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Module 9: Patient Adherence to Tuberculosis Treatment
Reading Material

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 treatment starts.
 

Table 9.4
Examples of Incentives and Enablers

  • Money

    Food

  • Fast food
  • Sandwiches
  • Canned food
  • Food vouchers
  • Applesauce or pudding (to mix medicine in)
  • Fruit
  • Homemade cakes and cookies
  • Ice cream

    Beverages

  • Soft drinks
  • Juices
  • Milk
  • Nutritional supplements
  • Coffee
  • Tea

    Clothing

  • Socks
  • Gloves
  • Stockings
  • Sweaters
  • Coats/Scarfs

    Automotive

  • Battery
  • Gasoline
  • Motor oil

    Fishing supplies

  • Fishing pole
  • Crickets
  • Worms

    Services

  • 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
  • Child care
  • Help in obtaining birth certificate
  • Washing patient's clothes
  • Help in obtaining driver's license
  • Repairing bicycle

    Household

  • Paying rent or mortgage
  • Wood stove
  • Kerosene
  • Fuel oil for heat
  • Smoke alarm
  • Cooking utensils
  • Furniture

    Transportation

  • Bus and subway fare
  • Taxi fare
  • Bicycle
  • Paying friend for transportation
  • Transportation provided by staff

    Seasonal

  • Special seasonal treats
  • Homemade Valentine cookies
  • Easter baskets
  • Food baskets
  • Birthday cakes and cards

    Personal care

  • Contraceptives (e.g., condoms)
  • Razor blades
  • Shaving cream
  • Face cream
  • Makeup
  • Nail polish

    Garden

  • Flowers
  • Flower bulbs

    For children

  • Toys
  • Reading stories
  • Painting child's nails
  • Tea party
  • Playing games
  • Charts with stars and stickers
  • Stuffed animals
  • Grab bag with assorted treats
  • Chewing gum
  • School supplies
  • Storybooks
  • 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 include

  • 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?

Answers  


 
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?

Answers 

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 be ensured.

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

9.24. What are five ways the health care worker can help parents improve adherence in children?

9.25. Why are adolescents at high risk for nonadherence?

Answers 


 
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