Youssef Tawfik

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The Role of Health Communication in Achieving TB
Control Targets Case Studies from Vietnam Peru

Johns Hopkins Bloomberg School of Public
Health Center for Communication Programs
Youssef Tawfik Associate Director, Health
Sciences February 2005
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Vietnam Do Huu Thuy, MD,MPH.
Nguyen Thi Mai Huong, MSc Youssef
Tawfik, MD, MPH Cathleen Church-Balin, MHS,
MBA Peru Fernandez Llanos-Zavalaga, MSc, MD
Patricia Poppe, MS. Youssef
Tawfik, MD, MPH Cathleen Church-Balin, MHS,
MBA http//www.hcpartnership.org/Publications/Ins
ights/

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The Vietnam Experience

• Background
• - Population 82 million
• 94 literate
• 61 provinces, 4 cities, 631 districts,
• 10,553 communes and 104,146 villages
• - Gross Domestic Product increased by 7.5 (1991
  2000)

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• Health Indicators
• Life expectancy 71.3 years ( 65.2 in 1979)
• IMR 26/1000 live births (46 in 1991)
• lt 5 mortality 35/1000 (55 in 1986)
• MMR 91/100,000 live births (200 in 1990)
• Total Fertility Rate 1.9 children/woman (3.8 in
  1989)

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• TB Burden in Vietnam
• Vietnam ranked 13th of highest TB burden
  countries.
• Incidence 115/100,000 population. (2000)
• TB related death 26/100,000 Population.
• Every day 178 new cases 55 related death.
• Level of transmission is twice in the south (more
  urban).

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• TB Control Program in Vietnam
• 1975 to 1985 limited resources impact.
• 1985 National TB Control Program (NTP) started.
• 1986 DOTS piloted in some districts.
• 1995 NTP became a national priority with central
  funds secured.
• Currently, international sources contribute.

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• Achievement
• 1999 Universal DOTS coverage
• 2001 80 of cases are detected
• (target 70)
• 93 completed treatment
• 89 cured (target 85)

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Figure 2 Percent of coverage of Vietnam's
Tuberculosis Program (NTP) and DOTS from
1996-2000


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Figure 3 Number of new tuberculosis patients per
100,000 population during 1991-2000 period
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• Health System
• Central level MOH specialized institutions
  such as National Institute of TB and Lung
  Diseases.
• Provincial health services
• District health services
• Commune Health Services
• Village health workers
• 213,000 public health personnel
• Health services are free

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Figure 1 Flowchart of the health system and TB
network in Vietnam
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• The Communication Component
• Common Misperception TB is hereditary TB is
  incurable.
• Political leaders recognized the essential role
  of communication.

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• Communication Strategy
• Political Will
• Keep TB high on the political agenda.
• Involve leaders at all levels let them own
  the program.
• National TB Program
• Integrate communication in all aspects of the
  NTP.
• Partner with CBO community leaders.
• Strengthen interpersonal communication
  counseling at service sites.

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• Communication Strategy (cont.)
• Communities and Individuals
• Use multiple media, yet consistent messages.
• Raise and maintain public awareness.
• Correct common misperception reduce stigma.
• Encourage patients to seek care.

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• 1. Advocacy Activities
• Educating Leaders
• seminars for national local officials
• Fact sheets letters to local authorities
• Explain TB burden to National Assembly
• Involving Leaders
• TB control steering committees at all levels
• Involve journalists and reporters
• International tours/conferences to local leaders

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• Advocacy Activities (cont.)
• Special Events
• Parades at all levels on World TB Day
• Televised speech by the Prime Minister at World
  TB Day
• Public meetings in crowded areas
• TB topics in School curricula

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• 2. Mass Media
• TV
• - 1996-2000 15 reports 2 entertainment-educat
  ion series
• 2 song and dance performances
• 2003 3 programs on TB HIV, drug-resistant TB
  and children with TB
• Q A live competition programs games
• Video spots released regularly at national
  provincial stations

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• Radio and Print Materials
• Programs spots on TB prevention and control
• Messages through local radio stations
• Logos and badges distributed widely
• Information reports to newspapers
• Quarterly newsletter on TB activities
• Posters and leaflets (hundreds of thousands)
• Locally produced materials for ethnic minorities

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• 3. Interpersonal Communication
• Counseling
• Training of provincial trainers on communication
  and counseling
• Patient-focused counseling skills training for
  health workers at all levels
• Special focus on counseling before during
  treatment

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• 4. Community Mobilization
• Partnership with CBOs
• Organized activities to CBO members
• Peer education by fully recovered patients
• Community meetings
• Community Q A sessions and school competitions

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• Impact of Communication
• Contribution to Case Detection
• Raise awareness of TB.
• Correct misperceptions about TB.
• Help health workers, communities and individuals
  identify TB cases.
• Encourage individuals to seek care.
• Reach the hard-to-reach population ( urban poor,
  prisoners, homeless).

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• Impact of Communication
• Increasing Treatment Success Rate
• Give patients hope of complete cure.
• Encourage patients to seek care from appropriate
  sources.
• Provide counseling before during treatment.
• Encourage patients to complete treatment even if
  they feel better.
• Engage fully recovered patients to support
  current TB patients.
• Engage CBOs and communities to support patients.

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• Impact of Communication
• KAP Indicators (2002)
• 80 of public knew TB symptoms.
• 65 knew the cause of TB how it is spread.
• 80 knew that TB is curable.
• 100 knew the appropriate source of TB treatment.
• 98 of public doctors 93 of private doctors
  knew how TB is transmitted.
• 94 of public doctors and 92 of private doctors
  knew how to diagnose TB.

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• New Challenges
• 3 multi drug resistance for new cases
• Co-infection with HIV/AIDS (3-14)

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• Additional Perspectives from Peru
• Motivating Shared Vision
• Treatment of one is prevention for all
• Health system and worker achievements reported
  widely through published reports
• All TB services are for free
• Patient Incentives
• food supplementation transportation money
• micro-credit loans to those who complete
  treatment - leave disease and poverty behind

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• Perspectives from Peru (cont.)
• Capitalize on Existing Resources
• Political power of the Association of TB
  Patients
• Interest and power of the press
• Partner with pharmaceutical industry include
  private practitioners
• Engage local communities (Community Surveillance
  Units)
• Build local capacity for Street Theater

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• Perspectives from Peru (cont.)
• Respond to Health Workers
• Face health workers stigma against TB patients
• Standardize counseling tools (flip chart, video
  spots)
• Clear and Consistent Messages
• Simple, consistent universally known messages,
  if you cough for more than 15 days, you should
  go to the health facility

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New challenge of MDR-TB

• 3 of new cases
• 16 of those who had not completed treatment

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Figure 1. Progress in developing community
surveillance units, 1995-2000
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Figure 3. Treatment Abandonment Rate, 1991-2000
Source National Program for Control of
Communicable Disease, National
Program for Tuberculosis Control, Ministry of
Health, Peru 2000
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Figure 2. Trend of TB Incidence in Peru, 1987-2000
Source National Program for Control of
Communicable Disease, National Program for
Tuberculosis Control, Ministry of
Health, Peru 2000
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• Lessons Learned (Vietnam Peru)
• Secure political commitment, make program a
  political priority.
• Set clear goals targets and motivate everyone
  to achieve them.
• Create positive encouraging culture about the
  program.
• Build on country programs strength.
• Integrate communication activities into program
  at all levels.

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• Lessons Learned (Cont.)
• Communication activities timed to correspond with
  expanding clinical services.
• Create partnerships at all levels.
• Include private practitioners in TB control.
• Use clear consistent messages through a mix of
  channels.
• Special efforts to reach high risk groups.

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• Lessons Learned (Cont.)
• Use public events to reach large numbers of
  people.
• Create a system to monitor progress in achieving
  communication results (indicators).
• Identify and address new challenges, e.g. MDR-TB
  TB/HIV co-infection.

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