1. How Can Communication And Social Mobilization Help the DOTS Strategy? An Outcome Map To Strengthen DOTS Strategy To STOP TB © Johns Hopkins University Center for Communication Programs HCP STOP TB Team Contact: Benjamin V. Lozare blozare@jhuccp.org

2. Main Point We would benefit significantly from a multi- disciplinary and multi-sectoral approach to DOTS.

3. Advocacy Gov’t makes TB control high priority Gov’t provides quality DOTS services Gov’t ensures adequate drug supply # Cases drop long term The DOTS Strategy to Providers detect potential cases and diagnose correctly Providers ensure correct treatment regimen STOP TB STOP TB Monitoring

4. Advocacy Gov’t makes TB control high priority Gov’t provides quality DOTS services Gov’t ensures adequate drug supply # Cases drop long term How well is the DOTS Strategy working? Very well in some countries, mixed in others. World wide # of cases are growing or dropping? Is this due to better detection? Providers detect potential cases and diagnose correctly Providers ensure correct treatment regimen STOP TB Monitoring

5. Advocacy Gov’t makes TB control high priority Gov’t provides quality DOTS services Providers detect potential cases and diagnose correctly Gov’t ensures adequate drug supply Providers ensure correct treatment regimen # Cases drop long term Key Challenges in the DOTS Strategy Weak STOP TB Monitoring

6. Advocacy Gov’t makes TB control high priority Gov’t provides quality DOTS services Providers detect potential cases and diagnose correctly Gov’t ensures adequate drug supply Providers ensure correct treatment regimen # Cases drop long term Key Challenges in the DOTS Strategy Weak Literature suggests lots of room for improvement Weakness is strategic as it dampens overall effort STOP TB Monitoring

7. Advocacy Gov’t makes TB control high priority Gov’t provides quality DOTS services Providers detect potential cases and diagnose correctly Gov’t ensures adequate drug supply Providers ensure correct treatment regimen # Cases drop long term Key Challenges in the DOTS Strategy Weak Only 42% cases detected worldwide against 70% target. DOTS expansion accounts for most of growth in detection. WHO estimates that without improvements, 100% coverage may not surpass 50% detection. Weakness is strategic as it dampens success in treatment! STOP TB Monitoring

8. Advocacy Gov’t makes TB control high priority Gov’t provides quality DOTS services Gov’t ensures adequate drug supply # Cases drop long term More Challenges in the DOTS Strategy Weak Close to target! Could improve Providers detect potential cases and diagnose correctly Providers ensure correct treatment regimen STOP TB Monitoring

9. Advocacy Gov’t makes TB control high priority Gov’t provides quality DOTS services Gov’t ensures adequate drug supply # Cases drop long term More Challenges in the DOTS Strategy Weak Close to target! Could improve Providers detect potential cases and diagnose correctly Providers ensure correct treatment regimen Literature suggests lots of room for improvement STOP TB Monitoring

10. Advocacy Gov’t makes TB control high priority Gov’t provides quality DOTS services Gov’t ensures adequate drug supply # Cases drop long term More Challenges in the DOTS Strategy Weak Close to target Could improve Providers detect potential cases and diagnose correctly Providers ensure correct treatment regimen 81% cure against 85% target! Outcome dampened by low detection rates. Growing concerns for MDR TB and lower quality of services as program expands STOP TB Monitoring

11. Advocacy Gov’t makes TB control high priority Gov’t provides quality DOTS services Gov’t ensures adequate drug supply Providers, community and households team up to encourage correct treatment regimen # Cases drop long term Are revisions in wording of the DOTS Strategy above better? If so, how do we make these outcomes happen? Providers, community and households team up to detect potential cases and diagnose correctly STOP TB Monitoring

12. Advocacy Communication Gov’t makes TB control high priority Gov’t provides quality DOTS services Gov’t ensures adequate drug supply Providers, community and households team up to encourage correct treatment regimen # Cases drop long term Social Mobilization The Comm- DOTS Strategy Would adding communication and social mobilization help produce better outcomes? Providers, community and households team up to detect potential cases and diagnose correctly Comm means plus communication and social mobilization STOP TB Monitoring

13. More Effecitve Advocacy Communication Gov’t makes TB control high priority People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term More Effective Social Mobilization Households learn about TB symptoms, transmission and treatment Possible Communication Contributions To Desired Outcomes to Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring

14. More Effective Advocacy More Effective Communication Gov’t makes TB control high priority Community works with Gov’t,and households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Possible Social Mobilization Contributions To Desired Outcomes to Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring

15. More Effective Advocacy More Effective Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase What is a TB Free Community? Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly No active untreated cases of TB detected the last 3 years Or No deaths from TB in community the last 3 years. STOP TB Monitoring

16. More Effective Advocacy More Effective Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Other Types of Communities To Compare With TB Free Communities Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly TB Free communities versus Communities with DOTS coverage No DOTS Coverage but with high prevalence of TB No DOTS Coverage but with low prevalence of TB Status unknown Every country can present this geographic based approach through a color coded TB Status Map. This visual representation could be of great value in planning and monitoring interventions. STOP TB

17. An example of data presented in a color coded map

18. More Effective Advocacy More Effective Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Why use the concept of TB Free Community? Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly Because TB transmission is by proximity, it is logical to use a geographic based strategy. TB is not evenly distributed. We need to allocate scarce resources more effectively and efficiently. We need to motivate communities with a community goal. Designation of a TB free community gives a clear sense of victory. Highly motivational. Easier to understand than number of cases per 100,000 which is not meaningful at community level. We can use the number and % of TB free communities and other types of communities for tracking and benchmarking purposes. TB-free communities can serve as model for high TB prevalence communities. STOP TB

19. More Effective Advocacy More Effective Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Some additional indicators to consider Note: There should be no conflict with continued use of current indicators like # cases per 100,000 to provide other views of overall macro picture Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB # of communities with DOTS coverage increase # of communities of unknown status decrease

20. Advocacy Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase An Outcome Map for Comm- DOTS Strategy to Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring

21. More Effective Advocacy More Effective Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t enlsures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase The Vietnam Case Study Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB Monitoring 80% know symptoms 65% know transmission 80 % know TB is curable 100% know that detected case of TB should seek medical care 80% cases detected 93% completed treatment 89% cured Gov’t declated TB high priority in 1995 All forms of media used to educate people High level of community mobilization Partnerships created at all levels Gov’t achieves almost 100 coverage in 1998 Peer education used fully recovered patients Quality ensured through effective monitoring Four program levels of TB control activity Wide range of advocacy activities conducted

22. More Effective Advocacy More Effective Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, Stigma is low 13% community, households team up to eliminate TB stigma Gov’t enlsures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase The Indonesian Case Study Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB Monitoring 76% knows about TB 77% claim know symptoms 65% know transmission 85 % know TB is curable 19% know treatment is free 40-56% go for treament to private clinics 30% go to Puskesmas 52% cases detected 85% cured National Gov’t sees TB Gov’t as priority but local govts not on same level Not all forms of media used to educate people Low level of community mobilization Partnerships being formed Fully recovered patients not used Quality ensured through effective monitoring Narrow range of advocacy activities conducted

23. Advocacy Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Illustrative Indicators of Outcomes Note: Click on colored text to see illustrative indicators. When finished, click on button on the right to see illustrative activities. Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring Click here to see illustrative activities

24. Advocacy Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Illustrative indicators for people’s knowledge Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring Clear TB control policy supported by rhetoric actions resources % of people who knows that TB control is a high priority of the country/community Strong collaboration between TB and HIV/AIDS programs and those of other communicable diseases Note: Click on text again to go return to framework

25. Advocacy Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Illustrative indicators for people’s knowledge Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring % who know about TB symptoms % who know how TB is transmitted % who know that TB is curable % who know that TB treatment is free % who know where to secure TB treatment if needed Note: Click on text again to go return to framework

26. Advocacy Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Illustrative activities to achieve an outcome Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring % who understand that people with TB symptoms should seek health care % who believe that people with TB symptoms should seek health care % who will encourage people they know with TB symptoms to seek health care. % of TB cases who come for diagnosis and treatment promptly. Mean time between occurrence of symptoms and visit to health facility. Note: Click on text again to go return to framework

27. Advocacy Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Illustrative indicators of TB stigma reduction Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring % or # of communities where Gov’t, households and communities plan and work together to eliminate TB stigma % or # of communities with support groups for TB patients and their families. % who believe that TB treatment should be provided to all in need. % who look at TB patients as people who need help rather than avoided Note: Click on text again to go return to framework

28. Advocacy Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Illustrative indicators of TB stigma reduction Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring % or # of communities where Gov’t, households and communities jointly conduct activities to ensure prompt detection of potential cases and to make correct diagnosis. % of TB control clinical staff who have correct knowledge and skills to detect potential cases and to diagnose correctly. % of TB control clinical staff who have adequate tools and resources for diagnosis and use them Note: Click on text again to go return to framework

29. Advocacy Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Illustrative indicators of TB stigma reduction Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring % or # of communities where Gov’t, households and communities conduct joint activities to ensure correct treatment regimen both on the part of patients and TB control providers. % of TB control providers who have correct knowledge and skills to administer treatment regimen. % of families with TB cases who understand the consequences of not observing treatment regimen. % of families with TB cases who encourage patients to observe correct treatment regimen. Note: Click on text again to go return to framework

30. Advocacy Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Illustrative indicators of TB stigma reduction Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring % or # of communities with vision of a TB free community shared by government, households and all stakeholders. % or # of communities who have a working partnership to make their community TB free which includes private sector, businesses, NGOs, CBOs, Faith-based organizations, PLWTB Note: Click on text again to go return to framework

31. Advocacy Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in theg community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Illustrative indicators of TB stigma reduction Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring % or # of communities which allocate local resources to make the community TB free % or # of communities that participate actively in the national effort to control TB. % or # of communities that have TB free partnerships that collaborate with HIV/AIDS programs and those of other communicable diseases. Note: Click on text again to go return to framework

32. Advocacy Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Illustrative indicators of TB stigma reduction Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring This requires development of a comprehensive instrument to measure people’s values, beliefs, practices, resource allocation related to health in general and to TB in particular. The basic idea is that TB control programs should become obsolete as soon as possible because cultures have already integrated appropriate values and practices. Note: Click on text again to go return to framework

33. Advocacy Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase Illustrative activities to achieve an outcome Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring Schools integrate TB information in health education courses and text books Enter-educate programs with TB information Use of former TB patients as spokespersons for anti-TB campaigns Workshops with selected media personnel Workshops with local officials and community leaders Use of folk media like street theater, etc. Visits to TB Free communities by select local officials Note: Click on text again to go return to framework or click on any part of the screen to go to next slide.

34. Advocacy Communication Gov’t makes TB control high priority Community works with Gov’t, households to eliminate TB in the community People with symptoms seek health care Gov’t provides quality DOTS services Gov’t, community, households team up to eliminate TB stigma Gov’t ensures adequate drug supply Providers, community and people team up to encourage correct treatment regimen # Cases drop long term Gov’t, community and households integrate into culture appropriate health values and practices Social Mobilization Households learn about TB symptoms, transmission and treatment # of TB free communities increase An Outcome Map for Comm -DOTS Strategy to Community allocates resources and nurtures appropriate environment to eliminate TB in community Providers, community and people team up to detect potential cases and diagnose correctly STOP TB STOP TB Monitoring

35. Benefits of Comm-DOTS approach Less jargon Uses actors, (government, providers, community, households) and desired specific behaviors of each to describe what we want to happen, not abstract ideas. Lays out an overall strategic picture. Provides practical way to plan, implement, monitor and evaluate.. Suggests a multi-disciplinary and multi-sectoral team approach and helps ensure everyone is on the same page. Together everyone achieves more. Let’s use the Comm-DOTS approach to STOP TB

36. Main Point We need a multi-disciplinary and multi- sectoral approach to DOTS. ???

37. Our choice Comm-DOTS DOTS-Comm DOTS ++ Comm OR ………………………………….DOTS Alone