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Advocacy, Communication and
Social Mobilization
National Strategy and Operational Guidelines
National TB Control Programme
Ministry of Health
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Preface
Tuberculosis continues to be a major public health problem in Pakistan. Every year
almost 300000 new TB patients add up to existent prevalent cases. Government of
Pakistan is committed to control Tuberculosis by achieving MDG targets through New
Stop TB Strategy. National TB Control Program (NTP) in partnership with Provincial TB
Control Programs (PTP) implemented the New Stop TB Strategy and achieved 100%
DOTS coverage in 2005. Through sustained commitment, Strengthening Partnership
with Public and Private Sectors and introducing new initiatives, the program steadily
improved case detection and treatment out come for TB patients. As part of its Human
Resource Development and Health System Strengthening policy, NTP has developed
many guidelines and training modules for implementation of quality DOTS in the
country. After years of operational experience, introduction of new initiatives like
Suspect Management, Contact Tracing and Public Private Mix (PPM), it was realized
that Guidelines, Training modules and Recording and Reporting tools should be revised
and synchronized with New STOP TB recommendations.
The Global Fund approved Round 6 Grant in Pakistan to address key components of
Stop TB Strategy. NTP has been given the role of Principal Recipient (PR) from the
public sector. NTP is also implementing activities under round 6 as a Sub Recipient (SR).
Advocacy, Communication and Social Mobilization (ACSM), Quality assured
bacteriology, role of tertiary care hospitals, HIV/TB co infection, MDR TB and health
system strengthening are the major areas for NTP intervention. Development of
National ACSM Strategy and Operational Guidelines is one of the key areas under
ACSM.
Advocacy, Communication and Social Mobilization - National Strategy and Operational
Guidelines has been developed by the National TB Control Program, Ministry of Health,
Government of Pakistan in collaboration with the four Provincial TB Control
Programmes; Mercy Corps Pakistan (Principal Recipient GFTAM/Round 6 Objective 3);
and Integrated Health Services (IHS), Basic Development Network (BDN), Agha Khan
Health Services (AKHS), Association of Social (ASD), Association for Community
Programme Development (ACD) and Bridge Development Consultants.
Much of literature, inventory of ACSM indicators and strategic guidance has been
derived from material produced by the World Health Organization on Advocacy,
Communication and Social Mobilization for Tuberculosis.
We owe Special thanks to Dr. Shahid Hanif, Deputy Programme Manager, Provincial
Programme Managers, Dr. Darakhshan Badar, Dr. Abdul Ghafoor, Dr. Baseer Achakzai
and Dr. Asmat Ara for providing leadership support throughout the process of
development. Also the whole ACSM team operating at national and provincial levels
including WHO Sociologists, National and Provincial ACSM Coordinators, Task
Coordinators and support staff played an important role in many ways.
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Mr. Khawar Azhar developed this national strategy based on the TOR; his contribution
in the form of consulting partner organizations; reviewing ACSM literature and
incorporating invaluable inputs from a diverse group of individuals played a pivotal
role in producing this document.
At the end we would like to especially thank Dr. Muhammad Tariq, Technical Advisor
ACSM for introducing the science of health communications within NTP and his
technical leadership in initiating and coordinating the development of National Strategy
and Operational Guidelines for ACSM.
I hope ACSM Strategy and Operational Guidelines will provide strategic direction for
ACSM activities in the public and private sectors.
Dr. Noor Ahmad Baloch
National TB Control Program
Manager, Pakistan
Authors:
Khawar Azhar – Communication Consultant, Dr. Muhammad Tariq, Technical Advisor ACSM, NTP
This work was supported by The Global Fund as part of National TB Control Programme‟s Implementation of
Objective 3 (2006 – 2011) and does not necessarily reflect the views of The Global Fund.
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Table of Contents
Preface ........................................................................................... 3
Acknowledgement .......................................... Error! Bookmark not defined.
Communicating for Health – An International Perspective .................................14
Section A -TB in Pakistan ........................................................................16
1. Background ..................................................................................17
2. The Pakistan National Tuberculosis Control Programme (NTP) ......................18
2.1 Overview .................................................................................18
2.2 Current Situation .......................................................................18
2.3 DOTS Strategy ...........................................................................20
2.4 ACSM Strategy in Light of NTP Strategic Plan ......................................20
2.5 Partners ..................................................................................21
Section B -Why the ACSM Strategy! ............................................................23
1. Review of Current ACSM Strategy ......................................................24
2. Situation Analysis ........................................................................25
3. Key Challenges............................................................................25
4. Function of ACSM Strategy ..............................................................26
5. Strategic Vision ...........................................................................26
6. ACSM Strategy Rationale ................................................................26
Section C- The ACSM Strategy ..................................................................27
1. Objectives ...................................................................................28
2. Strategy ......................................................................................28
3. Strategy Framework ........................................................................30
4. The New Dimension .........................................................................31
4.1 Brand – The Key Strategic Element ..................................................31
4.2 How Brand Works? ......................................................................31
4.3 Branding and Social Marketing ........................................................31
4.4 Benefits of Establishing a Brand ......................................................32
5. The Next Step – Strategic Behavior Change Communication (SBC) & IEEC .........32
5.1 Role of SBC ..............................................................................33
5.2 Effective SBC can: ......................................................................34
6. Target Groups ...............................................................................35
6.1 Federal Level ............................................................................35
6.2 Provincial Level .........................................................................35
6.3 District Level ............................................................................36
7. ACSM Programme Management ...........................................................37
7.1 National Steering Committee .........................................................37
8. Plan ...........................................................................................38
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8.1 Advocacy ..............................................................................40
8.1.1 Federal (National) Level Advocacy .............................................40
8.1.2 Provincial Level Advocacy .......................................................41
8.1.3 District/Community Level Advocacy ...........................................41
8.1.4 “Peer Education” Meetings ......................................................41
8.2 Communication ......................................................................44
8.2.1 Mass Media .........................................................................44
8.2.1.1 Radio .........................................................................44
8.2.1.2 Television ....................................................................44
8.2.1.3 Newsprint ....................................................................45
8.2.2 Outdoor Advertising & Below the Line Activities .............................45
8.2.3 Information, Education and Communication Material .......................46
8.2.4 Internet .............................................................................46
8.2.5 Cellular .............................................................................46
8.2.6 Branding Opportunities ...........................................................47
8.3 Social Mobilization ...................................................................49
8.3.1 Theatre .............................................................................49
8.3.2 Walks ................................................................................49
8.3.3 Melas, Folk Shows, Cultural events .............................................49
8.3.4 Health Stalls and Kiosks ..........................................................49
8.3.5 Mobile Cinema, Puppet Shows and Floats .....................................50
8.3.6 Communication with Children through Debates, Competitions, etc. ......50
8.3.7 Partnership .........................................................................50
8.3.7.1 Sponsorship ..................................................................50
8.3.7.2 Volunteers for Social Mobilization Activities ...........................50
8.3.7.3 Communication Resource and Distribution .............................51
9. Capacity Building .........................................................................51
10. Research and Analysis ................................................................51
Section D- Operational Guidelines and Process Management of ACSM Field
Interventions ......................................................................................52
1. TB Control in Pakistan ...................................................................53
2. Stigma, Discrimination and Gender Inequality .......................................54
3. How is ACSM Essential to the Stop TB STRATEGY? ...................................55
3.1 Empowering People and Communities Affected by TB .........................55
4. Effective ACSM Interventions ...........................................................55
5. Assigning Roles, Responsibilities and Coordinating Activities ......................56
6. Setting and following Realistic Timelines ............................................56
7. Developing ACSM Messages and Concepts ............................................56
7.1 Consistency of Messages ............................................................56
7.2 Targeting Messages Appropriately .................................................56
8. Developing ACSM materials .............................................................57
8.1 Understanding the Cycle of Developing Materials ...............................57
8.2 Identifying Materials Needed for Different Activities ..........................58
8.3 Selecting Appropriate Materials ...................................................58
8.4 Materials and their Specific Activities .......................................59
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9. Start-up Activities ..........................................................................60
10. Planning an Important Event - World TB Day ..........................................61
10.1 Reasons for Holding an Event .......................................................61
10.2 Planning Steps .........................................................................61
11. Key Components of the ACSM Strategy .................................................62
12. Planned Activities .........................................................................62
12.1 Institutional Strengthening and Capacity Building ............................63
12.2 ACSM Steering Committee ........................................................63
12.3 Formative Research .................................................................63
12.4 Social Marketing Campaigns .....................................................64
12.5 ACSM Information and Communication Resource Center ......................64
12.6 Community Based ACSM Events ....................................................64
12.7 Conducting Journalist Training ..................................................66
12.8 Orientating Advocates ..............................................................68
12.9 Establishing Community Coalitions ................................................69
12.10 Operational Details for Community Coalition ..................................70
12.11 Design and Formation and functioning .........................................70
12.12 Mobilizing Community Health Workers .........................................73
12.13 Quality Assurance Workshops with Health Care Providers .....................74
12.14 Monitoring and Evaluating ACSM Activities .......................................76
12.15 Conducting Short-term and Long-term Monitoring and Tracking .............76
12.16 Recognizing Problems via Feedback from the Field ............................77
12.17 Making Mid-course Corrections Based on Feedback .............................77
Section E-ACHIEVEMENTS ........................................................................81
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ACRONYMS
ACSM Advocacy Communication & Social mobilization
AIDS Acquired Immunodeficiency Syndrome
AJK Azad Jammu & Kashmir
AKHSP Aga Khan Health Services Pakistan
BBC British Broadcasting Corporation
BDN Basic Development Need
CBOs Community Based Organizations
DCO District Coordination Officer
DFID Department for International Development
DOTS Directly Observed Treatment Short-Course
DTC District TB Coordinator
EDO (H) Executive District Officer Health
FAQs Frequently Asked Questions
GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria
GLRA German Leprosy and TB Relief Association
GS Green Star
GTZ Gesellschaft für Technische Zusammenarbeit
HIV Human Immunodeficiency Virus
IACC Inter-Agency Coordination Committee
IEEC Information Education, Empowerment & Communication
IPC Interpersonal Communication
JICA Japan International Cooperation Agency
LHWs Lady Health Workers
M & E Monitoring & Evaluation
MC Mercy Corp
MoH Ministry of Health
NA Northern Area
NTP National TB Control Programme
NTPCS National TB Control Programme Communication Strategy
NWFP North-West Frontier Province
OIC Organization of Islamic Conference
PATA Provincially Administered Tribal Areas
PHC Primary Health Care
PTP Provincial TB Control Programme
SARC South Asian Regional Cooperation
SBC Strategic Behavior Change Communication
TAF The Asia Foundation
TB Tuberculosis
TGF The Global Fund
UC Union Council
UN United Nation
WHO World Health Organization
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THE NATIONAL TB CONTROL PROGRAM
Like other developing countries TB has been one of the major public health problems in
Pakistan. TB has been prevalent in Pakistan and unfortunately it has been one of the
neglected health areas in past. Pakistan ranks 8th amongst the countries with a highest
burden of TB in the world. Pakistan contributes about 54% of tuberculosis burden in the
Eastern Mediterranean Region. According to WHO (2001), the incidence of sputum
positive TB cases in Pakistan is 80/100,000 per year and for all types it is 177/100,000.TB
is responsible for 5.1 percent of the total national disease burden in Pakistan. The impact
of TB on socio economic status is substantial.
WHO declared TB a global emergency in 1993. Since then efforts have been made to
expand partnerships and bring all stakeholders on board in order to control this disease
more effectively. Government of Pakistan endorsed the DOTS strategy, following
WHO‘s declaration of TB as a global emergency, The National TB Control Program
(NTP) Pakistan adopted DOTS (Directly Observed Treatment, Short course) strategy in
1995.
In year 2001, the Ministry of Health declared Tuberculosis as a national emergency and
adopted the Islamabad Declaration calling upon all development partners and other
stakeholders to make concerted efforts for the control of the disease in the country. The
global targets were endorsed.
The declaration was followed up by the notification of an Inter-Agency Coordination
Committee (IACC) as the National TB Program had entered into meaningful
partnerships with a wide range of technical partners, donor agencies and civil society
organizations.
Objective and Targets:
The overall objective of NTP is to reduce mortality, morbidity and disease transmission
so that TB is no longer a public health problem. The National targets are in line with the
millennium development goals (MDGs). To cure 85% of detected new cases of sputum
smear positive pulmonary TB and to detect 70% of estimated cases once 85% cure rate is
achieved.
The National TB Control Program (NTP) has also received tremendous support from
partners/donors. The major projects are supported by USAID, three grants from the
GFATM (Round 2.3 and recently 56 million through Round 6). Moreover, the Global
Drug Facility (GDF) is supplementing ATT drugs.
High government Commitment coupled with strong technical leadership in the program
resulted in clear vision, which was translated into multi-year strategic plan (2001 – 2005)
to achieve 100% DOTS coverage by year 2005. The strategic plan was revised for the
period from 2005 to 2010. The Government of Pakistan increased the allocation of funds
for the control of TB. The new PC-1 of 1.184 billion is approved for the year 2002 – 2010.
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Progress:
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steady progress has been made from 2000 onwards to improve the case detection and
treatment success rate by emphasizing on quality assurance of smear microscopy, drug
management, community mobilization, involving tertiary care hospitals, NGOs, and
inter-sectoral organizations and above all involving private sector for service delivery.
Advocacy, community and social mobilization is also in the mandate of the program.
NTP has taken many new initiatives including a nation wide formative research for
identifying risky behaviors, development of a BCC strategy, initiation of Mass Media
Campaign, awareness seminars at provincial levels and advocacy activities at the district
level. Operational research is carried out and steps are taken to enhance the research
capacity at National Provincial and district levels and design the carryout researches.
NTP has completed and published10 research projects. A number of researches are in
progress.
The commitment resulted in a rapid expansion of the DOTS strategy from 2000 to 2005,
reaching DOTS-all-over in May 2005. Since then free diagnostic and treatment facilities
for TB patients are available all over the country within the public sector health care
delivery network, including rural health centers, tehsil and district headquarter hospitals
in addition to certain tertiary care teaching hospitals. Till date 1135 Diagnostic facilities
and approximately 5000 treatment facilities are available throughout the country.
Monitoring/ supervision is carried out regularly. NTP Pakistan also undergoes
assessments in the form of External Review Missions participated by International as
well as National partners. The recommendations of the review missions help to
improve and strengthen the Program.
In 2001, 20707 TB cases were registered. In 2007 234,100 were registered. The cases have
increased with the DOTS expansion to private sector and tertiary care hospital and in Q1
2008, 60354 TB patients are registered. Case detection rate for new SS+ increased from
2.8% in 2000 to 18% in 2003. In 2007 it is 68% and in the first quarter of 2008 the CDR
increased to 68% against the target of 70%. The treatment success rate, it has also been
increased from 74% in 2000 to 87% in 2006 and maintained till date, against the target of
85%.However, it is expected that the CDR will rise more rapidly, as DOTS-all-over has
been achieved and efforts are underway to make DOTS more comprehensive by greater
involvement of public and private sector health care providers.
On ACSM, Pakistan remains leader in the EMR and is the first country to develop
National Policy guidelines on ACSM Strategy, Operational Guidelines and M&E
Frameworks for both public and private sectors after a consultative process. Further, a
TB brand and branding strategy is under development process. PPM is being
implemented in the country and 200 health care providers have been recently trained
towards increasing access to DOTS services through the private sector.
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To empower people with TB, and communities
NTP has developed a Behavioural Change Communication (BCC) strategy, which
initiates Mass Media campaigns, and conducts awareness seminars at National,
Provincial and District levels along with advocacy activities at the grass-root level.
Advocacy, Communication and Social Mobilization (ACSM) are integral and cross
cutting segments to all programme components of the National TB Control Programme.
The ACSM activities predominantly focus to set agendas, improve awareness and
knowledge in shaping public attitudes toward risk behaviours. The ongoing efforts will
provide evidence based strategic and targeted communication for enhanced visibility,
acceptability and utilization of intended TB services throughout Pakistan – hence
creating high demand for TB services. The current funding plan envisages Social
Mobilization to contribute towards high utilization of desired TB services through
private sector partner organization operating within communities.
Advocacy, Communication and Social Mobilization (ACSM) are integral and cross
cutting to all programmatic components of the National TB Control Programme. The
ACSM activities predominantly focus to set agendas, improve awareness and
understanding and knowledge and shape public attitudes toward risk behaviors. The
ongoing efforts will provide evidence based strategic and targeted communication for
enhanced visibility, acceptability and utilization of intended TB services throughout
Pakistan. The current funding plan envisages social mobilization which primarily will
be addressed by the private sector will contribute to high acceptability and utility of
desired TB services.
NTP uses Socio Ecological Framework and principles of social marketing while making
use commercial marketing techniques to provide efficient means of communication for
the print, electronic media and social mobilization activities. Research based messages
will continue to deliver in the years to come. The implementation of BCC will involve
the use of TV, radio, newspaper, video and audiocassettes, and print materials including
posters, flip charts, and leaflets. Following approach will be employed to cover hard to
reach areas were previous ACSM interventions have been executed.
Research:
NTP has recently floated RFP for a comprehensive National Formative Research. The
evidence and data will guide meaningful and targeted ACSM activities throughout the
country. Moreover, NTP will use this data to guide development of National
Communication Strategy in addition to National Monitoring and Evaluation
Framework. The framework will essentially address the M&E needs of the National TB
Control Programme and Global Fund. Further, these national policy documents will
serve both for the public and private sectors with mile stones for communication at all
level.
Formative research will help identify desirous segments of population for building the
communication campaign, development and pre-testing of creative concepts to ensure
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cultural appropriateness for a meaningful impact. Large-scale social marketing
campaigns – television, radio print and outdoor media will be implemented to support
community based programmes and service delivery. Community based ACSM activities
and events – community theatre, music, dance and drama, community cinema, will be
developed, to support advocacy and social mobilization through interpersonal dialogue
based approaches.
Establishment of a Model Resource Center for TB Communication:
The need for developing a Model Resource Centre has been realized by the NTP. The
resource center will function at the national level and Logistics Management
Information System (LMIS) will be developed for ACSM local, regional and
international material for effectively communicating about tuberculosis. The resource
center will be reflection of high quality Pakistani, regional and international resource
material for TB communication. Resource center will further provide efficient means of
distribution of material to provinces, districts and partners from the private sector.
Enhanced ACSM coordination: management and partnership development
In order to achieve a meaningful impact of TB communication, NTP will spearhead
enhanced coordination for ACSM programme design, implementation and evaluation
through establishing a National ACSM Steering Committee comprising of MoH, NTP
and programme partners to coordinate and scale up the wide range of ACSM activities
around the country. The Steering Committee will contribute towards strategizing and
coordinating ACSM plan.
Increased awareness, knowledge and self efficacy toward screening and
treatment
There is high realization within NTP that Communication is cross cutting across all
components of DOTS realization in Pakistan. Despite the fact that the DOTS coverage
has reached 100% in public sector facilities, public awareness and knowledge of the
efficacy of TB screening and treatment is low. Other knowledge gaps include poor
understanding of the provision of free services and drugs provided by public sector
health facilities. Community feedback indicates continuing high levels of stigma driving
the disease and poor efficacy, especially amongst high risk, low income groups. In order
to build on the gains made to date, more intensive, large-scale, strategic communication
campaigns are required.
A number of diverse activities have been planned e.g. orientation sessions will be
conducted with key advocates, opinion leaders, key influencers and celebrities to
enhance dedicated support for TB in the country. Provide incentives and merchandising
opportunities to encourage involvement and leveraging advocacy opportunities.
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Further, Public Relations Services will be contracted and health and media journalists
will be identified, trained on effective evidence based communication for TB.
The current ACSM Unit has been strengthened and comprised of international and
national trained Pakistani staff under the leadership of a Technical Advisor to oversee
country wide communication initiatives. Further technical staff at the national and
provincial levels is being recruited. NTP is also spearheading the process of developing
integration with the general practitioners from the private sector for TB activities.
National TB Control Programme has secured funds from the Public Sector Development
Programme through PC-1 for 2008. NTP plans to implement Public Private Mix (PPM)
activities in the forty districts of Pakistan.
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Communicating for Health – An International Perspective
Methods traditionally used to deliver health products and services in developing
countries often do not reach a large portion of the population, especially the poor. Over-
burdened public health systems generally do not have enough outreach and service
provision for the less privileged consumers living in far flung areas. Government organs
are limited in the type and nature of motivational campaigns they can undertake. So the
general consumer is not aware of the health service even if it is available to him.
On the other hand commercial entities with their marketing skills and media muscle
enjoy a massive outreach for the demand generation of their products and services that
eventually results in their use by the target segments. Therefore, in presence of the
marketing techniques being practiced by commercial sector worldwide, creating a room
for public health awareness and call of action seems challenging. So, one has to follow
the same path to communicate with masses as they have been accustomed to.
Although marketing social change is much more difficult than marketing commercial
products, the basic premise is the same. However, traditional marketing principles of
product, price, place and promotion must be adjusted to address the environment in
which social change takes place – an additional factor must be considered: partners.
(„Marketing Public Health: Strategies to Promote Social Change‟ by Michael Siegel & Lynne Doner)
The term social marketing was first coined by Kotler and Zaltman in 1971 to refer to the
application of marketing to the solution of social and health problems. Marketing has
been remarkably successful in encouraging people to buy products such as Coca Cola
and Nike trainers, so, the argument runs; it can also encourage people to adopt
behaviors that will enhance their own - and their fellow citizens‘ - lives. („A Synopsis of
Social Marketing‟ by Lynn MacFadyen, Martine Stead and Gerard Hastings – 1999)
Social marketing, like generic marketing, is not a theory in itself. Rather, it is a
framework or structure that draws from many other bodies of knowledge such as
psychology, sociology, anthropology and communications theory to understand how to
influence people‘s behavior (Kotler and Zaltman, 1971). Like generic marketing, social
marketing offers a logical planning process involving consumer oriented research,
marketing analysis, market segmentation, objective setting and the identification of
strategies and tactics. It is based on the voluntary exchange of costs and benefits
between two or more parties (Kotler and Zaltman, 1971). However, social marketing is
more difficult than generic marketing. It involves changing intractable behaviors, in
complex economic, social and political climates with often very limited resources
(Lefebvre and Flora, 1988). Furthermore, while, for generic marketing the ultimate goal
is to meet shareholder objectives, for the social marketer the bottom line is to meet
society‘s desire to improve its citizens‘ quality of life. This is a much more ambitious -
and more blurred - bottom line.
Many social and health problems have behavioral causes: the spread of AIDS, traffic
accidents and unwanted pregnancies are all the result of everyday, voluntary human
activity. Social marketing provides a mechanism for tackling such problems by
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encouraging people to adopt healthier lifestyles. („A Synopsis of Social Marketing‟ by Lynn
MacFadyen, Martine Stead and Gerard Hastings – 1999)
All over the world public health organizations have been following the principles of
Social Marketing to reach and mobilize their target audiences. Social marketing has
become an effective way of motivating low-income and high-risk people to adopt
healthy behavior, including the use of needed health products and services. Social
marketing combines education to motivate healthy behavior with the provision of
needed health products and services to lower-income persons. Public is motivated to
adopt a wide variety of healthy behaviors, including use of products and services that is
to be encouraged. As practiced in commercial world products and services are branded,
attractively packaged, widely marketed, effectively promoted to the poor and selected
target groups, and are provided as promised.
A key ingredient of successful social marketing is effective communications to
encourage the adoption of appropriate health practices (including proper use of the
products and services). This is done by brand-specific advertising as well as by generic
educational campaigns, using a mix of strategies and channels, including mass media
and interpersonal communications, to reach the target audience(s).
Departures from Commercial Marketing
There are some important differences between social and commercial marketing.
Specifically, in social marketing:
the products tend to be more complex
demand is more varied
target groups are more challenging to reach
consumer involvement is more intense
the competition is more subtle and varied
This complexity makes social marketing products difficult to conceptualize. As a
consequence, social marketers have a bigger task in defining exactly what their product
is and the benefits associated with its use.
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Section A -TB in Pakistan
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1. Background
Tuberculosis (TB) has been there for centuries and one-third of world‘s population is
still infected by it. While TB has been stamped out in the developed world, it remains a
serious and constant threat to the lives of people in third world countries, killing almost
two million people a year. TB prevention and control face serious challenges.
TB is a contagious disease that spreads like the common cold. Ninety eight percent of
deaths take place in developing world, affecting mostly young adults in their
economically productive years. Active TB develops primarily in people with weakened
immune systems, especially in people with HIV, and can escalate to a serious infection
of the lungs, resulting in death. 30 percent of the world‘s population—2 billion people—
carry the TB bacilli; one in ten of these people will become sick with active TB and
without effective treatment, will infect 10-15 other people in a year.
AIDS and TB make for a deadly combination—TB is the leading killer among HIV
positive people due to their weakened immune systems and it is estimated that one
third of all HIV positive people also have TB. The World Health Organization estimates
that if left unchecked TB will kill 35 million people in the next 20 years.
Pakistan belongs to South Asian region and covers an area of about 796,095 sq.
kilometers. The geographic distribution of about 150 million people is uneven. Pakistan
has primarily an agrarian economy with almost 68 percent of its population living in
rural areas. Pakistan has a disease burden pattern that is typical of developing countries,
with some signs of ―epidemiological transition‖. The public sector expenditure on health
has been around 0.9 percent of GDP for the last several years. Pakistan has lagged it
neighbors and many other low-income countries in terms of health and fertility
indicators.
Pakistan ranks eighth among the countries with highest burden of tuberculosis in the
world1. It constitutes about 55% of tuberculosis burden in the Eastern Mediterranean
Region of WHO. According to WHO recent estimates, the incidence of sputum positive
tuberculosis in Pakistan is 81/100,000 per year, about two third of which belong to
economically productive age group. The case detection rates in Pakistan are far from
WHO targets. HIV infection is not yet a major problem and there is no documented
relationship yet with TB trends. However, experiences in other developing countries
suggest that there is a potential risk of an HIV epidemic in future, and TB-HIV co-
infection pose a serious challenge to the health services in developing countries
including Pakistan.
Since last five years, the government of Pakistan has committed itself to control of
Tuberculosis in the country through DOTS strategy. The National TB Control
1 WHO 2005
18
Programme (NTP) is the body primarily responsible for coordinating the nation-wide
TB-DOTS Programme. NTP successfully achieved its main short-term objective of
nation-wide DOTS coverage in public sector in year 2005 and is pursuing high quality
DOTS expansion and enhancement. The Programme has also gradually progressed
towards facing the challenge of MDR by developing and implementing protocols for
difficult to diagnose cases and pediatric Tuberculosis.
2. The Pakistan National Tuberculosis Control Programme (NTP)
2.1 Overview
Tuberculosis is responsible for 5.1% of the total national disease burden in Pakistan. Like
most of the low income developing countries, there has been almost no observable
decline in incidence in Pakistan and the absolute number of TB cases is probably
increasing due to population growth and worsening poverty. The emergence of multi-
drug resistance as a public health issue and a potentially threatening link between
tuberculosis and HIV/AIDS has contributed to the revived interest in tuberculosis
control in the country. In view of the seriousness of the problem, WHO in 1993 declared
TB to be a ‗Global Emergency.‘ Two billion people, equal to one third of world
population are estimated to be infected with the TB bacillus, 1.6 million die every year
from TB i.e. 4400 deaths a day. At the present time, it is estimated that there are 16 to 20
million cases worldwide with 8.8 million new cases every year, 80% of them in 22
countries. This constitutes 26% of eminently avoidable adult deaths worldwide. 450,000
new MDR cases every year (2007, WHO)
In Eastern Mediterranean Region TB incidence rate is 104 persons / 100,000 population
and while TB prevalence rate is 163 persons/100,000 population. TB mortality is 21
persons/100,000 population.
2.2 Current Situation
The health policy has emphasized the focus on primary health care and strengthening of
district-health systems. The National TB Control Programme (NTP) was initially
launched in the early sixties. However, Tuberculosis was declared a national emergency
in 2001. In 1995, the Government of Pakistan adopted DOTS (Directly Observed
Treatment Short-course strategy) as the national strategy for TB Control but its
implementation remained weak till it was revitalized in 2001. The NTP endorses the
MDG targets for TB control (MDG 6, target 8), is an active member in the Stop TB
Partnership, and has adopted the new STOP TB Strategy. Pakistan‘s commitment to the
STOP TB Strategy and the MDGs is reflected in its 5-year National Strategic Plan which
is in line with the Global Plan to Stop TB. The Mission, Overall Purpose and targets for
the NTP, Pakistan, as outlined in the Strategic Plan are as follows:
The Mission of NTP is to achieve countrywide control of TB through the DOTS
strategy by ensuring quality TB care through public and private sector health
facilities and enhancing the role of other partners, including private sector and
NGOs.
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The overall Purpose of NTP is to support the four provinces, AJK, the Northern
Areas and FATA in controlling TB by establishing and operating effective delivery
and management of TB care for their respective population.
As indicated in MDGs the Targets for NTP are to:
o by 2010 treat successfully, at least 85 percent of the registered new smear-
positive TB Patients; detect 70 percent of the estimated incident smear-
positive TB cases and; reduce, by 50 percent, the prevalence and the
mortality due to tuberculosis.
o by 2015 reduce TB in Pakistan by 50%
The National TB Control Programme (NTP) is responsible for the following:
Policy formulation and strategic planning
Technical and material support to provinces and AJK/NA/FATA
Supervision, monitoring and evaluation support to provinces and
AJK/NA/FATA
Coordination with national and international partners
Operational Research
Support to national reference laboratory
The Provincial TB Control Programmes (PTP) are mainly responsible for the following:
Participation in strategic planning, and carry out Programme and operational
planning
Technical and material support to districts
Supervision, monitoring and evaluation support to districts
Coordination and advocacy
Operational research, and
Support to provincial reference laboratory
Implementation at the provincial level
20
Communicating Tuberculosis Advocacy, Communication & Social
Communicating Tuberculosis Advocacy, Communication & Social Mobilisation
Mobilisation
Pakistan’s Strategic Positioning Framework for TB
Objective: Improve KAP = ~100% CDR/TSR
Recognition
Self risk perception
TB in PHC
Infrastructure
Positioning
RHC, THQ &
DHQ
Private Sector
Preparedness
Position mix of
Public and
Private Sector
Step 1 Step 3Step 2 Step 4
1960s 2001 2005 2006 2008 ….………………….
Reproduced from Pakistan‘s Strategic Positioning Framework for communicating TB (Tariq at el)
2.3 DOTS Strategy
The Government of Pakistan in collaboration with the Ministry of Health (MoH) has
launched the National Tuberculosis Programme (NTP) to undertake various
responsibilities including policy formulation, strategic planning, coordination and
communication with partners, technical support and supervision, monitoring and
evaluation, and research; at the national level to combat the disease in an effective
manner. Directly Observed Treatment Short Course (DOTS) strategy has been launched
which has five components:
Political commitment
Good quality diagnosis
Good quality drugs
Short-course chemotherapy
Systematic monitoring and accountability
DOTS coverage has increased sharply since its launch in 2001. Now 100% of more than
7,000 public sector health facilities have DOTS.
2.4 ACSM Strategy in Light of NTP Strategic Plan
In order to achieve its strategic objectives NTP, since its inception, has been designing
and implementing a comprehensive ACSM strategy. It devises guidelines for Advocacy,
Communication and Social Mobilization that supports the NTP Strategic Plan in the
following ways:
21
Provide a framework for communication activities
Provide guiding principles for the communication process
Identify key elements and activities for a multidimensional, integrated ACSM
strategy on TB
Mobilize the community to create a demand for DOTS
Advocate with key populations for greater political commitment and stakeholder
ownership
Enhance communication skills of health care providers
Increase the credibility of the public sector services provided through NTP
Highlight the services provided free of cost to patients
Reduce the stigma attached to TB
Emphasize that TB is curable
Increase knowledge of ―What is TB? How does it spread and How to prevent
and cure it‖
Reduce the default rate by emphasizing the importance of completing the 8-
month course
Build public-private partnerships
Increase ownership and hence accountability for DOTS
Communicating Tuberculosis Advocacy, Communication & Social
Communicating Tuberculosis Advocacy, Communication & Social Mobilisation
Mobilisation
Home
LHW +
Village
DHQ
Village
Cluster
Private HC
Establishments
IEEC
IPC
Social
Mobilizers
Health Systems Approach to TB
Communications
THQ
Tertiary
Hospital
Public & Private Sectors
RHC
Reproduced from Health Systems Approah to Communicating Tuberculosis (Tariq at el)
2.5 Partners
The National TB Control Programme enjoys one of the largest partnerships in the
country and internationally; supporting their efforts in all aspects of the Programme.
The partners include WHO, GFATM, JICA, Green Star, Asia Foundation, Mercy Corp.,
22
AKHSP, GTZ, GLRA, ACD, PATA, MALC, and many more. The NTP is looking on to
build further partnerships, especially with regards to its communications activities.
These include the corporate sector, other government organizations, media etc.
23
Section B -Why the ACSM
Strategy!
24
1. Review of Current ACSM Strategy
Realizing the importance of Strategic Behavior Change Communication (SBC) and
community mobilization activities through a coherent SBC/ACSM strategy for a
countrywide implementation of DOTS and to achieve the case detection and cure rate
targets and disease default, the Ministry of Health (MoH) involved advertising agencies
to devise a comprehensive strategy to utilize most effective media to reach the audience
and to meet the set objectives of the campaign. In this regard a number of campaigns
were launched employing numerous communication tools.
The End Term Project Impact Assessment has tried to look into the peoples‘ general
perception by using, both qualitative and quantitative methods of research, about
different modes of communication to set benchmarks as to which medium has created a
major impact on the understanding of the people. In this connection, survey
questionnaire, Focus Group Discussions and Key Informant Interviews have been used
to collect the data. This data has been collected by involving a large range of
stakeholders and later analyzed on the basis of set objectives of the campaign.
The study results indicate that the selection of different media to launch SBC has been
effective. While analyzing collected data, it is observed that there is still room for
improvement in many areas where the message has either not reached or not
understood properly.
With ever increasing viewer-ship, television has been one of the most important
medium of communication and behavior change in the current era. Given the wide
range of television channels available, the data collected through both qualitative and
quantitative methods reveals that there is no single television channel that has been used
by the respondents to collect the information about TB or DOTS Programme. Other
sources like radio, newspaper, printed materials and seminars are also used by the
target audience to get information. The impact assessment study also finds that a large
section of the participants also get information through their closed ones. However, the
nature of information provided and their source of information is not identified.
The study reveals that most of the peoples who have benefited through this campaign in
terms of awareness raising, accessing the health care facilities and getting free
medication have utilized television as their preferred source of information.
However, current ACSM is faced with following challenges:
Absence of a unified Brand
Lack of uniformity in communication originating from different sources
Low advertising budget to cater to fragmented media
Low frequency resulting in low recall of campaigns
Weak follow-up on ACSM guidelines by partners
A number of communication avenue not utilized
25
2. Situation Analysis
There is a big gap in the levels of awareness and a lack of comprehensive knowledge
about TB as a disease, how it spreads and the cure available through the DOTS strategy.
The rate at which TB is growing is alarming as well. The current situation shows a low
case detection rate, delay at the patient‘s side resulting in delayed diagnosis and
misconceptions very widely prevalent in the society about the disease and most
importantly the stigma associated with the disease.
Advocacy initiatives need more focus and concerted efforts; Communication has to be
simple, far reaching and well directed; and Social Mobilization activities are required to
be consistent, well designed and complimenting to the entire ACSM Programme.
This strategy argues that strategic behavior change communication (SBC) is a much
more intangible, complex and diffused process. There is a wide range of communication
design factors related to the types of appeals developed and their level of persuasion.
Also to be considered are audience mediating factors such as socio-economic, cultural,
spiritual and demographic factors that determine whether and how behavior change
occurs, how long it will take to occur, and whether it will be sustained.
The change of behavior is needed at all levels, starting from the decision maker to the
actual patient. This strategy aims to provide roadmap that will help all stakeholders
contribute to the better level of awareness of everyone involved through focused
interventions.
3. Key Challenges
At present NTP is faced with following challenges as regards ACSM:
Low literacy rate
Lack of ACSM baseline information
Lack awareness on public and private sector health establishments providing TB
diagnostic and treatment services
Myths associated with TB
Stigma attached to the disease
Lack of social acceptance of TB as a curable disease
Use of Public Relations services
Absence of community responsiveness towards TB patients
Minimum media support
Very little understanding and support from the influencers
Current Communication not reaching the grassroots level
Lack of political will to rid the country of the menace of TB
26
4. Function of ACSM Strategy
The purpose of this strategy is to define the framework, formulate guiding principles
and identify key elements of the Advocacy, Communication and Social Mobilization
that focuses on controlling TB in Pakistan. The strategy provides a multidimensional
platform of activities to illustrate how various stakeholders in TB Control
communication fit into the overall framework. The strategy also incorporates the
communication activities of the partners to avoid duplication and ensure that all work is
being conducted under one vision.
5. Strategic Vision
“Every citizen is aware and has knowledge about TB and services available for its care and cure
across Pakistan.”
6. ACSM Strategy Rationale
The challenge of controlling the spread and impact of TB in Pakistan is enormous,
complex and urgent. Awareness is low and behavior change hasn‘t even been initiated.
The targets set in NTP Strategic Plan need efforts to encourage those who are infected to
take personal responsibility for reducing the spread of the virus; to educate around them
about the curability of disease and availability of treatment. For this purpose a wide-
ranging ACSM strategy is needed that can inform and educate people about the disease
and the free availability of diagnosis and treatment facilities; and mobilize them to avail
these facilities.
As the problem poses a complex health and social issue, due consideration should be
given to ensuring a consistent and integrated approach to the disease management
paradigm that necessarily incorporates timely, accurate, continuous and far reaching
strategic communications.
Under the strategy, a variety of communication activities are planned. It is hoped that
these activities will increase awareness and knowledge about TB; TB transmission and
prevention; influence attitude and behavior change; improve the quality of health care
provided and support for the infected and affected; NTP and treatment of DOTS in
particular. Another important aspect of ACSM is to create and promote NTP
image/brand and address the need to build a positive image of the Programme. Besides
reinforcing existing preventive behaviors toward TB, communication Programmess
should encourage behavior and social change through coordinated, multi sectoral
approach and an integrated range of resources, Programmess and communication
delivery mechanisms. This strategy identifies communication approaches to operate at
national, provincial, district and Union Council levels, thereby defining roles and
outcomes of each stakeholder in TB control interventions. The strategy accounts for the
roles of gender, cultural, spiritual and socio-economic circumstances and their impact on
TB prevalence.
27
Section C- The ACSM Strategy
28
The ACSM Strategy
The Advocacy, Communication and Social Mobilization (ACSM) Strategy is what is
often referred to as 'the demand generation component'. Here communication refers to
activities seeking individual behavior change (often called SBC); advocacy refers to
activities that improve the political will; and social mobilization refers to the community
mobilization that brings together the messages and activities for action at the
community level.
The ACSM activities will occur at several levels. At the national level, they will be
targeted to improve advocacy efforts to create a more favorable environment. In
addition, mass media activities will be conducted for the general public to increase
awareness of the disease of TB. At provincial level, it will advocate for more resources
for communication activities and will focus on enhancing capacity of health education
managers. At the district level, it will work to build ACSM capacity of the government
and private partners. Districts can develop specific ACSM strategies to compliment the
national strategy. Finally, at the local level, community mobilization activities will
encourage communities to understand TB and play their role in curbing it. ACSM will
work with the implementing partners at the community level to ensure consistency in
all communication initiatives.
This document proposes guideline principles supporting communication Programmes
and lead partners at a national, regional and community level. The strategy aims to
propose focused and extensive action plans, that will help NTP and its partners increase
awareness and hence generate the demand of TB treatment in Pakistan.
1. Objectives
The key objectives of the strategy are:
Control spread of TB by creating mass awareness
Increase ownership of the TB Program/DOTS with stakeholders/ decision
makers at all levels
Address all the concerns related to the disease of TB
2. Strategy
Advocacy will help garner national support for the program as well as ensure
functioning facilities. Communication activities will challenge the current thinking and
behaviors by creating awareness of the problem and suggesting actions to change the
milieu. Community mobilization will be the mainstay of behavior change.
To achieve the above mentioned objectives following strategy will be followed:
29
1. Increase the advocacy role of the strategy using gatekeepers and key influencers
such as politicians, journalists and religious or other opinion leaders on central,
provincial and district levels.
by
Employing public relations and lobbying initiatives
2. Increase awareness and knowledge about TB/DOTS and the social and human
dimensions of TB within their cultural settings
by
Creating a unified/integrated mass media communication plan highlighting:
o Availability of treatment through DOTS
o Importance of continuing treatment to reduce default rate
o The process of spread of TB to prevent transmission of TB and reduce the
social stigma
o Identify treatment centers through clear signage
3. Change attitudes, perceptions and behavioral intentions to:
o Encourage TB preventive behaviors
o Sensitize the public of receiving timely treatment and cure for TB
o Facilitate stigma reduction
o Address traditional beliefs about TB (myths)
o Address the gender differential issues with respect to TB/DOTS
o Create a positive relationship between the patient and the health care
provider
o Encourage household decision makers for providing timely and correct
cure for TB
o Reduce negative social and economic impacts of the TB disease
o Improve care for the TB patients and their family and close friends
by
Supporting and scaling-up behavior and social change communication and
social mobilization Programmes currently being implemented by various
partners and NTP.
30
3. Strategy Framework
Goal: TB Free Pakistan
A Roadmap to Engage, Inform and Activate
using Identical Messages
Guiding
Principles
Advocacy
Communication
Social Mobilization
Result
o Sensitization
and
involvement
of all
stakeholders
o Building
integrated
Programme
communicati
on
o Mobilizing
communities
and
addressing
myths
o Develop
sustainable
interventions
Use of Public Relations
(PR) and Lobbying
initiatives to influence:
o Parliamentarians,
Provincial and
Distt. Govts.
o Govt. Functionaries
o Media
o Corporate Sector
o Religious Leaders
o NGOs/CSOs
o School Teachers
o Advertising
(Press, Radio,
TV, Cinema,
Outdoor)
o Publicity
through PR
with media
o Promotion
through day
brandings,
city
brandings,
facility
branding, etc
o Syndicated
programming
like Dramas
and thematic
Songs
o TV/Radio
Talk Shows
Activities like:
o Community
Dialogues
o Seminars
o Training Workshops
o Local Theatre
o Musical Shows
o Sports Events
o Floats
o Brand
Ambassadors/Celebr
ities
o Walks
o Media‘s Capacity
Building
o Incentive Plans
o Councilors
o Students/Youth
Groups
o More aware
masses
o Supportive
and effective
stakeholders
o Responsive
communities
o High
detection rate
o Low MDR
o TB free future
Branding is the Keyword
31
4. The New Dimension
As practiced in commercial sector, for the effective delivery under ACSM a distinct
brand should be built to signify NTP/the disease. It is imperative to achieve the greatest
objective of mass awareness about the disease of TB and availability of its treatment
opportunities, leading to demand generation.
The icon related to Brand (Logo) and its tag line will form the basis of a unified,
standardized and consistent communication that will lead the initiative of Advocacy,
Communication and Social Mobilization.
4.1 Brand – The Key Strategic Element
Brand is a unique and identifiable symbol, association, name or trademark that is both a
physical and emotional trigger to create a relationship between consumers/targets and
the product/service.
4.2 How Brand Works?
Nonprofits and government agencies are generally several steps behind the commercial
sector in applying marketing concepts to their health and social issues. Branding is a
word that is thrown around a lot by marketers of all stripes without a complete
understanding of what it actually means. We know we want to have a strong brand, but
to some that just means creating a logo and tagline. A brand is much more than just the
service itself, or the visuals you create to promote it.
Brand is the marketer‘s most advanced emotional tool. It is how your audience thinks
about your service and connects with it emotionally. It is the combination of how you
market your service and how the audience experiences it. It combines and reinforces the
functional and emotional benefits of the service and so adds value, encouraging
experience and loyalty. A good brand facilitates recognition, makes a promise, and,
provided the full marketing back-up is in place, delivers satisfaction.
The power of Brand is the delivering factor. Brand personality, positioning and
philosophy are so tactfully communicated through communication campaigns, that in
the end consumer just remembers the Brand and all other attributes come to his mind
instantaneously – first step towards creating Brand loyalty.
4.3 Branding and Social Marketing
There is also evidence that branding may be particularly effective way to reach people in
deprived communities. Experts in branding have concluded that the symbolic appeal of
brands is particularly effective in targeting those individuals who do not have the time,
skills and motivation to evaluate the objective attributes and benefits of a particular
campaign. A recent review conducted on behalf of the UK‘s National for Health and
32
Clinical Excellence also suggests that brands can be an effective way of reaching
information-deprived communities. Branding with these communities seems to hold
considerable promise. (Gerald Hastings in Social Marketing: Why should the devil have all the best
tunes?).
In the case of social marketing, the product/service is the health or social behavior you
are promoting or the brand is your organization, with various products that you offer
falling within that brand (e.g., if you are at a local health department with initiatives
addressing different health topics) — if the audience tries doing what you want them to
do but has an awful experience, the brand image suffers. So branding involves
strategically crafting all the elements of your audience‘s interactions with your
organization and its products/services so that they support the right image and evoke
the right emotions.
4.4 Benefits of Establishing a Brand
NTP can receive following benefits by introducing an indigenous brand:
Consistent and distinct visibility of the Programme in all areas and at all levels
Brand will guide all the communication towards a common focal point
The mileage of communication will increase manifold due to its direction
Communication Resources will be put to optimal use
All stakeholders will speak same language that will amplify the message
ACSM will be easy and effective – everything based on a single brand
Brand will facilitate masses to look for information and facilities under one
umbrella
The clear Programme identity created by Brand will generate the demand that
will enable NTP to meet its target
Everyone associated with the Programme will take the ownership of the Brand
and feel proud and motivated
NTP/ACSM will reap the fruits of Brand Equity after initial investment for the
years to come
The Brand equity will make future ACSM initiatives cost effective
5. The Next Step – Strategic Behavior Change Communication (SBC)
& IEEC
Once the Brand and Branding guidelines are ready comes the stage to develop targeted
communication for different audiences. This communication mainly includes Behavior
Change Communication (SBC) and Information & Education Communication.
Behavior Change Communication:
SBC is a process of working with individuals, communities and societies to:
- Develop communication strategies to promote positive behaviors which are
appropriate to their settings; AND
- Provide a supportive environment which will enable people to initiate and
sustain positive behaviors.
33
Information, Education and Communication:
IEC is a process of working with individuals, communities and societies to:
- Develop communication strategies to promote positive behaviors which are
appropriate to their settings.
What is the difference between SBC and IEEC?
Experience has shown that providing people with information and telling them
how they should behave (―teaching‖ them) is not enough to bring about
behavior change. While providing information to help people to make a personal
decision is a necessary part of behavior change, SBC recognizes that behavior is
not only a matter of having information and making a personal choice. Behavior
change also requires a supportive environment. Recalling the interventions
model, we learned that ―behavior change communication‖ is influenced by
―development‖ and ―health services provision‖ and that the individual is
influenced by community and society. Community and society provide the
supportive environment necessary for behavior change. IEC is thus part of SBC
while SBC builds on IEC.
5.1 Role of SBC
For decades Health workers/ professionals have been using Information, Education and
Communication (IEC) process of working with individuals, communities and societies
to promote positive behaviors that are appropriate to their settings. However, this
method usually works on a pattern that the ―Educator-Knows-Best‖. It does not take
into account that different communities would have different culture, traditions, ethos,
convictions, religion and coping mechanisms to deal with different issues and problems.
While people might understand why they need to bring about a certain behavioral
change, this change also requires a supportive environment for Individuals, who would
need the emotional support from the society. Since the society also has the same
traditions and ethos, chances are that the support, an individual requires would not be
available in the society.
Strategic Behavioral Change Communication (SBC) is a process of working with
individuals, communities and societies to develop communication strategies and to
promote positive behaviors that are appropriate to their settings. It is to work with the
ethos, culture, traditions and religious beliefs of the community. It also provides a
supportive environment that will enable people to initiate and sustain positive
behaviors.
It is to develop tailored messages and approaches using a variety of communication
channels to develop positive behaviors; promote and sustain individual, community and
societal behavior change; and maintain appropriate behaviors. SBC is an essential part of
a comprehensive Programme that includes both services (medical, social, psychological
and spiritual) and commodities (e.g., medication, treatments, isolation or
hospitalization).
34
Before individuals and communities can reduce their level of risk or change their
behaviors, they must first understand basic facts about Tuberculosis and adopt key
attitudes, learn a set of skills and be given access to appropriate products and services.
They must also perceive their environment as supporting behavior change and the
maintenance of safe behaviors, as well as supportive of seeking appropriate treatment
for prevention, care and support Development of a supportive environment requires
national and community-wide discussion of myths, risks, behaviors and cultural
practices that may increase the likelihood of Tuberculosis transmission.
A supportive environment is also one that deals, at the national and community levels,
with stigma, fear and discrimination, as well as with policy and law. The same issues
apply in parts of the world where pollution, contamination, lack of awareness and
disinformation forces societies to confront cultural ideals and practices that can
contribute to tuberculosis transmission.
Effective SBC is vital to setting the tone for compassionate and responsible interventions.
It can also produce insight into the broader socioeconomic impacts of the epidemic and
mobilize the political, social and economic responses needed to mount an effective
Programme. Pragmatic SBC approach, based on sound practice and experience, focuses
on building local, regional and national capacity to develop integrated SBC that leads to
positive action by stimulating society-wide discussions.
SBC is both an essential component of each programme area and the glue between the
various areas. However, society-wide change is slow; changes achieved through SBC
will not occur overnight.
5.2 Effective SBC can:
Increase knowledge. SBC can ensure that people are given the basic facts about
Tuberculosis through audio or visual medium (or any other medium that they can
understand and relate to).
Stimulate community dialogue. SBC can encourage community and national discussions
on the basic facts about Tuberculosis and the underlying factors that contribute to the
epidemic, such as risk behaviors and risk settings, environments and cultural practices,
and marginalized practices (such as smoking, gutka and paan) that create these
conditions. It can also stimulate discussion of healthcare-seeking behaviors for
prevention, care and support.
Promote essential attitude change. SBC can lead to appropriate attitudinal changes
about for example, perceived personal risk of TB infection, belief in the right to and
responsibility for safe practices and health supporting services, compassionate and non-
judgmental provision of services, greater open-mindedness concerning gender roles and
increasing the basic rights of those vulnerable to and affected by TB.
35
Reduce stigma and discrimination. Communication about TB prevention, mitigation
should address stigma and discrimination and attempt to influence social responses to
them.
Create a demand for information and services. SBC can spur individuals and
communities to demand information on TB and appropriate services.
Advocate. SBC can lead policymakers and opinion leaders toward effective approaches
to the epidemic.
Promote services for prevention, care and support. SBC can promote appropriate
services, their availability and health care providers to the masses.
6. Target Groups
As well as highlighting the importance of providing overarching communications on
TB/DOTS to the general public, the Communication Strategy emphasizes the need for
more targeted interventions to the following groups:
6.1 Federal Level
Heads of the Government and Political System
Ministry of Health officials
Heads of line ministries and relevant departments
Political leaders through the National Assembly, Cabinet and Senate
National Religious leaders
International agencies including Donors, UN agencies, Rotary etc
Foreign Governments through Embassies
National level NGOs
All IACC partners
Media members
Celebrities and goodwill ambassadors
Medical Associations
Private Sector including corporate sector (pharmaceuticals) and private health
care system
National level philanthropists
Heads of large schools, colleges and universities with emphasis on medical
schools
Health Education Department
6.2 Provincial Level
Heads of the government and political system (Governor, Chief Minister, Chief
Secretary etc)
Ministry of Health officials
Line ministries and department officials
36
Provincial NGOs
Private sector partners including corporate sector (pharmaceuticals etc) and
private health care system
Medical Associations
Media
Religious Groups
Political leaders through provincial assemblies
Provincial celebrities and goodwill ambassadors
Schools, colleges, and universities especially medical schools
Philanthropists
Health Education Department
6.3 District Level
District management team (Nazim, DCO and EDO-H)
Representatives of the government and political system (Nazims at all levels,
Counselors etc)
Department of Health officials
Line Departments including family planning and social welfare
Traditional Judicial systems (jirgas, kacheries etc)
Health care providers
Private practitioners
Hakeems
Homeopaths
Other private practitioners
Doctors
Lady health workers
Volunteers
Local NGOs/CBOs
Media
Private Sector
Local Celebrities
Village committees
Schools and colleges
Community leaders (elders, religious, feudal lords, influentials etc)
Patients with Tuberculosis (TB)
Families of the patients
Middle, middle to lower class communities
Specific cultural and ethnic groups – nomadic, border populations, minorities
Internally displaced populations – urban/settlement populations, homeless,
street children, street communities
37
7. ACSM Programme Management
The success of this strategy depends on the establishment of an effective system to
manage the many technical and commercial aspects of the strategy rollout. Good
governance and best practice in communication Programme management will ensure
the optimum delivery of the strategy. Furthermore, the quality of communication
Programmes and resources developed will depend on the caliber of relationships
established with partners and other service providers. ACSM Steering Committees will
be placed at national level and will meet on quarterly basis. They will have various
responsibilities as highlighted below:
7.1 National Steering Committee
The key activities of the committee will be to:
Monitor national ACSM strategy for TB/DOTS
Identify communication needs with respect to the Programme and the public,
and provide recommendations to address these
To coordinate and update on ACSM activities with other partners
To plan and manage communication research and use findings to develop and
implement strategies for addressing problems and obstacles and for seizing
opportunities
Mobilize international, national and local community resources in support of
communication strategies
38
8. Plan
The communication environment in Pakistan is well resourced with multiple and most
modern media channels available for message dissemination to the nook and corner of the
country. A wide range of media outlets provide penetration into urban, semi-urban and
rural populace. Emerging media like internet, cellular phones and outdoor have
successfully complimented the traditional media of television, radio, print and cinema.
Electronic media has met an unprecedented growth. The recent explosion of satellite TV
channels has revolutionized the society by informing the illiterate. On local level FM radio
is a reality now and every major district has its indigenous radio station that primarily
speaks their language. Print media is still reigning supreme with its credibility and high
shelf life; and new publications are emerging.
Billboards, wall chalking, vehicle branding, POS material, floats, theatre and mobile
cinemas are other effective options for message dissemination through branding.
Thus, a big number has an access to one or the other media tool now. This variety of
available media avenues offers a great opportunity for mass media communication.
However, in order to capitalize on this vital opportunity a comprehensive and well directed
ACSM plan has to be executed that can empower all the stakeholders to achieve the
strategic objectives.
The ACSM plan will revolve around a distinct Brand that will form the theme of all sorts of
communication initiatives of Advocacy, Mass Media and Community Mobilization. The
application of Brand will not only start creating a recall but will also develop Brand loyalty
among the masses about the DOTS. The cost effectiveness of Branded campaigns will
enable the programme to better utilize its resources for a multitude of initiatives.
The communication built on the Branded theme will not only provide an effective platform
to advocate with the influencers, opinion leaders, peers and religious leaders but will also
lend a direction to all the community based activities like workshops, theatres, fairs, etc.
This plan encompasses advocacy, communication and social mobilization that form the
ACSM.
39
Advocacy
40
8.1 Advocacy
Advocacy focuses on gaining and maintaining the support of and motivates decision-
makers, opinion leaders, stakeholders and policy influencers. Media is also a vital target
audience that is advocated with to gain support to address various communication
needs. Public Relations and lobbying is the most important tool used for advocacy all
over the world.
Traditional advocacy activities include meetings, presentations, workshops, visits,
events, etc. Development of information packages is also a tool of advocacy.
8.1.1 Federal (National) Level Advocacy
Following can be addressed by advocacy at the federal level:
Positioning of NTP as an Opportunity for Leadership to take Credit of
Response of Government/Health Authorities to Protect the Public
Budgetary Implications of Epidemic
Change of Public Opinion
The Liabilities of Inaction
Feasibility of Integrating Strategy with Existing Initiatives
Sustainability of Project
Common Agendas and Shared Visions
News Value and Timing
Information/Success Sharing
Opportunities to Use New Research and Innovations
The activities that can be used to achieve the above:
High Level Interactions – Meetings/Briefings
Putting TB-DOTS on the agenda at different forums like Senate, National
Assembly (internally) and SAARC, OIC, etc (externally)
Public Relations activities like Press Engagements, Media Orientation
Workshops, Journalist Call-ons/ Briefings, Press Conferences
Publication of News Releases, Feature Stories, Opinion Pieces, Editorials, Photo,
Interviews with Media, Discussions Programmes, Talk Shows, etc.
Workshops
Literature Development (Advocacy Kits, FAQs, Programme Updates), Letters,
CDs, Newsletters, Brochures, etc.
Videos Documentaries
Events like Seminars, Presentations, Press Forums, etc.
Merchandise/Giveaways e.g. Diaries, Planners, Calendars, Notebooks, T-shirts,
Caps, etc.
Morale Building/Recognition Initiatives like Media Awards, etc.
41
8.1.2 Provincial Level Advocacy
The potential concerns and target population categories for advocacy at the provincial
level are similar to the Federal level. The President and Prime Ministers will be replaced
with Governors, Chief Ministers and Chief Secretaries. The activities that can be used to
conduct advocacy at the provincial level are the same as well. At this level the focus is
going to be at provincial level influencers, decision makers, opinion leaders and media.
8.1.3 District/Community Level Advocacy
As with the provincial level the concerns can be addressed through advocacy at the
district/community level with their ownership and hence concrete positive action for
TB/DOTS can be expected. The activities that can be used for this purpose are the same
as for the federal and provincial level. However, some specific district/community level
activities would include organizing engagements with District Councils, District
Management, addressing open meetings (jalsas), public debates and using traditional
judicial meetings like kacheries, jirgas, village health committee meetings and
partnership committee meetings to advocate. PR with local media can play a vital role in
furthering the cause. FM channels and local language newspapers can be utilized to
create awareness amongst the masses and advocate with the local decision makers.
It has been noted that at the grass root level (UC Council level) community meetings,
especially the ―Peer Education‖ meetings are extremely beneficial for advocacy and
mobilizing the community. Following is a detail explanation of the mechanics of the
activity and is strongly suggested as an activity to take place at the grass root level.
8.1.4 “Peer Education” Meetings
Lessons learned from peer education meetings conducted in other developing nations
have shown that peer education can increase understanding, ownership and
involvement with issues like TB. Peer-led communication meetings ensure that
messages disseminated are more credible, and more likely to be heard and acted upon
by other peers. Moderators must be well trained and supported by appropriate
communication resources. Supporting resources could include publications, flip charts,
audio-visuals. At the grass root level two parallel core groups are formed – one for the
women and one for the men. The men‘s group consists of:
The Pesh Imam
The UC Councilor
Social Worker/volunteers
Tribal/Feudal Leader
Teacher
And/or any other influential person
The women‘s group will consists of:
The Pesh Imam‘s Wife
Lady Councilor
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Social Worker
Lady Health Worker
Nurses
Wife of Tribal/Feudal Leader
Lady Teacher
And/or any other influential person
43
Communication
44
8.2 Communication
Communication helps to create a general awareness and knowledge about an issue.
Over a period of time it also creates a mind frame (opinion) that is ripe for change in
behavior. Communication also supports the advocacy and social mobilization
approaches. This approach consists of two main components: Mass Media and IEC.
These two combined provide a vast range communication tools. The messages and
material is to be developed and produced at the federal level with the province adding
to the developed messages to make them culturally appropriate, localized and more
focused to local audiences.
8.2.1 Mass Media
Media research in Pakistan indicates that radio, television and print media coverage is
significant throughout the country. Therefore, these media can be a powerful force for
raising awareness, building knowledge and influencing public opinion. Research should
be conducted before media planning to ensure that these media channels are utilized in
a cost effective manner to achieve an optimum result of message dissemination to the
selected target audiences. The frequency of intervention should be such that messages
reach all the varied audiences at different time bands alike. It is also important to make
messages coherent by linking them to a ‗branding strategy‘. This can include the use of
visual devices or repeated slogans tiered from campaigns.
8.2.1.1 Radio
Radio has the greatest reach to peri-urban and rural population groups,
especially through the Pakistan Broadcasting Corporation, which broadcasts
nationally. FM Radios have seen a phenomenal growth with their number
crossing 50. These channels present an effective opportunity to talk to masses on
local level.
Proposed Activities:
Radio Ads
Public Service Messages
Branded Songs
Celebrity/RJ Endorsements
Infomercials
Talk Shows
Trivia on TB/DOTS
Thematic Consumers Promotions/Participations
8.2.1.2 Television
According to the Gallup survey there is around 70 – 80 % of coverage of
television in Pakistan. Even those who do not own TV sets have access to
television through communal, institutional or family sets. Television is the best
45
tool to talk to a vast variety of audiences spread over Pakistan especially the
illiterate. Television can provide the greatest impact through the depiction of
thematic campaigns and can assist in stimulating masses to learn about
TB/DOTS.
Proposed Activities:
TV Ads
Syndicated Programming (Issue Based Dramas, etc.)
Public Service Messages
Day Brandings
Road Shows
Branded Songs
Celebrity/RJ Endorsements
Infomercials
Talk Shows
Trivia on TB/DOTS
8.2.1.3 Newsprint
Print media is widespread across Pakistan with several major national papers
distributed in English and Urdu. Regional language newspapers also have
effective following in Sind and NWFP. There are also a number of women and
family magazines. Print media provides communication opportunities through
‗long copy, ‘informational approaches and news stories generated through
advocacy activities. Although access to daily newspapers in rural areas drops off
rapidly in the more remote the area, print is an important medium for opinion
leaders, with readership far exceeding circulation.
Proposed Activities:
Pres Ads
News Items
Features
Photographs
Articles
Columns
Forums
Interviews
Special Supplements
8.2.2 Outdoor Advertising & Below the Line Activities
Outdoor advertising and below the line advertising can enhance the campaign ability
factor, recall and longevity as it is accessible to large numbers of people in rural and
urban areas. Use of these tools is imperative to expand the spread of key messages of
TB/DOTS to diverse publics.
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Proposed Items:
Outdoor Displays (Hoardings, Bus Stops, etc.)
Branding of TB Facilities
Vehicle Branding/Mobiles
City Branding on Special Occasions
Floats
Banners
Streamers
Expo Stalls
Mela Kiosks
8.2.3 Information, Education and Communication Material
Information, Education and Communication material is not only a tool in itself, but also
serves as direct support for trainings, advocacy and social mobilization activities. A
range of core publication resources is required to explain the complex issue of TB.
Proposed Items:
Brochures & Booklets
Pamphlets, Flyers & Stickers
Posters
Calendars
8.2.4 Internet
This new media option has opened avenues to spread any message to a more focused
group of literate and empowered audience.
Proposed Items:
Website
Banners
Bulk Emails
8.2.5 Cellular
In Pakistan one of the most recent new media is mobile phone. This personal device has
virtually provided a novel way to reach individuals through short messages:
Proposed Use of SMSs:
TB Messages
Publicity of other Communication Initiatives like Dramas, Talk Shows and
Events
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8.2.6 Branding Opportunities
NTP can create partnerships with public and private sector organizations to disseminate
its messages through branding.
Proposed Avenues:
PIA Aircrafts
Railcars
Joint Branding Initiatives with Corporate/Commercial Sector e.g. Outdoor Sites
Packaging of TB Medicines
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Social Mobilization
49
8.3 Social Mobilization
Social Mobilization is a community based approach. It focuses on the districts, tehsil and
union council level interventions, hoping to target each individual through IPC and
community mobilization activities. It is the process of bringing together all feasible and
practical inter-sectoral social allies to raise people's awareness of and demand for a
particular development Programme, to assist in the delivery of resources and services
and to strengthen community participation for sustainability and self-reliance. Pakistan
has a culture steeped in oral tradition, with the large rural sector, in particular, having a
strong reliance on dialogue-oriented and participatory approaches to communication.
Key to the success of controlling TB is to build the momentum for change at a provincial
and community level. A range of different social mobilization tools can be used,
including traditional community theatre, folk media, art and other performance
festivals. These communication forms make use of idiomatic expressions, which vary
from one ethnic community to another and are the basis for communication within and
across generational and community leadership structures. Following are a few strongly
recommended social mobilization activities:
8.3.1 Theatre
Theater is a strong part of the culture in Punjab, Sind and some areas of Baluchistan and
NWFP. This medium has traditionally carried messages of morality, values and social
well being. With this experience theater performances based on creating awareness
about TB/DOTS will be executed throughout Pakistan.
8.3.2 Walks
Walks are a great tool to mobilize a community for a social cause. Individuals from all
fields of life participate for one cause with one voice to show their support. This activity
is used frequently for mobilizing societies and as a means of generating media attention.
8.3.3 Melas, Folk Shows, Cultural events
One of the most cost effective and useful way is to use existing events like melas, folk
shows, and religious gatherings to disseminate information about TBDOTS. The
community is already gathered at the venue, they only need to be mobilized for the
cause of TB-DOTS. Stalls can be put up and/or announcements can be made, or below
the line advertising and IEC material can be distributed to impart information.
8.3.4 Health Stalls and Kiosks
Stalls/kiosks for TB –DOTS carrying advocacy kits, IEC and Point of Sale (POS) material
can be set up at key venues like markets, bus stops, train stations, airports, private
clinics and any other venues that are frequently visited by the target population. The
stalls can be short term, while kiosks can stay in shops, pharmacies etc for a long period
50
of time, allowing access to a larger number of individuals. This is a great way to create
awareness and increase knowledge about TB at the grass root level.
8.3.5 Mobile Cinema, Puppet Shows and Floats
Although the use of mobile cinema, puppet shows and floats for a social cause has been
limited in Pakistan but in an environment that is hungry for entertainment; dramas,
documentaries and advertisements presented through mobile cinema technology can
entertain as well as stimulate community dialogue on TB/DOTS issues in rural areas.
An essential aspect of this activity is the careful design and development of content, as
messages are disseminated to a diverse range of population groups. This strategy when
combined with a range of other community activities and service delivery can be
effective in supporting the behavior change process.
8.3.6 Communication with Children through Debates, Competitions, etc.
Schools provide a great opportunity for the development of moral values since children
are in their formative years. They are more readily able to absorb information on TB and
to adopt safer attitudes and also take the information home to their families. Schools
provide many opportunities for accurate and comprehensive TB-DOTS education,
behavior development and values formation. Activities like debates, speech
competitions, poster competitions, assembly announcements, identification of TB
patients greatly mobilize this community for the cause of TB-DOTS.
8.3.7 Partnership
A critical component of the successful implementation of this strategy is management
and coordination through a multi-sectoral response to the TB control. A sectoral
approach also provides due recognition of the increased mobilization power of various
sectors and communities in a partnership for TB control and promotion of DOTS.
Partners could include the faith-based sector, schools, public and private sectors
including workplaces, the media, and corporate sector, among others. Some key
partnership activities are as follows:
8.3.7.1 Sponsorship
Sponsorship provides a mechanism to create community rallying points for
specific themes of the strategy. Sponsorship events could include school music
and drama festivals, music concerts, sports such as football, athletics, and
basketball.
8.3.7.2 Volunteers for Social Mobilization Activities
Realizing that communicating with a population of 160 million is no little task
and cannot be conducted by the NTP staff alone, it is important to take on board
volunteers at all levels to work in communications for TB-DOTS. There is no pre-
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requisite for recruiting volunteers, except that they can give adequate time for
the activities they are volunteering for and can stay for the full length of time
they are required for. After selection it is important to build their capacity for
them to be able to conduct their activities efficiently.
8.3.7.3 Communication Resource and Distribution
Resource material for communication includes material developed by the
communication committees, for example IEC material, advocacy kits, mass
media messages etc. and material received by other relevant agencies, for
example communication guidelines developed by WHO, global updates etc. IT is
important that all resource material is readily available at all levels for reference
and onward use.
9. Capacity Building
In order for the communication activities to run smoothly and also to ensure high
quality and adequate monitoring and supervision, it is essential that the capacity of all
the key players in TB-DOTS communication should be increased with respect to
development communications in general and the TB-DOTS strategy in particular.
10. Research and Analysis
To develop an effective communication and consequently a work plan, it is important to
conduct KAP studies, impact analysis and pre-and post tests among other research tools.
This activity needs to be conducted at all levels and at regular intervals, preferably
biannually. It is also important to revise the communication approaches according to the
results received from these researches.
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Section D- Operational Guidelines and Process
Management of ACSM Field Interventions
53
Introduction
The National ACSM Strategy follows a standardized, step-by-step process involving
assessment of current behaviors and factors that are barriers or incentives to people
practicing them, propose key behaviors for change, and work with individuals,
households, communities, health systems, and policymakers to develop effective,
feasible ACSM interventions aimed explicitly at these factors.
This section of the document is intended to provide guidelines to carry out standardized
ACSM activities in communities for effective Tuberculosis (TB) control. It will provide
essential knowledge and tools in implementing ACSM activities during the interim
period, until the NTP finalizes the National ACSM Strategy and develops workplans for
adaptation at the national, provincial and district level.
This document includes definitions of key terms and sets out the key principles
underpinning activity implementation, while it also includes activity-specific sections
specifically tailored with Round 6 requirements, with summary tables providing details
of each of field activity to be implemented by partners for the achievement of objective 3:
i.e. Empowering People and Communities with Tuberculosis.
This document is primarily intended for the staff of Round 6 partners to assist them to
plan, organize and supervise ACSM activities in their respective districts. Because
tackling TB requires commitment and work at all levels, these guidelines can also be
used by TB control staff at the district and provincial levels; by nongovernmental
organizations (NGOs) and others involved in TB control, including communications
officers, programme supervisors, doctors, nurses, health educators and ACSM trainers.
The guidelines provided in this document need to be followed by partners in
implementing ACSM activities to support of TB control, however decisions on the most
appropriate ACSM activities and how to implement need to be taken according to the
specific situations and demands of TB-affected communities within the 57 districts and
their respective implementing partners. While the precise combination of activities
needs to be determined by every partner at their individual level, this document has
one prime objective – to guide and support the planning and implementation of
standardized and effective advocacy, communication and social mobilization activities
in TB control at the district level.
1. TB Control in Pakistan
In developing countries like Pakistan, many factors can influence the demand and
supply of services for TB diagnosis and treatment; these may be social, cultural,
behavioral, epidemiological, economic, and political. Other critical factors affecting
demand and use of services include: multidrug-resistant TB (MDR-TB), HIV/AIDS,
stigma and discrimination, gender inequality, population displacement and mobility,
and changing communication environments.
Use of communication and social mobilization strategies is increasingly acknowledged
54
as necessary to encourage and support at-risk populations who have a cough for more
than three weeks to seek treatment; and to adopt other health-seeking behaviors related
to TB.
The link between lack of communication and poor case detection has been repeatedly
demonstrated. It is recognized that the patients with low knowledge about the
symptoms of TB are more likely to postpone seeking care and getting tested.
Communication is also seen as having an important role in improving treatment
adherence. ACSM strategies ensuring patient education, combined with broader
community support and empowerment initiatives, are essential if cure rates are to
improve and be sustained.
2. Stigma, Discrimination and Gender Inequality
Stigma has been defined as ―an attribute that is significantly discrediting‖ and ―an
attribute used to set the affected person or groups apart from the normalized social
order, and this separation implies devaluation‖. Stigmatization therefore describes the
process of devaluation within a particular culture or setting, where certain attributes are
seized upon and defined as discreditable or not worthy.
Stigma and discrimination associated with TB are among the greatest barriers to
preventing further infections, providing adequate 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 care providers are often a source of stigmatizing behaviors through
their inappropriate treatment of people with TB; prison staff may deny health services to
a person with TB; employers may terminate a worker‘s employment on the grounds of
his or her actual or presumed TB status. Young girls may find it difficult to get married
because of their TB status and married women may face divorce on account of having
TB. Such acts constitute discrimination based on presumed or actual TB status.
Lack of access to appropriate diagnosis and treatment of TB is a key issue that leads to
TB-related stigma and discrimination. The perceived ―untreatability‖ of TB is a key
factor contributing to the stigmatization of many of those affected. This also gives rise to
fear, lack of knowledge, and misconceptions that are often deep-rooted.
Stigma particularly affects women because social pressures and status often make them
especially vulnerable to marginalization and discrimination with the consequences of
contracting TB sometimes leading to divorce, desertion and separation from their
children.
Stigma as a ―disease of the poor‖ also persists and has been compounded more recently
by the link with HIV/AIDS. TB patients with HIV suffer a double stigma.
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Any ACSM strategy designed to confront these issues has to focus on social as well as
individual behavioral challenges. ACSM Programmes are essential in empowering
people with or affected by TB to take community action to confront stigma, and to
educate broader communities to reduce stigma. Any communication strategy designed
to combat TB needs to support both a process of social change in society to tackle stigma
and marginalization of people with TB, and a process of behavioral change designed to
persuade people to seek treatment.
3. How is ACSM Essential to the Stop TB STRATEGY?
The Stop TB Global Strategy, launched by the Stop TB Partnership in January 2006, has
six major goals, which are
1) To pursue high-quality expansion and enhancement of directly observed
treatment (DOTS) – short course
2) To address the co-occurrence of TB and HIV, multi drug-resistant TB (MDR-TB)
and other challenges
3) To contribute to strengthening of health systems
4) To engage all caregivers
5) To empower people suffering from TB and their communities
6) To enable and promote research
3.1 Empowering People and Communities Affected by TB
ACSM Programmes also need to ensure inclusion of people most affected by TB in the
design, planning and implementation of TB control strategies. In case HIV/AIDS, it has
been learnt that the greater the inclusion of those affected in the developing and
implementing the response to the disease, the greater the impact such responses are
likely to achieve and sustain.
4. Effective ACSM Interventions
The most important lesson learnt is that ACSM strategies are most effective when their
design is led by and appropriate to local processes and experiences. In other words, they
are effective when ACSM programming fully and broadly engages a larger number of
stakeholders, NGOs, patients and their families. ACSM activities can be used to achieve
all six goals. Although distinct from one another, advocacy, communication, and social
mobilization (ACSM) are most effective when used together. ACSM activities should
therefore be developed in parallel and not separately.
Linking ACSM goals with activities strengthens overall Programme effectiveness.
Several ACSM approaches can be considered for TB. Decisions on which approach or
combination of approaches to use should take into account the benefits and risks, the
time frame and the expertise and also by matching it requirements by the Global Fund,
the Principal Recipient and the National Strategy adopted by NTP.
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5. Assigning Roles, Responsibilities and Coordinating Activities
As part of determining roles and responsibilities of all the partners, and within the
teams of an organization; partners need to draw up a table to show the roles and
responsibilities assigned, and then ensure that everyone involved in the activity has
access to it and agrees to their respective assignments. Similarly such details can also be
shared in partner coordination meetings with the principal recipient to avoid
duplication.
6. Setting and following Realistic Timelines
There is a need to allocate time wisely when planning for ACSM activities. Create a
workplan which has a timeline with realistic expectations. Consider the preparatory
activities that need to be addressed first, and then identify the subsequent sequence of
activities involved. Estimate how long each activity will take.
Many factors can accelerate or slow down ACSM activities and must be considered
when creating a timeline. Some factors might include the uncertain schedules of district
health authorities or their unavailability, delays with producing and printing materials,
holidays or other observances, weather constraints, unexpected illnesses among key
personnel, and political transitions or civil society unrest as we may be expected in
preparation for the ACSM activities. (Checklist for sample workplan is attached in
Annex 1).
7. Developing ACSM Messages and Concepts
7.1 Consistency of Messages
The TB messages disseminated should be consistent and relevant across all channels and
activities. The more the messages reinforce each other across channels, the better the
results will be. Consistency makes the ACSM strategy effective – for example, ensure
that the health-care provider, the community mobilizer and the radio announcement all
give the same key information. This does not mean creating only one message for
everything. It means, rather, identifying key points that every message should convey,
no matter how it is communicated. This can be done by targeting messages
appropriately and considering appropriate logos, slogans and other creative aspects.
7.2 Targeting Messages Appropriately
Messages must be relevant to the various groups they target. Each group may have a
different level of knowledge of TB so target messages according to their respective level.
Messages should address the action or change that the intended audience is ready to
make – for example, a message to people who have never heard of DOTS should not
encourage them to start treatment immediately. It should rather focus on raising the
awareness of DOTS with the aim of moving the group toward getting treated.
57
Even if a group is motivated by a message, other factors may limit their ability to adopt
the proposed behavior or take the recommended action. For example, at-risk individuals
might not seek testing or treatment because they are afraid of being stigmatized by their
communities.
Accurate and clear messages are the most credible. Messages should be simple and
contain very few, if any, scientific terms. Include only information that is necessary for
priority groups to take the desired actions or decisions. Do not include information on
disease physiology, research debates or sponsoring organizations as this may be
complicated for the target population. Spoken messages need to address the target
audience while using clear, simple language, control and vary your voice‘s volume,
pitch, inflection, and speed. Talk about the subject in an interesting way, trying not to
quote too many facts and figures. Use interesting and clear slides and overheads if
possible; with statements of cured TB patients.
Consider the written and visual literacy levels of the target audience. Many people
cannot understand health materials written in technical language, particularly if their
literacy skills are low. Make specific choices on the writing style, vocabulary,
typography, layout, graphics and colors. These choices affect whether the message is
read and how well people with varying degrees of literacy will understand it.
Key messages ( used to date by national and international campaigns)
TB is a curable disease
How is tuberculosis spread
What are the symptoms of tuberculosis
How is TB detected
How is TB treated
Why is controlling TB necessary
Information neighboring diagnostic and treatment centers
8. Developing ACSM materials
8.1 Understanding the Cycle of Developing Materials
Efforts should be made to develop initial drafts of materials and pre-testing to ensure
that the messages are effective and reflect strategic guidelines. Pre-testing allows
partners to learn early in the process which messages, products or activities will be most
effective with the intended population. Knowing this will save time and money as it will
ensure that ineffective products are not mass produced and distributed.
This further helps to ensure that people understand the messages in the materials and
that the intended population draws the desired interpretations. Pre-testing also offers an
important opportunity for communities and other sub recipient groups at the district
level to become involved in the ACSM process early on and to share what they believe
will work or not work. Communities or individuals affected by TB should be brought
58
into the process even earlier to help create the materials. Staff and partners with
technical expertise should also be consulted to ensure that all scientific and technical
information is correct.
However while pre-testing can improve the effectiveness of materials, there is no
guarantee that activities and supporting materials will achieve their intended goals. Pre-
testing can provide an indication of the strengths and weaknesses of materials, but it
cannot definitively determine activities
8.2 Identifying Materials Needed for Different Activities
Several different types of materials can be developed to support ACSM activities.
Selecting channels that will be effective in reaching intended populations is important.
Leaflets placed in clinic waiting rooms, for example, will not encourage more people to
go to clinics to get diagnosed and treated for TB. Place materials for intended
populations in locations where the target audience normally goes, such as markets, bus
stations, train stations, taxi and truck parks, schools, places of worship (Masjids),
workplaces, community buildings where meetings are held, and in front of the homes of
village elders or other places where people gather informally.
The material developed for religious leaders must directly address any cultural
constraints and false beliefs , and will be in the form of fact sheets and presentations;
teachers can be involved in school base interactive/informative activities etc.
community groups need messages about symptoms of TB, how TB can be cured, and
when and where services are available free of charge. When developing messages for a
specific person or group, keep in mind that the message is technically sound and should
focus on written messages by using clear, simple language that is not condescending
but is free of medical terms and jargon, while still technically accurate. Choose the most
important message and repeat them. If possible Use pictures, bold headings, and
photographs; these will be remembered; whereas lengthy text and details will soon be
forgotten.
8.3 Selecting Appropriate Materials
Development and production of materials can be time consuming and costly and
although this activity is adequately funded for the national stakeholder; i.e. NTP, the
programme partners can before taking this step, determine whether new materials are
necessary and make use of alternate options.
Communication materials such as booklets, leaflets, posters, public service
announcements and videotapes may already exist; as some have already been produced
by NTP from previous Rounds. This can be checked for existing materials through the
ministry of health, NTP, WHO, or trusted Internet sites such as Stop TB Partnership.
However when such material is made available, decide whether are useful as they are or
whether they need to be modified according to ACSM activity design.
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In reviewing any existing materials, the following questions needs to be kept in mind:
Are the messages accurate, current, complete, and relevant?
Are the format, style, cultural considerations and readability level appropriate for
the targeted audience? If not, could they be modified easily?
Will the materials meet the communication objectives?
Pre-testing can help answer some of these questions. If possible, check each item
with the group that originally produced it to find out
Results of any pre-testing (be sure to ask which groups the materials were pre-tested
with)
Effectiveness of the materials to date
Any advice or recommendations related to the Programme‘s ACSM needs.
In deciding whether to use existing materials, ask the original producers several
questions.
Are the materials available?
Can the NTP/partners have permission to use the materials? Modify them? Would
reprinting be easy?
Are they affordable?
How have they been used?
How have they been received?
Is there any information about their effectiveness?
8.4 Materials and their Specific Activities
1. For meetings with policy makers (e.g. meetings with law makers to advocate for
increased TB funding, the following material can be used)
Fact sheets
Presentations, other visual aids such as slides, photos, posters
Letters
Briefs that summarize data
Letters to the editor
Opinion-editorial write-ups
Press releases
Public service announcements, live-read scripts/ announcements
Summaries of key findings, articles (and authors)
2. For outreach to media (e.g. to promote World TB Day, awareness campaign)
Informational booklets, leaflets/flyers, posters
Radio and television spots (live-read scripts or produced public service
advertisements)
3 For public awareness activities (e.g. increase awareness/reduce misconceptions
about TB, reduce stigma)
Training modules
Fact sheets
Leaflets
Flip charts/flannel boards
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Instructional posters/wall paintings/job aids
Videotapes
4 Peer education and training (e.g. for health care workers and communities to
identify TB cases, provide the proper care/treatment)
Presentation slides or other visual aids such as photos
Displays (including posters, photographs, real objects, models)
5 Presentations at seminars or other gatherings (e.g. with decision makers or health
care professionals)
9. Start-up Activities
Start-up activities need to be planned so as to introduce the project objectives in a
manner which clearly lays emphasis on long-term sustainable partners; the communities
and the government/district health authorities.
Outreach to the public can be a major part of launching ACSM campaigns or activities.
Many organizations can hold a ―kick-off event‖ to introduce their activities to the media
and the community. This can be a press conference or any other event that spotlights the
TB situation and Programme and motivates public commitment from district and
regional authorities.
The events could include activities such as a walk or parade, health fair, an expert panel
discussion including people living with TB, a concert/entertainment event disease-
screening event or a celebrity appearance. The event should meet three criteria:
It must attract members of the priority populations
It must communicate key messages
It must be considered sufficiently newsworthy by the media for it to be covered
Planners should decide in advance which media outlets to target – regional or district
outlets, television, cable or radio. Designate one group or a person and a back-up to
address and respond to potential questions from partners and communities. This
person, in most cases the regional coordinator, can serve as the Programme‘s
spokesperson. He/she should be prepared to respond as needed and should ideally
have some training in media relations that offers guidance on how to effectively
communicate with journalists and other members of the news media. Skills in media
relations can also help in talking to journalists, to interest them in covering the events
and perhaps even becoming partners or advocates of the cause. All calls or
communications that require any type of public comment should be directed to this
person. Create talking points to help the spokesperson(s) to explain to the media and
others who might ask questions about why the activity is taking place (for details see
annexure 3: Worksheet for a creative/ strategic brief).
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Talking points can include other information such as:
Facts about TB, including local statistics
How the Programme is addressing the problem
Why these approaches have been chosen
Responses to foreseeable objections to activities and interventions
If there is news coverage, planners should be prepared to provide follow-up
information; if the coverage conveys anything incorrect or misleading, they need to talk
to the media and clarify any misconceptions. Even if there is no follow-up to provide or
misconceptions to clarify, it is still advisable to contact the reporters covering the event
and thank them for their interest. This helps to build a relationship with the media that
can continue to be useful in promoting the Programme‘s activities. Distributing
materials is another key aspect of such events.
10. Planning an Important Event - World TB Day
World TB Day is a valuable opportunity to raise awareness of the prevalence and impact of TB –
as well as the state of TB prevention and control efforts – at the national, regional and local levels.
10.1 Reasons for Holding an Event
To highlight achievements of the NTP
To obtain additional political commitment
To mobilize new partners to address TB in their work
To increase the demand for TB services (diagnosis and treatment)
To attract media attention (television, radio, newspaper) to increase understanding
of TB in the general public, and increase commitment from local leaders and
politicians to support TB control activities
10.2 Planning Steps
1. Set up a World TB Day planning committee that includes partners, organizations
and other motivated people (e.g., NGOs, student groups, religious groups, media,
medical associations, and networks of people living with TB, women‘s groups,
HIV/AIDS organizations and Programmes). Hold regular meetings of the
committee, keep minutes of the proceedings and distribute them widely after each
session
2. Consider mobilizing external resources by involving influential private industry or
businesses
3. Determine interesting and relevant activities
4. Determine what each member of the planning committee can contribute and assign
tasks and responsibilities
5. Set deadlines for accomplishing the various tasks
6. Make provisions to assess the impact of the event
7. Collect information to build a case for supporting TB control
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8. Transform statistics into key messages and stories to state the extent and effects of
the problem; share success stories about what can be done to address the problem;
and provide human interest examples that document the impact of TB on the
individual
9. Design activities and events that will mobilize partners for action (forums, seminars,
courses, parades, competitions, street events and other ―infotainment‖ events)
10. Organize media events to make news (such as a press conference with politicians or
other leaders e.g. to highlight the opening of a new DOTS centre)
11. Prepare speeches, fact sheets, video, and other visual materials with statistics and
key messages
12. Assess the event afterwards and compile the lessons learnt
13. Organize a ―thank you‖ event for members of the planning committee to build on
successes
11. Key Components of the ACSM Strategy
Advocacy, Communication and Social Mobilization (ACSM) is recognized as a critical
gap in TB control efforts. This is essential for TB control efforts as it will contribute to
enhanced case detection and adherence to treatment by increasing service demand. The
Principal Recipient and partners are well aware of the importance to ensure a strategic
and standardized approach of ACSM in improving TB awareness in communities.
The scope of ACSM interventions remains nationwide, however, the key components for
Round 6 targets people with TB and communities; to include effective ACSM focused at
the community and large scale media awareness campaigns to facilitate ongoing
activities in social mobilization and advocacy in 57 selected districts of the country. The
districts selected cover hard to reach areas and were not part of previous ACSM
interventions.
In order to achieve this, a national ACSM Steering committee, comprised of the Principal
Recipient, NTP and other Programme implementation partners, will be established to
finalize the national TB ACSM strategy and coordinate and scale up the wide range of
ACSM activities around the country.
12. Planned Activities
The main activities under this objective include establishing a national ACSM Steering
committee, finalizing the national TB ACSM strategy, coordinating and scaling up the
wide range of ACSM activities around the country (including community-based events,
social marketing campaigns, public and media advocacy and social mobilization). The
capacity of the NTP‘s ACSM unit will be enhanced through technical support and
trainings.
The following activities have been specifically designed to be implemented in a more
efficient and strategic way through the involvement of partners. The guidelines given
below in the respective outline provide the approach towards implementing these
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ACSM activities; Partners are encouraged to implement the most appropriate ACSM
strategies and ways to implement these activities need to be taken according to the
specific situations and demands of TB-affected communities within their geographical
districts
The specific interventions related to TGF Round 6 will be conducted by eight partners
namely: Pakistan Anti TB Association (PATA-15 districts); Mercy Corps (MC-11
districts); Bridge (7 districts); Integrated Health Services (IHS will implement school
awareness Programme in 10 districts covered by other partners); Basic Development
Needs (BDN-8 districts); Association of Community Development (ACD-6 districts/
Agencies of FATA); Aga Khan Foundation Pakistan (AKFP-5 districts); and Association
for Social Development (ASD-5 districts) in social mobilization and advocacy in 57
selected districts of the country while strengthening NTP capacity to i) take the lead in
finalization of a coherent ACSM strategy, ii) design of standardized protocols,
frameworks and resource material for social mobilization to be carried out the partners
and iii) implementation of national social marketing campaigns; details of which are
given below.
12.1 Institutional Strengthening and Capacity Building
NTP‘s institutional capacity will be enhanced to manage and coordinate a large scale
ACSM Programme, by recruiting more technical staff to manage the coordination of the
wide range of activities conducted by Programme partners. NTP will also provide
technical assistance to ACSM partners in order to build capacity for the development of
effective interventions and scaling up of activities. This will support capacity building
through training and human resources support.
12.2 ACSM Steering Committee
In order to improve current programming efforts and enhance partnerships, a more
strategic approach to ACSM Programme design, implementation and evaluation will be
employed; this would include a national ACSM Steering Committee comprising of NTP
and Programme partners to coordinate and scale up the wide range of ACSM activities
around the country.
The Steering Committee will finalize the national TB ACSM strategy, which is being
developed, and coordinate its implementation. Coordination activities will include the
wide range of ACSM community based responses as well as planning of national Social
Marketing Campaigns to raise awareness and set agendas for TB Control around the
country. The Steering Committee will also be involved in coordinating the provincial
and district level implementation of the ACSM Programme.
12.3 Formative Research
In early 2008, National TB Control Programme redefined research agenda and in
addition to qualitative research; quantitative component was added to guide both
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messages development and audience segmentation. The National Knowledge, Attitude,
Practices (KAP) Survey for Tuberculosis will be the first comprehensive baseline survey.
A formative research with campaign target groups will be carried out to develop and
pre-test creative concepts to ensure cultural appropriateness and impact. Designed to
specifically gather information about TB, what the respondents know about TB, what
they think about the disease, the health system response to TB and what they actually do
in regard to seeking care and service delivery. The data collected is thus essential to
plan, implement and evaluate the ACSM work, firstly by addressing the needs,
problems and barriers in programme delivery as well as providing solutions for
improving quality and accessibility of services.
For Programme managers and ACSM coordinators, this would mean that the research
will provide fundamental information needed to make strategic refinements by
identifying partner specific needs, estimating resources allocated for various activities
and selecting the most effective channels of communication.
12.4 Social Marketing Campaigns
Private sector partners will be contracted to support the planning and implementation of
national, social marketing campaigns and disseminate materials. The large-scale social
marketing campaigns including – television, radio, print and outdoor media will be
used to support community-based Programmes and service delivery. RFPs for media
agency, PR firm and Formative research to be advertised in newspapers.
12.5 ACSM Information and Communication Resource Center
A national level resource center will be developed along with a Logistics Management
Information System (LMIS) by NTP to ensure efficient distribution of ACSM resource
materials to provinces and Programme partners. This will include design, production
and dissemination toolkits, flip charts, posters and merchandise, T-shirts, caps and
stickers for different ACSM events and activities.
12.6 Community Based ACSM Events
A variety of community events such as theater, dance, music, drama, Mehfil-e-Meelad
etc will be held to support advocacy and social mobilization through interpersonal and
dialogue based approach. Community feedback indicates continuing high levels of
stigma and poor efficacy, especially among the high risk and low income groups; thus
justifying the demand for more intensive and large scale strategic communication
activities which will be implemented at the district level. The events aim at increasing
the number of suspects to diagnostic centers and additionally this would increase KAP
of community and enhance the trust of communities in the DOTS Programme.
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Table 1: Outline for Conducting /Establishing Community Events
Name of the Activity
Community Events
Resource and Material
Requirement
Banners, camera, IEC material, stationery, activity check list,
attendance Sheet
Resource person i.e. theater team /musical group/any other
celebrity or community fair participants
Methodology of Activity.
Raising awareness tactics will be used on health issues specific
to TB, promoting the DOTs treatment with the community
through interactive means using entertaining sessions of
music, concert or community fairs
Activity Strategy
The event must be realistically planned, allowing enough time
for programmatic and financial requirements.
In preparation for holding the community event ,the
Community Mobilization team will visit the area and find a
suitable venue for community gathering; this must be within
easy approach and access of the target community
The criteria for choosing the venue will be based on nearest
weak diagnostic centre or hard to reach area, which usually
has limited KAP representation within the target population.
The team will decide in advance the appropriateness of event;
whether the timing and circumstances are feasible to hold a
theatre /Musical Programme or any other community event
The Programme will be organized in a well-spaced and secure
area, which can cater to a large number of community
members. Invitations will be done through announcements
and involvement of community coalitions
Resource person/Community Mobilizer will introduce
him/her self and ask the participants to do the same in a
cordial manner
The resource person will Introduce TB Project & with
emphasis on community participation as an integral
component of the project
The resource person explains in simple language the
conditions pertaining to the overall situation of TB in Pakistan,
avoiding difficult jargons or too many figures.
Resource person will talk about the objective of this activity
with focus on involvement of community participation
The Resource person will disseminate the information agreed
upon on TB-DOTS: the following messages will be given at
suitable intervals of the Programme; beginning, mid and most
prominently during the wrap up sessions. The content of the
messages should focus on facts related to TB i.e.
o Tuberculosis is a Curable Disease
o How is TB spread?
o Who is vulnerable to TB?
o What are the symptoms of TB?
o How is TB detected?
o How is it treated?
o Why is controlling TB necessary?
o Information of neighboring diagnosis & treatment centers
The process to make referrals will be explained
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Distribution of agreed literature
The role of supporter will be explained
The celebrity/theatre team/ fair will display key messages
(briefed earlier) using interactive techniques of infotainment
If possible, the involvement of community coalition can be
fruitful in community event Programmes
Target Audience
Different community groups at UC & sub Tehsil, Tehsil and District
levels
Venue, Duration & Date
Will be finalized according to Monthly Work plan
Area selection Criteria
Technical Committee comprising of DTC, CDO & District
Mobilization team will jointly finalize the area and group
Stationary, IEC Material
Dissemination
NTP or WHO endorsed material will be used for dissemination
No. of Participants
(approximately)
Approximate number of participants will be the same as reflected in
the Monthly Workplan
Expected Outcome of the
Activity
To improve KAP representation of the target community and build
trust in the DOTS Programme. Additionally this will add to the
number of suspects from near by Diagnostic Centers.
Means of Verification
Activity report, photographs, attendance sheets(duly filled with
addresses and signatures)
Remarks
An event specific checklist will be used
12.7 Conducting Journalist Training
The focus of this activity is to provide incentives and encourage advocacy through
media journalists and health writers at the provincial and district networks. Emphasis
on sensitizing journalists will result in the media playing a greater role in awareness
raising among masses about tuberculosis; media professionals will use media power in
disseminating information about the disease among common people; a special
awareness raising campaign about the disease on electronic and print media especially
on important occasions such as the world TB Day through enhanced regional news
coverage in articles and forums. These workshops will aim at sensitizing media
professionals on TB issues, as well as enhance the knowledge of participants about
Round 6 activities and existing TB situation at the global and local level. This will in turn
mobilize media support in awareness raising and information sharing with masses. By
the end of the workshop, the participants will be able to understand the real threat of the
disease and the crucial role of media in disseminating appropriate information as well as
removing misconceptions and apprehensions related to tuberculosis in Pakistan.
Table 2: Outline for Conducting Journalist Training/ Orientation
Name of the Activity
Journalist Training/Orientation
Resource and Material
Requirement
Banners, camera, , OHP/Multimedia, IEC Material, stationery,
activity Check List, attendance sheet
Resource persons on TB DOTS
Methodology
Training session/Brainstorming/interactive counseling by
resource persons /Group work
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Activity Strategy
The groups will be selected from Press Club including print
and electronic media reporters; more specifically health
reporters will be invited
The objective is also to prepare journalist groups for enhancing
effective commitment and support for Programme and
highlighting effective Programme implementation of TB DOTS
through common messages to community
The group will be invited to an appropriate hall setting
Resource person/Community Mobilizer will introduce
him/her self and participants will follow self introduction
The resource person will talk about role of TB Project & assure
the responsibility of this group in its commitment towards
advocacy to community and health reporting on TB DOTS
The resource person shed light on the situation of TB in
Pakistan using multimedia presentation
Resource person will discuss the objective of this activity with
focus on the involvement of the target journalist group
The Resource person will present the information on TB-
DOTS: messages approved prior to the workshop will be
disseminated during the programme in between intervals such
as:
o Tuberculosis is a Curable Disease
o How does TB spread?
o Who is vulnerable to TB?
o What are the symptoms of TB?
o How TB detected?
o How is treated?
o Why TB control is necessary?
o Information of diagnosis & treatment centers
Role of media in TB DOTS programme will be highlighted.
Possible programme commitments can be shared
Group work to follow through the use of interactive sessions
i.e. role play of an interesting situation
Certificates will be distributed at the end of programme by key
persons and key message will be repeated
The second facilitator will take attendance of the whole group,
conduct a photographic session and fill the activity check list
Target Audience
Journalists from of print/electronic media and health reporters
Venue, Duration & Date
Will be finalized according to Monthly Work plan
Area Selection Criteria
Technical Committee comprising of DTC, CDO & District
Mobilization team will jointly finalize the area and group
Stationary, IEC Material
Dissemination
NTP or WHO endorsed material will be used for dissemination
Number of Participants
15-25
Expected Outcome of the
Activity
The committed group will work for TB DOTS and enhance KAP
representation of community through electronic and print media
Means of Verification
Activity report, photographs, attendance sheets(duly filled with
addresses and signatures)
Remarks
An event specific checklist will be used
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12.8 Orientating Advocates
Orientation sessions with key advocates, opinion leaders, key influencers and celebrity
role models will be conducted; where appropriate, they will be provided incentives and
merchandising opportunities to encourage involvement and leverage advocacy
opportunities.
Table 3: Outline for Orientation of Advocates
Activity Name
Orientate Advocates
Resource and Material
requirement
Banners, camera, , OHP/ Multimedia, IEC Material, stationery,
activity check list, attendance sheet
Resource persons on TB DOTS
Methodology
Brainstorming/interactive counseling by advocates/resource
persons or community elders to orientate the target group
Activity Strategy
The groups will be selected with focus on more influential and
effective personalities like Nazims, GPs, advocates, professors,
Imaam Masjid and spiritual leaders
The objective is to prepare groups for enhanced and effective
commitment and support for Programme
The group will be invited to an appropriate hall setting
Resource person/Community Mobilizer will introduce
him/her self and participants will do the same
The resource person will talk about relevant TB Project &
assure the responsibility of this group in its commitment,
regarding awareness raising
The resource person explain the situation of TB in Pakistan
and its impact at the district level
Resource person will highlight the objective of the activity,
with focus on the involvement of the target advocates to play
their role more dynamically within their communities
The Resource person will disseminate information on TB-
DOTS; approved key messages will be disseminated during
the Programme and in between suitable intervals:
o Tuberculosis is a Curable Disease
o How does TB spread?
o Who is vulnerable to TB?
o What are the symptoms of TB?
o How TB detected?
o How is treated?
o Why TB control is necessary?
o Information of diagnosis & treatment centers
o How to follow the referral protocols
The role of supporter to be highlighted
The team of advocates will disseminate key messages in an
interactive way
The role of these advocates will be made clear and
anticipations will be talked about; possible Programme
commitments will be shared
The 2nd facilitator will take attendance of the whole group,
photograph the session and fill out the activity check list
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Target Audience
Nazims, advocates, professors, elders, GPs,line departments,
religious and spiritual leaders
Venue, Duration & Date
Will be finalized according to Monthly Work plan
Area Selection Criteria
A committee comprising of DTC; CDO & District Mobilization
team will jointly finalize the area and group
Stationary, IEC Material
Dissemination
NTP or WHO endorsed material will be used for dissemination
Number of Participants
15-25
Expected Outcome
The committed group will work closely and enhance commitment
by increasing involvement and advocacy opportunities.
Means of Verification
Activity report, photographs and attendance sheets
Remarks
Check list will be observed.
12.9 Establishing Community Coalitions
Limited client involvement in TB care through public facilities indicates that a greater
commitment is required for preventive care treatment; the presence of these coalitions
aims at contributing to create a more enabling environment. The coalitions will
compromise of local NGO/ CBO/ FBO /LSOs (Local Support Organizations) as well as
the community leaders and other stakeholders to become more actively involved in
detection, encouraging screening and TB treatment support. Additionally, these coalitions
will work for raising awareness on TB DOTS, improving the referral system, to trace out
default patients and especially to provide treatment supporters. Coalitions will help in
organizing the Community Mobilization activities in their areas and provide access to
information regarding TB DOTS. Additionally, community coalitions can inform the
community of TB control services, encourage use of the services, and actively encourage
the community to come for TB control. Additionally they also provide support to TB
patients during treatment to encourage adherence; e.g. in helping TB patients with
transportation or with childcare while the patient is away for treatment.
A clear objective can be set with the TB Coalition, i.e. to create, coordinate, and mobilize
a variety of resources to focus on the elimination of tuberculosis in neighboring villages.
The purpose for these coalitions is to assist and develop community-based strategies
and plans to prevent and ultimately eliminate the threat to the communities within
Tehsils and Union Councils through raising awareness and educating people on free
testing and treatment of tuberculosis.
Since Coalition formed are usually chaired by a public sector representative, besides
local NGOs, faith-based organizations, Edhi homeless shelters, public and private
health care providers. Each of these groups convenes meetings in their own
communities to plan strategies and collaborations for the elimination of tuberculosis. For
different topics of discussion, the group identified key issues, problems, and constraints
and suggested solutions in the form of recommendations, which are detailed as action
points. Additionally the Coalitions can also play an active role in organizing World TB
Day and other important events each year.
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12.10 Operational Details for Community Coalition
Initially all implementing partners will hold regular meetings in which the planning and
preparation for coalition mobilization will take place; as a result, after an average of six
such meetings, one coalition will be established. The sub recipient will establish the
methodology and monitor the progress of the coalition in implementing ACSM activities
with the target communities.
According to the agreed work plan, first determine the number of community coalitions
to be established and operationalized in the ACSM project districts. At the tehsil-level
hospitals may be enabled to act as the focal point for the formation and activities of
community coalition. Each coalition will have about 15 - 20 selected CBO/NGO from the
area, engaged in social uplift/ community development activities. The coalition
partners will meet as budgeted in the workplan, to plan awareness activities and to
identify patients for referrals. . The expenses allocated for community coalition
meetings must be according to an approved budget guidelines agreed upon with
Regional and ACSM Coordinator
12.11 Design and Formation and functioning
NGO/CBO Short listing
Working field (preference: poverty alleviation, community development,
agriculture, health, education, others)
Geographic coverage – whole district, whole tehsil, localities within tehsil, smaller
localized locality
Working experience – years of working, documentation, perception of community
development staff
NGO/CBO Selection Process
Criteria-based short listing
Screening the short listed NGOs, with EDO CD
Inviting the short listed ones to the first coalition meeting.
Those show interest and attend meeting, will form the coalition. The membership
will be kept open to new eligible and interested members (till the size become
optimal i.e. 17).
Coalition Formation Process
The organization of the coalition will comprise of
A chair and a vice chair – to be elected by the coalition members
A secretary – preferably the DOTS Facilitator at the host hospital.
Meeting of coalition partners
Agenda – is drafted in-advance by Coalition Secretary, in consultation with Social
Mobilizer, and endorsed by the Core Committee
Participants will be informed by the Secretary through written letter, supplemented
by telephone calls.
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Local logistic arrangements (seating, refreshment etc.)
Chaired by – an elected chair or the vice chair (in absence of chair), or chaired by a
senior member (in absence of chair and vice chair)
The district staff (health and/or community development) will participate as
facilitators, where possible.
The secretary coalition will take minutes of the meeting and maintain record.
SMs will make the payments to the participants and facilitator(s) and also reimburse
the arrangement costs (completing the procedural requirement e.g, attendance sheet,
photos etc.).
The (coalition/ staff) member will monitor the working of coalition.
The members give feedback on their ongoing referral cases, during the quarterly
coalition meeting.
Required Documents:
One-pager on community coalition
Terms of References of the coalition formation
Format for minutes of quarterly meeting
Table 4: Outline for Conducting/Establishing Community Coalition Sessions
Name of the activity
Formation of “Community Coalitions”
Materials and Human
Resource Required
Banners, camera, white board, flip chart, marker, IEC
material(s), stationery, activity check list, attendance sheet,
office space (provided by community), visibility boards and
membership cards
Resource person/Community Mobilizers
Methodology
Interactive, participatory approach by motivating community
for formation of coalition on TB DOTS
Activity Strategy
For the formation of coalitions, Community Mobilizers will
visit the area and identify motivated groups among the
community
The group will provide office space
Fixed amount for furniture and stationary will be provided by
the Community Mobilizers
Performance-based honoraria will be provided by the
Community Mobilizers
The Community will take the responsibility for looking after
the visibility material and office premises of this coalition
which will in turn enhance and strengthen the partnership
After the coalition has been established, the Resource
person/Community Mobilizer will introduce him/her self in a
friendly manner and ask participants to do the same
Resource person will state the objective of this activity in
simple terms and encourage community participation
The resource person will introduce relevant TB Project with
emphasis on the role of community and the responsibly
towards visibility
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The resource person will explain the situation of TB in
Pakistan and globally
The resource person‘s role in the formation of community
coalition will be discussed
The Resource person will provide information on TB-DOTS;
the content of which will highlight the following details:
o Tuberculosis is a Curable Disease
o How does TB spread?
o Who are most vulnerable to TB
o What are the symptoms of TB
o How can TB be detected
o How is it treated
o Why is TB control necessary
o Information of diagnosis & treatment centers within
vicinity
o How to make referrals
The specific role of NGOs/CBOs/ CCBs will be:
Referral of TB suspects
Identification of treatment supporters (volunteers)
Dissemination of information regarding TB DOTS
Raising awareness in the communities around TB
Distribution of related IEC materials
Explaining the role of treatment supporters
Finding solutions to issues highlighted by the group
The 2nd facilitator will take attendance of the whole group,
photograph the meeting and fill the activity check list
The name and members of coalitions will be selected along
with the name of the partner organization
Target Audience
Different community groups at Union Council (UC), Tehsil/Taluka
and District levels
Venue, Duration & Date
Will be finalized according to Monthly Work plan
Selection Criteria
Technical Committee comprising of District TB Coordinator,
Regional Coordinator, Community Mobilizer and other
stakeholders will jointly finalize the geographic area and coalition
members
Stationary, IEC Material
Dissemination
NTP or WHO endorsed material will be used for dissemination
Number of Participants
15-25
Outcome
The formation of community coalitions, will work for raising
awareness on TB DOTS, identifying and referring suspects, track
the patients who have defaulted on treatment, to provide treatment
supporters. Additionally, Coalitions will also help in organizing the
Community Mobilization activities in their areas. be a source of
community TB treatment supporters, support TB patients during
treatment to encourage adherence, help TB patients with
transportation or with child care while they go for
Means of Verification
Activity Report, list of Coalition members, list of referral
Remarks
Check list will be observed accordingly
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12.12 Mobilizing Community Health Workers
Conducting regular trainings on TB ACSM at the district level with health care
providers comprising of Lady Health workers, medical officers, and DOTS facilitators
will ensure that they play an active role as a committed group of service providers
working for TB DOTS resulting in enhanced KAP representation of communities
through focused IPC messaging. Additionally the health care providers will be provided
with incentives i.e. recognition and training opportunities and merchandise for LHWs,
especially in remote rural areas, for case detection and treatment support. The LHWs
will be trained to enhance their interpersonal communication and counseling skills, in
the use of IEC material related to TB, its management and prevention and will receive
basic training in community mobilization to form local alliances and support groups.
Table 5: Outline for Conducting Workshop for Community Health Workers
Name of the activity
LHW Training
Materials and Human
Resource Required
Banners, camera, white board, flip chart, marker, IEC
material(s), stationery, activity check list, attendance sheet,
office space (provided by community), visibility boards and
membership cards
Resource person/Community Mobilizers
Methodology
Interactive, participatory approach by motivating community
for formation of coalition on TB DOTS
Activity Strategy
The Community Health workers training using IPC (NTP)
Module will be conducted for a full day
An appropriate group will be identified and invited officially,
the training session will start in the morning with a pre test
The resource person/Community Mobilizer will introduce
him/her self followed by participant introductions
The resource person will speak about relevant TB Project &
explain the responsibility of this target group; its commitment
regarding advocacy within the community promoting health
messages particularly on TB DOTS
The resource person to explain the situation of TB in Pakistan
and its over all district impact
Resource person will discuss the objective of this activity;
laying stress and on involvement of Community Health
Workers
The Resource person will provide the information on TB-
DOTS
The following messages will be disseminated in the
Programme in between intervals:
o What is communication
o Barriers of communication
o Types of communication
o Communication Techniques
o Patient counseling
o Counseling with TB Suspect
o Information on TB DOTS
o Routine key messages on TB
Through group work and interactive learning techniques
different topics of IPC will be covered such as role modeling
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Possible Programme commitments will be shared, certificates
will be distributed at the end of orientation session by key
persons and important messages will be repeated
The 2nd facilitator will take attendance of the whole group,
photograph the session and fill the activity check list
Target Audience
CHWs from National Programme, NCHD, NGOs (where available)
Venue, Duration & Date
Will be finalized according to Monthly Work plan
Area selection Criteria
Technical Committee comprising of DTC, CDO & District
Mobilization team will jointly finalize the area and group
Stationary, IEC Material
Dissemination
NTP or WHO endorsed material will be used for dissemination
Number of Participants
20-30
Outcome
The committed group will work towards improved TB DOTS and
enhanced KAP representation of community through IPC
messaging and play an active role in promoting effective TB care,
reducing misconceptions and social stigma
Means of Verification
Activity report, photographs and duly filled attendance sheets with
addresses
Remarks
Check list will be observed accordingly
12.13 Quality Assurance Workshops with Health Care Providers
Despite reported improvements in CDR, not enough has been done to assess service
quality or to ensure that resources are having an optimal impact. Quality Assurance
workshops will provide effective strategies for monitoring quality and correcting
systemic deficiencies; as well as to refine existing methods for ensuring optimal quality
health care. The target participants will comprise of policy makers, upper-level health
officials, and district-level health service managers.
The objective of having these workshops is that Quality Assurance (QA) methods can
help health programme at the district level to define clinical guidelines and standard
operating procedures, to assess performance compared with selected performance
standards, and to take tangible steps toward improving performance and effectiveness.
These can alternately address deficiencies in