell and broke her leg during the course of giving DOT and, in spite of a compound fracture, she demanded that the ambulance drivers take her on to her next two visits so she could complete her DOT rounds.) Those big hearts in the TB nurses were hooked and the concepts of DOT and incentives really took hold. Soon everyone in South Carolina was using DOT and the stories of the incentives that were used were told and the success rate of completion of therapy got better and better.

In those early days the incentives were simple: juice, hamburgers, chicken snacks, fruit, candy, even condoms. Today, the staff have moved to more sophisticated incentives such as smoke alarms for fire protection in substandard housing and swimming lessons for underprivileged children. TB nurses and DOT workers have big hearts and they dig deep to personalize the incentives and enablers for their patients.

Dr. Dixie Snider, former Director of CDC's Division of TB Elimination, knew about the success of the incentives and enablers program in South Carolina and gave us encouragement to publicize the stories about incentives and DOT in order to educate other TB programs, so that they might begin to use incentives. With the help of the ALA of South Carolina, the booklet Using Incentives and Enablers in a Tuberculosis Control Program was published. The book gives the history of incentives and helpful advice about their use. Still popular after many printings, the book continues to help TB workers in their use of incentives both in the United States and in other countries. TB workers and others love to hear the stories and see the pictures of real patients with their caregivers. The pictures give a real face to TB and give encouragement to new staff in the program that they too can be successful with incentives. Whenever I am asked to speak about improving compliance, naturally I also talk about the importance of using incentives and enablers to make our work easier, but more importantly to bond the caregiver with the patient in a trusting relationship.

The successful use of DOT and DOPT in South Carolina could not have ever happened without the use of incentives. Who would have thought that something as unscientific as a red bridle for a mule, a cold drink on a hot day, a pair of warm socks, or an old overstuffed chair would contribute significantly to the successful treatment and prevention of TB in the United States?


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

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