Stop TB: Exploring Global Trends in TB Advocacy – Aishwarya Lakshmi Vidyasagaran
An estimated one-third of the world’s population is infected with Tuberculosis bacterium and nearly 9 million people get sick with TB every year (1). With the rise in the HIV epidemic, TB is the most common cause of death in HIV-infected individuals in developing countries and is threatening to re-emerge as a public health problem in developed countries as well (2). The emergence of Multi Drug Resistant TB (MDR – TB) and more recently, extensively drug resistant TB (XDR-TB) has compounded the burden of disease worldwide. The Stop TB strategy, launched by the World Health Organization is working to halve TB deaths and prevalence by 2015 (3) and one of six components of the strategy is to empower people with TB and communities through advocacy, communication and social mobilization (4).
Despite TB being a major public health problem worldwide, little effort has been made in sensitising the public about the disease and its symptoms, especially in rural areas (5). A practical guide for TB advocacy published by the WHO in 1999 states that despite the successful implementation of Directly Observed Treatment, Short-course (DOTS), TB is responsible for more deaths among the youth and adults than any other infectious disease (6). The disease has large social implications due to the stigma attached to it and its control remains a low political priority in many countries. All these support the need for greater TB advocacy worldwide.
However, advocacy for TB has failed as a public health intervention because of financial and political barriers, failure to involve the private health care sector and failure to include different need-based strategies for different target audiences.
Failure to address needs of different target audiences
There are two basic messages provided for most advocacy strategies – TB is a devastating disease and DOTS can control it (6,7). However different audiences have different concerns and advocates have to target messages accordingly. Audience segmentation is a basic principle of the social marketing theory, which addresses the issues of those those we are specifically trying to reach (8,9). Also, in McGuire’s communication/persuasion matrix, the first of the six steps to consumer decision-making is exposure to the information, where the importance of market segmentation is emphasized (10). The Human Face of TB is a video campaign launched by the WHO – Stop TB partnership (11). The campaign focuses on increasing awareness of the global TB prevalence and the success of DOTS worldwide. Although this campaign provides general information about TB in a very compelling manner, it is not tailored specifically to address concerns of different target audiences. While decision makers and politicians are concerned about budget implications, public opinions and the liabilities of their actions as leaders, health practitioners are concerned about the feasibility of implementing DOTS. Advocacy messages should be framed to address these concerns and those of corporations and businessmen, such as impact of the disease on workers and on the market (12). Framing theory also supports the importance of focusing the attention of people within a field of meaning. Contrary to the concept of making rational choices, framing theory suggests that the way in which something is presented will influence people’s choices (13).
Another important factor to consider is message development. Drawing from advertising theory, the message should be created in order to change the awareness, knowledge and attitude of decision makers (14). Although the film mentioned earlier clearly reinforces the two basic TB advocacy messages, this information by itself does not provide decision makers with any tools to address the problem of TB. These messages do not promote self-efficacy – they do not make the audiences believe that they are capable of attaining certain goals (15,16). The advocacy campaign will not succeed unless key policy makers are made to feel that their decisions will help control TB.
There is also a need for social mobilization as a type of grass-roots level advocacy, whereby the existing concerns among the public are explored, including stigma and gender issues and they are all incorporated in a collective effort of decision-making (17).
Failure to target the private health sector
Choosing the correct target audiences - the people, who can make changes to solve problems, plays a key role in the success of any advocacy campaign. The role of private medical practitioners cannot be underestimated, particularly in South-East Asia (18). It has been estimated that the first point of contact with health care services has been the private sector for over 50% of TB patients because of convenience and perceived quality of care (18,19). Other causes for concern include the treatment provided by the private practitioners, which does not always follow a standard regimen and is oftentimes different from the regimen provided by the National Tuberculosis Programme (NTP) and also the quality of care especially at the more informal end of traditional healers. These practices have implications not only for the individuals treated but also for disease transmission and development of drug resistance (18). Despite this, the NTP in many countries has been unprepared or even reluctant to involve the private sector.
Involving the private heath sector in private-public mix (PPM) health programmes has been successful in the treatment of STDs, malaria and family planning interventions (20,21). Social marketing is another method that has successfully been used to involve private sectors. This approach uses commercial marketing technique to address the lack of consumer information and stimulate a demand from the public for effective interventions, which are then sold through the private sector at subsidized rates to increase affordability (20). TB advocacy campaigns lack such innovative approaches in involving private practitioners.
TB advocacy campaigns have failed to target private pharmacists and pharmaceuticals and this has contributed to its failure as a public health intervention. With easy availability of ‘over-the-counter’ drugs in many developing countries (18,22), patients directly approach pharmacies for common symptoms such as cough and fever, which could be symptoms of TB and we could hence potentially be missing opportunities for early diagnosis of disease. In Asia and Latin America, anti-TB drugs are also available over the counter and self-medication is common (23). By not targeting pharmacists through advocacy, especially in these regions, the risk of primary resistance to anti-TB drugs increases. Yet another important target audience is pharmaceutical companies that manufacture TB drugs. With increasing reports of MDR-TB and XDR-TB, the urgency to discover novel compounds to treat tuberculosis cannot be sufficiently stressed.
Political and financial barriers
Advocacy denotes activities that are designed to place TB control high on the political agenda, foster political will, increase financial and other resources on a sustainable basis, and hold authorities accountable to ensure that pledges are fulfilled and results achieved (24). But TB advocacy has failed because of political and financial obstacles. There is a global indifference to tuberculosis, largely because it is considered to be a disease of the poor and destitute and so more of a social issue than a medical issue (25,26). But this is a fallacy because even in the some of the poorest areas in the world, a good TB control program has been successful in reducing the burden of disease. This is the case in Bangladesh, a country with a huge caseload and poor resources (6,25).
As tuberculosis is considered a disease of poverty, the solution proposed is general improvement in living standards worldwide. But Szreter argues that the concept that good health is a natural consequence of socio-economic improvement is naïve. It neglects the political actions that have resulted from public health advocacy and the impacts that these actions have had on health services (27).
A major challenge has been raising and sustaining financial support for TB advocacy and this arises in relation to insufficient political commitment. This could also be because the issue of TB is too big or too complex especially in the context of poverty. The Global TB control report (2007) estimates that the funding gap for TB worldwide in 2007 was about $1.1 billion (28). Such figures translated in terms of human lives shows the uphill struggle in addressing the current situation.
Conclusion
There are several adverse implications of failure of TB advocacy. The most serious of which is MDR-TB and XDR-TB, which render patients extremely difficult to treat. Lack of advocacy, resulting in misconceptions and lack of awareness among people in power would affect policy decisions and if they make harmful statements about TB more so in the setting of HIV/AIDS, then that would contribute to increased stigma and discrimination (29). On a global level, re-emergence of TB in developed countries in the setting of increased immigration needs to be considered (30) and one of the challenges to alter political will in the developed countries arises from the popular perception that tuberculosis is not a problem in these regions (31).
Another challenge in designing advocacy campaigns can be the difficulty in defining the concept in many languages and cultures, which may contribute to keeping people from participating in advocacy work and governance (29). However, in recent times, there have been advocacy campaigns that use the media as vehicles to promote messages with powerful language and imagery, keeping written information simple. Advocacy for TB control is at the core of the WHO Global plan and the goals are two fold. (I) To create political accountability and social pressure to shape policy agendas around the world; and (II) To mobilize US$ 56 billion from 2006 to 2015 for TB control and development (32). With such newer initiatives and promising trends in TB advocacy, it would certainly prove a valuable tool in the Global fight against TB.
REFERENCES
CDC Division of Tuberculosis Elimination. TB Elimination: Now is the Time! 2007. http://www.cdc.gov/TB/pubs/nowisthetime/default.htm
CDC TB and HIV/AIDS. http://www.cdc.gov/hiv/resources/factsheets/hivtb.htm
WHO A world free of TB. http://www.who.int/tb/en/
WHO The Stop TB Strategy. http://www.who.int/tb/strategy/stop_tb_strategy/en/index.html
Global TB candlelight meditation. About the GTBCM. http://www.afroglobal.org/2007_GTBCM_website/aboutus.html
WHO Global TB Programme. TB advocacy: A practical guide 1999. http://whqlibdoc.who.int/hq/1998/WHO_TB_98.239.pdf
Lee B. Reichman, Earl S. Hershfield. Tuberculosis: A comprehensive international approach. New York, Marcel Dekker, 1993.
Learn marketing; Requirements of segmentation. http://www.learnmarketing.net/requirementsofsegmentation.htm
Sonya Grier, Carol. A. Bryant. Social Marketing in Public Health. Annu. Rev. Public Health 2005. 26:319–39.
Information processing and other hierarchy of effects theories – Maggi Machado. http://www.ciadvertising.org/SA/fall_02/adv382j/machadoma/paper1/paper1total.html
Stop TB Partnership. The Human Face of TB. http://www.stoptb.org/
SEATC 2004, NTI Bangalore. Advocacy - a vital tool in expanding and strengthening TB control! www.searo.who.int/LinkFiles/Programme_Management_Advocacy.ppt
Value Based Management. Net. Focussing Attention Within a Field of Meaning using Frames. http://www.valuebasedmanagement.net/methods_tversky_framing.html
Daniel Mayfield. Advertising Theory. http://www.ciadvertising.org/SA/fall_02/adv382j/dan02/proj3/theory.htm
Wikipedia. Self-efficacy. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Self_efficacy.
Wikipedia. Social Cognitive Theory. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Social_cognitive_theory
Central TB Division, Government of India. Planning and implementing a health communication strategy for RNTCP – A practical guide. http://www.tbcindia.org/pdfs/Health%20Community%20Strategy%20for%20RNTCP.pdf
WHO.Involving Private Medical Practitioners in TB and STI control. http://www.searo.who.int/en/Section10/Section18/Section356/Section413_1890.htm
K. J. R. Murthy, T. R. Frieden, A. Yazdani, P. Hreshikesh. Public-private partnership in tuberculosis control: Experience in Hyderabad, India. INT J TUBERC LUNG DIS 5(4):354–359
Mill A, Brugha R, Hanson K, McPake B. What can be done about private health sector in low-income countries? Bull World Health Organ. 2002; 80(4): 325-30
Editorial. Progress of Public-Private mix in Tuberculosis control – Indian context. Indian J Tuberc 2005; 52:59-61
Kamini Walia. Emerging Problem of Antimicrobial Resistance in Developing Countries: Intertwining Socioeconomic Issues. RHF. Volume 7, Number 1.
MMWR Weekly. Current Trends Primary Resistance to Antituberculosis Drugs -- United States. October 14, 1983 / 32(40); 521-23
Red Cross and Red Crescent action. Supporting global tuberculosis control. http://www.ifrc.org/docs/pubs/health/pochette-tb-en.pdf
World Health Organisation. TB, a global emergency. Geneva: World Health Organisation, 1994.
Zumla A, Grange JM. Doing something about tuberculosis. BMJ 1999;318:956
Szreter S. The importance of social intervention in Britain's mortality decline: a reinterpretation of the role of public health. Soc Hist Med 1988; 1: 1-37.
Stop TB Partnership. Global advocacy for resource mobilization. http://www.stoptb.org/wg/advocacy_communication/acsmga/
Tools for planning and implementing a successful HIV and AIDS treatment advocacy campaign. http://www.safaids.org.zw/publications/Advocacy_Toolkit_131106.pdf
P. D. O. Davies. The changing face of tuberculosis: a new challenge to the developing world. http://www.priory.com/cmol/tbanga.htm
F. Du Melle. The role of advocacy in Tuberculosis elimination. INT J TUBERC LUNG DIS 4(12):S215–S218
Advocacy, communication and social mobilization to fight TB: A 10-year framework for action. Available from: http://www.stoptb.org/resource_center/assets/documents/TB-ADVOCACY.pdf
Despite TB being a major public health problem worldwide, little effort has been made in sensitising the public about the disease and its symptoms, especially in rural areas (5). A practical guide for TB advocacy published by the WHO in 1999 states that despite the successful implementation of Directly Observed Treatment, Short-course (DOTS), TB is responsible for more deaths among the youth and adults than any other infectious disease (6). The disease has large social implications due to the stigma attached to it and its control remains a low political priority in many countries. All these support the need for greater TB advocacy worldwide.
However, advocacy for TB has failed as a public health intervention because of financial and political barriers, failure to involve the private health care sector and failure to include different need-based strategies for different target audiences.
Failure to address needs of different target audiences
There are two basic messages provided for most advocacy strategies – TB is a devastating disease and DOTS can control it (6,7). However different audiences have different concerns and advocates have to target messages accordingly. Audience segmentation is a basic principle of the social marketing theory, which addresses the issues of those those we are specifically trying to reach (8,9). Also, in McGuire’s communication/persuasion matrix, the first of the six steps to consumer decision-making is exposure to the information, where the importance of market segmentation is emphasized (10). The Human Face of TB is a video campaign launched by the WHO – Stop TB partnership (11). The campaign focuses on increasing awareness of the global TB prevalence and the success of DOTS worldwide. Although this campaign provides general information about TB in a very compelling manner, it is not tailored specifically to address concerns of different target audiences. While decision makers and politicians are concerned about budget implications, public opinions and the liabilities of their actions as leaders, health practitioners are concerned about the feasibility of implementing DOTS. Advocacy messages should be framed to address these concerns and those of corporations and businessmen, such as impact of the disease on workers and on the market (12). Framing theory also supports the importance of focusing the attention of people within a field of meaning. Contrary to the concept of making rational choices, framing theory suggests that the way in which something is presented will influence people’s choices (13).
Another important factor to consider is message development. Drawing from advertising theory, the message should be created in order to change the awareness, knowledge and attitude of decision makers (14). Although the film mentioned earlier clearly reinforces the two basic TB advocacy messages, this information by itself does not provide decision makers with any tools to address the problem of TB. These messages do not promote self-efficacy – they do not make the audiences believe that they are capable of attaining certain goals (15,16). The advocacy campaign will not succeed unless key policy makers are made to feel that their decisions will help control TB.
There is also a need for social mobilization as a type of grass-roots level advocacy, whereby the existing concerns among the public are explored, including stigma and gender issues and they are all incorporated in a collective effort of decision-making (17).
Failure to target the private health sector
Choosing the correct target audiences - the people, who can make changes to solve problems, plays a key role in the success of any advocacy campaign. The role of private medical practitioners cannot be underestimated, particularly in South-East Asia (18). It has been estimated that the first point of contact with health care services has been the private sector for over 50% of TB patients because of convenience and perceived quality of care (18,19). Other causes for concern include the treatment provided by the private practitioners, which does not always follow a standard regimen and is oftentimes different from the regimen provided by the National Tuberculosis Programme (NTP) and also the quality of care especially at the more informal end of traditional healers. These practices have implications not only for the individuals treated but also for disease transmission and development of drug resistance (18). Despite this, the NTP in many countries has been unprepared or even reluctant to involve the private sector.
Involving the private heath sector in private-public mix (PPM) health programmes has been successful in the treatment of STDs, malaria and family planning interventions (20,21). Social marketing is another method that has successfully been used to involve private sectors. This approach uses commercial marketing technique to address the lack of consumer information and stimulate a demand from the public for effective interventions, which are then sold through the private sector at subsidized rates to increase affordability (20). TB advocacy campaigns lack such innovative approaches in involving private practitioners.
TB advocacy campaigns have failed to target private pharmacists and pharmaceuticals and this has contributed to its failure as a public health intervention. With easy availability of ‘over-the-counter’ drugs in many developing countries (18,22), patients directly approach pharmacies for common symptoms such as cough and fever, which could be symptoms of TB and we could hence potentially be missing opportunities for early diagnosis of disease. In Asia and Latin America, anti-TB drugs are also available over the counter and self-medication is common (23). By not targeting pharmacists through advocacy, especially in these regions, the risk of primary resistance to anti-TB drugs increases. Yet another important target audience is pharmaceutical companies that manufacture TB drugs. With increasing reports of MDR-TB and XDR-TB, the urgency to discover novel compounds to treat tuberculosis cannot be sufficiently stressed.
Political and financial barriers
Advocacy denotes activities that are designed to place TB control high on the political agenda, foster political will, increase financial and other resources on a sustainable basis, and hold authorities accountable to ensure that pledges are fulfilled and results achieved (24). But TB advocacy has failed because of political and financial obstacles. There is a global indifference to tuberculosis, largely because it is considered to be a disease of the poor and destitute and so more of a social issue than a medical issue (25,26). But this is a fallacy because even in the some of the poorest areas in the world, a good TB control program has been successful in reducing the burden of disease. This is the case in Bangladesh, a country with a huge caseload and poor resources (6,25).
As tuberculosis is considered a disease of poverty, the solution proposed is general improvement in living standards worldwide. But Szreter argues that the concept that good health is a natural consequence of socio-economic improvement is naïve. It neglects the political actions that have resulted from public health advocacy and the impacts that these actions have had on health services (27).
A major challenge has been raising and sustaining financial support for TB advocacy and this arises in relation to insufficient political commitment. This could also be because the issue of TB is too big or too complex especially in the context of poverty. The Global TB control report (2007) estimates that the funding gap for TB worldwide in 2007 was about $1.1 billion (28). Such figures translated in terms of human lives shows the uphill struggle in addressing the current situation.
Conclusion
There are several adverse implications of failure of TB advocacy. The most serious of which is MDR-TB and XDR-TB, which render patients extremely difficult to treat. Lack of advocacy, resulting in misconceptions and lack of awareness among people in power would affect policy decisions and if they make harmful statements about TB more so in the setting of HIV/AIDS, then that would contribute to increased stigma and discrimination (29). On a global level, re-emergence of TB in developed countries in the setting of increased immigration needs to be considered (30) and one of the challenges to alter political will in the developed countries arises from the popular perception that tuberculosis is not a problem in these regions (31).
Another challenge in designing advocacy campaigns can be the difficulty in defining the concept in many languages and cultures, which may contribute to keeping people from participating in advocacy work and governance (29). However, in recent times, there have been advocacy campaigns that use the media as vehicles to promote messages with powerful language and imagery, keeping written information simple. Advocacy for TB control is at the core of the WHO Global plan and the goals are two fold. (I) To create political accountability and social pressure to shape policy agendas around the world; and (II) To mobilize US$ 56 billion from 2006 to 2015 for TB control and development (32). With such newer initiatives and promising trends in TB advocacy, it would certainly prove a valuable tool in the Global fight against TB.
REFERENCES
CDC Division of Tuberculosis Elimination. TB Elimination: Now is the Time! 2007. http://www.cdc.gov/TB/pubs/nowisthetime/default.htm
CDC TB and HIV/AIDS. http://www.cdc.gov/hiv/resources/factsheets/hivtb.htm
WHO A world free of TB. http://www.who.int/tb/en/
WHO The Stop TB Strategy. http://www.who.int/tb/strategy/stop_tb_strategy/en/index.html
Global TB candlelight meditation. About the GTBCM. http://www.afroglobal.org/2007_GTBCM_website/aboutus.html
WHO Global TB Programme. TB advocacy: A practical guide 1999. http://whqlibdoc.who.int/hq/1998/WHO_TB_98.239.pdf
Lee B. Reichman, Earl S. Hershfield. Tuberculosis: A comprehensive international approach. New York, Marcel Dekker, 1993.
Learn marketing; Requirements of segmentation. http://www.learnmarketing.net/requirementsofsegmentation.htm
Sonya Grier, Carol. A. Bryant. Social Marketing in Public Health. Annu. Rev. Public Health 2005. 26:319–39.
Information processing and other hierarchy of effects theories – Maggi Machado. http://www.ciadvertising.org/SA/fall_02/adv382j/machadoma/paper1/paper1total.html
Stop TB Partnership. The Human Face of TB. http://www.stoptb.org/
SEATC 2004, NTI Bangalore. Advocacy - a vital tool in expanding and strengthening TB control! www.searo.who.int/LinkFiles/Programme_Management_Advocacy.ppt
Value Based Management. Net. Focussing Attention Within a Field of Meaning using Frames. http://www.valuebasedmanagement.net/methods_tversky_framing.html
Daniel Mayfield. Advertising Theory. http://www.ciadvertising.org/SA/fall_02/adv382j/dan02/proj3/theory.htm
Wikipedia. Self-efficacy. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Self_efficacy.
Wikipedia. Social Cognitive Theory. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Social_cognitive_theory
Central TB Division, Government of India. Planning and implementing a health communication strategy for RNTCP – A practical guide. http://www.tbcindia.org/pdfs/Health%20Community%20Strategy%20for%20RNTCP.pdf
WHO.Involving Private Medical Practitioners in TB and STI control. http://www.searo.who.int/en/Section10/Section18/Section356/Section413_1890.htm
K. J. R. Murthy, T. R. Frieden, A. Yazdani, P. Hreshikesh. Public-private partnership in tuberculosis control: Experience in Hyderabad, India. INT J TUBERC LUNG DIS 5(4):354–359
Mill A, Brugha R, Hanson K, McPake B. What can be done about private health sector in low-income countries? Bull World Health Organ. 2002; 80(4): 325-30
Editorial. Progress of Public-Private mix in Tuberculosis control – Indian context. Indian J Tuberc 2005; 52:59-61
Kamini Walia. Emerging Problem of Antimicrobial Resistance in Developing Countries: Intertwining Socioeconomic Issues. RHF. Volume 7, Number 1.
MMWR Weekly. Current Trends Primary Resistance to Antituberculosis Drugs -- United States. October 14, 1983 / 32(40); 521-23
Red Cross and Red Crescent action. Supporting global tuberculosis control. http://www.ifrc.org/docs/pubs/health/pochette-tb-en.pdf
World Health Organisation. TB, a global emergency. Geneva: World Health Organisation, 1994.
Zumla A, Grange JM. Doing something about tuberculosis. BMJ 1999;318:956
Szreter S. The importance of social intervention in Britain's mortality decline: a reinterpretation of the role of public health. Soc Hist Med 1988; 1: 1-37.
Stop TB Partnership. Global advocacy for resource mobilization. http://www.stoptb.org/wg/advocacy_communication/acsmga/
Tools for planning and implementing a successful HIV and AIDS treatment advocacy campaign. http://www.safaids.org.zw/publications/Advocacy_Toolkit_131106.pdf
P. D. O. Davies. The changing face of tuberculosis: a new challenge to the developing world. http://www.priory.com/cmol/tbanga.htm
F. Du Melle. The role of advocacy in Tuberculosis elimination. INT J TUBERC LUNG DIS 4(12):S215–S218
Advocacy, communication and social mobilization to fight TB: A 10-year framework for action. Available from: http://www.stoptb.org/resource_center/assets/documents/TB-ADVOCACY.pdf
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