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Cough to Cure: Applying a Pathway of Ideal Behaviors in TB Control AED: Dr. Silvio Waisbord Dr....
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Transcript of Cough to Cure: Applying a Pathway of Ideal Behaviors in TB Control AED: Dr. Silvio Waisbord Dr....
Cough to Cure: Applying a Pathway of Ideal Behaviors in TB Control
AED: Dr. Silvio Waisbord
Dr. Susan Zimicki
Stop TB Partnership: Thaddeus Pennas
Overview of Presentation
Introduction: The “Cough to Cure Pathway” - a diagnostic and planning tool
The "Cough to Cure Pathway“ - six steps to ideal TB treatment
Applying the Pathway: 4 diagnostic steps
Overview of Presentation
Introduction: The “Cough to Cure Pathway” is a diagnostic and planning tool.
– Why another tool?– What is new about the tool?– How was it developed?
The "Cough to Cure Pathway” Applying the Pathway: 4 diagnostic steps
Why another tool?
Response to expressed need. Countries and technical programs request support
and guidance regarding advocacy, communication and social mobilization (ACS):
This diagnostic and planning tool supports cost-
effective implementation of ACS support and services.
What is new about this tool?
Frame of reference – way of conceptualizing problems– Think about communication by thinking about
behaviors– Behaviors instead of logistics and structure
Focus– People (patients and providers)
View of system – Enabling environment
How was it developed?
AED working with Stop TB: Defined the steps in the pathway “from cough to
cure” from the patient’s care-seeking practices Identified the social and behavioural barriers to
completing each of these steps (through literature review and interviews)
Mapped possible ACS entry points drawing on lessons from other behavioural change interventions
Overview of Presentation
Introduction: The “Cough to Cure Pathway” is a diagnostic and planning tool.
The "Cough to Cure Pathway”– How does it work? – Basic structure – six steps– Barriers (individual, group, system)– Examples
Applying the Pathway: 4 diagnostic steps
How does it work?
This pathway was developed to serve as a road map to understand the interrelationship of behaviour, DOTS services and other societal structures on treatment-seeking behaviour and compliance.
The pathway focuses on the patient, and how the system can facilitate patients’ “going through” the ideal steps.
The Pathway – basic structure
Six steps to ideal TB treatment behavior :
1) Seek timely care2) Go to a DOTS facility3) Get accurate diagnosis
4) Begin treatment5) Persist in getting treatment6) Complete treatment
Case detection Goal: 70% Current average: 44%
Treatment completion Goal: 85% Current average: 82%
Ideal vs reality
In an ideal world, for every 100 infected people, all 100 would: – Seek timely care– Go to a DOTS facility either directly through referral– Be correctly diagnosed– Begin treatment– Persist with treatment for more than 2 months– Complete treatment
These are the six steps that form the basic structure of the pathway
As the following slide shows, things are far from ideal
The Pathway – List of barriers
At each step, the pathway also lists the common barriers to completion of the step
Barriers can occur at the level of the – Individual – Group– System
The current list of barriers is based on AED’s literature review and interviews; it will be updated as program experience accrues
Barriers - individual and group levelStep 2 – Go to DOTS
Common reasons for non-completion are that the individual – Prefers to go to a provider s/he knows, and fears going to
someone unknown– Believes attending DOTS facility will be expensive– Doesn’t prioritize TB over other health issues– Low-risk perception of TB symptoms
And that the group (community/family)– Stigmatizes people with tuberculosis and, by extension,
anyone attending a TB clinic
Barriers – system levelStep 2 – Go to DOTS
Few DOTS facilities, so that people live relatively far away and traveling to the facility takes time and money
Lack of linkages between non-DOTS and DOTS facilities = providers do not refer patients with possible TB to
DOTS facilities;
= providers do not consider TB (e.g., treat HIV patients only for HIV & acute illnesses)
Barriers - individual and group level Step 5 (Persist with treatment)
Common reasons for drop-out are that the individual and his/her social support group (family, neighbors) – Do not know how long treatment takes– Do not understand or accept the importance of
continuing treatment even after the patient feels better or despite side effects
– Cannot financially support the cost of distant treatment or “good food”
– Stigmatize those with TB
Barriers – system level Step 5 (Persist with treatment)
Lack of medicines Lack of DOTS facilities - trouble (time,
money) to attend Providers fail to give adequate information
about length of treatment, importance of persistence, side effects
Poor quality of services (e.g., non-supportive or abusive providers)
Overview of Presentation
Introduction: The “Cough to Cure Pathway” is a diagnostic and planning tool.
The "Cough to Cure Pathway"—six steps to ideal TB treatment
Applying the Pathway: 4 diagnostic steps– Description– Examples
Applying the Pathway: 4 Steps
1. Identify the steps that patients are not completing
2. Examine the reasons for non-completion at the individual, group and systems levels
3. Decide which barriers to address. Need to weigh relative importance of factors
4. Choose an intervention based on understand of motivating factors, and likely effectiveness and impact
How to examine step completion
Obtain information about step completion from a variety of sources
– Routine information– Special studies– Key informants
Chart out the data and let it guide the decision making process
Important: be clear about denominators– Make sure all your percents refer to the same base population
Step 2. Examine reasons for missed steps
In this case, the program should examine individual, group and systems barriers that are likely to be problems for both step 1 and for step 2.
Example: for Step 2 (Go to DOTS)
Possible reasons include– Individual:
Misperceptions of costs of diagnosis and treatment; Reluctance to go to an unknown provider
– Group Stigma
– System Distance to DOTS provider No or weak links between non-DOTS and DOTS providers;
non-referral
How to examine reasons
Use both qualitative and quantitative research Examples of some questions relevant to individual
and group-level barriers for Step 2:– Where should someone go to find out if she or he has TB?– How much does it cost to be tested?– Can TB be cured?– How much does it cost?– How long does it take?– How would your family and neighbors react if they knew
that you went to a DOTS clinic?
Step 3. Decide which barrier(s) to address
What is the relative importance of this barrier compared to others?
How feasible is to reduce this barrier within a short-to-medium period?
How much will it cost (cost/benefit analysis)? Does the program have the right expertise to
tackle the problem (human resource analysis) ?
Step 4. Choose an intervention
What kinds of interventions will best address the identified barrier(s)?– Systems improvement (e.g., logistics)– Behavioural change of patients and/or
providers– Mixed (what is the sequence?)
What kind of communication strategy is best adequate to address barriers?
Core questions for communication interventions
Who is the primary and secondary audience? What is it that they are expected to do? What will it take to get people to do it?
– What do they need to know?– What do they value?– How will they overcome perceived and existing
barriers?– What factors promote their doing it?
these come from the BEHAVE model; many other models exist: NCI Pink Book, P-Process, Combi, CDCynergy, …)