When all else fails, incentives do the trick

TB programs get creative and personal

Crickets. That’s what it took to get Luther, a noncompliant TB patient, to agree to stay put and not go fishing when a nurse was scheduled to visit and administer his TB drugs.

"Luther was one of our first DOT [directly observed therapy] patients and the nurse could never find him because he was always fishing to feed his family," explained Carol Pozsik, RN, MPH, director of the South Carolina Department of Health’s TB program in Columbia. "Out of frustration, she finally asked him what it would take to make him stay put, and he said, ‘Well, you can buy me some crickets.’"

Luther was one of a dozen cases Pozsik used at a recent TB conference sponsored by Grady Hospital in Atlanta to illustrate the importance of incentives in getting patients to comply with treatment. South Carolina began using incentives in 1981, and even in the era of DOT it still finds them useful, particularly in getting noncompliant patients to clinics or assuring they complete their therapy at home.

Some health care providers eschew incentives, equating them with bribery. Pozsik replies that providers are paid to make sure a patient receives treatment. If they don’t, then "it is your responsibility to make sure they do, and giving encouragement is not a new idea by any means."

Supporting the use of incentives requires not only a firm conviction that they are useful but also funding. South Carolina receives much of its incentive dollars from the state chapter of the American Lung Association. Charity and religious organizations also provide financial assistance when asked by local TB programs, she adds.

As part of its patient documentation requirements, the state TB program encourages TB nurses to make monthly assessments of patient compliance. When a patient becomes noncompliant, putting them on DOT or performing "pill counts" often succeeds in assuring they complete therapy. In those difficult cases, whether they involve children who hate taking medicine or adults who mistrust providers, incentives can be the determining factor in compliance, Pozsik says.

South Carolina health officials found that incentives, particularly in the early days of DOT, made patients more likely to make their appointments and helped them understand the importance of compliance.

"People often ask why you need incentives if you have DOT," Pozsik says. "If 30 patients are coming into the health department for DOT and one doesn’t show up and you have to go looking for him, it’s a pain in the neck and your whole day can be ruined."

The success of incentives depends on tailoring them to the individual patient. Visiting nurses should be on the lookout for barriers that may be preventing patients from coming to clinics. For example, do they lack transportation or child care? One patient, an elderly man who lived four miles from town, walked to work each day and then had to walk to the clinic. The clinic used incentive money to buy him a bicycle, Pozsik says.

Nurses use chickens, turkeys, fans

Sometimes the best incentives are the most obvious and ordinary ones. If a patient or family lacks food or clothing items, these "gifts" can have an impact, she says. Nurses will buy whole chickens on sale and freeze them until they are needed. One clinic provides Thanksgiving turkeys to needy patients who keep their appointments. Others hold raffles for fans — each time a patient comes for treatment they can put their name in the hat.

For homeless patients, shampoos and soaps collected from hotels make valuable token gifts, Pozsik notes. Unused cosmetics, particularly lipstick, is welcomed by homeless women. For patients who have never celebrated their birthdays, cake and candles can seem like an extravagance.

"These are small things but many of our patients don’t have the money to buy them," she says.

For recalcitrant children, who can be the bane of a nurse’s existence, incentives that work best are those that can take their attention away from the yucky medicine. One nurse who was treating a large family spent more than an hour for each visit because the children would invariably throw up after treatment.

"They hated to see her coming so badly that they would literally gag when she pulled into the driveway," Pozsik relates. "By the time she had the liquid medicine in one child, another would start throwing up."

One day the nurse saw her daughter’s story book in the car, sat the children on the porch, and read to them immediately after they ingested the medicine. Ten minutes of reading took their mind off the medicine and saved the nurse about 45 minutes, Pozsik says, adding the nurse donated a story book when treatment was completed.

Another nurse, faced with a child who spit and kicked when she tried to give her medicine, made a ritual of bringing nail polish and painting the child’s nails red as a reward for taking medicine.

The list of incentives used in South Carolina is long. One patient was a farmer who still plowed with a mule. When they saw that he used rope and wire for a halter, they bought him a new one. As a reward for staying put instead of fishing, the nurse who treated Luther gave him daffodil bulbs to plant and wood for the bird houses he liked to build. While some nurses may take incentives too far, their gifts reflect the most important aspect of incentive programs — building relationships with patients, Pozsik says.

"Many times it’s not the incentives that you give but what you give of yourself, because it’s the relationship that is important and incentives [are] another way to get that accomplished," she says. "I’m not saying you have to love every patient, but I certainly think it helps."