Local solutions solve local problems best

PPT CCP 04/21/23 1Center for Communication ProgramsCenter for Communication ProgramsU N I V E R S I T Y U N I V E R S I T Y

OHNS HOPKINS OHNS HOPKINS J J

Local solutions solve local Local solutions solve local problems best.problems best.



Somewhere in the futureSomewhere in the future

Masri and Fitri represent Masri and Fitri represent the resourceful couple. He the resourceful couple. He is a driver; she is a street is a driver; she is a street vendor. Health is a vendor. Health is a priority in their lives and priority in their lives and like their friends, they like their friends, they invest time and money to invest time and money to ensure that they remain ensure that they remain healthy. healthy.




Masri and Fitri have only two Masri and Fitri have only two children because they wanted to children because they wanted to provide them with love and care provide them with love and care and ensure their health, and ensure their health, education and welfare. They education and welfare. They saved enough money before they saved enough money before they had their first child. They sought had their first child. They sought information on pregnancy and information on pregnancy and child birth and learned the child birth and learned the danger signs of pregnancy. It did danger signs of pregnancy. It did not matter to them whether their not matter to them whether their child was a boy or girl. child was a boy or girl.




When Masri developed fever and When Masri developed fever and severe coughing that lasted for two severe coughing that lasted for two weeks, FItri was extremely worried weeks, FItri was extremely worried not just for Masri but for their not just for Masri but for their children as well.children as well.

Masri and Fitri understand the risks Masri and Fitri understand the risks of tuberculosis so they went to a of tuberculosis so they went to a health clinic where Masri had a health clinic where Masri had a sputum smear microscopy.sputum smear microscopy.




The result was positive and Masri was The result was positive and Masri was placed in a standardized short-course placed in a standardized short-course chemotherapy for 6-8 months. Fitri chemotherapy for 6-8 months. Fitri and Masri were so impressed with the and Masri were so impressed with the courtesy and professionalism of the courtesy and professionalism of the providers. providers.

When they asked providers why they When they asked providers why they were committed to providing were committed to providing excellent treatment, the providers excellent treatment, the providers replied that thanks to the NTP, STOP replied that thanks to the NTP, STOP TB and WHO and other cooperating TB and WHO and other cooperating institutions, they receive adequate institutions, they receive adequate resources and high quality training on resources and high quality training on a continuing basis. a continuing basis.




Even the private sector contribute to Even the private sector contribute to the program. Policy makers and local the program. Policy makers and local leaders are all knowledgeable about leaders are all knowledgeable about TB and have made elimination of TB TB and have made elimination of TB high priority. high priority.

Their neighbors and friends were Their neighbors and friends were supportive and encouraged Masri to supportive and encouraged Masri to follow the treatment protocol strictly.follow the treatment protocol strictly.

Masri recovered completely and Masri recovered completely and resumed his normal activities and resumed his normal activities and zest for life!zest for life!




Masri and Fitri were so grateful at Masri and Fitri were so grateful at his complete recovery that they his complete recovery that they organized a Health and TB organized a Health and TB prevention support group among prevention support group among their friends and neighbors. They their friends and neighbors. They shared their positive experience shared their positive experience with the DOTS approach and with the DOTS approach and encouraged their support group encouraged their support group members to see their providers if members to see their providers if they experience TB symptoms. they experience TB symptoms.




Knowing that TB is contagious, Masri Knowing that TB is contagious, Masri made sure that he got better and that made sure that he got better and that he won’t infect his children. he won’t infect his children.

Both Masri and Fitri are deeply Both Masri and Fitri are deeply concerned about the political and concerned about the political and economic future of their country. economic future of their country. They vote intelligently and always They vote intelligently and always encourage their friends to do the encourage their friends to do the same.same.



Somewhere nowSomewhere now

Parman and Wulan are living Parman and Wulan are living together. Parman is a mechanic who together. Parman is a mechanic who works when he wants to. Wulan works when he wants to. Wulan would like to earn some money but would like to earn some money but Parman refuses to let her work. They Parman refuses to let her work. They do not know much about health and do not know much about health and have not been to a health clinic in have not been to a health clinic in five years. They believe that people five years. They believe that people get sick because of the “evil eye” or get sick because of the “evil eye” or because they committed a sin.because they committed a sin.



Somewhere in nowSomewhere in now

They have six children, all They have six children, all unplanned. Four are seriously unplanned. Four are seriously malnourished. Because malnourished. Because Parman income is meager and Parman income is meager and irregular, their children often irregular, their children often go hungry. When there is go hungry. When there is food, the boys get the largest food, the boys get the largest portions and eat first. portions and eat first.




Parman and Wulan do not Parman and Wulan do not talk about their condition or talk about their condition or the future. Parman has a bad the future. Parman has a bad temper and often beats Wulan temper and often beats Wulan when he is in a bad mood. He when he is in a bad mood. He was surprised one time when was surprised one time when Walan fought back. This Walan fought back. This made him so furious that he made him so furious that he beat her severely.beat her severely.




Wulan ended up in the Wulan ended up in the hospital. The police jailed hospital. The police jailed Parman briefly but he did not Parman briefly but he did not have any remorse when have any remorse when released. released.

Recently, Wulan started Recently, Wulan started having fever and severe having fever and severe cough but Parman refused cough but Parman refused Wulan’s request to go to a Wulan’s request to go to a clinic.clinic.



Somewhere now Somewhere now

Wulan did not know that she had Wulan did not know that she had developed active tuberculosis. Her developed active tuberculosis. Her neighbors and friends shunned neighbors and friends shunned away when they suspected that she away when they suspected that she has TB. She was treated rudely by has TB. She was treated rudely by the providers in a clinic. The clinic the providers in a clinic. The clinic staff did not know about sputum staff did not know about sputum smear microscopy as they do not smear microscopy as they do not have sufficient training. They wanted have sufficient training. They wanted her to have an x-ray but for a fee, her to have an x-ray but for a fee, money she did not have. She ended money she did not have. She ended in a hospital but never recovered. in a hospital but never recovered.



Somewhere now Somewhere now

Wulan’s death went unnoticed by local Wulan’s death went unnoticed by local leaders who did not feel that the TB leaders who did not feel that the TB program is their concern. Her death program is their concern. Her death was just a number added to statistics was just a number added to statistics which most policymakers, program which most policymakers, program managers hardly read or understand.managers hardly read or understand.

There were many more Wulans the day There were many more Wulans the day she died. There were also several she died. There were also several workshops that opened to talk about workshops that opened to talk about lack of coordination, poor planning, lack of coordination, poor planning, lack of accurate data as often done lack of accurate data as often done every year.every year.



Why is there a difference?Why is there a difference?

Our challenge is to Our challenge is to think deeply and think deeply and then act.then act.



Shared vision for TB – By 2015,Shared vision for TB – By 2015,

Households, communities and government are working Households, communities and government are working together so that no person dies from TB in community X, Y, together so that no person dies from TB in community X, Y, or Z. or Z.

There is universal knowledge about TB symptoms, the There is universal knowledge about TB symptoms, the treatment process, and its availability. Those with disease treatment process, and its availability. Those with disease symptoms seek care immediately and conform rigorously to symptoms seek care immediately and conform rigorously to treatment regimen. treatment regimen.

There is strong family and community support to have any There is strong family and community support to have any case of TB to be treated and stigma regarding the disease is case of TB to be treated and stigma regarding the disease is absent. DOTS is implemented from a multidisciplinary and absent. DOTS is implemented from a multidisciplinary and multi-sectoral perspective.multi-sectoral perspective.



Example -Current SituationExample -Current Situation

At present, the government works alone in implementing a DOTS At present, the government works alone in implementing a DOTS strategy without ACSstrategy without ACS

Because there is no enabling environment to support DOTS, Because there is no enabling environment to support DOTS, knowledge about TB symptoms, the treatment process, and its knowledge about TB symptoms, the treatment process, and its availability is lowavailability is low

Those with disease symptoms do not seek care immediatelyThose with disease symptoms do not seek care immediatelyThose diagnosed with TB do not conform rigorously to treatment Those diagnosed with TB do not conform rigorously to treatment

regimen. regimen. There is little family and community support to treat TB cases and There is little family and community support to treat TB cases and

TB stigma is prevalent. People engage in “medical shopping”, TB stigma is prevalent. People engage in “medical shopping”, try self-treatment and rely on traditional healers before seeking try self-treatment and rely on traditional healers before seeking professional help. professional help.

Government implements DOTS from a single discipline perspective Government implements DOTS from a single discipline perspective (bio-medical) without engagement of other sectors. (bio-medical) without engagement of other sectors.



The DOTS program suffers from:The DOTS program suffers from:1.1. Lack of material and non-material Lack of material and non-material

resources and resourcefulness.resources and resourcefulness.2.2. Slow and cumbersome process in flow Slow and cumbersome process in flow

of funds.of funds.3.3. Lack of district planning.Lack of district planning.4.4. Weak coordinationWeak coordination5.5. Lack of accurate reporting data.Lack of accurate reporting data.



Why is there a difference?Why is there a difference?

Our challenge is to Our challenge is to think deeply and think deeply and then act.then act.



Where do leaders operate?Where do leaders operate?

Beyond Imagination

That’s Impossible

Looks Difficult

Easy to do



1. How do we usually define “health problems?1. How do we usually define “health problems?

1. Deviation from “norm” or “indicator 1. Deviation from “norm” or “indicator chasing” chasing” 2. Existing “solutions” in tool box2. Existing “solutions” in tool box

- Ideology- Ideology

- Training - Training

3. Knee-jerk “lack of resources”3. Knee-jerk “lack of resources”



Deviation from the “norm”Deviation from the “norm”

1. Who determines the “norm”?1. Who determines the “norm”?

2. What if “norm” is the source of 2. What if “norm” is the source of the problem?the problem?

3. Restoration of “norm” is system 3. Restoration of “norm” is system maintenance not improvementmaintenance not improvement



Use existing solutions - When we have a Use existing solutions - When we have a hammer, everything looks like a nail!hammer, everything looks like a nail!

1. Trainer - everything is a training problem.1. Trainer - everything is a training problem.

2. Manager - everything is a management 2. Manager - everything is a management problem.problem.

3. Community mobilizer - everything is a 3. Community mobilizer - everything is a community mobilization problem.community mobilization problem.

4. Medical doctor -everything is a medical 4. Medical doctor -everything is a medical problem.problem.



Lack of resourcesLack of resources

1. Resources are universal 1. Resources are universal constraints - when will we ever constraints - when will we ever have enough?have enough?

2. Are we using existing resources 2. Are we using existing resources effectively and efficiently?effectively and efficiently?

3. How resourceful are we?3. How resourceful are we?



Relationship between income and Relationship between income and malnutritionmalnutrition



The “disconnect” between income and malnutrition

Alternatively,

Malnutrition “falls” independent of “rises” in income(among the lowest income countries)



Examples – Deviation from normExamples – Deviation from norm

Overall strategic objectives:Overall strategic objectives:

1.1. Detect at least 70% of active TB Detect at least 70% of active TB casescases

2.2. Successfully treat at least 85% of Successfully treat at least 85% of TB cases detectedTB cases detected



AnalysisAnalysis

1.1. What are the factors that lead to case What are the factors that lead to case detection and successful treatment?detection and successful treatment?

2.2. Which factors account for the gaps in: Which factors account for the gaps in:

A. Case detectionA. Case detection

B. Successful B. Successful treatmenttreatment



Analysis – Existing tools in our tool boxAnalysis – Existing tools in our tool box

1.1. Communication – Which Communication – Which communication factors impact on communication factors impact on case detection and successful case detection and successful treatment?treatment?

2.2. Which communication factors are Which communication factors are weakest in the current situation? weakest in the current situation? KAP?KAP?



Analysis – Lack of resourcesAnalysis – Lack of resources

1.1. Which communication activity Which communication activity impacts the most on case impacts the most on case detection and successful detection and successful treatment?treatment?

2.2. How much do we allocate for How much do we allocate for these activities?these activities?



2. What is an alternative way to 2. What is an alternative way to defining problems? defining problems?

Define problems in terms of why Define problems in terms of why there is a difference between what we there is a difference between what we want (shared vision) and what is want (shared vision) and what is happening (current situation) and happening (current situation) and how to bridge this difference.how to bridge this difference.



Approach requires two thingsApproach requires two things

1. We need to know clearly what we 1. We need to know clearly what we want.want.

2. We need to know clearly what is 2. We need to know clearly what is happening now.happening now.



Work backwards and ask why there is a difference. Work backwards and ask why there is a difference. Determine what need to happen to realize the shared Determine what need to happen to realize the shared visionvision

High TB mortality

No one dies from TB

Political will at all levels

Universal effective DOTS treatment

Marginal improvements

Poor adherence totreatment

Lack of Political will

Universal access to SSM

Poor access and diagnosis



Which approach is best for your Which approach is best for your country to STOP TB? country to STOP TB?

1) Change conditions one at a time. 1) Change conditions one at a time.

2) Achieve doses of improvement in 2) Achieve doses of improvement in several conditions over time. several conditions over time.

3) Conduct local experiments and 3) Conduct local experiments and scale up scale up

4) Devolve or decentralize 4) Devolve or decentralize



Change one condition at a timeChange one condition at a time

High TB mortality

No one dies from TB

Political will at all levels

Universal Effective DOTS treatmentUniversal

access to SSM



Little changes in all conditions over time – Vietnam Little changes in all conditions over time – Vietnam and Peruand Peru

High TB mortality

Less deaths from TB

Improvements in political will at all levels

Improvements in effectiveness of DOTS treatment

Improvements in access to SSM



We improve through local experiments and scaling We improve through local experiments and scaling upup

High TB mortality

No deaths from TB

Local experiments

National scaling up

Learning communities



Devolve or decentralize Devolve or decentralize

L oca l H ea lth U n its

S ta te M in is try o f H ea lth





F ed era l M in is try o f H ea lth



Who should be our audience in Who should be our audience in tuberculosis control and tuberculosis control and prevention campaigns?prevention campaigns?

1. Audiences on the program side1. Audiences on the program side

2. Audiences on the client side2. Audiences on the client side



Audiences on the program sideAudiences on the program side

Policy makersPolicy makers

InfluentialsInfluentials

Program managersProgram managers

Health workersHealth workers

Donor agenciesDonor agencies



Audiences on the client sideAudiences on the client side1. Everyone1. Everyone

2. High risk groups2. High risk groups

Those in areas with highThose in areas with high

incidence and incidence and

prevalence of active TBprevalence of active TB

3. Low risk groups3. Low risk groups

Those in areas with lowThose in areas with low

incidence and prevalence of active incidence and prevalence of active TBTB



Audiences on the client side –High Audiences on the client side –High prevalence areasprevalence areas

1.1. Those with low levels of education Those with low levels of education and access to mass mediaand access to mass media

2.2. ““Connectors”Connectors”3.3. ““Mavens”Mavens”4.4. ““Salesmen”Salesmen”5.5. Very youngVery young6.6. Very oldVery old7.7. ImmunosuppressedImmunosuppressed



What is audience segmentation?What is audience segmentation?

Audience segmentation categorizes Audience segmentation categorizes audiences into logical groups to audiences into logical groups to enhance a better fit amongenhance a better fit among

• Audiences

• Messages

• Media

• Service or products



Audience Profile - NailaAudience Profile - NailaNaila has been married for 12 years Naila has been married for 12 years and has given birth seven times. and has given birth seven times. One child died within 30 days of One child died within 30 days of giving birth. She lives in a small giving birth. She lives in a small village outside Lahore where she village outside Lahore where she washes clothes for other families. washes clothes for other families. She is illiterate. She does not want She is illiterate. She does not want more children but she is afraid to more children but she is afraid to talk to her husband, Azmat, a talk to her husband, Azmat, a farmer. She is fearful of a severe farmer. She is fearful of a severe cough and blood in her sputum. cough and blood in her sputum.



Audience Profile - DenebAudience Profile - DenebDeneb is a health worker. She lives in Deneb is a health worker. She lives in Rawalpindi with her husband, Akhtar, a Rawalpindi with her husband, Akhtar, a business executive in a computer firm. business executive in a computer firm. Deneb is so tired from doing housework Deneb is so tired from doing housework and a fulltime job at the same time. She and a fulltime job at the same time. She does not have state of the art knowledge does not have state of the art knowledge about TB and thinks unkindly of patients about TB and thinks unkindly of patients who come for treatment. She is rude to who come for treatment. She is rude to them most of the time. She is afraid that them most of the time. She is afraid that she will also get TB from her patients and she will also get TB from her patients and keeps her distance. keeps her distance.



Audience profile - AhmedAudience profile - AhmedAhmed is a camel driver in a Ahmed is a camel driver in a caravan. He lives in Sindh. He caravan. He lives in Sindh. He has been married for seven has been married for seven years and has four daughters. years and has four daughters. He wants to have a son but he He wants to have a son but he knows that his wife’s health has knows that his wife’s health has been poor. Her wife has been been poor. Her wife has been losing weight and appetite, has losing weight and appetite, has chills and fever and nighttime chills and fever and nighttime sweating. He is kind and does sweating. He is kind and does not want his wife to die. not want his wife to die.



Audience profile – The modern Audience profile – The modern couplecouple

Amir and Sadia are a modern Amir and Sadia are a modern couple. In a recent seminar in couple. In a recent seminar in his work, Amir learned about his work, Amir learned about TB symptoms and shared TB symptoms and shared them with Sadia. Sadia became them with Sadia. Sadia became alarmed because she noted alarmed because she noted that their maid seems to have that their maid seems to have symptoms of TB. They are symptoms of TB. They are even more concerned because even more concerned because they have a newly born child. they have a newly born child.



Possible questionsPossible questions

1.1. What are your strategic What are your strategic communication objectives?communication objectives?

2.2. What is the overall What is the overall communication strategy that communication strategy that matches the situation in the matches the situation in the community /governorate/countrycommunity /governorate/country



3. Who should be your intended 3. Who should be your intended audiences?audiences?

a. Program side? – Program managers, policymakers, health workers, media, donors

b. Client side? – People with are about to marry, ante-natal, child-birth, post partum, child care.

c. Both –phased or simultaneous?



What are the key messages of each What are the key messages of each intended audience?intended audience?

What is the best way to present these What is the best way to present these messages?messages?

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Local solutions solve local problems best