A number of poster presentations at the 2009 Union World Conference on Lung Health nicely illustrated how some countries have put ACSM into practice, and crucially, how they are also evaluating their ACSM programmes’ effectiveness.
Some common initial steps mentioned include engaging the key national players in a partnership and developing a ACSM working group and plan; starting sensitisation efforts for advocacy to secure political commitment; and performing some initial research — a needs assessment and a situational analysis such as a ‘knowledge, attitudes and practice’ (KAP) survey — to establish baseline evidence to help plan, implement, and evaluate the ACSM work.
Like the studies mentioned earlier in this article, these surveys should assess current awareness, knowledge gaps, cultural beliefs and behaviour related to TB (see Resources for a guide on conducting KAPs).
BRAC, an NGO operating in Pakistan, has helped the national TB programme launch an ACSM programme.21 This began by orienting other potential partners on ACSM and advocacy efforts with policy makers, health professionals and media personnel. Baseline situational assessments were performed to assess TB awareness, health seeking behaviour and to assess which methods of communication would be most effective. Then a mass media campaign was launched with TV dramas, commercials, public service announcements, radio commercials, popular theatre with folk songs, etc.
Social mobilisation efforts involved cured (or close to cured) TB patients, orientations with village doctors and pharmacists, general practitioners, local government officials and religious leaders, school students, girl scouts and other NGOs. IEC materials have been developed and field tested. Monitoring and evaluation is ongoing and routine.
Several posters described Mexico’s ACSM effort, ‘Solucion TB’, which is working in collaboration with the national TB programme in thirteen priority states.22
After a six-month needs assessment, a capacity building project (empowering DOTS), health staff training on ACSM and developing ACSM plans, Solucion TB launched the country’s first large KAP survey (which is still in progress) and a stigma and discrimination survey to validate TB-HIV stigma instruments adapted for Mexico.23, 24 The programme also implemented ACSM activities, including advocacy presentations at both state and municipal levels, as well as a TV, radio and print media campaign.
One of Solucion TB’s interesting cross-cutting interventions is ‘Voices and Images’ which has engaged people with TB to document (with disposable cameras and diaries) their lives and challenges.25
In addition to empowering participants, a gallery of their images has been produced and presented to policy makers to inform them about the human impact of disease, and exhibited in a variety of forums to increase awareness and reduce stigma. Some key themes that have emerged in their work is the need to improve the quality of health services, and the need for integrated services including nutrition and mental health services to help manage depression associated with having TB .
According to one of the Solucion TB posters, the programme has stressed the meaningful involvement of people and families affected by TB and integrated a ‘person-centred’ approach into state and district TB programmes.26
“ACSM efforts cannot be successful without engaging persons affected by TB, not as recipients or victims or even as patients, but as decision makers, advocates, peers, highly valuable resources and keys to ultimate success,” the authors wrote.
The poster also reported that, within the last four years, average case detection rates in the thirteen target states have gone up from 75.8% to 98.7%, and cure rates from 75.3% up to 84%. But the authors noted it is difficult to pin this overall success on any one intervention: “any one project or initiative, regardless of how successful, is only part of the solution.”
In Kenya, a national working group was established and NGO partners were trained on ACSM activities.27 In 2007-8, a mass media campaign was launched using television, radio and newspapers; a community drama programme was conducted in a variety of venues to spread TB messages; TB community-based health workers were trained; and a school programme was started to teach children about TB.
Cross sectional surveys were conducted to assess the impact of the interventions. One involved over one thousand school children. Although levels of knowledge were uneven on different questions, 91% correctly identified that TB was airborne, 90% mentioned cough as the main symptom. 36% said that they knew somebody with TB signs and symptoms, and 94% said that they would refer people with such symptoms to a health facility for screening. (Note, at IAS 2009, Dr Helen Ayles of ZAMSTAR, a study to increase community based TB case detection, described a similar project targeting school children, which encouraged them to refer adults they know for TB screening.)
The other Kenyan survey included 1200-1300 adults (in baseline and follow-up assessments) in 13 districts, and although the baseline was not described in the poster, it reports a very high level of post-intervention TB knowledge, with 85.9% knowing that TB transmission is airborne, for example.
The most accessible communication media was reported to be radio, with the study authors recommending the use of local vernacular radio stations. Nevertheless, the researchers also noted that exposure and access to different media varied greatly: “the various channels for ACSM should be maintained to reach diverse audiences,” they wrote, adding that both TB message dissemination and monitoring and evaluation of the ACSM programme need to be continuous.
In a poster from South Africa, TBFree (a joint venture between the South African Department of Health, Sanofi-Aventis and the Nelson Mandela Foundation) reports having trained over 25,000 community DOTS supporters in the last five years and launching an ACSM campaign, with adverts on TV stations, mainstream radio, and print, as well as door-to-door and school campaigns, advertisements in buses and taxis, and recently a national TB awareness road show with theatre in local languages.28 The road show has reached over 30,000 people, screening many for HIV (747 people) and TB (4318 people).
The poster reports that TBFREE has also found that radio is the most widely used medium — especially since many cannot afford a TV or the electricity to operate it. Local language broadcasts in either medium attract the most interest. As for newsprint, free newspapers have been found to reach a much wider audience.
Another common activity is the development of IEC materials, but a poster from ICAP in Tanzania described how evaluations are necessary because these aren’t always as effective as one would hope.29 Working with the National TB and Leprosy Programme, ICAP and PharmAccess developed posters and other materials on cough hygiene, TB intensified case finding and infection control. These were field tested in a few facilities before nationwide scale-up.
During this assessment, it was found that the materials were not always being displayed correctly: for instance, posters for health workers were put up in the waiting areas. Meanwhile, clients in focus group discussions told the researchers that posters targeted to people with TB were not easy to understand, and there was often no one there to explain what the posters meant. They noted that the posters contained multiple messages and the images were not realistic.
So the materials were formally revised to simplify the messages, use images that capture the audience’s attention, and improve the Swahili translation. These materials are now distributed along with an explanatory guide and a better onsite orientation on how to use them. In addition, ICAP has trained volunteers living with HIV/AIDS to conduct educational sessions in the waiting areas and wards.
There was also a discussion at the Union World Meeting in 2008 about the limited usefulness of flyers and pamphlets for IEC.
“We found that when developing IEC material in a country like ours where there are literacy challenges, you would later find those flyers scattered all over the streets because people find it difficult to read, at some point it becomes boring and whatnot,” said one audience member who worked for TBFREE. “Then we started branding taxis and printed messages on everyday things that people use so that at least that message stays with them and it's at a place where they are.”