Health Promotions Section

DLTLD ADVOCACY COMMUNICATION AND SOCIAL MOBILIZATION

DEFINITION OF TERMINOLOGIES
Advocacy:
These are activities designed to place TB high on the political and development agenda, foster political will, increase financial and other resources on a sustainable basis and also to facilitate the development or change of policies and guidelines.

Communication:
Is a process of increasing knowledge among general public on TB and TB control services, improving interpersonal communication between patients and program providers contributing towards behavioral change.

Social Mobilization:
This is and activity aimed at empowering the communities to action to fight stigma and eliminate TB as a public health threat/burden.

ACSM AN INTEGRAL PART OF NLTP
Advocacy and social mobilization seek to enhance political commitment, increase resources allocation, commitment and also seek to prioritize TB as a public health burden at all levels thereby increasing services for TB. In this respect, increasing communication creates demands for establishment of more services. At the same time, a principal task of communication and social mobilization is to stimulate demand among publics for TB services. It is critical that, while advocacy efforts put pressure on authorities to increase services, communication and social mobilization efforts generate demand only for services that are available. Much harm can be inflicted in persuading people to seek services that do not exist. In other words, any communication and social mobilization strategy needs to be carefully integrated into a National TB control plan, generating demand and supporting efforts that are available.

Neglect of the right to information can have substantial health impacts, and no health programme can be successful if those who could potentially benefit from it lack the information they need. Education and information can promote understanding, respect, tolerance, and nondiscrimination for people with TB.

ACSM strategies can be most effectively used to help addressing key challenges in TB control and prevention:

1. Improving case detection and treatment adherence
2. Combating stigma and discrimination
3. Empowering people affected and infected by TB
4. Mobilizing political commitment and resources for TB

IMPROVING CASE DETECTION AND ADHERENCE
The targets for National Tuberculosis Programme aim at detecting 70% of new infectious TB cases and successfully curing 85% of these cases as stipulated by the Global Stop TB. Currently, around 50% of the estimated of new cases each year are reached, and detected. These targets, which are considered too conservative by many groups, can only be met if the response from the TB community shifts from passive case-finding to active case detection. Critical factors affecting demand and use of services include: HIV/AIDS, multidrug-resistant TB (MDR-TB), stigma and discrimination, gender inequality, public service reforms, population displacement and mobility, and changing communication environments. Strategic and intensive deployment of communication and social mobilization strategies is increasingly acknowledged as necessary to encourage and support at-risk populations who have a cough for more than two weeks to seek treatment; and to adopt other health-seeking behaviours related to TB.

The link between lack of communication and poor case detection has been repeatedly demonstrated. Studies from Ethiopia, India, Mexico, Nigeria, Pakistan and Thailand, have shown that patients with low knowledge about the symptoms of TB are more likely to postpone seeking health care and getting tested. Studies in the United Republic of Tanzania found that in some communities, patients with low knowledge are more likely to visit traditional healers and pharmacists than DOTS (Direct Observed Treatment Short course) providers.

Communication is also seen as having an important role in improving treatment adherence. Progress towards the target of 85% treatment success has been much more marked than that against case detection, although every effort must be made to maintain cure rates in many TB Zones in Kenya. Communication and social mobilization programmes ensuring patient education, combined with broader community support and empowerment initiatives, are essential if cure and detection rates are to improved and be sustained.

COMBATING STIGMA AND DISCRIMINATION
Stigma and discrimination associated with TB are among the greatest barriers to preventing further infections, providing adequate health care, support, and treatment. TB-related stigma and discrimination are universal. Stigma is harmful, both in itself, since it can lead to feelings of shame, guilt and isolation of people living with TB, and also because negative thoughts often lead individuals to do things, or omit to do things, that harm others or deny them services or entitlements (i.e. discrimination). For example, health workers are often than not a key source of stigmatizing behaviour through their treatment of people with TB; hospital or prison staff may deny health services to a person with TB, or employers may terminate a worker’s employment on the grounds of his or her actual or presumed TB-positive status. Families and communities may reject and ostracize those living, or believed to be living, with TB. Such acts constitute discrimination based on presumed or actual TB-positive status.

Studies have repeatedly demonstrated that stigma deters people from seeking diagnosis and treatment and that woman bear the highest burden of stigmatizing behaviours. Stigma and discrimination are triggered by many forces, including lack of understanding of the disease, myths about how TB is transmitted, prejudice, lack of access to diagnosis and treatment, irresponsible media reporting, the link between HIV/AIDS and TB, and fears relating to illness and death. Lack of access to TB diagnosis and treatment is a key issue that enhances or advances TB-related stigma and discrimination in many TB zones. The perceived “untreatability” of TB is a key factor contributing to the stigmatization of many of those affected.

The challenge of reducing stigma and discrimination needs to be addressed within public and private health sectors and among health workers. Where fear, lack of knowledge, and misconception exist enhanced sensitization should be done. Services need to have a more patient-oriented approach. Stigma to some extent may result in part from misinformation or a lack of information. Misinformation about what causes TB, how it is transmitted and whether it can be cured is may linked to the stigmatization. Some culture may associate TB with morally and socially unacceptable behaviour. TB may also be believed to be inherited, and people who have TB are often discriminated.

Public education and awareness-raising programmes designed to counteract myths and to encourage greater inclusion of people with TB are pertinent to efforts in combating TB stigma. Stigma has its roots not only in lack of information but also in deep-seated social mores and structures. Stigma particularly affects women because social pressures and status often make them especially vulnerable to marginalization. Any ACSM strategy designed to confront these issues has to focus on community as well as individual behavioural challenges. ACSM programmes are important in empowering people with or affected by TB to take community action to confront stigma, and to educate broader communities to reduce stigmatization.

EMPOWERING PEOPLE AND COMMUNITIES AFFECTED BY TB
Other challenges in ACSM programmes include combating insufficient inclusion of people most affected by TB and related diseases in the design, planning and implementation of TB control strategies. An important lesson learnt from HIV/AIDS is that the greater the inclusion of those most affected in the response to the crises, the greater the impact such responses are likely to achieve and sustain. Communication strategies have much to offer in this regard, both in terms of advocacy interventions and in how different communication actions/programmes can enable people with and affected by TB to have their voices heard in the public domain. Contemporary health communication strategies are increasingly preoccupied with providing spaces and channels, particularly through the media, where people affected by health issues can make their voices heard, engage in dialogue and debate and achieve greater visibility and profile. Community empowerment has also been shown to be critical to successful implementation of DOTS programmes.

POLITICAL COMMITMENT AND SECURING RESOURCES FOR TB CONTROL
Political commitment has been recognized as a crucial element of DOTS. Lack of political may hamper the development of appropriate TB control policies and the successful implementation of those policies at the central, district, and local levels. Even when good TB policies exist, there may be often a gap between the policies and the programmes on the ground. Experience suggests that TB control services are negatively affected without strong commitment from different sectors of society, particularly decision-makers and influential political and community leaders.
Challenges in relation to insufficient political commitment can include:

• Insufficient resources—both human and financial
• Lack of local ownership and buy-in of NLTP Services
• Weak leadership in the NLTP and/or a loss of coherence
• Weak capacity of the NLTP to provide guidance to district and local-level programmes (both public and private providers)
• Low levels of knowledge among policy-makers and other stakeholders about TB
• Lack of integration of NLTP with other MoH programmes
• Lack of clear and relevant ACSM guidance available locally and weak capacity to develop effective ACSM programmes
• Weak advocacy and communication capacity to advocate upwards for TB programme prioritization, particularly with ministers of health and finance.