Community empowerment and mobilization strategies for tuberculosis control

Intervention Plan

A description of the intervention

Empowerment and Mobilization

In the pursuit of eradicating Tuberculosis, community involvement will be able to set the scene for empowerment and mobilization. Therefore, it becomes important that all stakeholders appreciate the community\'s role in promoting health, and the association, based on principles of human rights and social justice. In turn, the community needs to recognize the fact that this novel effort represents a partnership, rather than a mere decentralization of management of tuberculosis services. Early solicitation of local leaders\' political backing and commitment is the key to achieve such collaboration (COREGroup, 2013).

Tuberculosis care is affected by stigma in a number of ways. The communities of certain places believe the disease to be incurable, and isolate and shun individuals diagnosed with the disease. In addition, TB patients fail to seek treatment as they, too, hold the belief that their ailment is incurable and do not desire to be faced with the horrible truth. Such stigma may be reduced through dissemination of information and education on TB transmission, its curability, and available services (COREGroup, 2013).

Many programs have been able to achieve increased mobilization and decreased stigma owing to extensive communication activities. Central Ghanaians believe tuberculosis happens because of \'bad spirits\'. Hence, the tuberculosis training and advocacy program incorporate the participation of community leaders, for dealing with this belief. Consequently, improved case detection, improved success rates of treatment, and lesser treatment interruption were achieved. The people of Senegal linked the disease to ancestral curses. Community support was gleaned by sharing ideas and perceptions with the elders in the communities -- often the grandmothers in the communities. Subsequently, the society started believing the disease is what it truly is: a health issue and not some irreversible, spiritual phenomenon such as personal or familial curse (COREGroup, 2013).

Support in training will be offered for improving the capacity of healthcare programs and systems at the local-level. Non-government organizations (NGOs) have employed their expertise in related areas for developing training on the aspects of case detection, Advocacy, Communication, and Social Mobilization (ASCM), and Directly Observed Treatment (DOT), as well as enhancing HR availability for different program-related activities. They will hence be able to train community workers and their own workforce, in addition to providing national-level TB Programs (NTPs) with training aid. Combined training sessions will be able to reinforce program-community partnerships. Public health personnel can engage in training volunteers or NGO workers in the areas of appropriate drug storage, medical record maintenance, and referring individuals suspected of having contracted the disease. All workers need to understand the established referral system and right time and condition to refer patients to the national programs (COREGroup, 2013).

A key element in achieving universal TB service access is engendering a facilitative climate that upholds and assists recognition of every patient having symptoms similar to those of TB; timely commencement and efficacious completion of treatment; and swift and precise TB testing and diagnosis (USGov, 2015).

Standardized treatment regimen with patient support and supervision

An individual diagnosed with the ailment must consume proper medication on schedule, spanning several months. Caregivers must monitor the individual\'s dosage consumption, keep meticulous records (which have to be forwarded to the NTP), and offer required support in the event of any problem (e.g., side effects).

What support can civil society provide?

Considering the protracted clinical course of the treatment, and aspects such as patient convenience, considerable potential exists for the participation and assistance of civil society. NGOs may offer direct observation services, aid patients in seeking answers and treatment to manage side effects of medication, and ensure proper maintenance of records and NTP submissions (COREGroup, 2013).

An efficient medicine management and supply system

One important requirement in effective care of TB patients is providing an uninterrupted supply of medications of assured quality. Without drugs, patients cannot be cured. Instead, they may develop a worse variant of the disease, namely drug-resistant tuberculosis (COREGroup, 2013).

International institutions offer such quality-assured medication to states; high-level NGOs can aid NTPs in procuring funds from those sources. Additionally, they can facilitate medication supply by ascertaining proper administration of superior-quality NTP-sourced or NTP-approved or international standard-compliant medication. They can educate relevant bodies on quality medication\'s significances. Lastly, bigger NGOs can facilitate medication procurement, stock management, distribution, and quality testing and assurance, as well as training in the aforementioned activities (COREGroup, 2013).

Engaging the key stakeholders

Patient families are the most important stakeholders. Female members, in particular, typically play the role of caregiver and contribute significantly to family health promotion. A study of community involvement in controlling tuberculosis revealed that neighbors and close relatives, brethren and colleagues have a key role in the everyday life of individuals. They serve as the direct reference point for guidance, opinion, and support. Developing an operational relationship with individual communities with an aim to improve community members\' health status represents a step beyond involvement and participation. In case of partnerships, the organization empowered to deliver social and health services for addressing communities\' fundamental needs qualitative support through its professional expertise and normative position to aid communities in their effort to improve their members\' health statuses (WHO, Community involvement in Tuberculosis care and prevention, 2008)

People suffering from tuberculosis may first turn to private clinics, traditional healers, and physicians for treatment. In some regions, this is applicable to over 50% of those afflicted. The private healthcare sector encompasses private practitioners delivering contemporary healthcare, traditional healers, pharmacists, and alternative medical (e.g. herbal medicine) practitioners. Patients may prefer the aforementioned healthcare providers as public sector providers are generally considered inaccessibly, rude, and incompetent. Furthermore, shame and stigma prevents patients from availing themselves of public services (COREGroup, 2013).

Not all private practitioners are competent. Some services do not cooperate properly with NTPs and do not report tuberculosis cases accurately. Further, ineffective management or slow diagnoses may be affecting their efforts. In view of private sector institutions\' influence, efficiency and scale of effort, one cannot overlook them in the efforts to fight TB -- they are, in fact, potentially strong partners (COREGroup, 2013).

Involving these entities and setting up private-public partnerships is being prioritized for tuberculosis diagnosis and treatment. In such partnerships, one can effectively meet key DOTS (Directly Observed Treatment Short course) requirements. Private practitioners can prove helpful in numerous ways; this includes straightforward referrals of suspected tuberculosis patients to clinics belonging to the public sector, and patient treatment with free-of-cost, government-provided drugs under direct supervision. In every case, they must refer to NTP, keeping it aware of the developments and incidents, as it constitutes a vital element of tuberculosis management (COREGroup, 2013).

Potential or anticipated influences that might hinder or support the intervention

Over 90% of tuberculosis patients can be successfully cured if diagnosed on time, recommended the right treatment, and administered medications correctly: every single day for about half a year. Most nations provide free-of-cost tuberculosis diagnosis services and drugs. In spite of these facilities, people succumb to the disease daily (COREGroup, 2013).

Governments have made immense progress across the globe in handling the issue. The \'Stop TB\' Partnership, the WHO (World Health Organization), and other international institutions are focusing on this issue, and providing help and advice. Private sector firms are striving to develop technologies aimed at TB diagnosis, prevention, and treatment. Health facilities belonging to the private sector provide TB diagnoses and care services in a number of nations. However, one entity whose active participation is still necessary is civil society (including NGOs, civil society bodies, community members, community healthcare initiatives and groups, religious groups, development organizations, kinship groups, patient advocates, midwives, traditional healers, neighborhood associations, and the like) (COREGroup, 2013).

Tuberculosis advocates across the globe are planning and carrying out activities to secure political commitment against the disease. This DOTS keystone is imperative to TB interventions\' success. Such commitment may take the form of national policies, HR and funds allocation to TB interventions. Progress will not be easy in the absence of the above measures (COREGroup, 2013).

Expected outcomes

Healthcare organizations and professionals are incapable of achieving the global TB-related goals on their own. For universal elimination of the disease, involvement of more organizations and individuals is imperative. Broad ranges of entities need to collaborate with and engage communities for eradicating TB. Teamwork will facilitate recovery of those diagnosed with TB and help prevent many individuals from contracting the disease. The aforementioned goals are particularly critical in areas with large HIV-positive populations, as tuberculosis is the greatest killer of HIV-diagnosed individuals (COREGroup, 2013).

1. Case detection: Provide access to diagnostic services to individuals suspected of having TB. This stage may be accomplished by means of contact tracing (finding individuals exposed to a TB patient) or symptom screening.

1. Make sure TB patients are supplied quality-assured drugs, commence medication, and can completely and consistently consume the whole medicine course

1. Minimize disease transmission by means of infection control and prevention (COREGroup, 2013).

Evaluation Plan

A description of the evaluation

Community-based TB care and its efficiency can be monitored and gauged using numerous parameters. For instance, research can compare the outcomes between individuals treated via formal services and those treated in community-based facilities. Operations Research will be able to determine approaches for improving treatment compliance, and record good incentives for caregivers and patients. Community-based KAP (Knowledge, Attitudes, and Practices) surveys may be utilized for evaluating ACSM activities\' impacts, and measuring change. The aforementioned activities may be associated with certain detection or outcome gaps, and proper indicators determined for measuring the effect of those activities. Facts and data obtained by means of operations research (OR) must be communicated to groups such as the NTP for reinforcing health systems through corrective measures. Appraisal and monitoring represent key OR elements. Local workers must participate in the designing and application of a monitoring and appraisal system. Also, ideally, continuous data analysis and monitoring must be enabled even after project completion (COREGroup, 2013).

Appraisal and monitoring of collaborative HIV/TB efforts helps evaluate service coverage, quality, delivery, and efficiency, and fosters a culture of learning in organizations and program settings, thereby ensuring continuous health improvements. Via the tracking of individuals receiving the support of two disease-specific, entrenched control programs and a variety of other organizations and services, the task of appraisal and monitoring & facilitates the pursuit of \'inclusive care\'. HIV and TB control programs can perform collaboratively and gather information relevant to each other\'s management (WHO, A guide to monitoring nd evaluation for collaborative TB/HIV activities, 2009)

What will be evaluated and how

No single data source adequately addresses the issue of whether or not a particular intervention or collection of interventions significantly improves tuberculosis case notification. Therefore, triangulation will be utilized for analyzing multiple data sources making unique contributions to TB care providers\' understanding of community approaches\' efficiency (Colvin, et al., 2014).

Firstly, regular case notification information will be examined for comparing trends before implementation, in the initial stage, and 12 months following intervention implementation for assessing whether improvements were achieved in the general case notification trend, over time.

Secondly, program information will be reviewed for ascertaining intervention performance over time, and assessing quantitative and qualitative yields with medium and short-term results associated with case notification. A set of tools will be created, in order to aid traditional healers and pharmacists in documenting symptomatic individuals\' referrals to DOTS facilities. Referrals will be followed for ascertaining the number of individuals ultimately found suffering from TB, for estimating the role of such activities in case notification. Programmatic outcomes, like number of tuberculosis diagnoses following referral, will be compared to regular case notification information for ascertaining the referral mechanism\'s contribution by quarter (WHO, Stop TB Partnership. The Stop TB strategy: building on and enhancing DOTS to meet the TB-related Millennium Development Goals., 2006).

Training of traditional healers and pharmacists, will be followed up via supportive supervision. This includes continuous exploration of provider referrals received at DOTS centers. Such assessment aims to improve tuberculosis case notification and generates useful insights on possible intervention outcomes and intrinsic challenges (that undermine program efficiency and optimum implementation) (MHSW, 2009).

Situational assessment of current tuberculosis efforts, including national engagement, offers necessary intelligence for laying the groundwork for the organization\'s endeavors: partnership. Concurrently with situational analysis, one can also start cultivating fruitful relationships with important stakeholders, such as private and public healthcare leaders and personnel, Ministry of Health and NTP workers, other NGOs and civil service organizations, community groups, local government workers, etc. (COREGroup, 2013).

What metrics will adequately measure the outcomes?

Outcomes can be measured adequately using logic models. This tool will work best in \"tracing back\" factors influencing poor or good performance. For instance, if the share of tuberculosis patients who complete treatment is not up to the stipulated figure, a logic model will reveal what aspect of the intervention was expected to generate the required outcome (in this instance, patient support and tracing). These elements\' process evaluation helps bring to light whether the activities current quality and level are adequate, and whether more effective activities need to be devised (DHHS, 2006).

Program monitoring outputs may be depicted as a console of indicators as well, offering a cross-sectional view of performance in terms of important indicators for some specific duration. Instead of concentrating solely on patient progress, the console provides actionable facts on program performance at individual steps of the care continuum. As metrics comprise of complex indicators, a number of factors will impact program performance on individual indicators. Indicator data and graphs of consolidated measures prove as a reference point for additional investigations for understanding performance determinants and identifying solutions. Program performance over the care continuum is impacted by numerous factors, which include service content and quality; resource availability; relationships between services; and service acceptability and accessibility (WHO, Metrics for monitoring the cascade of HIV testing, care and treatment services in Asia and the Pacific, 2014).