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Module 9: Patient Adherence to Tuberculosis Treatment
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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.
 

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.
 

 

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.