A Health Communication Strategy for RNTCP

Published by

Central TB Division Directorate General of Health Services Ministry of Health and Family Welfare Government of India
in collaboration with DANTB

A Health Communication Strategy for RNTCP

Published by

Central TB Division Directorate General of Health Services Ministry of Health and Family Welfare Government of India
in collaboration with DANTB

Contents
Foreword Abbreviations Executive Summary v vii xi

Part 1 Strategic Planning Framework
1. 2. 3. 4. 5. 6. Introduction Communication in a TB Control Programme Communication Strategy for TB Control Programme Monitoring and Evaluation of Communication in RNTCP Capacity-building Special IEC Needs in RNTCP Phase II

1
5 6 15 33 37 40

Part 2 Planning and Implementing a Health Communication Strategy of RNTCP – A Practical Guide
1. 2. Introduction Implementation of the Strategy 47 59

Annexures
1. 2. 3. 4. 5. 6. 7. Implementation Guide to Health Communication Activities IEC Resource Centre of Central TB Division User Guidelines Index of Materials Available in the Central TB Division’s Web-based IEC Resource Centre Index of Health Communication Materials Used in Orissa User Guidelines for the Health Communication Video Modules CD Suggested Format for Planning IEC Activities at State and District IEC Reporting Formats 73 145 149 156 173 175 176

Contents

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Foreword
India has the largest number of tuberculosis (TB) cases in the world, accounting for more than one-third of the global burden, and TB is the leading cause of death among adults in the country. With this background, the Governments of Denmark and India agreed in 1996 that the Danish development cooperation in India should be further expanded to include the fight against TB. This happened at a time when India was playing a pivotal role in developing and testing the DOTS strategy (Directly Observed Treatment, Short-course) for TB control—a strategy that was subsequently globally recommended by WHO. There was a need to establish solid experiences in implementing DOTS in different parts of India. In agreement between Danida, Government of India (GoI) and Government of Orissa (GoO), the State of Orissa was selected as a relevant and important locus for the Danish support, being one of the poorest states of India, with a large tribal population and high TB prevalence. The Danish assistance to the Revised National Tuberculosis Control Programme in India, DANTB, was established in 1997. In addition to the financial and technical support to establishing the necessary infrastructure for RNTCP, the project made Orissa special compared to other states of India by the development of two specific components dedicated to work with TB-related information, education and communication (IEC) and health systems research (HSR) by DANTB. DANTB has been fortunate to have highly creative and dedicated staff working with IEC throughout the project and while HSR provided input for IEC in terms of formative and problem-based research, the IEC activities were also set to develop innovative approaches and strategies as well as making use of successful experiences with health communication from other projects. The project attracted substantial additional funding for IEC in Orissa in comparison with other states of India, and examples of innovations include: patientprovider interaction meetings; interactive stalls at weekly markets; a wide range of folk media; involvement of panchayati raj institutions, self-help groups and community-based organisations; as well as locally-designed IEC materials. Orissa became an IEC laboratory with involvement of villagers, DOT Providers, former patients, health staff at all levels and NGOs and voluntary organisations as lab technicians. When all the districts were covered by the end of 2004, the project set focus on mass media in support of IEC, and the trialogue approach, originally developed by the Danida-supported leprosy programme, was introduced. The development of IEC in Orissa has taken place in a continuous dialogue with both GoO and GoI. It has always been the aim of Danida and DANTB to ensure that, whenever possible, successful approaches, activities and materials should be considered for large-scale adoption at the national level. An example of this

Foreword | V

is the jointly-produced web-based IEC Resource Centre, placed at the website of the Central TB Division, a landmark for IEC not only for RNTCP but for health programmes in general due to its innovative use of the Internet. In August 2005, IEC officers from all states of India were invited to Orissa to share experiences. The present Health Communication Strategy, which was circulated and discussed on that occasion, is a logical outcome of this long-standing collaboration between strong partners on IEC for RNTCP. As Danida is phasing out development activities by the end of 2005, DANTB will also cease its operations. It is indeed positive that the project leaves behind an IEC heritage that is well appreciated by GoI and that will continue to live at the national level in RNTCP II. It is hoped that the present volume will be helpful to planners at state- and district-levels in the implementation of the IEC component of RNTCP II, and that it will be widely used and disseminated.

Mariann Lyby Development Counsellor for Health Royal Danish Embassy New Delhi November 2005

VI | A Health Communication Strategy for RNTCP

Abbreviations
ADMO AIDS AIR ANM ATD&TC AWW BCC BDO BEE BPL Cat I, II & III CBO CDMO CDPO CHW CII CME CTD Danida DANLEP DANTB DD DDG DfID DHS DMET DOTS DP DTC DTO Assistant District Medical Officer Acquired Immunodeficiency Syndrome All India Radio Auxiliary Nurse Midwife Anti-Tuberculosis Demonstration and Training Centre Anganwadi Worker Behaviour change communication Block Development Officer Block Extension Educator Below poverty line Category I, II & III (anti-tuberculosis drug treatment classification) Community-based organisation Chief District Medical Officer Child Development Project Officer Community Health Worker Confederation of Indian Industry Continuing medical education Central Tuberculosis Division Danish International Development Assistance Danish Assistance to the National Leprosy Eradication Programme Danish Assistance to the Revised National Tuberculosis Control Programme Doordarshan (Indian national television network) Deputy Director General Department for International Development (UK) Director of Health Services Director of Medical Education and Training Directly observed treatment, short-course DOT provider District Tuberculosis Centre District Tuberculosis Officer

Abbreviation | VII

ESI FW GoI HIV HSR HW ICDS IEC IMA IPC LHV LT MC MCI MDR-TB MEIO MO MO-PHI MO-TU MoH&FW MPHS NGO NTI NTP NYK NSS OHP OPD PHC PHI PIP PMOE PRA PRI RD RMP

Employees’ State Insurance Family welfare Government of India Human Immunodeficiency Virus Health systems research Health worker Integrated Child Development Services Information, education and communication Indian Medical Association Inter-personal communication Lady Health Visitor Laboratory Technician Microscopy Centre Medical Council of India Multi-drug resistant-TB Mass Education and Information Officer Medical Officer Medical Officer of the peripheral health institution Medical Officer, Tuberculosis Unit (sub-district) Ministry of Health and Family Welfare Multi-purpose Health Supervisor Non-governmental organisation National Tuberculosis Institute National Tuberculosis Programme Nehru Yuva Kendra National Service Scheme Overhead Projector Outpatient department Primary Health Centre Peripheral health institution Project Implementation Plan Participatory monitoring and ongoing evaluation Participatory rapid appraisal Panchayati raj institution Rural Development Registered Medical Practitioner

VIII | A Health Communication Strategy for RNTCP

RMS RNTCP SC SDTU SHG SIH&FW SSC ST STD STDC STI STLS STO STS TAI TB TBA TOT TRC TU VHG WB WCD WHO

Review, monitoring and supervision Revised National Tuberculosis Control Programme Scheduled Caste Sub-district Tuberculosis Unit Self-help Group State Institute for Health and Family Welfare State Steering Committee Scheduled Tribe Sexually transmitted diseases State Tuberculosis Demonstration Centre State Tuberculosis Institute Senior Tuberculosis Laboratory Supervisor State Tuberculosis Officer Senior Treatment Supervisor Tuberculosis Association of India Tuberculosis Traditional Birth Attendant (trained) Training of trainers Tuberculosis Research Centre Tuberculosis Unit Village Health Guide World Bank Women and Child Development World Health Organization

Abbreviation | IX

Executive Summary
The purpose of this health communication strategy is to provide a framework to those who are in a position to plan, design, implement or support a strategic communication effort for the Revised National Tuberculosis Control Programme (RNTCP). This document addresses various target groups:      Central level decision-makers/planners State-level decision-makers/planners District-level managers and implementers Service providers (public and private) NGOs/CBOs

The communication strategy framework for RNTCP draws on the experiences of communication in RNTCP in the various states as well as the experiences in other health programmes such as the National Leprosy Eradication Programme (NLEP), Reproductive and Child Health Programme (RCH) and the National AIDS Control Programme (NACP). It builds on the Orissa model of communication in RNTCP developed by the Danish Assistance to the Revised National Tuberculosis National Programme (DANTB) and also draws pertinent lessons from the health systems research conducted by DANTB in Orissa. The Orissa model of communication involved seven strategic elements: 1. 2. 3. 4. 5. 6. 7. Universal right to know Cultural sensitivity Gender sensitivity Community participation Multi-level partnership Appropriate media mix Research, monitoring and evaluation

The document is divided into two parts. Part I provides a framework for designing and planning a communication programme for RNTCP. While the implementation of directly observed treatment, short-course (DOTS) in India is beginning to bear fruit in terms of decreased morbidity and mortality, TB is still the leading cause of death among adults. From an estimated one TB death per minute in India in 1999, the death rate has decreased to an estimated two deaths every three minutes in 2004.

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Communication has played a prominent role in RNTCP. While the project was being implemented in a phased manner during Phase I, the Centre, states and districts have realised the importance of communication to reach the vast number of people in a nation characterised by tremendous diversity. But, given the diversity and uneven development of the country in terms of infrastructure and socioeconomic indicators, this is a challenging task. Building on Phase I, the communication component of RNTCP in Phase II has three main objectives: 1. Awareness-raising for behaviour change to increase understanding about TB and the use of RNTCP services and preventive action among  the public, so that they make use of DOTS and  medical practitioners across the country, so that they know about correct TB diagnosis and treatment and they refer symptomatic cases for sputum test, or become DOT providers themselves. 2. Advocacy to create, facilitate, develop and forge political, administrative and community-level commitment to TB control in India. 3. Patient-provider communication and counselling to help ensure patient compliance with the treatment regimen, enhance the reputation of a patientfriendly service, improve provider-attitude and skills, and encourage patients and their families to become advocates for the programme. The communication strategy is guided by the following principles:     The communication approach is people-centred and client-friendly. Communication efforts and initiatives are process- rather than productoriented. Detailed planning, choice of communication channels and monitoring are decentralised Communication strategies address social and cultural issues related to TB

In resonance with the three objectives of communication in the TB-control programme, three basic essential behavioural goals are critical for success, viz. 1. Treatment-seeking 2. Timely detection 3. Completion of treatment

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The target groups for the communication strategy are:

Primary target group
1. TB patients/potential TB patients 2. Families/neighbours/general public

Secondary target group
1. 2. 3. 4. 5. Doctors/RMPs/clinic operators/medical students DOT providers Local leaders ANMs/AWWs SHGs/CBOs/NGOs/PRIs

The strategic communication framework identifies target behaviour and barriers and suggests a set of key messages and support services to be used for communicating to the group. The framework also suggests channels to reach the target group. Of particular importance to inter-personal communication (IPC) is the trialogue approach. Trialogue is a strategy that which aims at changing community attitudes and behaviour through active participation in caring for persons affected by the disease as well as open and honest discussions regarding fears, prejudice and problems concerning TB. The framework encourages the use of participatory techniques such as participatory rapid appraisal (PRA), for assessing group and community resources, identifying and prioritising problems and appraising strategies for solving them. Monitoring and ongoing evaluation are essential components of the communication framework. Planning for ongoing communication capacity-building is essential in implementing an information, education and communication (IEC) strategy, whether in regard to formative IEC assessment, design, communication product development, pre-testing, monitoring or evaluation. The framework takes cognizance of this. In order for the Government of India (GoI) to meet the challenge of coming up with an effective response to the TB situation, the involvement and reach of partners such as NGOs and CBOs is very important. Part II of this document provides detailed steps in designing and implementation of the activities, events and materials at the central, state-, district- and PHI-

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levels. This part, along with the Annexures, is particularly relevant for microplanning and may guide implementers of IEC in the adoption of a wide range of IEC activities to address specific needs and target audiences. The steps and processes are supported by a list of suggested communication activities and communication materials. In addition, a set of video modules is enclosed with the book on a VCD. They demonstrate a number of IEC activities, taking RNTCP in Orissa as an example. Also, the Annexures provide an overview of and guidelines for the web-based RNTCP IEC Resource Centre set up by the Central TB Division in collaboration with DANTB.

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Part 1
Strategic Planning Framework

Strategic Framework

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2 | A Health Communication Strategy for RNTCP

Contents
1. 2.
2.1 2.2 2.3 2.4 2.5

Introduction Communication in a TB Control Programme
TB control programme in India Communication in RNTCP Key concepts Knowledge and behavioural change The Orissa IEC model—an example

5 6
6 7 8 9 12

3.
3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

Communication Strategy for TB Control Programme
Objectives and focus of communication in RNTCP Phase II Strategic framework Guiding principles for IEC in TB control programme Behavioural goals for IEC strategy Health systems research for IEC Defining behavioural change objectives Planning at state and district level Checklist for strategic planning framework

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15 16 16 17 18 19 30 31

4.

Monitoring and Evaluation of Communication in RNTCP
What is monitoring and evaluation? Monitoring Evaluation Monitoring and evaluation in RNTCP Phase II An example: IEC and acceptability of DOTS

33

4.1 4.2 4.3 4.4 4.5

33 33 33 34 35

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5.
5.1 5.2 5.3

Capacity-building
Central level: advocacy and IEC unit State-level capacity for IEC District-level

37
37 37 38

6.
6.1

Special IEC needs in RNTCP Phase II
Improving access to hand to reach people

40
40

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1 Introduction
The purpose of this planning and implementation strategy is to provide a framework for planning, designing, implementing and supporting strategic health communication activities for the Revised National Tuberculosis Control Programme (RNTCP). The first part of the communication strategy provides a conceptual framework and is particularly intended for state-level decision-makers and planners, district-level managers and non-governmental organisations (NGOs) in charge of implementing information, education and communication (IEC) activities. The second part of this volume focuses on planning and implementing the strategy. It is particularly relevant for district- and block-level managers and implementers and for NGOs working with IEC activities. During RNTCP Phase I, IEC activities were given particular attention in the state of Orissa, where special funding and technical assistance was made available for the development of IEC activities and materials through the Danish Assistance to the Revised National Tuberculosis Programme (DANTB) project funded by Danish International Development Assistance (Danida). While the comparatively high level of IEC activities in Orissa has provided important input for the development of the present strategy, which is developed by the Central TB Division of the Directorate General of Health Services, under the Ministry of Health and Family Welfare of the Government of India, in collaboration with DANTB, it is important to point out that IEC activities have taken place in most other states in India as well, and that the present strategy is intended for a national programme. Actual implementation at state- and district-levels should take place through flexible adaptation in view of local needs and constraints; however, care has been taken to make this strategy relevant and applicable to all states of India.

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2 Communication in a TB Control Programme
Tuberculosis (TB) is an infectious disease caused by a bacillus, Mycobacterium tuberculosis. Nearly two billion people around the world are infected with the bacillus that causes TB. Each year, about 8.4 million people develop active, or infectious, TB and about two million deaths are related to TB. TB is the world’s biggest single infectious cause of death among adults. India accounts for one-fifth of the global TB incidence and is estimated to have the highest number of active TB cases amongst the countries of the world. Nearly 1.8 million new cases occur each year. TB has killed more people than any other infectious disease in India.

2.1 TB Control Programme in India
The National Tuberculosis Control Programme (NTCP), established in 1962, created an infrastructure for TB-control throughout the country and was integrated with the general health services. The programme provided free service to the community. There was no specific focus on health communication. The NTCP was reviewed during 1992 by a panel of experts. Based on the findings and recommendations of the review, the Government of India (GoI) evolved a Revised National Tuberculosis Control Programme (RNTCP) on the basis of the strategy of directly observed treatment, short course (DOTS) recommended by the World Health Organization (WHO). Objectives of RNTCP included achieving a 70 percent case detection rate and a treatment success rate of 85 percent of new smear-positive cases. This strategy was pilot-tested in 1993-94 in five sites covering a population of 2.35 million, and thereafter expanded to 17 project sites covering a population of 13.85 million, to assess technical and operational feasibility. Encouraged by the results of the pilot studies, the GoI decided to expand the programme in a phased manner to cover the entire population of India by the end of 2005 with assistance from the World Bank. Danida supported the programme in Orissa, and

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the Department for International Development (DfID) in Andhra Pradesh, Global Fund to Fight AIDS, TB, and Malaria (GFATM) in Bihar, Chhattisgarh, Jharkhand, Uttaranchal and Uttar Pradesh and the United States Agency for International Development (USAID) in Haryana. An estimated one billion people in India were covered under the DOTS strategy for TB control and more than four million people were treated as of March 2005. However, TB control in India still faces many challenges and health communication is seen as an essential component to ensure a growing public demand for RNTCP services.

2.2 Communication in RNTCP
Health communication activities for RNTCP presuppose that free quality services are in place for the target group. Accordingly, the initial emphasis in RNTCP has been on establishing and maintaining the required quality of services. From 2000 onwards, once quality services were established and their availability ensured, IEC played a more prominent role in the programme. DOTS services are now available to more than one billion people and the Centre, states and districts have realised the importance of communication to reach the vast number of people in a country characterised by tremendous diversity. Several states have taken up IEC for RNTCP using new and innovative ways. Orissa, Tamil Nadu, Gujarat, Delhi, Rajasthan and Maharashtra have tried several initiatives and developed strategies that have proved very successful. In RNTCP Phase II, the IEC component has three main objectives: 1. Awareness-raising to increase understanding about TB amongst:   the public, so that they make use of RNTCP services and medical practitioners across the country, so that they know about correct TB diagnosis and treatment and they refer patients to DOTS services, or become DOT providers themselves.

2. Advocacy to develop political, administrative and community-level commitment to TB control in India. 3. Patient-provider communication and counselling to help ensure patient compliance with the treatment regimen, to enhance the reputation of a patient-friendly service, and to encourage patients and their families become advocates for the programme.

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The IEC strategy will be guided by the following principles: 1. IEC should be process-rather than product-oriented. This has two dimensions. TB-control requires a long-term commitment from patients, providers, policymakers and communities; this commitment is built through interaction and partnerships, not by simply transmitting information. Communication strategies for TB-control therefore need to maximise opportunities for interactive communication, such as engaging cured patients to convince and support others, group meetings to discuss all aspects of TB-control, including social aspects. The other dimension of the concept of process rather than product is the list of steps required to plan IEC within a national disease control programme. To avoid over-reliance on media and materials, overall IEC planning should be based on an analysis of the needs and include a package of three components (formative research, strategy to address the needs and monitoring). 2. Detailed planning, choice of communication channels and monitoring should be decentralised to ensure local relevance and wide reach of information. The Centre will provide leadership and develop core messages, mass media and advocacy events. The states and districts will base their specific strategies on the core framework and messages, and will encourage local adaptation and innovation to reach all possible groups with the most appropriate communication tools. 3. Strategies should address social issues related to TB such as stigma and gender.

2.3 Key Concepts
In the field of communication, a number of different terms are currently in use, with different meanings and emphases, leading at times to a narrow focus on method rather than purpose. In this document the concept of ‘health communication’ is used as a generic term, whereas ‘information, education and communication’ (IEC) has been preferred over more recent terminology that stressed this or that specific aspect of health communication. For the sake of clarity, we wish to emphasise that IEC is used here as a broad category, including, for example, interpersonal communication (IPC) and behaviour change communication (BCC).  Behaviour change communication (BCC) – An approach that is specifically designed to change or sustain the behaviour of individuals or social groups, using a variety of communication techniques.

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Information and communication technologies (ICT) – A broad concept describing a range of communication and computing media that includes e-mail, the Internet, satellite and digital communication as well as television, radio, film and video. Information, education and communication (IEC) – IEC can be defined as ‘a public health approach aiming at changing or reinforcing health-related behaviours in a target audience, concerning a specific problem and within a pre-defined period of time, through communication methods and principles’ (WHO). Social mobilisation – This is an approach that empowers people to actively participate in the development process actively through local initiatives and well-informed dialogue. Social marketing – A market-oriented strategy that seeks to utilise commercially-developed marketing techniques for public health purposes by promoting and selling products, ideas, or services that are considered to have social value, using a variety of outlets and marketing approaches. Often, goods are made available at subsidised prices.

2.4 Knowledge and Behavioural Change
The concept of knowledge
In the past, health communication activities assumed that if medically-based information was disseminated in the public, this would be sufficient to lead people to change their behaviour to optimise their health. An obvious example of the failure of this assumption is smoking. If knowledge about the negative impact of smoking on health would in itself be sufficient to achieve healthy behaviour change, no medical doctors would be smokers. Human Immunodeficiency Virus(HIV) prevention campaigns during the 1980s and 1990s showed that human behaviour is, at best, only partially guided by ‘textbook knowledge’ about risky behaviour. In terms of sexual behaviour, emotions obviously constitute a very important motive; in certain situations, this is further modified by other factors, such as financial circumstances, use of substances like alcohol and drugs, inter-personal power relations, access to prevention, positive values associated with risky behaviour etc. Knowledge about transmission of infection and how to protect oneself against it is a necessary, but not sufficient, pre-condition. Therefore, health communication with the objective of HIV-prevention through the promotion of safe practices needs to be based on an analysis of human behaviour of relevance to the issue at hand. The lessons from HIV prevention are also relevant for TB: it is equally true, that merely providing factual messages like ‘Go for sputum test if coughing persists for more than three weeks’ may

Strategic Framework

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be insufficient to stimulate people to follow the advice. This is so because the message competes with local knowledge, e.g. about common cold which may be perceived as both non-serious and long-term. Therefore, the message must be packaged in such a way that it challenges this perception. Programmes, which take into account local realities when identifying key behavioural determinants, are much more likely to be effective.

Examples of contextual factors that influence behaviour change
For IEC to lead to the desired objective, contextual factors play a significant role.  Stigma Tuberculosis is very unevenly stigmatised. Experiences in India indicate that TB patients are more frequently stigmatised in urban than in rural and tribal areas. Stigmatisation cannot generally be seen as associated with lack of knowledge about tuberculosis, and it is more frequent among more educated groups than among uneducated or illiterate people. Stigma is known to be closely related to fear, and fear in relation to TB is associated with the disease being potentially fatal and infectious. Therefore, information in itself is not sufficient to de-stigmatise TB. Specific IEC activities must address the emotional aspects of stigma at the community-level. This can be done by showing carefully how care of and support to TB patients at the same time can protect the community from infection. In urban areas, mass media and involvement of role models should be utilised to address stigma. In rural areas, the trialogue approach (see below) has been developed with this purpose in mind.  Gender There is a gender imbalance in TB case detection. Proportionally however female cases are detected and treated. The reasons for this are not clearly understood yet and both biological and social determinants may be involved. In terms of IEC, gender as a social determinant for TB infection needs to be addressed. A special concern is delay of diagnosis among women due to limitations in access to diagnostic services. A study in Orissa1 found substantial gender differences when it came to action taken in response to the symptoms. Fifteen percent of women took no action when having symptoms as compared to eight percent of men. Fifty percent of women did not go to a peripheral health institution (PHI) as the first point of treatment, as compared to

DANTB and New Concept Information Systems: Low Utilisation of TB Services by Women. New Delhi, 2002.

1

10 | A Health Communication Strategy for RNTCP

41 percent of men. Nearly a third of the female respondents who did not go first to the PHI waited anywhere between one and four months before they took any action. Another study in rural Maharashtra2 queried respondents without active disease about vignettes depicting a man and a woman with typical features of TB. Emotional and social symptoms were frequently reported for both vignettes, but more often considered most distressing for the female vignette; specified problems included arranging marriages, social isolation, and inability to care for children and family. Job loss and reduced income were regarded most troubling for the male vignette. Men and women typically identified sexual experience as the cause of TB for opposite-sex vignettes. With wider access to information about TB, male respondents more frequently recommended allopathic doctors and specialty services. The planning of IEC activities must take gender aspects into account to reach women effectively both in terms of ensuring that IEC reaches women and that IEC messages are relevant in view of the constraints that women may face in society. But gender issues also include attention to health issues that are specific to men; an example in some communities could be the problem use of alcohol being more common among men and requiring special attention to increase completion of treatment.  Poverty The epidemiological pattern of tuberculosis follows income patterns and the disease is closely linked to poverty, poor housing conditions and poor hygiene. It follows that TB patients are more likely to be poor and illiterate than the average population. Accordingly, a variety of means and media must be used to reach the target groups. Furthermore, it must be acknowledged that poverty itself drastically decreases the freedom to make choices in life. Hence, it may be very difficult for patients to give priority to treatment over work, once they feel better. The IEC strategy must take into account the living conditions of the target groups and the limited possibilities for poor people to follow advice provided from a public health perspective.

Atre SR, Kudale AM, Morankar SN, Rangan SG, Weiss MG. Cultural concepts of tuberculosis and gender among the general population without tuberculosis in rural Maharashtra, India. Trop Med Int Health. 2004 Nov. 9 (11):1228-38.

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 Behavioural Change
A Basic Model of Communication for Behavioural Change can be Summarised as Follows: Accurate and timely information is a necessary, but not sufficient, prerequisite to behavioural development and change. Information alone seldom leads to behavioural change. Communicating information through appropriate channels in motivating formats is one essential component of successful programmes. People need to be empowered to make basic everyday decisions about their own lives in order for them to act on the information received, no matter how motivated they are. Their wider environment must support and facilitate change for the effect of the programme to be sustained.

2.5 The Orissa IEC Model—An Example
From the outset, communication activities have been a major part of the RNTCP/ DANTB partnership in Orissa. While many new and innovative communication activities have been tried in various states, the Orissa experience was a welldocumented one. Based on the experience and learning over the years in several phases of implementation and scaling up of the TB control programme in Orissa, a model of communication has emerged, which is characterised by seven elements:
Cultural Sensitivity

Right to Know

Gender Sensitivity

Appropriate Media Mix

TB Control

Elements of Orissa Communication Model

Research, Monitoring and Evaluation

Community Participation

Multi-level Partnership

12 | A Health Communication Strategy for RNTCP

2.5.1 Universal right to know
The over-riding principle of the strategy is that every person has a right to essential health information, including the basics about DOTS. It is the responsibility of the government at all levels to ensure that this information is made available to all people, irrespective of their social and economic status, level of education, gender, religion or any other specific individual or group characteristics.

2.5.2 Cultural sensitivity
It has been characteristic of the development of IEC activities for RNTCP in Orissa that communities have been involved in a bottom-up approach. This has been guided by a systematic effort to challenge the marginalisation of certain groups and individuals at the community-level, and which has worked to reduce the distance between service providers, patients and communities. For example, special initiatives have been designed to decrease social distance between tribal communities and non-tribal service provides, targeting the latter to increase their understanding and tolerance of cultural variation.

2.5.3 Gender sensitivity
Gender issues influence timely detection and treatment completion for both men and women. The communication strategy needs to address gender through special gender sensitisation initiatives and through mainstreaming gender in the planning, development and implementation of any communication activity.

2.5.4 Community participation
Community involvement in planning and implementation of IEC activities foster a sense of ownership of the programme at the local level. Social mobilisation is based on direct dialogue with the community to understand and explore existing concerns and possible social conflicts with relevance to diagnosis and treatment. Potential or actual processes of social marginalisation need to be identified and addressed. Ideally, this will create a self-supporting and sustainable system for voluntary reporting of people with TB symptoms. Only by creating a shared understanding that DOTS is possible in spite of these factors, and that cure of TB is necessary for individuals, the active involvement of communities in demanding RNTCP services can be ensured.

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2.5.5 Multi-level partnership
It requires the involvement and multi-level partnership of a broad range of people to support large-scale adoption of health practices that can bring down TB morbidity and mortality. It is a strategic aim to involve relevant partners in IEC activities as the patient may come into contact with a range of different people and institutions in connection with diagnosis and treatment. Partners may include private practitioners, NGOs at local, state and national levels, corporate bodies and commercial establishments including pharmaceutical companies; community groups (in particular women’s groups); local government and panchayati raj institutions (PRI); self-help groups (SHG) and other communitybased organisations (CBO).

Different media have different qualities of communication and they carry different aspects (intellectual, emotional etc.) of a message. In addition, different target groups may have different degrees of access to different media. Importantly, illiteracy is a barrier for some people in accessing any written IEC. Material development is an essential component of any IEC programme. It is necessary to develop different types of materials for different types of audiences with focused, targeted messages. Professional designers may often belong to the middle class and employ middle class aesthetics. In Orissa, the use of drawings made by artists from tribal communities proved highly successful both in terms of the key audience’s ability to understand the messages and of increased ownership of the programme.

TB Control

2.5.6 Appropriate media mix

2.5.7 Research, monitoring and evaluation
Research is required to assess communication needs and to understand barriers to the desired health-related behaviour in order to develop an optimal communication strategy and design. Particularly for needs assessment and impact evaluation, and to address identified problems and bottlenecks, participatory research methods should be used to involve communities in analysing inputs and outcomes. Monitoring and evaluation are separate from research and should be built into the IEC activities as a routine component. Monitoring and evaluation help to identify problems, measure progress towards achievement of objectives and assess results in order to correct the problems identified. In addition, a routine monitoring system with standard formats to document all IEC activities needs to be in place (see Annexure 7 for monitoring formats).

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3 Communication Strategy for TB Control Programme
While the implementation of the DOTS strategy in India is beginning to bear fruit in terms of decreased morbidity and mortality, TB is still the leading cause of death among adults. From an estimated one TB death per minute in India in 1999, the rate has come down to an estimated two deaths every three minutes in 2004. During Phase I, the Centre, states and districts realised the importance of communication to reach the vast number of people in a nation characterised by tremendous diversity. But, given the diversity and uneven development of the country in terms of infrastructure and socioeconomic indicators, this is a challenging task.

3.1 Objectives and Focus of Communication in RNTCP Phase II
Building on Phase I, the communication component of RNTCP in Phase II has three main objectives: 1. Awareness-raising for behaviour change to increase understanding about TB and the use of DOTS services and preventive action among:  the public, so that they make use of RNTCP services and  medical practitioners across the country, so that they know about correct TB diagnosis and treatment and they refer patients to DOTS services, or become DOT providers themselves. 2. Advocacy to create, facilitate, develop and forge political, administrative and community-level commitment to TB control in India. 3. Patient-provider communication and counselling to help ensure patient compliance with the treatment regimen, to enhance the reputation of a patient-

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friendly service, to improve provider attitude and skills and to encourage patients and their families to become advocates for the programme.

3.2 Strategic Framework
The aim of developing a strategic framework for IEC is to identify the communication need (objectives), communication players/audience (target groups) and communication tools (channels, activities and materials). This framework will build on the work already undertaken within RNTCP in Phase I. It will be further modified to encourage a needs-based approach and will include aspects of monitoring and assessment. The focus in RNTCP Phase II is on a combination of Centrally-produced core messages and media, and needs-based planning to develop state-and districtspecific strategies, with local innovations to reach all possible groups through the most appropriate channels, materials and activities. The Central core framework provides the general outline, and each state will come up with a more detailed strategy based on their own needs, analysis of the problem and the target groups, so that IEC activities are tailored to address local needs, and reflect local culture. The framework has six components: objectives, target groups, messages, channels, activities/materials and research and monitoring. These are applied to each of the three objectives or IEC components. All IEC sub-components will be analysed qualitatively to assess the needs, correct and refine the programme as it evolves and help in gauging programme success in real-time. The core strategic framework has been developed for use across the programme to ensure a clear and unified strategic direction for IEC throughout RNTCP. Core messages for the broad categories of target groups for each of the three objectives will be standardised at the Central level to ensure that the accuracy of messages is not compromised or diverted from the national programme’s key objectives. The framework’s contents may be modified over time. More detailed segmentation of audiences at the state and district levels will help to formulate more specific and targeted messages, identify appropriate channels and to develop context-specific activities and materials.

3.3 Guiding Principles for IEC in TB Control Programme
The over-riding principle of a communication strategy in the TB control programme is that every person has a right to essential health information, including the basics about DOTS, which involves timely diagnosis and necessary treatment.

16 | A Health Communication Strategy for RNTCP

The communication strategy is guided by the following principles: 1. The communication approach is people-centred and client-friendly. This means understanding the audience, their context, their perceptions and their beliefs, and that too from their perspective, by learning from them, listening to them and working with them. 2. Communication efforts and initiatives are process- rather than productoriented. TB control requires a long-term commitment from providers, policymakers and communities; this commitment is built through interaction and partnerships, not simply by transmitting information. A systematic analysis of needs and ongoing monitoring and evaluation are required to continuously guide this process. 3. Detailed planning, choice of communication channels and monitoring are decentralised to ensure contextual relevance and a wide reach of information. The Centre provides leadership, develops core messages and mass media and advocacy events but otherwise supports a decentralised approach. The states and districts base their local strategies on the core framework and messages and promote local adaptation and innovation to reach all possible groups with the most appropriate communication tools. 4. Communication strategies address social and cultural issues related to TB such as stigma, social distance between patients and providers, poverty, illiteracy and gender. Addressing socio-cultural issues has a positive impact on treatment-seeking and -completion.

3.4 Behavioural Goals for IEC Strategy
In RNTCP three basic essential behavioural goals are , critical for success, viz. 1. treatment-seeking, 2. timely detection and 3. completion of treatment.

Trea

t

m

en

t Seeki n

g
Ti

m
ely

General awareness of TB symptoms forms a necessary backdrop for treatment-seeking behaviour during the early stages of disease.

Treatmen

1. Treatment-seeking

t

Det

ec

pletion o

Treatment-seeking leads the person with symptoms into contact with the health system, where diagnosis

om

2. Timely detection

f

Strategic Framework

ti

on

C

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can be performed. The earlier the correct diagnosis is established, the sooner the treatment can begin and the patient cease to be a potential source of infection.

3. Completion of treatment
The treatment for TB is long and must be completed for a patient to be cured. After one or two months of treatment, the symptoms of TB subside and this often leads to a shift in the patient’s priorities. Patients may live in circumstances where earning a living, family responsibilities or job compulsions are seen as more compelling than going to the DOT provider or the health centre. Since it has proved impossible to predict risk of defaulting, it is critical that the patient is given unremitting support and counselling. We shall consider treatment-seeking, timely detection and completion of treatment as our strategic behavioural goals.

3.5 Health Systems Research for IEC
Health systems research (HSR) can provide essential input for IEC. HSR is an umbrella concept for multidisciplinary research on identified health systemrelated problems. Complementary research methods are selected accordingly.

3.5.1 Utilisation of research for IEC development: an example
Prior to the development of the Orissa IEC model for RNTCP, an HSR project was undertaken with the objective of determining the knowledge, perceptions and health-seeking behaviour of three tribal districts of Orissa with regard to chest symptoms and to assess local sources of information on health and disease.1 The findings of this study revealed that blood in sputum was perceived as the main distinctive symptom of TB and was also seen by villagers as leading inevitably to the death of the victim. The causes of TB were perceived to be alcohol, tobacco and hereditary disposition, while at the same time TB could spread through direct social interaction. The first point of contact for people with TB symptoms was the traditional healer. Half the population knew that TB treatment was now free, but most knew patients who had spent lots of money on treatment. The defaulter rate was as high as 15 per cent, and the average minimum delay in diagnosis was 111 days for men and 146 days for women. These results pointed to the need to develop new kinds of communication activities that could effectively make appropriate TB information available to largely illiterate populations, including the tribal communities. With the

Health-Seeking Behaviour of Tribal Communities for TB: Perceptions and Practices — a study in three districts of Orissa, October, 2000, DANTB, Orissa. www.dantb.org
1

18 | A Health Communication Strategy for RNTCP

expansion of RNTCP coverage beyond the initial districts, the communication activities also expanded, and, in 2003, a comprehensive IEC strategy for RNTCP in Orissa was developed on the basis of the experiences gained. The ultimate goal of health research is to contribute to the solution of priority health problems. However, the purpose is to produce research results of sufficient quality to inform and guide policy decisions. The above example illustrates how research, when integrated into health programme planning and implementation, can play an important role in improving the utilisation and coverage of health services by creating a dialogue between programme staff, policy-makers and researchers.

3.6 Defining Behavioural Change Objectives
Whether the target population is a particular group or the general public, it is important first to refer to the TB control programme’s behavioural change objectives. What changes in behaviour does the programme intend to achieve?

3.6.1 Understanding audience and target behaviour
While selecting and addressing the target groups we need to consider that the ultimate goal is to promote behavioural change among potential and current patients so that they seek treatment, get diagnosed and complete treatment. Given these goals, the primary and secondary target groups for the communication strategy include (but is not limited to):
Primary Target Group
 TB patients/potential TB patients  Families/neighbours/general public

Secondary Target Group
 Doctors/RMPs/clinic operators/medical students  DOT providers  Local leaders  ANMs/AWWs  SHGs/CBOs/NGOs/PRIs

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Often, intermediate agents, such as media and influential community members, play an important role in reaching both primary and secondary target groups.

3.6.2 Defining the communication objectives for the target audience
Once local needs have been assessed, a matrix is developed to identify the objectives for each target group. Below is given an example for illustration.
Primary target group 1. TB patients/potential TB patients 2. Families/neighbours/general public Secondary target group 1. Doctors/RMPs/clinic operators/ medical students 2. DOT providers 3. Local leaders 4. ANMs/AWWs 5. SHGs/CBOs/NGOs 6. PRIs Raising awareness about TB 1. Seeking timely treatment 2. Taking care of self and family members 3. Reducing stigma and discrimination 1. Equipping with information to communicate better 2. Increasing capacity for providing care and making services more accessible

3.6.3 Identifying and defining barriers
Having defined the primary and secondary target audiences and the communication objectives, the next step is to use the available knowledge and/ or findings of the needs assessment to identify barriers and means to overcome them. It must be noted that not all barriers can be addressed by communication alone. The table below shows possible barriers that could emerge in such an exercise:
Target audience Primary target group TB patients/potential TB patients Low awareness about TB Low risk perception Misconceptions about cure and treatment Fear of TB Stigma and discrimination Accessibility to services Cost of services and treatment Attitudes of service providers Treatments process and time taken Low awareness about TB Barriers

20 | A Health Communication Strategy for RNTCP

Primary target group Families/neighbours/general public Low risk perception Misconceptions about cure and treatment Fear of TB Stigma and discrimination Accessibility to services Cost of services and treatment Secondary target group 1. 2. 3. 4. 5. 6. Doctors/RMPs/clinic operators/medical students DOT providers Local leaders ANMs/AWWs SHGs/CBOs PRIs Inability to communicate effectively Lack of relevant information Lack of counselling skills

3.6.4 Understanding barriers and target behaviour
A participatory communication strategy with emphasis on community participation needs to have a bottom-up approach, which systematically seeks to challenge the dynamics that marginalise certain groups and individuals at the community level. A key concern is to overcome communication gaps and social distance between service providers, patients and communities. A small but symbolically very important example of this is to insist that all participants sit at the same level during meetings, irrespective of their status outside. An antihierarchical approach establishes a context in which it is seen as meaningful for people to change their behaviour actively and participate in the implementation of the DOTS programme for themselves as patients and for other patients in their community. In order to involve all members in group activities, participatory learning methods are required.

Participatory learning
Participatory learning is a creative problem-solving method in which every member participates actively. In the participatory approach, the learning process is just as important as the subject of learning. Participatory learning:
    

focuses on the needs and problems of group members, uses each group member’s knowledge, experience and skills, considers every participant a trainee and a trainer, uses practical real-life activities so participants learn by doing and takes place at a location and in a setting where participants feel at ease.

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Participatory learning increases group members’ understanding of their situation and makes them more aware of their own values, attitudes, skills and knowledge. It allows them to discover their hidden talents and capacities and strengthens democratic community-level problem-solving and decision-making processes. One of the well-established forms of participatory learning is participatory rapid appraisal (PRA). Individuals with PRA experience should be involved and/or specific literature be consulted when adopting PRA techniques. An illustrative list of behavioural barriers is provided below that may be identified through participatory learning processes.

Illustrative List of Behavioural Barriers with Examples
S No. 1. Behaviour The target behaviour exists but not to an adequate degree or with sufficient frequency. The target behaviour exists but not for sufficient duration. Example Patients do not approach a health facility for investigation after the onset of TB symptoms for more than three weeks. Patients do not complete treatment but stop when the symptoms disappear. Reason Early symptoms are not considered serious.

2.

Implications of stopping treatment are not understood. The DP has been insufficiently trained and/or supervised. Importance of early treatment not understood. Services are not trusted. DOTS and/or curability of TB is not accepted.

3

The target behaviour exists but not in the form desired.

The DOT provider visits the patient for follow-up but gives information in a patronising manner and does not provide support for completing the treatment. The patient is not taken for sputum test and treatment until a late stage where chances of cure are small.

4

The target behaviour exists but not at the right time.

5

The social and cultural aspects of the disease in question may block the desired practice.

Stigmatisation may effectively block timely detection of TB for particular groups, e.g. women.

6

A woman may not be allowed to leave the house at the The life conditions of the target time of an interaction meeting because no man will population block them from accessing either IEC information or accompany her. services or both. The target behaviour has a competing priority behaviour. The opportunity cost for continuing treatment or the need to resume work after the relief of symptoms may affect treatment completion. Taking seven pills every alternate day for two to three months, followed by a sputum examination, followed by three to four months of continued medication, may appear simple on paper, but practising it may be difficult for a variety of reasons as mentioned above.

Gender discrimination blocks women’s access to services.

7

Poverty affects choices of patient.

8

Desirable health practices are frequently more complex than they may appear to be.

As provided above.

22 | A Health Communication Strategy for RNTCP

3.6.5 Developing approaches to address the barriers
After having defined the barriers to be addressed, the next step is to identify the relevant communication approaches. The matrix below provides an example with target groups to be addressed, barriers, key messages that will be communicated and support services that would be needed to achieve these changes.
Target groups Primary target group  TB patients  Potential TB patients Barriers  Low awareness about TB  Low risk-perception  Misconceptions about cure and treatment  Fear of TB  Stigma and discrimination  Accessibility to services  Cost of services and treatment  Attitude of service providers  Treatment process and time taken Primary target group  Families  Neighbours  General public  Low awareness about TB  Low risk-perception  Misconceptions about cure and treatment  Fear of TB  Stigma and discrimination  Accessibility to services  Cost of services and treatment Secondary target group  Doctors  RMPs  Clinic operators  Medical students  DOT providers  Local leaders  ANMs/AWWs  SHGs/CBOs  NGOs  Inability to communicate effectively  Lack of relevant information  Lack of counselling skills  Today there is a sure cure for TB but your support is needed to make it fully effective  Provision or access to health services  Education services  Counselling services  Information services  There is a sure cure for TB through DOTS  Save somebody’s life by convincing them to take the full treatment for TB  Provision and access to health services  Counselling services  Information services Key Messages  A cough that lasts for more than three weeks could be TB  There is a sure cure for TB through DOTS  Availability of free diagnosis and treatment through PHCs Support Services  Provision of and access to user-friendly health services  Counselling services  Testing facilities  Treatment facilities

3.6.6 Develop themes and messages
While the strategy puts emphasis on understanding the local needs, stateand district-level implementers need not re-invent the wheel. The online IEC Resource Centre should be consulted to assess whether suitable materials exist that can be adapted to the local needs.

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When a new campaign is developed, it should have an overall theme that will appeal to and attract the target populations. The theme should stem from the BCC formative assessment and further consultation. It should provide overall guidance for the development of messages, which should therefore be consistent with the theme. The theme should be positive. It is now commonly understood that fear campaigns and campaigns blaming particular groups are ineffective. Most experts agree that fear tends to focus an audience’s attention on what not to do, or what to avoid, and they may increase victim-blaming and stigma that in turn cause people to avoid services that may benefit them. Approaches are more effective when they promote positive messages that state clearly what audiences can and should do. The theme should be catchy and devised in such a way that all target populations can relate to it and identify with it. People who see different messages for different audiences should be able to link any of these diverse elements with the theme of the campaign.

3.6.7 Developing a creative brief
After collecting information on the target audience and determining the best communication materials to be used, and before beginning the actual design of communication materials, the material development team should prepare a ‘creative brief’ for each material to be prepared. The creative brief serves as a guide, assisting those who carry out actual material design and production. The creative brief should define the objectives of the IEC material, identify obstacles to be expected in its use or acceptance, develop draft messages or advice and support statements, define the tone of the messages and list any other necessary creative considerations such as different language versions or social conditions. In short, the creative brief serves as a map or guidebook for the IEC material development team and the creative designers.

3.6.8 Designing messages
A message is a short phrase or sentence that summarises an idea in a simple, attractive and understandable term. It is the ‘take-away’ information that is repeated to friends, colleagues and other interested parties. A good message is short and to the point and answers to the hopes and aspirations of the target population: ‘If I do X (get information, go for diagnosis), I will benefit by Y’ (not get very ill and lose income, protect my family, be completely cured). Whatever the benefit, it will have to outweigh any disadvantage or ‘cost’ the audiences might perceive. People may also need messages that help them feel they can succeed. This may be accomplished through messages that model success and positive outcomes.

24 | A Health Communication Strategy for RNTCP

3.6.9 Pre-testing materials
The pre-testing of IEC materials is an important step in the development process. Without pre-testing, IEC materials stand the risk of becoming inefficient and detached from the needs of the target audience. Such IEC materials may be neutralised, transmit useless information, not motivate, or not build upon existing positive practices. Pre-testing draft materials can help determine whether the materials and messages are acceptable to the intended target audience and the individuals charged with using or distributing the material. Pre-testing of draft IEC material ensures that the material is ‘right’ from the audience’s perspective.

3.6.10 Selecting suitable channels
Communication channels are used to access the target groups with the intended messages. While the profiles of target groups are indicative of how they can be reached, it is important to understand and clarify the main mechanisms to be adopted for reaching each target group. Typology of media (interpersonal/mass media) (one way/two way, advocacy)       Folk media/street theatre Interactive/IPC Events/exhibition/World TB Day rallies Mass media—electronic, broadcast, print, outdoor Advocacy Capacity-building

For each type of media, there can be a number of specific forms of implementation. To choose the best mix for a particular target audience and communication purpose, the advantages and disadvantages of the different types and forms should be carefully considered. The table below provides a sample analysis of this.
Media Type
Main television channels Local television channels Film Print

Advantages
 Reaches communities on a large scale

Disadvantages/Special Requirements
 Does not reach the poorest and

most disadvantaged groups
 Expensive to produce  Reaches communities through their  Reach is limited  Expensive to produce  One-way communication  Expensive to produce  Requires writing/reading skills (does

Mass Media

dialects
 Information/education through

entertainment
 Can use the material more than once  Can mobilise public opinion  Can contain more detailed information

not reach illiterate people)

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Hoardings

 High visibility if well-placed

 Easily removed  One-way communication  Stationary  Requires writing/reading skills (does

Bus panels Outdoor Wall paintings

 High visibility if well-placed  Mobile  High visibility if well-placed  Can be used in relevant context (i.e,

not reach illiterate people)
 One-way communication

PHI walls) Exhibitions
 Can combine numerous materials and

media  Can be interactive Street plays Puppets Song and Dance
 Focuses directly on real-life issues and

 Expensive  Requires staff  Requires troupe of actors  Requires travel from village to village  Requires puppet theatre  Requires travel from village to village  Requires singing and dancing

Folk Media

provides a platform for solutions  Flexible infotainment method for educating communities  Can effectively reach illiterate communities  Can be combined with counselling  Is liked by all age groups (including children)
 Interactive method to address

troupe
 Requires travel from village to village  Requires skilled persons for

Haats

questions from target audience  Weekly market setting reaches both men and women Communication Media Community radio
 Can generate vivid local-level

communicating
 Requires travel from village to village  Women may not attend

discussion  Particularly useful at village clubs/ gatherings
 Large-scale participation  Strong coordination of activities at all  Short-lived  Requires organising capacity  Requires good communication skills

Rally Events World TB Day Patientprovider interaction meetings IPC Trialogue

levels simultaneously
 Decreases social distance  Creates mutual confidence between

patients and providers
 Establishes community support for  Requires good communication and

patient  Addresses stigma Peer education  Critical-awareness-building Group meetings
 Can create critical mass of change

facilitation skills
 Requires careful selection and

training of peer educators
 Effect depends on social

agents at community-level  Interactive and participatory communication process
 Can create critical mass of change

cohesiveness of group outside the activity
 Requires good communication skills

Community meetings

agents at community-level  Interactive and participatory communication process

26 | A Health Communication Strategy for RNTCP

1. Treatment-seeking Behaviour

IEC Strategic Framework, Goals, Objectives, Audience, Themes, Activity and Indicators
Audience  Community groups  Local community leaders  Opinion leaders  Role models  Perception —right, respect, responsibility  Concept of DOTS  Mass media  IPC  Folk media  Advocacy  Social mobilisation  Intersectoral partnership with NGOs/ PRIs/SHGs/teaching institutions Key Barriers Themes/Message Focus Activities/ Channels/ Media Indicators  Positive reports in media  Decrease of delay in diagnosis  Decreased fear of TB diagnosis  Increased support to people with TB symptoms to go for diagnosis  Increased uptake of services  Increased community support from PRIs

Goals

Objectives

Awareness

Advocacy  Community groups  Formal/informal community organisations  PRI members  Importance of early detection and effects of complete treatment

Treatment-seeking Behaviour

TB CONTROL

 General mistrust due to previous bad experiences with health services  Unauthorised TB treatment exists  Low awareness about TB  Low risk-perception  Misconceptions about cure and treatment  Fear of TB  Stigma and discrimination  Accessibility of services  Cost of services and treatment  Negative attitude of service providers  Mass media  IPC  Folk media  Advocacy  Social mobilisation  Intersectoral partnership with NGOs  IPC  Role play  Street theatre  Games  Display/print media  Interaction in groups  Previous bad experience with health services  Poor communication skills  Good provider behaviour  Importance of friendly and informative communication with patients

Patient Patients with TB provider symptoms and Communication their families  Staff of PHI

 Decreased rejection by community and family  No. of people with TB symptoms seen by medical doctors  Increased voluntary testing

Strategic Framework

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2. Timely Detection
Audience  Community members  Community groups  Community leaders  Political representatives  Health system staff  NGOs/PRIs/ SHGs  Insufficient attention importance being given to TB symptoms among health staff  Low risk-perception  Misconceptions about cure and treatment  Fear of TB  Stigma and discrimination  Accessibility to services  Negative attitudes of service providers  Illiteracy  Competing interests and priorities  Competing demands for attention  Role models  Perception —right, respect, responsibility  Knowledge of  Timely detection  Availability of free drugs  DOTS strategy  Mass media  Print media  Folk media  Display media  Advocacy  Social mobilisation  Intersectoral partnership with NGOs/ PRIs/SHGs/ teaching institutions. Key Barriers Themes/Message Focus Activities/Channels/ Media Indicators  Increased demand for diagnostic services  Increase in correct and complete information  Decrease in stigma and discrimination  Increased community support for diagnosis

Goals

Objectives

Timely Detection

28 | A Health Communication Strategy for RNTCP  Opinion leaders  Political representatives  Media representatives  Knowledge about TB, symptoms, mode of infection and treatment  Information on DOTS strategy  Mass media  IPC  Folk media  Advocacy  Social mobilisation  Intersectoral partnership with NGOs/ PRIs/SHGs/ teaching institutions  Role models  Perception – right, respect, responsibility  Knowledge of DOTS strategy  IPC  Role play  Games  Display/print media  Interaction in groups  Communication strengthening activities  Increased support for DOTS  Increased demand for diagnostic services  Increased support from PRIs and other institutions  Increased media coverage of TB  Increased support to patients with TB or TB symptoms  Increased trust between patients, families and providers  Decrease of both diagnosis and treatment delay  Increased voluntary testing

Awareness

Advocacy

TB CONTROL

Patient Patients  Insufficient attention/ provider importance being given  Family members Communication to TB symptoms among of affected health staff people with TB  Lack of counselling skills  Staff of PHI  Poor communication skills

3. Treatment Completion
Audience  TB patients  Community  General public  Low risk-perception  Misconceptions about cure and treatment  Adverse effects of treatment  Difficulty in swallowing many tablets  Accessibility to services  Attitude of service providers  Treatment process and time taken  Financial constraints  Importance of correct, complete treatment and regular sputum check-up  Proper counseling on routes of transmission, methods of prevention  Role models  Perception  Effects of correct, complete treatment and regular sputum check-up  Implications of not completing treatment  Mass media  IPC  Folk media  Advocacy  Social mobilisation  Intersectoral partnership with NGOs/PRIs/SHGs  Games Key Barriers Themes/Messages Focus Activities/Channels/ Media Indicators  Increase in correct and complete treatment  Decrease in defaulting

Goals

Objectives

Awareness

Advocacy

 Increased support for DOTS

Treatment Completion

TB CONTROL

 Community groups  Formal/informal community organisations

 Lack of relevant information  Lack of communication skills  Poor communication skills

 Mass media  IPC  Folk media  Advocacy  Social mobilisation  Intersectoral partnership with NGOs  Proper counselling  IPC  Role play  Street theatre  Games  Display/print media  Interaction in groups

Patientprovider Communication  Patients  Family members of TB patients

 Competing priorities for patient/family  Inability to take medicines/ go for sputum test  Distance between DP and patient  Lack of counselling skills

 Increased use of DOTS services  Increased support for patient to complete treatment  Increased regularity of treatments

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3.7 Planning at State- and District-level
It has been described above that a plan of action should be based on audience needs, putting objectives and goals first. This could be filled in a matrix, as given below.

Action Plan
S.No. Goal Objective Audience Activity/Materials/ Events Budget

1 2 3

Awareness Advocacy PP Communication

The next step is to develop a media plan of how the activities and materials will flow over the months in the year. This should ensure that activities and materials are taking place in the planned manner. It should also help to synchronise activities for maximum benefit. This requires knowledge of media habits and the differential reach of various media and their relevance to the target audience. A planning matrix has been given below that can be used to get an overview of the media mix over a period of 12 months.

Media Plan
TV Jan Feb Mar Apl May Jun Radio Press Outdoor

Jul Aug Sep Oct Nov Dec

30 | A Health Communication Strategy for RNTCP

3.8 Checklist for Strategic Planning Framework
1. Analysis of the situation
1. Purpose (health situation that the programme is trying to improve) 2. Key health issue (behaviour or change that needs to occur to improve the health situation) 3. Context (wtrengths, weaknesses, opportunities and threats (SWOT) that affects the health situation) 4. Gaps in information available to the programme planners and to the audience that limit the programme’s ability to develop sound strategy. These gaps will be addressed through research in preparation for executing the strategy 5. Formative research (new information that will address the gaps identified above)

2. Communication strategy
1. 2. 3. 4. 5. 6. Audiences (primary, secondary and/or influencing audiences) Objectives Positioning and long-term identity Strategic approach Key message points Channels and tools

3. Management considerations
1. 2. 3. 4. Partner roles and responsibilities Timeline for strategy implementation Budget Monitoring plan

4. Evaluation—tracking progress and evaluating impact strategy review checklist
The table below is a checklist to help you ensure that the communication strategy is completely integrated into the RNTCP. As mentioned at the beginning of the book, strategic communication is the steering wheel that guides the rest of the programme. This checklist helps to ensure that the steering wheel is working successfully.

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Review Checklist
Subject Key Question Degree of integration (Score) (1-lowest, 10-highest)

Objectives Programme implementation

Do the behaviour change objectives fit with the programme objectives? Do the communication activities fit well with other programme functions such as service delivery, logistics, policies and staffing? Are the communication messages consistent with availability, access and cost (financial and psychological) of the service? Are the tools and channels being used to guide the audience through the steps to behaviour change? Is the message design consistent with the positioning of the product, service or behaviour? Are all internal and partner organisations working together in accordance with an agreed upon plan and strategy with regular progress meetings? Is the budget being used in the most efficient and effective way to ensure that the economies of scale are achieved? Level of integration (total) (Total possible score=70)

Message integration

Communication mix integration Message design integration Management integration

Financial integration

32 | A Health Communication Strategy for RNTCP

4 Monitoring and Evaluation of Communication in RNTCP
The design of any health communication campaign needs to include monitoring and evaluation activities to be complete. Monitoring and evaluation help to identify problems, measure progress toward objectives and assess results.

4.1 What is Monitoring and Evaluation?
 Monitoring is a regular assessment of routine records of decisions, activities, expenditures and, if possible, outcome indicators to ensure that actions are taken according to plan and that the expected outcome is achieved. Evaluation is an analysis of activities and outcomes relative to project or programme objectives.

4.2 Monitoring
Documentation of activities is a necessary pre-condition for ongoing monitoring. Therefore, standard formats need to be used. Sample formats have been annexed in this book, but additional formats will have to be developed according to the specific needs and further development of the IEC component. Monitoring is particularly useful in two areas: 1. Monitoring for management: Careful monitoring is essential throughout implementation to be able to identify bottlenecks and critical barriers that may otherwise derail the programme. 2. Monitoring for accountability: Monitoring enables the state and funding agencies to assess the value of the programme and demonstrates appropriate use of funds.

4.3 Evaluation
Evaluation questions are formulated by using the behavioural objectives as criteria after the media are finalised, reproduced and put to use. Evaluation may look at processes and/or outcomes. Process evaluation will often be qualitative in nature and analyse organisational, managerial, administrative and technical aspects of a programme, a project or an intervention. Outcome

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evaluation may often use both qualitative and quantitative methods and will assess whether the objectives of the activity were achieved. While outcome indicators seem straightforward in terms of IEC activities for RNTCP, in practice they are not. Even though it is known that IEC will certainly strengthen both case-detection and case-holding, it is difficult to know what is the contribution of IEC is in a particular case, compared to other factors (such as vacancies at PHI level, personal relationship between DP and patient, role of private practitioners in community etc.). Because of the many possible compounding factors the success of IEC activities cannot simply be read from the standard quantitative IEC indicators. What can be assessed are qualitative indicators such as general awareness of signs and symptoms at the communitylevel, reasons for preferring a particular first-line treatment option, and community-level acceptability of DOTS.

4.4 Monitoring and Evaluation in RNTCP Phase II
At the Central level, monitoring and evaluation has been the policy of the programme and will be continued. An end-term impact assessment of the Phase I media activities would be the basis for developing a media plan for the Phase II project. At least one mid-term review/impact assessment will be conducted to help in fine-tuning the media campaign during the project period, and one detailed end-term impact assessment will be carried out. Opportunities for feedback on IEC activities would be found during routine meetings, such as the weekly meetings of PHIs and designated MCs, fortnightly reviews of the STS/ STLS by the MO-TC, monthly district-level review meetings between the DTO and staff, state-level review meetings held at the end of each quarter and CTD review meetings of STOs twice a year. These review meetings are useful tools for monitoring the implementation of the IEC components. Focused qualitative studies would be encouraged to be undertaken by some states. These would be useful both in designing and refining IEC strategies. These could be outsourced to local institutes or NGOs. Larger studies would fall under the operational research agenda. Process indicators for monitoring state capacity to formulate and implement needs-based IEC activities will be developed over the course of the first year, and used for monitoring the decentralisation of IEC activities. An appropriate checklist designed by the programme would be used as a standard tool for monitoring state level activities. State annual action plans would be monitored against achievements at the statelevel, and IEC would be included in the periodic internal evaluations conducted by states and CTDs.

34 | A Health Communication Strategy for RNTCP

The following issues are some examples included in the National Operational Research Agenda:   Study profile of initial defaulters and analyse barriers to their access to DOT Qualitative studies to document the impact of stigma on access to and utilisation of RNTCP services Qualitative assessment of effectiveness of patient information leaflets and other materials Qualitative assessment of impact of IPC training on sensitivity of providers to socio-economic needs of patients Qualitative study to understand the barriers to utilisation of RNTCP services in tribal areas Evaluation of IEC messages prepared in locally relevant tribal dialects/languages

4.5 An Example: IEC and Acceptability of DOTS
A study was carried out in 2005 to assess the impact of IEC/BCC activities in RNTCP with special attention to the issue of acceptability of DOTS at the , community-level in selected districts of Orissa.3 Of the 30 districts of Orissa, 14 districts with RNTCP implementation before 1 January 2003, were included and stratified according to the year of implementation of the RNTCP. One district from each stratum was randomly selected for the study and IEC activities mapped and ranked under a threepronged classification according to direction and purpose: 1. One-way communication (IEC) 2. Two-way communication (IPC/BCC) 3. Advocacy Based on the calculated intensity of IEC activities, MCs were sorted into quartiles. Two MCs, one with high and one with low intensity of IEC activities, were selected in each of the four districts. Two villages for each of these MCs were selected randomly for in-depth study. In addition, six villages were included where street theatre performances (which is a key tool for community-level IEC) about TB had taken place. In all villages, group discussions and semi-structured interviews at

3

A detailed study report will be published at www.dantb.org by the end of 2005.

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the community-level were conducted to assess the awareness and acceptability of DOTS. In addition, available RNTCP statistics were analysed. In one district, the qualitative study showed that knowledge about TB as an infectious disease that could be cured by DOTS after diagnosis on the basis of a sputum test (and X-ray) was substantially more consolidated in villages of the MC with high IEC-intensity than in the MC with low IEC-intensity. The information about TB was more coherent, and more people were able to volunteer information about signs and symptoms, treatment and curability. The study also showed that in both areas, there was cause for some concern about indirect cost of treatment and/or travel to the health facility. Perhaps most importantly in terms of IEC and acceptability of DOTS, it was clear that health communication is perceived in a context of : 1. what is already known, 2. competing interests of various actors (including, for example, traditional healers, drug vendors and private practitioners), 3. the quality and accessibility of health services in the community, and 4. prior experiences in the community with TB in particular and with various practitioners and services offering treatment in general. It was also found that the RNTCP indicators were not sufficiently sensitive to assess IEC impact directly. One of the main conclusions of the study is that former patients play an essential role as RNTCP advocates and sources of knowledge. This implies that patientprovider interaction meetings and the trialogue approach should be given high priority in the future.

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5 Capacity-building
5.1 Central Level: Advocacy and IEC Unit
An Advocacy and IEC unit within the CTD will be established to provide overall leadership for the IEC component, to procure services of the IEC agency at the central level and coordinate activities, to manage the mass media component at the national level, and to provide oversight, assess capacity and ensure consolidation of further development of IEC materials. During Phase I, the programme took advantage of expertise from outside sources. For example, deciding on indicators for the baseline studies and tracking, and the review of IEC materials for developing the web-based Resource Centre (December 2002 to December 2003), the CTD IEC team was assisted by a number of institutions such as WHO, the World Bank, Danida, media and social research agencies and NGOs. In RNTCP Phase II, this concept of profiting from outside advice is formalised in the form of an IEC advisory group for infusion of ideas and sharing of experience. WHO consultants provide technical assistance to districts, states and the Centre. They assist districts and states in developing action plans including IEC activities.

5.2 State-level Capacity for IEC
At the state-level, responsibility for IEC activities within the State TB Cell rests with the STO who is assisted by an IEC officer. Responsibilities include:         Vision for communication aspects in RNTCP Planning of IEC activities Monitoring of IEC activities Tapping resources for IEC activities Supervision of IEC activities Support to districts Developing material in local languages Organising events for advocacy

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 

Supervision by IEC officer Capacity building of the districts for implementing activities for awareness generation and social mobilisation.

Training for the IEC officers will be provided in two stages: 1) induction training when they first join, which will introduce them to the RNTCP; and 2) specific training in IEC for RNTCP will be conducted in batches by the CTD with the support of Danida in Orissa. The curriculum developed with the support of Danida would be used for subsequent training and retraining of IEC Officers at the national/regional institutes. Inter-state visits will provide opportunities for IEC officers to learn from others and share ideas. A communication facilitator who may be an individual or a group/institution/ NGO will work with the state TB Cell to facilitate activities across about five districts to address a felt need that experienced and helping hands are needed at the district level to support the medical officers to organise and implement social mobilisation activities.

5.3 District-level
Districts will have an active role in developing plans for IEC activities with sufficient flexibility to allow for local initiatives and variations. IEC activities at the district-level would use the appropriate local medium for dissemination of information. IEC activities at the district-level would involve local organisations, leaders, panchayats and NGOs for IEC. Each district will organise a certain minimum number of minimum activities, such as community meetings, mike publicity, display of posters at each PHI, interaction meetings, trialogue meetings, wall paintings and puppet shows and street plays. Each PHI will have one such activity organised at the village-level in a year. Wall writings are proposed in each village. Facilitation of IEC activities will be by the newly-created level of Communication Facilitator from the state who will support in planning and organising social mobilisation activities at district and sub-district level. In addition, support from outside the formal health system would be sought. The wide range of players such as gram panchayats, NGOs, mahila mandals, youth groups, and schools along with support and resources from state and district administration, such as information/ education officer would be co-opted. Capacity-building would also include sharing of material and innovations across districts and states. While the Centre takes the leadership, states and districts will plan and implement need based health communication activities. There would

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be a two-way flow of information from and to the Centre and the states. The establishment of a web-based IEC Resource Centre at the official website is the first step in this direction. This would be strengthened further with the regular addition of new material. The local communication teams at the district-and sub-district-levels are recommended to try different approaches and resources in view of the different local resources in terms of leadership and groups. For example, in one district the team might revolve around PRIs and in another a local NGO might take the lead. States and districts would be encouraged to explore innovative approaches in communication, particularly for hard-to-reach groups. The lessons learnt from these approaches could be disseminated widely across districts and states. A detailed guide for implementation with special attention to district and subdistrict level activities is provided in Part 2 of this document.

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6 Special IEC Needs in RNTCP Phase II
6.1 Improving Access to Hard-to-Reach Populations
During Phase II, RNTCP has prioritised hard-to-reach groups and IEC will play an important role. The following groups have been identified for special attention:    Tribal populations Marginalised populations in urban slums Other marginalised and vulnerable sections of the community

Tribal populations
The studies done in the first phase of the project, i.e. studies on accessibility and utilisation of RNTCP services by the marginalised sections, along with field experience, have identified specific areas for IEC attention. These studies have made the following suggestions for promoting community participation and intersectoral coordination:  Involvement of NGOs, traditional healers, private practitioners, AWWs, community health workers (CHWs), cured patients, tribal youth and other community based volunteers in IEC activities and to provide DOT, using local (tribal) origin as a selection criterion  Developing locally relevant IEC messages and patient education material using local vocabulary, prepared by taking help of local primary school teachers and members of PRIs  Using local chemists, grocery shops and other places frequently visited by tribals to disseminate information on RNTCP and DOTS  Using the opportunity offered by village fairs and festivals as well as weekly market days to inform the tribal population about DOT  Link IEC in RNTCP with the social mobilisation campaigns held in other disease control programmes  Decrease communication gaps and social distance between nontribal service providers and tribal communities through culture and communication sensitisation workshops and other similar activities

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Marginalised populations in urban slums
Evidence from studies suggest that special efforts are needed to increase access to DOT for the marginalised population in urban areas – the poor, homeless and migrants – and for patients who are under-represented in RNTCP, like working and elderly males and males and females of marriageable age. IEC interventions to reach these groups would include:  Involvement of cured patients, student and community volunteers to motivate patients, provide DOT and trace defaulters  Involvement of NGOs and support groups working with alcoholics and drug addicts in counselling and DOT provision  Involving support groups for migrants working in cities such as social networks in the city encompassing relatives and friends extending from the places of origin of migrants to help in case detection, patient motivation and DOT  Providing workplace information about TB and DOTS, particularly in sites where male representation in the programme is poor and in cities where migrant populations are engaged in specific activities (hotel workers, taxi and rickshaw drivers and daily wage labourers engaged in loading and unloading activities in ports, railway stations etc) by sensitising and involving employers and contractors as DOT providers

IEC for people living with HIV
Opportunities for reaching HIV-positive patients with information about TB, and for reaching TB patients with information about the possible link with HIV, will be found through strengthening the links between TB and HIV programmes. TB– HIV coordination has been initiated in the first phase of the project, and includes IEC activities. Measures to synergise efforts for IEC would be taken in future for the benefit of patients. Both the programmes will ensure availability of health education material to the other programme. RNTCP believes that the most useful channel is interpersonal communication, and there is an existing infrastructure of services and NGOs to facilitate this. While TB is stigmatised to some degree and among some populations, HIV/AIDS is much more so. While de-stigmatisation of both HIV/AIDS and TB should be pursued as a high priority, IEC activities addressing the co-infection of TB and HIV should seek to avoid the inadvertent message that all TB patients are believed to have HIV/AIDS, since this could inadvertently jeopardise the gains that have been achieved by RNTCP.

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IEC for non-public providers
This target group can be further segmented into  private providers,  practitioners of other health systems and  traditional health providers Data from available studies suggests that a neighbourhood private provider continues to be the people’s first port of call for TB in urban and semi-urban areas. The involvement of private practitioners and NGOs is a crucial component of the IEC strategy. The IEC activities to address this groups would include:  A sensitisation package for healthcare providers as well as for the beneficiaries will be developed and disseminated by the CTD. This will contain a guide to RNTCP for medical practitioners, PowerPoint and OHP slides presentations, a booklet on frequently-asked questions, desktop reference material, posters, provider-specific definitions, diagnostic algorithms, treatment regimes and DOTS directory of MCs and DOT providers.  Advocacy of the RNTCP amongst health providers by sensitisation and training through the Indian Medical Association and other professional bodies  Workshops and continuing medical education (CME) programmes for medical colleges and the private sector  Use of newsletters, the press and other media to spread the RNTCP message to a wider audience

Enhancing patient-provider communication
Interpersonal communication builds trust with patients, their families and their social networks. RNTCP aims to create and maintain good interpersonal communication and counselling skills among the programme staff, bridge the gap between patients and providers, and provide support to patients during the course of treatment so that they complete treatment and continue to be advocates for DOTS. Interpersonal communication skills and counselling are important at all levels of the programme. Communication pervades diagnostic services, treatment administration and patient supervision. A module on improving interpersonal communication skills in RNTCP training was introduced in the training curriculum of all key TB personnel and is implemented as part of the overall training package. The module, in the form of a book, contains role-plays that enable trainees to experience field situations in the classroom. The training and associated curricula are research-based.

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Part 2
Planning and Implementing a Health Communication Strategy for RNTCP –

A Practical Guide

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44 | A Health Communication Strategy for RNTCP

Contents
1. Introduction
1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Goal and essential elements of the health communication strategy for RNTCP Target audiences Messages Channels Main objectives of the health communication strategy Health communication strategy framework Involving partners Timeframe for health communication activities Development of health communication materials and pre-testing

47
47 48 49 51 51 53 54 54 57 58

1.10 Monitoring, evaluation and research

2. Implementation of the Health Communication Strategy
2.1 2.2 2.3 2.4 2.5 Implementation at the central level Implementation at the state-level Implementation at the district-level Implementation at the PHI-level Health communication activity implementation matrix

59
60 61 63 64 65

Annexures
1. Implementation Guide to Health Communication Activities 2. IEC Resource Centre of Central TB Division User Guidelines 3. Index of Materials Available in the Central TB Division’s Web-based IEC Resource Centre 4. Index of Health Communication Materials Used in Orissa 5. User Guidelines for the Health Communication Video Modules CD 6. Suggested Format for Planning IEC Activities at State and District 7. IEC Reporting Formats

69
73 145 149 156 173 175 176

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46 | A Health Communication Strategy for RNTCP

1 Introduction
This part of the document provides information to facilitate the implementation of the health communication strategy for RNTCP at the central, state-, district- and PHI/MClevels. It provides information on how to implement a range of health communication activities covering: 1. Support for policy implementation and RNTCP 2. Media advocacy 3. Health communication activities for capacitybuilding 4. Health communication material development 5. Involvement of partners in BCC for RNTCP 6. Involvement of other organisations and individuals in BCC 7. Monitoring, evaluation and research The Annexures give detailed instructions on the use of the web-based IEC Resource Centre set up by the CTD as well as the video-based modules on health communication activities produced by DANTB. The document is accompanied by two compact disks (CD). The first CD contains the video-based modules on health communication activities that can be viewed on a desktop computer or shown to an audience using a projector. The second CD contains resource material for the communicator, including an index of communication materials developed by DANTB for RNTCP in Orissa that can be adapted and used for various communication activities suggested in the document.

1.1 Goal and Essential Elements of the Health Communication Strategy for RNTCP
Large-scale adoption of health practices by the people, resulting in lower TB morbidity and mortality rates, requires appropriate behaviour change

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tools and techniques throughout the planning, design and implementation of communication activities. A necessary pre-condition is to learn the most appropriate ways to communicate desirable behavioural change and convert this information into effective health messages for IPC, broadcast media and print materials to provide skills-based training and implement programmes to support health practices over time. This process pre-supposes a thorough understanding of RNTCP and of working with stakeholders in applying an appropriate health communication methodology. The goal of such a communication strategy for RNTCP can be defined as follows: To facilitate and enable clients, service providers and the community at large to engage themselves in informed and supportive counselling, interaction and action at all levels and at all stages of tuberculosis detection, diagnosis and treatment, thereby empowering individuals, families and communities to be responsible for behavioural change to achieve the cure of people infected and infectious with tuberculosis. The strategy to achieve this goal is built on three essential elements of the successful cure of a potential TB case: timely detection, treatment seeking and completion of treatment.

1.2 Target Audiences
Following the importance of timely detection, treatment-seeking and completion of treatment, the primary audiences for health communication activities for the TB programme are:

Primary Target Group
  TB patients/potential TB patients Families/neighbours/general public

Secondary Target Group
      Doctors/RMPs/clinic operators/medical students DOT providers Local leaders ANMs/AWWs SHGs/CBOs PRIs

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The following secondary audiences are equally important from a communication perspective:
Centre, State, District Central TB Division (CTD), National Tuberculosis Institute (NTI), Tuberculosis Research Centre (TRC), State TB Institute (STI), State Steering Committee (SSC) Indian Medical Association (IMA), Tuberculosis Association of India (TAI), Medical Council of India (MCI), Nursing Council of India (NCI) Bilateral and multilateral agencies, e.g. Danish International Development Assistance (Danida) Department for International Development (UK) (DfID), World Bank (WB), World Health Organization (WHO) Press, radio, television Confederation of Indian Industries (CII), Employees' State Insurance (ESI), Indian Railways, industrial houses, pharmaceutical companies Departments of Women and Child Development (WCD), Rural Development (RD), Integrated Child Development Services (ICDS), Family Welfare (FW)

Professional Bodies Development Partners

Mass Media Corporate Bodies Intersectoral Linkages

It is important to assess the needs of these audiences at state-, district- and subdistrict levels and to map or otherwise assess their demographic and geographical distribution. Providers need training in IPC and management of IEC programmes. Community-members and families obviously constitute a primary target group and should be involved in health communication activities. The need to involve the community and educate them to support symptomatic persons for early diagnosis and registering for treatment or to act as DOTS providers implies participatory education and information activities. The involvement of other audience segments like drug companies, local leaders and the media helps to create a supporting environment.

1.3 Messages
Messages should be tailor-made for the target audience. These messages should be pre-tested at various levels so that they conform to the contextual variables and may be suitably modified for a given local setting. Health communication messages can be generic or specific. Some of the messages would be of a generic type to create an enabling environment. This could be handled by the state and central agencies. Along with generic messages there would be development and utilisation of specific messages related to access and quality treatment. Message design should take into consideration factors like gender, rural-urban population ratios, socioeconomic status, literacy and media exposure.

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For analytical purposes the dimensions of a message are defined as follows:  Appeal  Approach  Content  Text or image  Context  Source  Recipient These dimensions help to decide the message and to design it appropriately. Some of the standard messages in RNTCP are as follows: “If you have cough for three weeks or more go to the nearest health centre to get your sputum checked.” "TB is curable." "Diagnosis and treatment is available free of cost." "If you stop the treatment in-between, it has dangerous consequences." "Take DOTS and you will be free of TB." "We have a cure for TB—we have to tell the people about it." The importance of these simple messages rests in their ability to convey the ideas behind them and thus have an impact on timely detection, treatment seeking and completion of treatment. For example, is the universal World TB Day 2003 message `DOTS cured me—it will cure you too' understandable for a patient in a village? Will it help a person to approach the health centre or seek treatment? Is it clear to the patient what DOTS refers to? Is the message placed in the context of the patient? One needs to break the apparently simple messages carefully into understandable information that would prompt the desired health behaviour. The key issues for message development are the following: 1. Message selection needs a careful and systematic analysis. Seemingly simple messages need to be looked at closely for their meaning, comprehension, effect and adequacy. 2. Messages need to be creatively designed and tested methodically. Different evaluation designs for different messages for different audiences may be required. 3. The benefit or gain aspect for the patients instead of the provider needs additional emphasis in message selection and design. 4. The elements of message selection and design should be incorporated in the standard RNTCP training modules.

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1.4 Channels
A number of channels can be used effectively to disseminate health communication messages. These are: 1. Folk media 2. Melas/festivals 3. Interpersonal communication 4. Trialogue approach 5. Sensitisation meetings for PRIs 6. Print media 7. Electronic media 8. Broadcast media 9. Workshops and seminars 10. Health camps 11. Other innovative channels Using an appropriate multimedia mix enhances the reach and impact of health communication messages. The point of contact for interaction with patients at the health facility or the DOTS centre can be effectively used for patient education and information. However, this calls for skills in IPC. Supportive supervision as part of monitoring can be used to address misinformation and misunderstandings concerning TB. Other channels that can be used are exhibitions, camps, radio, television shows, public service announcements, panel discussions, print advertisements, workshops and seminars. As certain mass media activities are expensive, intersectoral and cross-provider systems and private donors should be tapped to sponsor media space and time, and appropriate links with commercial agencies and NGOs should be explored and their experiences and expertise adopted. Within the RNTCP set-up, competent and responsible personnel at the state- and district-levels are trained to manage a media plan.

1.5 Main Objectives of the Health Communication Strategy
The health communication component in RNTCP has three main objectives: 1. Awareness-raising and capacity-building to increase understanding about TB amongst   the public, so that they make use of RNTCP services and practitioners across the country, so that they know about correct TB diagnosis and treatment and they refer patients to DOTS services, or become DOT providers themselves.
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2. Advocacy and social mobilisation to develop political, administrative and community-level commitment to TB control in India. 3. Patient-provider communication and counselling to help ensure patient compliance with the treatment regimen, to enhance the reputation of a patient-friendly service, and to encourage patients and their families to become advocates for the programme.

1.5.1 Awareness-raising and capacity-building
While the dissemination of necessary information on TB is an essential element for achieving this goal, and indeed is a right of the community, it is not a sufficient factor. The community will also discuss issues of poverty, access, availability, fear of stigma, illiteracy problems, competing health beliefs and barriers for motivation (such as alcoholism, work routines, etc.) with the facilitator. Only by creating a shared understanding that DOTS is possible in spite of these factors, and that cure of TB patients will help to overcome such barriers, the involvement of communities be ensured. Training activities form a very important part of the health communication strategy. Training focuses primarily on three levels: 1) training of health workers 2) training of DOT providers and 3) training of IEC staff as well as training of trainers for all three levels. All training consists essentially of two components: 1) TB-specific information concerning all stages of TB management and 2) communication skills concerning different types of health communication activities. The training should involve hands-on use of IEC materials by relevant audiences as well as mutual assessment of IEC implementation practices. Modules for medical officers, senior treatment supervisors and other health workers should be suitably modified to incorporate IPC and counselling, dynamic and participatory group interaction and use of available IEC materials. These exercises should take into account male/female differentials in behaviour and treatment-seeking patterns and social dynamics, and particular emphasis should be placed on role-plays and similar activities whereby providers can experience the patient's point of perspective.

1.5.2 Advocacy and social mobilisation
Advocacy is done to win the support of key decision-makers in order to influence policies and ensure financial and other resources, and to promote a conducive environment for the implementation and sustainability of the programme. It is necessary to identify the target group and how to access and communicate with them. It can be useful to organise a network and establish strategic coalitions to create a support base that can convey persuasive arguments to key decision-makers. The media constitute one such strategic partner. Advocacy works differently at different levels and with
TB CONTROL

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different players. Advocacy at higher levels may facilitate behaviour change at lower levels by offering a behaviour model and affirming community norms. Social mobilisation is a type of grass-roots level advocacy whereby the collective force of a community is mobilised for a cause. It is necessary to meet people at their own level of understanding and to explore existing concerns and possible social conflicts in the community with relevance to the RNTCP agenda, including in particular, gender issues and other potential or actual processes of social marginalisation. The entire community must participate in decision-making in a way that reinforces the common interest in the objectives of developing a network of community members who will work actively for timely detection and support treatment-seeking behaviour and completion of treatment, and thereby create a self-supporting and sustainable system for voluntary reporting of suspected TB cases.

1.5.3 Patient-provider communication and counselling (trialogue approach)
Success of any health communication strategy depends largely on the close interaction and coordination between stakeholders. In RNTCP, this can be done through the trialogue approach. This is a community-based activity. In this approach there are three ‘p’s: the patients, the providers and the people. In this meeting the participants spend a whole day together, siting on a common mat and eating from a common plate. This meeting gives an opportunity for people to air their feelings. It also provides an excellent opportunity for women to participate. Irregular and defaulter cases are specially addressed to identify their problems and needs for counseling. Influential people from the community such as panchayati raj members are encouraged to participate actively in spreading awareness about TB diagnosis and DOTS. The trialogue approach reduces the gap between patients, providers and community through informal, interactive meetings.

1.6 Health Communication Strategy Framework
The matrix shown in page 29 depicts the health communication strategy framework for RNTCP. Based on this framework, the statelevel and district level implementers can develop detailed needsbased framework and action plans.

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1.7 Involving Partners
The patient comes across and uses many systems for services and is influenced by many different systems—public, private, NGOs and community among others. The strategy should take cognisance of the importance of these players: Private medical practitioners should be educated in the proper diagnosis and treatment of TB, as well as on important messages to be given to the public. NGOs, whether grass-roots, state-wide or national, should be involved by appropriate training in participatory and interactive techniques so that they can organise and carry out education and community awareness, as also in service delivery by way of working as DOTS providers. Corporate or commercial companies, particularly pharmaceutical firms, can play an important role in influencing the outcome of the programme by providing appropriate information as well as involving private providers for using the standard regimens for the revised strategy. Local self-government agencies and community groups have many roles to play. Through community participation they can help reduce stigma, facilitate the selection of DOT providers and help in organising health or TB melas. A sustained interest of the community in the TB control programme will depend upon the information and benefits provided by the programme and the sympathetic attitude of public sector providers. Lastly, the involvement of PRIs would provide an opportunity for coordination among various sectors and personnel working for rural development such as the ICDS, AWWs, BDOs, SHGs and ANMs which can have a positive bearing on health programmes.

1.8 Timeframe for Health Communication Activities
There are important differences between communication activities in connection with the initial phase of implementing RNTCP in a new area and the ongoing communication activities.

1.8.1 Initiating RNTCP in a new area
6-9 months before launch:  Training of trainers in IEC, counselling and communication skills. 3-6 months before launch:  Training of medical officers, DOT providers, laboratory technicians, senior treatment supervisors and senior tuberculosis laboratory supervisors in IEC and counselling.

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1-3 months before launch:  Development and production of banners, posters and other IEC materials on  signs and symptoms of TB  availability of free diagnosis and treatment  central slogans of the campaign  Advocacy activities involving central stakeholders and the media At the time of launch of RNTCP in an area:  Conduct campaigns at each primary health centre involving  District Collector/zila parishad Chairman  Panchayat  Health system leaders  Block development staff  Women and youth groups  ICDS
     Using Folk media Exhibition stalls Mela kits for demonstration Demonstration of medicines, given by popular leaders to patients Launch area-wide media campaign involving:  Local and area-wide newspaper coverage  Radio and TV coverage  Cable operators, district publicity staff and other available media systems Using Regular news coverage Ads, jingles Educational and entertaining dramas adapted for radio and TV

  

1.8.2 Ongoing communication activities throughout RNTCP
The table in the following page 56 indicate the frequency of ongoing health communication activities to be carried out on a continuous basis upon the initial launch of RNTCP in a district, as seen in a yearly and a three-monthly (13 weeks) perspective. Hence, the timeframes do not indicate how often one single person/group/institution should be involved in the same IEC activity, but provide an experience-based indication of the frequency of communication activities at the district level required to ensure the successful implementation of RNTCP However, for a few activities, state-level . implementation has been specifically indicated.

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Health Communication Activities Throughout the Year
Fortnightly
• Patient-provider interaction meetings

Monthly
• (Re)orientation training of ICDS officers and supervisors (different blocks) • Orientation of PRI members (different blocks) • Interactive stalls in weekly markets • Interaction meetings with SHGs and women's groups

Quarterly
• (Re)orientation training for NGOs and CBOs • (Re)orientation of tribal link workers (in tribal districts/blocks) • (Re)orientation of traditional healers, TBAs, VHGs

Half-yearly
• Workshop for media personnel (AIR, DD, DIPRO, field publicity officers) • (Re)orientation of NSS volunteers • (Re)training of cured former TB patients as DOT providers • (Re)orientation of industrial workers, union leaders and representatives • (Re)orientation of members of NYK • (Re) orientation of SHG groups at district- and block-level • Workshop to develop posters and other printed materials • Workshop on the role of media for increasing visibility of RNTCP at state-, district- and block-levels • Street theatre technique and script writing workshop

Yearly
• CME programmes at medical colleges and nursing institutions • (Re)orientation of NGOs at district- and state-level • Audio-visual material development with tribal and other unreached communities • (Re)orientation of PRI members at block-level • Trialogue approach with patient group; interaction with people at PHI level • Workshop on script writing of TB-related dramas for professional writers (usually conducted at state-level) • Patient group meeting at PHI-level • (Re)orientation of jail inmates and employees

Special IEC Activities
• Leading up to and on World TB Day, 24 March

In contrast to the planning of communication activities prior to the launch of RNTCP where the sequence is to be followed strictly, planning for ongoing districts , should be kept flexible according to need-based and practical circumstances. Hence, the tables are primarily intended to communicate the relative frequency of the various activities. Training of regular staff involved in IEC activities has not been included in the figures and should be dealt with separately.

1.9 Health Communication Material Development and Pre-testing
Material development is an essential component of any health communication programme. It is necessary to develop different types of materials for different types of audiences with focused, targeted messages. An index to the communication material available in the web-based IEC Resource Centre of the CTD has been provided in Annexure 3. An index to the communication materials developed in Orissa by DANTB is given in Annexure 4. While professional designs may suit the aesthetics of the producer who may often belong to the middle class, they are no guarantee for high quality products. In the Orissa experience, through the PRA technique, the use of drawings made by members of tribal communities proved highly successful both in terms of the key audience's ability to understand the messages as well as increased ownership of the programme. One needs to conduct assessments for different products—pamphlets, posters, radio announcements, TV spots, wall paintings, handouts, press advertisements and exhibitions. Whether conceptualised inhouse or contracted to NGOs or professional agencies for development and pretesting, the products should be grounded in local perceptions of the problems pertaining to DOTS implementation and should preferably include input from target audiences. Periodic reviews should be carried out for continued validation and updating of the information contained in the materials produced. Pre-testing of health communication materials is a necessary tool to avoid spending of resources on communication activities that do not achieve the desired objectives or that can be directly counter-productive. Pre-testing should take place with a representative sample of the target audience. The need and methodology to pre-test varies widely according to the type of communication activity and the costs involved. In relatively inexpensive communication interventions, one would be reluctant to spend more resources on pre-testing than the intervention costs, whereas in very expensive interventions like TV productions, the resources spent for pre-testing to ensure benefits from large investments would be more. In such cases, the use of focus groups for previewing the product can often be a useful and effective pre-testing methodology.

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Certain types of communication activities cannot be pre-tested effectively because they are interactive in a way that pre-supposes the involvement of a real target audience. Such activities include folk media like street theatre, interaction meetings and interaction stalls at melas (fairs) and haats (village markets). In such cases, it is essential to systematically evaluate the activity and feed the results back to the active IEC agents who then should modify the activity according to the feedback.

1.10 Monitoring, Evaluation and Research
The response from the field is critical for the successful adoption and modification of IEC components. Periodic reviews should be conducted to assess the value and utility of the campaign or its message. A positive impact of an IEC activity on TB control can be maintained by refining the message or design as required. Systematic research should be conducted periodically, preferably by independent agencies and/or persons not directly involved in the communication activities, to monitor and evaluate the IEC programme and the activities undertaken. The process, outcome and impact parameters should be defined at the outset and the findings utilised to bring about improvements in the programme. Monitoring would be particularly useful in three areas: 1. Management: Careful monitoring is essential at the early-implementation or the pilot-testing stage of the programme. 2. Evaluation: Proper monitoring enables accurate interpretation of final evaluation results. 3. Accountability: Monitoring enables the state and funding agencies to assess the value of the programme and demonstrates appropriate use of funds.

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2 Implementation of the Strategy
This strategic framework for communication identifies the communication need (objectives), communication players/audience (target groups), and communication tools (channels, activities and materials). This framework will build on the work already undertaken within RNTCP Phase I. The focus of this framework is on a combination of centrally produced core messages and media, and needs-based planning and IEC development to develop state and district specific strategies, with local innovations to reach all possible groups through the most appropriate channels, materials and activities. The Central core framework provides the general outline, and each state will come up with a locally-adapted strategy based on their own needs, analysis of the problem and the target groups, so that communication activities are tailored to address local needs, and reflect local culture. A suggested list of activities and details of implementation have been provided in the following pages.

Financial Provisions for Communication
The Project Implementation Plan (PIP) for RNTCP Phase II has recommended the following budgets for activities at various levels. State-level
Population Small States Medium-size States Large States
1

Budget** (Rs) 500,000 700,000 1,200,000 1,700,000

Up to 10 million 10-30 million 30-50 million 50 million and above

Source: Draft PIP of TB-2, CTD

** Each state will have additional budget for engaging agencies/NGOs to work as communication facilitators for the state and districts. (The proposed budget is approximately Rs.20,000 per district per year, or about Rs.1,600 per district per month). This budget would be over and above the state and district allocation for health communication activities.

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District-level Budget allocation at the district levels would be Rs 75,000 per million population per year. Sixteen urban centres (already identified in the previous project) with populations of more than one million will have Rs 150,000 lakh per million populations per year. All other urban cities with a populations of more than one million will have a budget of Rs 100,000 per year. The district level budget would be over and above the state budget for IEC mentioned above. In addition, Rs 25,000 per million population is available for NGOs for IEC at the district-level under schemes for NGOs.

2.1 Implementation at the Central Level
2.1.1 Roles and responsibilities
At this level, the CTD is the principal advocate for RNTCP. As far as implementation of BCC activities is concerned, the CTD provides leadership and support to the state and district levels. An advocacy and strategic communication unit within the CTD  provides overall leadership for the IEC component,  procures services of the comunication agency at the central level and coordinate activities,  manages the mass media component at the national level,  provides oversight of the national level communication strategy, assessing capacity for strategic communication at the state-level, and providing support where necessary and  ensures that achievements and lessons learnt in RNTCP Phase I are consolidated and used for further IEC development. The CTD involves national bodies like the IMA and the TAI and national-level NGOs to take responsibility to involve their members throughout the state. It involves the MCI and other bodies to recommend appropriate changes to policies and curricula with respect to the control of TB. It also reviews the capacity and competency of the central training institutes with respect to BCC activities. The media campaign can be effectively and economically handled from the central level. Given its nature, where media cannot be segmented by states, the Centre would handle the national media campaign. A media agency would assist the CTD in planning and executing media activities based on the studies conducted for RNTCP and the viewership survey and media research. State-specific popular

60 | A Health Communication Strategy for RNTCP

channels could be included in the media planning and execution. Options for the careful use of ‘free media’ will also be considered.

2.1.2 Target audience
At this level, the target audience consists of:  National-level institutes and bodies such as National Tuberculosis Institute (NTI), Tuberculosis Research Centre (TRC), etc.  Professional bodies such as Indian Medical Association (IMA), Tuberculosis Association of India (TAI), Medical Council of India (MCI), Nursing Council of India (NCI), etc.  Development partners such as bilateral and multilateral agencies, e.g., Danida, Department of International Development (UK) (DfID) and World Bank (WB), World Health Organization  Mass media—national-level television, radio and press  Corporate bodies such as Confederation of Indian Industries (CII), Employees’ State Insurance (ESI), railways, industrial houses, pharmaceutical companies  Ministries, and departments such as the Departments of Women and Child Development (WCD), Rural Development (RD), Integrated Child Development Services (ICDS), Family Welfare (FW) at the state-level  Opinion-leaders and politicians—ministers, eminent personalities, religious leaders etc.

2.2 Implementation at the State-level
2.2.1 Roles and responsibilities
The state government is the key operating agency for RNTCP. It has ownership of communication activities at all levels of the health care system. It makes adequate budgetary allocations for communication programmes, based on inputs from the District TB Centres (DTCs). It advocates the use of communication activities in RNTCP and takes steps to build public-private partnerships at the state level, by involving NGOs, private practitioners and pharmaceutical and other relevant industries. At the state level, the strategic communication responsibility within the State TB Cell rests with the STO who is assisted by an IEC Officer. The role of the State TB Cell in strategic communication is as follows:  Vision for communication aspects in RNTCP  Planning of health communication activities  Monitoring of health communication activities  Tapping resources for health communication activities

Planning and Implementing a Health Communication Strategy for RNTCP | 61

     

Supervision of health communication activities Support to districts Developing materials in local languages Organising events for advocacy Supervision by IEC officer Capacity-building of the districts for implementing activities for awareness generation and social mobilisation.

The state government develops generic communication materials in close collaboration with the district and peripheral TB staff and IEC officers. The State Tuberculosis Officer (STO) is responsible for planning, coordinating and monitoring the implementation of all communication training activities through the State Institute of Health and Family Welfare (SIH&FW) and outlines the personnel requirements for training needs in communication. The state government is responsible for the initiation and appropriate utilisation of operational research and monitoring evaluation to assess the impact of health communication activities and to modify them, if required. The STO is actively assisted in developing and coordinating the communication activities by the SIH&FW or a designated IEC officer, who is capable of involving the media and PRIs for disseminating the central messages for TB control. Once RNTCP services are available in all districts, the programme will embark on mass media campaign which are envisaged to be powerful in reaching all urban and peri-urban areas. The states have a role in mass media as follows:  Pre-testing materials intended for nation-wide use, and in providing feedback  Dissemination of centrally produced media materials  Providing feedback on how national level campaigns are being received  Adapting centrally produced materials to ensure contextual relevance  Sharing media successes with the central level

2.2.2 Target audience/players/partners
At this level, the target audience consists of:  Health service providers  Community  State-level institutes and bodies such as state TB institutes, state steering committees  Professional bodies such as the state-level branches of the Indian Medical Association (IMA), Tuberculosis Association of India (TAI), Medical Council of India (MCI), Nursing Council of India (NCI) etc.

62 | A Health Communication Strategy for RNTCP

 

Development partners such as state-level offices of bilateral and multi-lateral agencies, e.g., Danish International Development Assistance (Danida), Department of International Development (UK) (DfID), World Bank (WB), World Health Organisation (WHO) etc. Mass media. Corporate bodies at the state-level such as industry and business associations, Employees’ State Insurance (ESI), Indian Railways, industrial houses, pharmaceutical companies, etc. Ministries and departments at the state-level such as the departments of Women and Child Development (WCD), Rural Development, Integrated Child Development Scheme (ICDS), Family Welfare (FW), etc. Opinion leaders, politicians and administrators at the state-level—MPs, MLAs, eminent personalities, religious leaders etc.

2.3 Implementation at the District-level
2.3.1 Roles and responsibilities
The district is the link between the state and PHIs in terms of training and dissemination of IEC materials. The district TB society is responsible for planning, implementing and monitoring RNTCP communication activities at the district level with the DTO/ADMO being the responsible officer. The DTO is responsible for involvement of PRIs, NGOs and other relevant district-level organisations in health communication activities. The CDMO is responsible for actively obtaining the necessary information from the DTO/MEIO/BEEs in order to ensure the implementation of the communication strategy. In addition, the support from the outside the formal health system would be drawn. A wide range of players such as gram panchayats, NGOs, mahila mandals, youth groups and schools along with support and resources from the state and district administrations such as information/education officers would be co-opted. Capacity-building would also include sharing of material and innovations across districts and states. While the Centre takes the leadership, the state and districts will plan and implement need-based health communication activities. There would be a two-way flow of information from and to the Centre and the states. The establishment of a web-based IEC Resource Centre at the official website is the first step in this direction. This would be strengthened further with regular addition of new material. The local communication teams at the district- and sub-district levels are encouraged to try different approaches and resources, keeping in mind the different local resources in terms of leadership and groups. For example, in one district the team might revolve around PRI and in another a local NGO may

Planning and Implementing a Health Communication Strategy for RNTCP | 63

take the lead. States and districts would be encouraged to explore innovative approaches in communication, particularly for hard-to-reach groups. The lessons learnt from these approaches could be disseminated widely across districts and states. It is at the district- and local levels that the challenge of reaching the ‘interior pockets’ and engaging hard-to-reach populations becomes relevant. Districts will bear the responsibility of reaching those who may not be exposed to mass media campaigns, and for complementing the information that is received from national and state sources with locally relevant activities. Adapting RNTCP’s core messages will rely on the locally available talent to adapt messages using the local language and reflecting local interests and concerns. Districts will therefore have flexibility in planning and implementation to meet the specific needs of the populations in those areas.

2.3.2 Target audience
At this level, the target audience consists of:  Health service providers, CDPOs, MEIO, BEEs  Community  District-level institutes and bodies  Professional bodies at the district-level  Mass media—district-level television, radio and press  Corporate bodies at the district level  Opinion leaders, politicians and administrators at the district-level  NGOs

2.4. Implementation at the PHI-level
PRIMARY HEALTH CENTRE

2.4.1 Roles and responsibilities

The PHI is the community-level centre for health communication activities. This facility has an active role to play in timely detection, treatment and promotion of the adoption of DOTS by patients and the community. The entire staff at a PHI should be specially trained in IPC and counselling. IEC materials should be easily available and adequately displayed and used regularly. The PHC level should explore the possibilities of increasingly utilising the ‘cured person’ for IEC purposes, and should promote local ownership of the TB programme.

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2.4.2 Target audience
     Women and men, rural and urban, hard-to-reach groups such as tribals, marginalised populations in slums etc. Patients Private providers, practitioners of other health systems, traditional health providers School children, teachers, NGOs, CBOs, SHGs, PRI members, etc Media

2.5 Health Communication Activity Implementation Matrix
The matrix in the following page suggests a comprehensive list of health communication activities for RNTCP and the levels at which they are appropriate. The health communication activities have been broadly grouped into the following types:       Policy support Media support Capacity-building Communication material development Involvement of partners in communication activities Involvement of other organisations and individuals

Detailed guidelines for the planning and implementation of each health communication activity are given In the following pages. Each activity should be understood in the context of the overall strategic health communication framework for RNTCP. The activities should be timed at intervals as described earlier. For each activity, a list of health communication material has been suggested. Samples of the health communication material that can be adapted to the requirements at the local level have been provided in the annexures.

Planning and Implementing a Health Communication Strategy for RNTCP | 65

Health Communication Activity Implementation Matrix
Ref No Health Communication Activity Central Level Statelevel Districtlevel PHI/MClevel

3.1 3.1.1 3.1.2 3.1.3 3.1.4 3.2 3.2.1 3.2.2 3.2.3 3.2.4 3.3 3.3.1 3.3.2 3.3.3 3.3.4 3.3.5 3.4 3.4.1 3.4.2 3.4.3 3.4.4 3.4.5 3.4.6 3.4.7 3.4.8 3.4.9 3.5 3.5.1 3.5.2 3.5.3 3.5.4 3.5.5

Support for policy implementation and for RNTCP Interactive stall at haats Organisation of mass rally Observation of World TB Day—24 March Exhibition Media advocacy Print media Electronic media Display media Policy support Health communication activities for capacity-building Training of health workers RNTCP training of TB programme staff CME programme for health workers Training of DOT providers Strengthening the state IEC organisation IEC development material Poster development workshop Other display material development Development of radio spots Development of TV spots Development of cinema slides Development of music cassette Development of role-play Training on street theatre technique Pre-testing of IEC material Involvement of parterners in IEC for RNTCP Use of street theatre Puppets Trialogue approach Orientation of tribal link workers Orientation of cured, former patients as RNTCP advocates

           

       

       

   

   

   

               

 

 

 

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66 | A Health Communication Strategy for RNTCP

Health Communication Activity Implementation Matrix
Ref No Health Communication Activity Central Level Statelevel Districtlevel PHI/MClevel

3.5.6 3.5.7 3.5.8 3.5.9 3.5.10

Orientation of NGOs Sensitisation meeting for PRI members Orientation of SHGs Orientation of volunteers, teachers, students and religious organisations Orientation of traditional healers, traditional birth attendants and other indigenous practitioners Orientation of members of CBOs Training/workshop for CDPOs/supervisors at district-level Group discussion Kalyani clubs Workshop on culture and communication Involvement of other organisations and individuals Orientation of industrial workers Orientation of jail immates and employees Sensitisation workshop for journalists Monitoring, evaluation and research RNTCP programme documentation

                 

3.5.11 3.5.12 3.5.13 3.5.14 3.5.15 3.6 3.6.1 3.6.2 3.6.3 3.7 3.7.1

       

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Annexures

Annexure 1 | 69

Contents
1. Implementation Guide to Health Communication Activities 1.1 Support for policy implementation and for RNTCP 1.1.1 Interactive stall at haat 1.1.2 Organisation of mass rally 1.1.3 Observation of World TB Day—24 March 1.1.4 Exhibition 1.2 Media advocacy 1.2.1 Print media 1.2.2 Electronic media 1.2.3 Display media 1.3 Health communication activities for capacity building 1.3.1 Training of health workers 1.3.2 RNTCP training of TB programme staff 1.3.3 CME for health workers 1.3.4 Training of DOT providers 1.3.5 Strengthening the state IEC organisation 1.4 IEC material development 1.4.1 Poster development workshop 1.4.2 Other display material development 1.4.3 Development of radio spots 1.4.4 Development of TV spots 1.4.5 Development of cinema slides 1.4.6 Development of music cassette 1.4.7 Development of role-play 1.4.8 Training on street theatre technique 1.4.9 Pre-testing of IEC material 1.5 Involvement of partners in IEC for RNTCP 1.5.1 Use of street theatre 1.5.2 Puppets 1.5.3 Patient-DP-community interaction meeting 1.5.4 Trialogue approach 1.5.5 Orientation of tribal link workers 1.5.6 Orientation of cured, former patients as RNTCP advocates 1.5.7 Orientation of NGOs 1.5.8 Sensitisation meeting for PRI members 1.5.9 Orientation of SHGs 1.5.10 Orientation of volunteers, teachers, students and religious organisations 73 73 73 74 75 76 78 78 80 82 83 83 88 91 92 96 100 100 102 103 104 106 106 107 109 111 112 112 114 115 117 119 121 122 124 125 127

Annexure 1 | 71

1.6

1.7

1.5.11 Orientation of traditional healers, traditional birth attendants and other indigenous practitioners 1.5.12 Orientation of members of CBOs 1.5.13 Training/workshop for CDPOs/supervisors at district level 1.5.14 Group discussion 1.5.15 Kalyani clubs 1.5.16 Workshop on culture and communication Involvement of other organisations and individuals 1.6.1 Orientation of industrial workers 1.6.2 Orientation of jail immates and employees 1.6.3 Sensitisation workshop for journalists Monitoring, evaluation and research 1.7.1 RNTCP programme documentation

129 130 132 134 136 137 138 138 139 141 143 143 145 149 156 173 175 176

2. IEC Resource Centre of Central TB Division User Guidelines 3. Index of Materials available in the Central TB Division’s Web-based IEC Resource Centre 4. Index of Health Communication Materials Used in Orissa 5. User Guidelines for the Health Communication Video Modules CD 6. Suggested Format for Planning IEC Activities at State and District 7. IEC Reporting Formats

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Annexure 1

Implementation Guide to Health Communication Activities
There are a number of health communication activities that can be implemented as part of the strategy. Illustrated below are activities designed by DANTB in Orissa.

1.1 Support for Policy Implementation and for RNTCP
1.1.1 Interactive stall at haats
Objective
To inform the community on different aspects of TB and avail facilities provided by RNTCP.

Duration
Four hours on weekly market day.

Venue
Suitable open place in the haat.

Participants
Local villagers (male/female/children) and vendors.

Facilitators
MO-PHI, Dy. MEIO, BEE, STS, HWs.

Process of organisation
       Planning for interactive stall by ADMO/MO-TU, BEE, STS Selection of haats in a block Letter to MO-PHI for organising stall Arrangement of IEC materials by Dy. MEIO/BEE/STS Invite cured male/female patients to participate Sharing of responsibility among health personnel and cured patients to facilitate the process Display of IEC materials, and a mobile exhibition unit with captions on TB

Annexure 1 | 73

Messages used
   Cause of TB, how it spreads and signs and symptoms of TB Free diagnostic and treatment facilities available at PHIs Importance of early reporting

Methodology
   Interaction Explaining exhibit materials Street play

Health communication materials
Banners (19-23), posters (7-12), exhibition model (32), tent for exhibition stall, leaflets (5-6), snake and ladder game, tape recorder, mela kits, pocket folders, register to record comments of audience. While planning your activity view the ‘Advocacy and Social Mobilisation’ module in the accompanying CD.

Outcome
Regular meetings at gram panchayat-level/community-level to discuss RNTCP by HWs/BEE

1.1.2 Organisation of mass rally
TB CONTROL

Objective
To disseminate TB messages to the public

Participants
School students/NSS volunteers/PRI members/SHG members/DOT providers (HW/[male/female], AWW), NGO members/cured patients and public (participants around 100 to 200, both male and female)

Process of organisation
 CDMO invites DTO, MO-TU, MO-PHI, STS, CDPO, DIPRO, MEIO, BEE, programme officer of NSS, district coordinator of NYK, BDO, CDPO, local school headmaster, NGO secretary for planning meeting. They decide the date, time and area to be covered CDMO informs DTO, MO-TU, MO-PHI, STS, DIPRO, Dy. MEIO, BEE, Programme Officer of NSS, district coordinator of NYK, BDO, headmaster, NGO secretary by letter Programme officer selects the NSS volunteers and informs them about the rally District coordinator selects the NYK volunteers and inform them about the rally BDO informs sarpanches Headmaster selects the students and tells them to participate in the rally

   

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  

  

NGO secretary selects NGO members and informs them to participate CDPO selects the AWWs and informs them to participate STS informs the DOT provider and DOT provider informs the cured patients Caption preparation by MO-PHI, DIPRO/Dy. MEIO/BEE/STS/DOT providers/ NSS volunteers/NYK volunteers Arrange ambulance (DTO) Arrange drinking water (municipality) Arrange media personnel (like press, TV, radio, photographer) by DIPRO

Health communication materials
  Banners (19-23), leaflets (5-6), placards Messages for slogans, e.g.  TB is curable.  Stop TB—use DOTS.  DOTS cured me. It will cure you too.

Outcome
  Increased awareness of TB among the public. Symptomatic case reporting increases at PHI-level.

Report-writing
DIPRO/Dy. MEIO

1.1.3 Observation of World TB Day—24 march
Objective
MARCH

24

 To create large-scale awareness in the community  To motivate and encourage community to avail the facilities available at the PHI for TB  To highlight special messages on World TB Day

Target group
General public/patients/providers/peoples’ representatives

Venue
District-/sub-district-/block-/PHI-level, any suitable place

Process of organisation
 CDMO/ADMO invites MO-TU/STS/STLS/MO-PHI/Dy. MEIO/DIPRO/ BEE/NSS/NYK Programme Officer/NGO representative for planning the observance of World TB Day Listing of health communication activities with detailed planning, including budget, by concerned MO-TU/MO-PHI/BEE/Dy. MEIO and submission to CDMO

Annexure 1 | 75

  

  

MO-TU/STS/STLS/Dy. MEIO/DIPRO plan to observe World TB Day at district level CDMO releases funds to carry out the activities MO-PHI invites all block-level officials/PRI members/cured patients/ active NGOs/teachers/ICDS personnel to participate in the World TB Day arrangements At the district-level, CDMO invites collector/sub-collector/zila parishad Chairman/PRI members/cured patients/ICDS personnel/DSWO/block officials/doctors/nurses of district hospital to participate in World TB Day observance. Sharing of responsibility at district-/PHI-level to carry out these activities. Procurement of IEC materials for distribution to PHIs by ADMO (Med.)/MOTU/Dy. MEIO. Emphasis is given to involve cured, former patients to share their experiences in different activities.

Suggested health communication activities
         Rally by cured and former patients, school students and health personnel Orientation of students followed by debate/quiz competition among high school/college students Exhibition on RNTCP at district and PHI levels Mass meeting with block officials, PRI members, NGOs and chief functionaries from colleges and AIR Street play in weekly markets in each block to disseminate the messages on RNTCP RNTCP chariot Interactive stall at weekly haats Talks on TB and RNTCP jingle/spot could be organised for broadcast by local private channels, All India Radio and Doordarshan stations Other innovative activities may be carried out as per need

Health communication materials
Mela kit, banners, posters, leaflet, booklet, pamphlet, exhibition models, mike set, cassette with player, TV, VCR, placard, folders

Reporting
MO-PHI/MO-TU/DTO are responsible for submitting a detailed report on the observance of World TB Day to CDMO who reports to Dy. Director of Health Services

1.1.4 Exhibition
Exhibition is one of the important health communication activities that meets the information needs of different target groups from various parts of a district and state.

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Purpose
To create awareness in the community regarding different technical aspects of TB and encourage people to avail the services provided under the RNTCP.

Venue
At a suitable place of festival/mela/function.

Target group
General community, patients and service providers.

Duration
Depends upon the length of the festival or function. Usually one day to one week.

Process of organisation
A request letter is written by the MO-PHC to the district authority (CDMO/DTO) to organise and provide support for such an exhibition sufficiently ahead of the occasion. After the decision is taken, a suitable place is identified in consultation with the local organiser of the festival/mela.

Construction of the stall
 In many instances, ready-made stalls are provided by the organiser of the festival. Otherwise, a contractor is entrusted to erect a stall with the provision of sufficient lighting arrangements, electricity and cloth decoration. Usually the size of the stall is 15’ x 12’ with two gates, i.e. entrance and exit.

Health communication materials
 Exhibits and other display materials pertaining to necessary information on TB and RNTCP are put up in the stall. These may be models, boards, posters, banners, equipments, medicines, etc. Sometimes, story boards are put up to explain to the audience the disease or programme. This is very useful for practical demonstrations, which are generally appreciated by many people. TV, VCR and audiocassettes are played to disseminate information in an entertaining way. A person is given responsibility to explain about TB to the audience as well as to answer queries through interpersonal communication.

Video-based training modules
While planning your activity, view the ‘Advocacy and Social Mobilisation’ module in the accompanying CD.

Annexure 1 | 77

TB Control

1.2 Media Advocacy
1.2.1 Print media
Print media can be a useful way of reaching the community with IEC messages. It will only reach those who can read and can afford to buy them. The audience will often include opinion leaders and influential persons.

Newspapers
Can provide detailed information about a topic. It is easy to present technical data, such as achievements of RNTCP in a clearly-designed text. Important topics, such as five important components of RNTCP, can be covered in a series of articles.

Objective
To create awareness and mobilise public opinion on TB/RNTCP.

Formats used in newspaper
News: Description of important, recent events accompanied by photographs (e.g. launching of RNTCP in a PHI). Future events: Details of future events, public announcements (mass run on World TB Day). Advertisements: These can be of any size from small ads to full-page ads containing important messages on TB (e.g. ‘Use DOTS, Fight Poverty’). Features: Features are longer articles describing events or reviewing topics. They contain items of general interest and short stories. RNTCP can be a subject for features, such as description of TB as a disease, problems emerging from late diagnosis and irregular treatment and effects of utilising DOTS. Letters: There is usually a section with letters from the public responding to various issues of RNTCP. Special interest sections: Many newspapers have a health section. Often, this contains an ‘advice column’ responding to issues raised by readers that can include TB.

Advantages
  Influential in creating awareness and mobilising public opinion Can be used to support radio and TV for educational purposes

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Disadvantages
    Can be used only for literates Can be expensive for the poor It is a one-way communication Requires special writing and editing skills

Leaflets
   Use of leaflets is most common in health education. The simplest leaflet is a single sheet of paper, printed on one/both sides and folded into half or three parts. Leaflets can be larger with two or more sheets of paper (pamphlets/ brochures).

Target audience
All literate women and men.

Objective
To spread mass awareness in the community regarding TB as a disease and the availability of free treatment.

Preparation and production
     Should be interesting to look at Should contain relevant information for target readership (e.g. signs and symptoms of TB, free diagnosis and treatment, PHIs providing DOTS) Language should be easy to read and understand Complicated technical words should be avoided Should mention place for getting further information

Pre-testing
All leaflets/pamphlets/booklets should be pre-tested and changes made accordingly before printing.

Distribution
Look out for opportunities to distribute materials, such as:  Campaigns and rallies  Group discussions  Public meetings—World TB Week  In-service training programmes  Exhibitions

Advantages
  Excellent format for presentation of technical information Can support other media for educational purposes

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 

Useful in individual and group sessions; can serve as a reminder of the main points made Helpful for sensitive subjects like TB and AIDS—when people are too shy to ask, they can pick up a leaflet and read the information

Disadvantages
  Can be used only by literates Can only be effective only if well-designed and appealingly produced

1.2.2 Electronic media
For mass communication of ideas, messages and important events.

Objectives
   To spread mass awareness regarding basic scientific facts about TB To bring about a change in the beliefs and attitudes towards TB as a disease and its curability To support parallel initiatives for behavioural change

Target audience
Patients, service providers and the community at large.

Radio
It is the media channel that now reaches the widest audience. Our country still depends on centralised production of broadcast programmes. However, local radio stations produce programmes in regional languages with locally-relevant content that are increasingly common.

Advantages
       Radio technology is available all over the country and can reach mass audiences cheaply Receivers are cheap and are available in the remotest areas (unreachable areas) Messages can be repeated at low cost Easy to reach illiterate population Is flexible and formats can be of varied types Effective in spreading awareness and announcing events (e.g. World TB Day) Can mobilise community to participate in public events and projects (e.g. mass run for ‘Use DOTS, Stop TB’ campaign)

Disadvantages
   One-way channel Difficult to assess audience reaction and interest Content may not be suitably-tailored for small communities

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Television
DOTS programmes containing stories and educational elements could be shown from VCR equipment generating a one-night cinema hall experience at village-level (using VCR, projector, simple screen, electricity from generator). The existence of many channels reduces the audience of any one channel and provides stiff competition for health-related messages on TV.

Advantages
    Its novelty attracts audiences (spots on effective use of DOTS) Messages can be repeated and thus reinforced (helps in behavioural change) Suitable for motivation through utilisation of different formats (drama, music, folk-media, events) Can create awareness, even among illiterates

Disadvantages
    Expensive to operate One-way method – no audience participation Not available among very poor people Requires extensive planning and preparation

Formats for radio and TV
 News – An IEC activity mentioned in the news bulletin gives wide coverage and credibility at no cost (e.g. mass meeting on ‘Use DOTS, Stop TB’ on Independence Day) Spot announcements, for example on the inauguration of RNTCP in a district with a list of PHIs where DOTS is available. Spot announcements are useful for quick circulation of messages in the community.

Slogans and jingles
 Slogans are short catchy sentences, designed to attract attention, usually moulded on well-known sayings or rhymes. They can identify a campaign, e.g. ‘World TB week’ Jingles are slogans set to music and are more memorable; set to identify a programme (RNTCP)

‘Phone-in’ programmmes
Programmes in which listeners ring a studio either ‘live’ or ‘off-air’ and give their views, ask questions or ask for advice. They are dealt with by an expert, or by a panel in the studio.

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Talks and documentaries
Five to ten minute talks by doctor/DOT provider/cured patient are used. Documentaries explore a single topic and include different effects.

Drama
Long/short plays, soap operas, serials and dramas have enormous potential for IEC because the audience can identify with the characters and their problems (patients/traditional healers/providers). Dramas are expensive to produce.

Quizzes and panel games
Quizzes and panel games are popular. Those watching them try to answer the questions themselves and learn something from the answers. This can be effectively used for awareness-building on RNTCP. All these activities are jointly taken up with the State Institute of Health and Family Welfare (IEC Cell).

Health communication materials
Posters, folders, leaflets, booklets

Video-based training modules
While planning your activity view the ‘Types of IEC Material and their Use’ module in the accompanying CD.

1.2.3 Display media
Display materials present information and ideas on health and TB in exciting and challenging ways. Display materials commonly used are:  Exhibits  Models  Tin plates  Banners  Hoardings  Wall paintings  Display boards  Posters  Photographs

Objective
To disseminate messages to create awareness amongst the community

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Target group
Patients and their families, service providers and the community at large. Using display materials as teaching/learning aids can stimulate participatory teaching, e.g. a model on a TB patient’s experience of diagnosis, treatment and outcome or an actual demonstration of food to be taken while on treatment for TB. People are more likely to believe something if they can see, feel and touch it for themselves. Display materials can be used to promote learning and spread awareness. Well-developed and properly used display materials can  convey vital information (banners on signs and symptoms of TB);  show something that people cannot see in real life (positive slide under a microscope with TB organism);  provide a substitute for the real thing (pictures/posters of persons suffering from TB—now and then);  arouse people’s interest and gain attention (mela kit with key messages);  help people to remember key points (exhibition set); and  make difficult ideas easy to understand (wall painting).

1.3 Health Communication Activities for Capacitybuilding
Orientation at state-level of CDMOs/ADMOs/DTOs/RNTCP MOs

1.3.1 Training of health workers
Objective
  To orientate district-level managers on technical, operational and programme management aspects of the RNTCP and update them To involve participants in micro-planning exercises for the selection of PHI/ TU/DTC and personnel identification for DOT providers, STS, STLS, LT, MOPHI, MO-TU, etc., and make district resource mapping/identification and prepare RNTCP District Action Plan Review RNTCP performance indicators as per national guidelines and generate problem-solving discussions

Duration
Two days

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Venue
Conference hall of the SIH&FW or in a hotel at the state capital

Participants
CDMOs, ADMOs, DTOs and RNTCP MOs. Ideally, 30 participants in each batch; a total of three batches for the state of Orissa. Participants from 10 districts in one batch (CDMO, ADMO/DTO, RNTCP MO).

Date
Once every six months. Date is fixed as per the convenience of the participants and the facilitators. The orientation should be made mandatory before the RNTCP preparatory work starts for new areas/districts.

Facilitators
     Dy. Director General TB and/or representative from Central TB Division Secretary, Health and Family Welfare and/or Dy. Secretary, Health and Family Welfare Director, Health Services, Jt. Director (TB/Leprosy), Dy. Director TB RNTCP trainer from State TB Demonstration and Training Centre WHO consultant and Danida representatives.

Process
An official letter is issued from the Government/Director of Health Services to CDMO requesting him/her to participate in the programme and CDMO, in turn, allowing the other two to join. CDMOs are asked to bring certain data related to the programme for discussion/ planning.

Session content
       Inaugural formalities, objective of the workshop, key issues and general address, etc., done by the Secretary, Jt. Director and Director respectively Brief introduction on RNTCP, extent of problem of TB and control measures Technical and operational aspects of RNTCP Assessment of resources at district level as per district-wise information presented by the participants Programme review, micro-planning and action to be taken Problems and bottlenecks—an open discussion to sort out issues Preparation of district-wise action plans and follow-up action plans

Teaching methodology
Lecture, presentation, participatory process, group discussion, panel discussion, question and answer, demonstration, audio-visual etc.

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Health communication materials
Banners, posters, flipbooks, leaflets

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Outcome
    RNTCP information updated and district-level programme managers orientated Problems and difficulties discussed and sorted out to the extent possible Review of RNTCP activities done District Action Plan and Gannt chart prepared for the next six months

Report writing
Report/proceedings preparation by the ministerial staff of the State TB Cell.

Evaluation
At the end of the training, an evaluation is carried out using developed question formats to assess whether the objective of the training has been achieved.

Follow-up
     Apprise the District Collector and discuss in the District Health Society meeting Discussion at the district-level monthly meetings and RNTCP in regular review agenda Preparation of Gannt chart and District Action Plan Micro-planning exercises at PHC level involving all staff Regular organisation of quarterly review, monitoring and supervision workshops

Modular training for MO-PHI at state level
Objective
 To train the designated medical officers of PHIs in diagnosis and treatment of TB patients in their respective areas and in overseeing quality control of microscopy activities and drug distribution To enable the designated medical officers to participate in and review all technical aspects of RNTCP and preparation of monthly and quarterly reports to be submitted to the TU/district and make supervisory visits To be able to act as training coordinator during the DOT providers’ training and ensure participation of all

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Duration
Seven days, including one day for field exposure (residential).

Venue
Any of the Chest and TB departments of the three medical colleges in Orissa.

Participants
CDMO selects medical officers of a designated MC who are willing and regular in service. Ideally, 20–24 medical officers in a batch will be trained in two groups with three facilitators.

Date
The date is decided by the state based on the training needs and workload. As per the RNTCP national norm, there should be a trained designated medical officer in each PHI at any given point of time.

Facilitators
 Professors/assistant professors/lecturers of the Chest and TB and SPM departments of three medical colleges who are trained as trainers of trainers (TOT) in RNTCP. Other senior medical officers with specialisation in TB and chest diseases from the districts who are also trained as TOTs in RNTCP. Retired professors/assistant professors/DMETs who may have been involved in the training programmes earlier.

 

Process
A state-wide training calendar to be prepared by the STO as per the needs and load of the districts. The professors of the respective medical colleges need to be consulted and a formal letter from the Director of Health Services, along with the approved training calendar, to be served to the districts/medical colleges/ facilitators for information and necessary action.

Session content
  All ten modules (1 to 10) of the training course with relevant exercises for each module One-day field visit to a district to experience the practicalities and interaction with patients and providers

Teaching methodology
Reading the modules, lecture, participatory discussion, doing exercises, quiz, question answer, ice-breaker and demonstration (medicine, sputum container, TB register, forms etc.).

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Health communication materials
Training modules, banners, posters, flipbooks, leaflets and booklets.

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Outcome
The medical officer  is sound in RNTCP and is updated with the latest information on the disease and can advise on sputum microscopy examination,  is confident of diagnosing and treating a TB patient in accordance with RNTCP guidelines and  can counsel the TB patients properly and advise the DOT provider on the do’s and don’ts of treatment.

Evaluation
At the end of the training, an evaluation is carried out using developed question formats to assess whether the objectives of the training have been achieved.

Follow-up
The medical officer  ensures identification of TB suspects, collects sputum from them, refers patients for diagnosis or further examination and advises treatment;  supports laboratory services, monitors documentation related to microscopy examinations, maintains an adequate supply of re-agents and other materials and ensures disposal of contaminated materials;  communicates with patients, monitors drug administration and administers preventive treatment;  ensures that patients brought under treatment are registered, monitors the regularity of sputum examinations and identifies and records treatment outcomes; and  periodically assesses the quality of reports, conducts support supervision visits, maintains a regular supply of drugs and other materials and participates in and presents quarterly progress reports in the quarterly review, monitoring and supervision workshops to be held at the TB Unit-level.

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1.3.2 RNTCP training of TB programme staff
Training of Senior Treatment Supervisors (STS) at state-level Objectives
To train and orient key RNTCP personnel in order to  make them well-acquainted and skilled to perform relevant job responsibilities under RNTCP,  ensure proper treatment and  ensure proper registration and reporting.

Duration
Six days, including two days of field visit.

Venue
The training hall of Anti-tuberculosis Demonstration and Training Centre (ATD&TC), Cuttack, or in an RNTCP district having conference facilities.

Participants
 Existing supervisory staff at PHC level Multi-purpose Health Supervisor (MPHS), Sanitary Inspector, Senior Health Worker, Pharmacist, Ophthalmic Assistant) to be decided by the CDMO/ADMO of the district. Contractual personnel (in this case an extensive training plan is needed on duration, curriculum and module). Must know two-wheeler driving and be willing to travel extensively. 20-24 participants in one batch to be trained in two groups.

  

Date
As per workload and requirements. One STS to be selected for a TU with 500,000 population. S/he should be trained before the DOT provider training starts at the PHI level.

Facilitators
 State-level RNTCP (TOT) trainer.

Process
A state-wide training calendar is to be prepared by the STO. A formal letter from the Director of Health Services to be sent to the CDMOs of the districts where the training need is assessed along with the calendar.

Session content
 DOT provider training module

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   

STS module 1 and 2 Dummy TB register Training exercise sheet Field visit

Teaching methodology
Lectures, readings, presentations, participatory processes, questions and answers, demonstrations, practical exercises, audio-visuals etc.

Health communication materials
Banners, posters, flipbooks and leaflets

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Outcome
The STS is  well-acquainted with RNTCP,  confident of doing the job,  well-versed with field practicalities and  able to plan and report independently.

Evaluation
At the end of the training, an evaluation is carried out using developed question formats to assess whether the objectives of the training have been achieved.

Follow-up
The STS  ensures identification of TB suspects and proper treatment of patients during frequent and regular visits to the PHIs;  records results of follow-up sputum smear examinations till end of treatment;  records drug collection (during the continuation phase) and records remarks;  communicates with patients and gives health education to community;  ensures proper drug administration and appropriate preventive treatment for children;  maintains the TB register and ensures that all patients under treatment are given TB numbers; and  helps prepare the quarterly reports including programme management and logistics.

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Training of Senior Tuberculosis Laboratory Supervisor (STLS) at state-level
Objectives
  To train and orient STLS to perform laboratory quality control in the PHI. To plan and make regular supervisory visits to PHIs at least once a month in order to ensure that all sputum-positive slides and 10-15 percent of negative slides are cross-checked. To ensure that contaminated materials are disposed of safely, and monitor the maintenance of the TB laboratory register at regular intervals.

Duration
Five days including field visit. In order to be eligible for STLS training, it is a prerequisite for the participant to first undergo the six-day laboratory technician training.

Venue
Training hall of the ATD&TC, Cuttack, or in an old RNTCP district.

Participants
Qualified pathology laboratory technicians. Ideally, 20 participants in a batch to be trained in two groups. Must know two-wheeler driving.

Date
State training calendar to be prepared by the STO. Training to be organised as per workload assessment and convenience of the facilitator and the participants.

Facilitators
   State RNTCP (TOT) trainer Senior Laboratory Technicians of ATD&TC, Cuttack Experienced STLS of the old RNTCP districts

Process
A formal letter from the Director of Health Services to be issued to all CDMOs concerned. The venue details and training schedule is attached to the training calendar of the STS. Both the STLS and STS visit the same PHI but with different checklists—the STS on the treatment part and the STLS on laboratory aspects.

Session content
   DOT provider module Laboratory technician module Module for STLS

90 | A Health Communication Strategy for RNTCP

 

Field visit Training exercise sheet

Teaching methodology
Lectures, readings, demonstrations, participatory processes, questions and answers, audio-visual presentations, practical exercises etc.

Health communication materials
Banners, posters, flipbooks and leaflets.

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Outcome
The STLS is  sensitised on RNTCP,  sound and confident in laboratory supervision work and  able to prepare independent travel plans and report back from the field.

Evaluation
At the end of the training, an evaluation is carried out using developed question formats to assess whether the objectives of the training have been achieved.

Follow-up
The STLS  conducts visits to microscopy centres;  performs laboratory quality control;  ensures that contaminated materials are disposed of safely;  ensures that treatment cards are correctly filled;  monitors the maintenance of the TB laboratory register; and  monitors documentation related to microscopy.

1.3.3 CME for health workers CME in medical colleges
Objectives
   To update the participants’ knowledge on RNTCP To apprise the participants about the objectives and strategies adopted under RNTCP To encourage the participants to follow the principles of diagnosis and treatment procedures as prescribed under RNTCP

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Target group
House surgeons, post-graduate students.

Duration
Half day.

Venue
Conference hall of medical college.

Organising process
DANTB issues a request letter to the Principal/Professor and HoD of TB and Chest Department to organise a CME programme, under intimation to the Director of Medical Education and Training. A suitable date is decided as per the convenience of all concerned.

Facilitators
   State trainer on RNTCP Director/Jt. Director (TB) of Health Services Deputy Director

Session content
    Brief introduction on RNTCP Components of DOTS Diagnosis and treatment procedures Role of doctors in the promotion of RNTCP.

Teaching methodology
Lectures/discussions/demonstrations.

Training materials
OHP, handouts, writing materials.

1.3.4 Training of DOT providers training and re-training of DOT providers at PHI level
Objectives
 To train and re-orientate DOT providers in basic information about various aspects of TB; this includes exercises on various activities and skills which the DOT provider has to perform while implementing RNTCP On successful completion of training, DOT providers working at the periphery will be well-acquainted with and skilled to perform all job requirements related to RNTCP.

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To keep DOT providers abreast and updated about RNTCP in order to treat and cure TB patients smoothly and effectively.

Duration
One day at the MC.

Venue
PHC training/meeting hall, local school premises, meeting hall of the BDO office or any public place free of outside disturbance.

Participants
Multi-purpose health workers, anganwadi workers, volunteers, village health guides, NGOs, teachers and cured patients. Ideally, 20-30 participants in a batch for one facilitator.

Date
Once a year in PHIs. MOs-PHI to send the list of participants; ADMO/RNTCPMO to prepare the calendar for the district, and CDMO to issue letters to PHIs for the training.

Facilitators
    District trainers trained in TOT MO-PHI as training coordinator STS and STLS RNTCP-MO/ADMO/CDMO (any one)

Process
CDMO to send an official letter with training guidelines and funds to MO-PHI to conduct the training.

Session content
       TB as a disease, its cause, mode of transmission, type, magnitude of problem, etc. RNTCP Treatment formalities under RNTCP, including diagnostic procedures and intake of medicines Filling-up of treatment card Counselling and health education for TB patients Role and responsibilities of DOT provider Gender disparities and IEC in RNTCP

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Teaching methodology
Lectures, reading of modules, participatory discussions, questions and answers, role-plays, quizzes, demonstrations, ice-breakers, sputum collection procedures and experience-sharing by cured patients.

Health communication materials
Banners, posters, flipbooks, leaflets, booklets, success stories and snakes and ladders .

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Outcome
     The DOT provider (DP) has first-hand knowledge about RNTCP. DP is confident of referring suspected cases for sputum microscopy and to give DOTS. DP is aware about the seriousness of irregular/default treatment and the follow-up sputum tests. DP is able to fill the treatment card and keep the medicine packet intact. DP is able to give proper and right health education to the patient and the community.

Evaluation
At the end of the training, an evaluation is carried out using developed question formats to assess whether the objective of the training has been achieved.

Follow-up
The DP is enabled to  motivate the suspected TB patient to get his sputum examined, explain treatment requirements and expected duration of treatment with advice on regular follow-up of sputum examinations;  ensure that every patient diagnosed as a case of TB is registered and treated for the full term;  fix the time and place for DOT, keeping in mind the patient’s convenience and operational feasibility;  maintain the treatment card up-to-date and ensure that the patient is allotted a TB number;  ensure immediate defaulter retrieval and impart health education to the patient, the family and the community.

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Involvement of cured patients as DOT providers
Introduction
It is mainly health staff, anganwadi workers and volunteers from some NGOs who have been identified as DOT providers.

Rationale
It is well-known that satisfied users are the best motivators. One who has undergone the process himself and has gained experiences, both positive and negative, can share his views with others more convincingly than others.

Objective
To facilitate and enable cured TB patients to provide DOTS, counsel patients, refer suspected cases and disseminate RNTCP information.

Participants
Cured patients of both sexes who are literate or semi-literate.

Process
A list of participants using the above-mentioned criteria is prepared by laboratory technicians/STS from the patient register of PHI/TB register of a TU. The patients are then contacted to assess their willingness to take part in the training and to act as DOT providers. After a batch of 10-15 participants are enlisted, the training date is decided by the MO-TU and the DTO. The participants are intimated personally by the LT/concerned health worker of the date, time and venue of the training.

Venue
TU headquarter/any other convenient place for the participants to attend.

Duration
One day.

Resource persons
  MO-TU/MO-PHI/STS/STLS/LT/BEE CDMO/DTO/SDMO may also attend the training programme.

Session content
Theory—Technical aspects of TB such as cause, mode of spread, type, categorisation of treatment, diet, sputum follow-up and principles of counselling. Practical—Filling of patient cards.

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Training methodology
Discussions, sharing of experiences, group work/individual assignments, roleplays, demonstrations and quizzes.

Health communication materials
Flipbooks and/or flashcards, medicine boxes and treatment cards.

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Evaluation
Questionnaire and quiz given by trainer. Ongoing supervision in the field by STS/MO-PHI to assess and support their performance in providing DOTS, filling of treatment cards and counselling.

Follow-up
Once the participants start their work, MO-PHI, STS and health workers of that area to keep contact with them and guide them regularly.

1.3.5 Strengthening the state IEC organisation Training for BEEs on community-based health communication activities
Health communication activities are the key to success for all health programmes. Such activities have better success rate when organised by the communities themselves instead of being planned and organised from outside. All health communication functionaries need to be trained on community-based health communication activities so that they can play their roles successfully.

Objectives
On completion of the training, the participants (BEEs) would be able to implement successful community-based health communication programmes in their respective areas with the help of new communication technologies.

Specific objectives
    Utilise their knowledge and skill on recent communication technologies Use PRA technique to identify health-seeking behaviour of the community and the lacunae between knowledge and practice Organise effective trialogue approach sessions to sort out problems and improve programme performances Develop and use low-cost media to provide health communication support for the programme

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Duration
Two days

Venue
Conference hall of the SIH&FW or in a hotel in the state capital

Participants
CDMOs, ADMOs, BEEs and RNTCP MOs. Ideally, 30 participants per batch.

Facilitators
   Director, (Health Services), Jt. Director (TB), Dy. Director TB RNTCP trainer from State TB Demonstration and Training Centre Communication specialists

Process
An official letter is issued from the Government/Director of Health Services to CDMO informing him/her to participate in the programme. The CDMO, in turn, will arrange for the BEEs to participate.

Session content
            Introductory session The TB scenario Communication basics and its relevance in RNTCP Community-based health communication and media PRA exercise and its relevance Social mobilisation and partnership development Assignments on media production Field visit—trialogue approach Presentation of field experiences Presentation of assignments Preparation and presentation of activity plan Evaluation

Teaching methodology
Lecture, presentation, participatory process, group discussion, demonstration, ice-breakers, field visits, audio-visual etc.

Communication materials
Banners, posters, leaflets, handouts

Evaluation
At the end of the workshop, an evaluation is carried out using evaluation formats to assess whether the objective of the training has been achieved.

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Training of Mass Education and Information Officer (MEIO) and district-level media officers
Objective
Capacity-building of media officers in planning and implementing media activities towards creation of awareness for promotion of RNTCP.

Duration
Two and a half days

Venue
State/zonal headquarters

Participants
     MEIO, DHRO MEIO (H&FW) District Information and Public Relations Officer (PR Department) Field Publicity Officers Programme Executives (Health) (Doordarshan and AIR)

Resource persons
   State trainer on RNTCP Director/Dy. Director from SIH&FW MO-TU/MO-PHI

Process of organisation
SIH&FW, PR Department, Field Publicity Department and AIR/DD decides a suitable date and venue. Request letters are issued to concerned district authorities/officials from their respective heads of department to relieve the participants for the training programme.

Session content 1st day
     Brief introduction on RNTCP and the DOTS strategy Technical aspects of TB Role of IEC for promotion of RNTCP Introduction on gender disparities in health with special reference to TB Media and materials for community education, including community media

2nd day
 Field visits to observe interaction meeting of patients and DP as an effective community medium.

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  

Street theatre Presentation of field observations Review of media and materials, suggestions for improvement and developing new ones

3rd day
  Presentation of new ideas for media materials Prepare and present need of action plan for the district for next six months

Training methodology
Lecture discussion  RNTCP and DOTS strategy  Technical aspects of TB  Gender

Demonstration
   Street theatre Involving TB patients, showing medicines, technical aspects of TB Media materials

Observation
  Interaction meeting Street theatre

Group work
  Review of media materials Plan of action

Health communication materials
OHP flip chart/blackboard, posters, flip book , banners, video/audio cassette, TV , and VCR.

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Training state IEC staff
Objective
To enhance professional competency in the production of IEC materials, organisation of training programmes for block- and district-level media officers and reviewing district-level health communication activities related to RNTCP.

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Duration
One day

Venue
State headquarters (SIH&FW)

Participants
     Deputy Director, IEC Health Education Officer Production Officer Health Educators Artists-cum-photographers

Resource Persons
  Director, SIH&FW DHS/Jt. DHS

Process of organisation
Director Health Services (DHS) and the Director of SIH&FW, Orissa, decide a convenient date for the training.

Session content
    Brief introduction on RNTCP and DOTS strategy Technical aspects of TB Media production—some basic points Role of IEC cell officers in the production of IEC materials, organisation of training and review of health communication activities related to RNTCP .

Training methodology
Lecture-discussions, video presentations and demonstrations.

Health communication materials
OHP, video/audio cassette , posters, production of posters, final products selected for printing, pretesting and handouts.

1.4 IEC Material Development

1.4.1 Poster development workshop
In print/display media, posters are considered to be one of the important means for disseminating information to literate and semi-literate groups. Posters are developed for RNTCP in a systematic manner during a workshop.

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Objective
To facilitate the participants to design posters with important messages on TB for creating awareness among different target groups, suitable to their culture and language.

Venue
Suitable location at district headquarters.

Duration
Three days (residential).

Participants
Local artists, artist-cum-photographer from the Department of Health and Family Welfare and other departments.

Process of organisation
CDMOs/DTOs are informed regarding the workshop and are requested to select participants from their districts and obtain their willingness. After a list of 10-12 participants is finalised, a request letter is sent to them through their department heads to attend the workshop.

Session content
      Brief introduction of RNTCP Technical aspects of TB Target group and message development Principles of poster development Individual assignments on poster development Presentation of final products

Health communication materials
Posters, flipbooks and/or leaflets

Video-based training modules
While planning your activity view the ‘Types of IEC material and their use’ module in the accompanying CD.

Facilitators
  TB and Chest specialist of the district headquarter hospital Dy. Director/Director of SIH&FW

Selection of posters for pre-test
At the final presentation, posters are selected by the Directorate of SIH&FW (State IEC cell) for pre-testing.

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Responsibility of pre-testing and printing
The State IEC cell takes the responsibility to pre-test the posters in the field among the respective target groups and, after necessary changes, the printing process is started.

1.4.2 Development of other display material
Display materials need to be attractively presented in order to help viewers retain what they have visualised. Display materials commonly used are:  Exhibits  Models  Tin plates  Banners  Hoardings  Wall-paintings  Display boards  Posters (see section 4.1)  Photographs

Objective
To disseminate important messages on RNTCP to the community.

Target groups
All community members.

Deciding on format
The overall appearance of the materials should never distract viewers from the lesson in hand. The format chosen should  be clear  have a pleasing layout  use appropriate colours and illustrations and  promote a desire to learn. When deciding on the appropriate format, imagine that you are assembling a picture that consists of different parts—all needing to fit together harmoniously. The type of format chosen should depend upon the materials being developed. Consider the following aspects:

Purpose
Be clear about what you want to achieve. Take into account the type of material being used and the messages you want to convey. This is essential if you are to know how to lay your materials out, what to include and where to position photographs, sketches and other illustrations.

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Experimentation
Ideas for layout come from experimenting and brainstorming. Try out different ideas by sketching them on a piece of paper to see what they look like. You do not have to go into any detail at this stage—just make a rough sketch.

Relevance
All the elements in your design should be relevant to your objectives and the target audience. They should help the viewers understand and retain the messages being conveyed.

Proportion
The size of the elements that make up your material should be determined by their importance (the use of headlines, illustrations etc.).

Direction
Effective design (exhibit) should direct the audience, making it easy for them to move around and find the information they require.

Contrast
Building visual contrast into your materials makes the information more eyecatching and interesting. You may want to make your titles (in a flip-book) larger than the text, or present figures and percentages as a graph or chart.

Simplicity
Decide which design most effortlessly enhances the message you want to convey and meets the objectives. Finally, pre-test the display material and make necessary additions and changes.

1.4.3 Development of radio spots
Objective
To disseminate important messages to the community on a wide basis.

Target groups
All radio listeners, especially adult women and men, and adolescents. Points to be considered while developing radio spots:  Present only one idea  Begin with an attention-getter  Be very explicit  Ask listeners to take action

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 

Make the audience feel the importance of the tuberculosis situation and adopt the DOTS strategy Repeat the key idea two to three times

Process
The group that develops the radio spots, comprises members from the IEC cell, TB cell, staff of AIR and DANTB staff. This group develops and finalises the concept, message and the format (jingles, music, drama) and determines the length of the spots (one to three minutes). The time for broadcast is planned—prime time before and after news is preferable in accordance with the budget allocation. The staff of AIR, along with artists, develops the lyrics and music and makes the spot, which is pre-tested prior to final production. The final product is screened by the group and used for broadcasting. Full details of the number of broadcasts, the time span and the time and dates of broadcasting are to be well-maintained to record the outcome of the programme. The Audience Research wing of All India Radio or any other research institution can be requested to evaluate the outcome of such programmes and provide suggestions.

1.4.4 Development of TV spots
TV spots provide a useful way of reaching large-scale communities with health education messages.

Objective
To disseminate information about RNTCP and TB to a wider range of people in a quick, entertaining and comprehensible manner.

Target groups
All sections of the community including influential groups in the private/public sectors who watch TV. Points to be considered while making TV spots:

Be brief
Assume the viewer gets bored easily and can ‘switch off’ mentally/physically at any time.

Be entertaining
The viewer needs to be entertained by the telecast. Make it as lively and interesting as possible. Try to make the message more acceptable by use of music/comedy/ drama. Do not lecture.

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Be clear
It is no use burying the message too far in the entertainment or making it obscure. Be simple, use straight-forward ordinary language (local dialect). Speak clearly and do not rush.

Aim for maximum impact
Always try to start a spot with something that catches attention—music, jingle or a striking word/question. End with something that people will remember.

Dialogue or discussion
Dialogue or discussion is always more interesting than one person talking. It is very difficult to hold attention with one voice.

Aim for variety
Do not put in too much speech or too long pieces of music. Try putting a music background to the speech, use different voices, ask questions, keep the viewers guessing—try not to be predictable.

Process
       The group that develops the TV spot comprises the TV staff, state IEC cell, state TB cell and DANTB staff. The message concept and the format (jingles, music, drama, script) is then finalised. Time span of spot is determined (one to three minutes). Time of broadcast—prime time before and after news is preferable in accordance with budget allocation. The TV staff along with other artists develop the lyrics, music and dialogue and produce the spot, which is pre-tested prior to final production. Final product is screened by the group and used for telecasting. Full details of the number of telecasts, the time span and the time and dates of telecast are to be well-maintained to record the outcome of the programme. The audience research wing of Doordarshan or any other research institution can be requested to evaluate the outcome of such programmes and give suggestions.

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1.4.5 Development of cinema slides
Objective
To disseminate messages on TB and RNTCP through screening of slides at different cinema halls in the state.

Target group
Cinema theatre audiences. Important messages for slides  Early signs and symptoms of TB  Place of availability of free diagnosis and treatment facilities  Importance of regular intake of drugs

Process
Development of messages and selection of photographs to be done in a brainstorming session. In this session, the Project Officer of DANTB, representatives from the State IEC Cell/TB Cell and IEC Advisor would suggest different important messages. One/two messages for use will be selected and finalised. Relevant pictures will be placed with the message. The slides are pre-tested. After messages and pictures are finalised an advertising firm with expertise in preparing cinema slides is identified and given orders. The IEC Advisor and the Dy. Director, IEC, both work with the firm to finalise the preparation of slides. The slides are then handed over to the Mass Education and Information Officer of the district for distribution at cinema halls, with a letter from the Collector to screen them free of cost.

1.4.6 Development of music cassette
Objective
To disseminate RNTCP and TB messages in an entertaining way in the local dialect with local music.

Target group
Adult men, women, adolescents and school/college students.

Process
A group of local artistes are identified and sensitized for three to four hours on RNTCP and TB. The social aspects are fully discussed. They are encouraged

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to develop lyrics with important messages on TB and RNTCP. These lyrics are examined by a group of IEC and TB experts and necessary alterations/ improvements are made.

Composition of music
The composition of music and identification of local singers then takes place. Once the lyrics are finalised, music is composed with the help of local music experts and singers. Importance is given to traditional music and instruments. After a number of rehearsals, songs are recorded in a well-equipped professional studio.

Important messages
     Cause of TB, mode of spread Early signs and symptoms Procedure of diagnosis and treatment Availability of facilities, free of cost Importance of regularity of treatment and timely sputum follow-up

Cassettes are distributed to MOs/BEEs of each PHI for use at     interaction meetings amongst DPs, patients and programme personnel, exhibitions, melas/festivals and interactive stalls at haats.

1.4.7 Development of role-plays
A role-play is a type of drama where trainees/participants act out real-life situations relating to a chosen issue in front of their colleagues/peers.

Objectives
   To enable trainees/participants to explore issues/events from different points of view and develop empathy for patients/communities. To enable use of available intellectual and emotional faculties and existing experience for problem-solving. To enable participants to practise counselling skills and making difficult decisions in a realistic situation.

Purpose
Role-plays can help a group  get to know one another,  think about a particular problem/issue,  be more sympathetic to others’ point of view and  strengthen communication and counselling problem-solving skills.

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Use a role-play  to help trainees/participants realise that others, too, have situations/ problems similar to their’s,  where active involvement can produce a sound basis for discussion and  to demonstrate different ways of dealing with a problem/situation.

Organisation of process
The facilitator  decides on the learning objective and chooses a problem (Ram Babu, Cat-I patient, aged 40 years, a labourer, has stopped taking DOTS after six doses. He is an alcoholic and does not listen to the TB staff );  describes the situation for the role-play to all present;  explains the role of actors (patients can also be actors) and observers;  explains to observers that acting skills are not being evaluated; rather, they must observe the reasoning, attitudes and responses to the issue;  lets the role-play continue till its logical conclusion (10—15 minutes).

Target audience
Trainees, participants in meetings/workshops (interactive meetings of patients and DOT providers); also trainees in relation to supportive supervision.

Venue
   Orientation training of medical/non-medical staff Training workshop of health staff Interactive meeting of patients and DOT providers

Facilitators
    Trainers Resource persons at different meetings MEIO/BEE/principals of HW training centre STS/STLS

Review
   Ask actors to share their feelings while enacting their roles Ask observers for comments and questions How can the role-play help them in their work?

Evaluation
   Listen carefully to points made in response to questions. Note the perception and values that emerge which will help trainees/ participants in future activities. Ask trainees/participants on ways to improve the role-play.

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Methodology
Participatory training method

Advantages
    Focuses directly on the problem. Helps trainees/participants to deal with it through direct/indirect involvement. Does not require monetary or material support. Exposes an individual to various points of view.

Disadvantages
   If trainees/participants are not fully involved, the session may only be of entertainment value. Roles can be exaggerated and distorted. Learning can be hampered if the discussion group focuses on unimportant aspects while ignoring important/relevant ones.

Therefore, facilitators have to take meticulous care to avoid such unwanted situations.

1.4.8 Training on street theatre technique
Objective
To enhance skills on development of street theatre scripts for RNTCP.

Duration
Seven days residential training

Venue
A suitable place, preferably a big hall, youth club, community centre or an NGO office building. The concerned cultural/street play/NGO groups who organise the training programme select the venue for the participants.

Participants
Those with a cultural background, a flair for acting and an interest to perform before the community are selected. The group size is 10–12 persons including males and females; two groups of NGOs are trained in one batch.

Resource person
External persons who have teaching experience with street theatre technique, scriptwriting and acting. He/she usually holds a degree from Sangeet Sahitya (Kala) Academy, Orissa.

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For technical session
MO-PHI, STS, BEE

Process of organisation
CDMO discusses with ADMO/MO-TU/MO-PHI/STS/BEEs during monthly meetings or RMS meetings to identify potential cultural groups; BEE/STS contacts cultural/street play group leaders and discusses about street theatre workshop. The district authority selects two active groups at sub-district and district levels, and informs them accordingly. CDMO/ADMO is responsible for the training and sends a letter to the cultural groups regarding a suitable date and venue for the training programme. BEE contacts concerned NGO/cultural/ street-play groups for selection of the training venue and boarding and food arrangements. District authority contacts resource persons for the training programme.

Content
  Technical knowledge on TB and programme implementation. Basic concept and principles of street theatre technique.

Scriptwriting
At the end of the closing day, the troupes demonstrate a street theatre show for the public in the presence of health personnel and resource persons. After the performance, technical errors are rectified by the resource persons.

Teaching methodology
Discussions, group demonstrations. work, lectures, role-plays, demonstrations, re-

Health communication materials
Banner, posters, flipbooks, folders and leaflets .

Video-based training modules
While planning your activity view the ‘Advocacy and Social Mobilisation’ module in the accompanying CD.

Outcome
Capacity to develop and perform high-quality street theatre on RNTCP is enhanced.

Follow-up
After returning to their community the participants are selected. The script may be modified as per local needs. At this time they are provided technical guidance and programme expertise from the theatre. After a number of rehearsals they are ready for the field performance.

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Report-writing
Consultants in street theatre, and health personnel.

1.4.9 Pre-testing IEC materials
Pre-testing means field-testing communication materials before they are produced or printed. By interviewing the target audience the materials are made for, it is assessed whether they are well understood and appreciated by the audience. Posters, flip charts, flash cards, leaflets, pamphlets, storybooks, booklets and video programmes are some of the materials than can be pre-tested.

Why pre-testing?
Communication materials are most often developed by urban, educated, modern, comparatively well-off and healthy men surrounded by visual stimulation, but are most often meant for rural, illiterate, conservative, comparatively poor and relatively unhealthy people – including women – who live in villages with limited exposure to pictures, posters or other visual aids. There is a gap between these two groups and the planners must verify their visuals with the target groups to ensure effective communication. Pre-testing is a cost-effective mechanism to prevent expensive mistakes.

Process
Preparation before going to the field include research on the communication material, the target audience, objective of the material and the questions to be addressed. In the field, local leaders are contacted and explained about the pre-test. Explain that you are testing the materials and not the villagers, and that you want the villagers’ suggestions for improving the materials.

Interview techniques
       Establish a social setting—a place where there will be no disturbance. Establish rapport. The introduction is important; respondents should be encouraged to give time and suggestions. Let people touch and hold the material. Encourage people to talk freely. Put different types of questions (open-ended and close ended) and listen carefully. Probing and follow-up questions should be asked. Thank the respondents for their time. Always let them know that they were of great help and that the information gathered will be used to improve the material.

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Recording
Pre-testers should work in pairs if possible. One should conduct the interview, while the other writes down the questions and answers.

Analysing the results of pre-testing
Today, computers can be used to analyse the results. Normally, the material is pre-tested with 30-50 people which is usually sufficient to assess the materials.

Final production
  After making necessary changes, the final product is ready for printing. Care has to be taken to use materials (paper, cloth, colour etc.) that are durable for a long period.

1.5 Involvement of Partners in Health Communication for RNTCP
1.5.1 Use of street theatre
Open-air shows like yatra, theatre, pala, dance, drama and puppet show and other folk forms of communication have widespread popularity. A story is presented in combination with dance, music and humour through these genres and entertains the community. Based on the principles of forms of folk communication, street theatre is considered an effective medium for educating the community. Street theatre has come to be widely used in socio-development programmes in diverse areas such as education, health, agriculture, social forestry, prevention of dowry, prohibition and labour exploitation. Street theatre was first adopted in Orissa by DANLEP to promote early diagnosis and regular treatment of leprosy by reducing the social stigma and was proved to be very effective. Based on this experience, street theatre was also utilised in RNTCP.

Objective
To create awareness in order to enhance timely case-detection, treatment adherence and generate knowledge about TB and RNTCP.

Target audience
Community, patients and service providers of all age groups.

Process of organisation
After a formal five-day training, the teams contact the CDMO/DTO of a district, who sends them to the MO-PHI with an official letter regarding performance of street theatre.

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Planning at PHC-level
The team meets the MO-PHC and the BEE to prepare a calendar for shows at the sub-centre level, indicating the date, place and time of each show. A maximum of two shows are planned in a day. The calendar is sent to health workers of all sub-centres well in advance with instructions for their presence at the show. The time of performance is chosen to suit local communities.

Performance in the field
The team proceeds to different sub-centres and contacts health workers for selection of a suitable venue. Once the venue is selected, the troupe moves around the village playing music to make people aware of the show. Once the audience is gathered, the play is started.

Content
The show is presented in a story form with all necessary messages on TB and RNTCP including cause, mode of spread, signs and symptoms, availability of , diagnostic and treatment facilities, importance of regular treatment and timely sputum follow-up. Usually, the script is developed based on one of the local issues related to RNTCP. The audience enjoys the story with music, humour, dance and song. The show continues for 45 minutes to one hour. In most of the shows cured TB patients are involved to narrate their experiences, which attracts and encourages symptomatic cases to come forward to report. Also, the general public is convinced that TB is curable and treatment is available free of cost.

Question-answer session
At the end of the show, the health worker asks the audience about the message they have received. He/she also answers questions asked by the audience to address their doubts.

Reporting of suspects
It has been experienced that a number of chest symptomatics from among the audience report to the team on the spot, who, in turn, advise them to get their sputum examined at the nearest PHI. They also prepare a list of such cases and hand it over to the health staff, and send a copy to the medical officer of PHI.

Distribution of IEC materials
At the end of the show leaflets and handbills are also distributed to the audience to enable them to know more about the disease and the programme.

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Record-keeping
A format containing the date, time and place of the show, the number of people present, (both male and female), influential persons/leaders of the locality present and the names of the symptomatics reported is filled up by the troupe and submitted to the concerned district authorities.

Follow-up
The symptomatics reported during the show are followed up and necessary action is taken by the STS, the MO-PHI and the DOT provider.

Evaluation
Usually the performance is evaluated by the following indicators in respective PHIs:  Increase of information on TB and RNTCP at the community  Increase of chest symptomatic cases reporting to PHIs  Increase in drug compliance  Reduction in defaulter rate

1.5.2 Puppets
Puppets are a form of drama with considerable potential for IEC. They are part of a tradition of folk-media used in many parts of Orissa.

Objectives
  To disseminate messages on TB that are easily absorbed. To spread awareness on DOTS to all segments of the community.

Target audience
Children and women and men of all age groups. Many people see puppets as being relevant only for children and are surprised when they realise how useful they can be with adults.

Duration
30 – 45 minutes.

Venue
School premises, village haats/festivals, community halls or a central, open space in a village.

Resource persons
Skilled persons practising puppetry are given an orientation on RNTCP and the first performance is supervised by the media/TB staff.

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Process
 Different types of puppets according to the characters are made and portrayed:  Glove puppets, with heads made of papier-mâché/clay.  Rod puppets, with figures on wooden rods.  Jointed puppets, moved by strings. Do not wave the puppets around. Make them active—dance, chase, fight, hit and even hug. Give the puppets names, special clothing and personalities. Include humour, music and songs to entertain. Keep it simple. Do not try to cover too much. Make a stage that can be easily put up and taken down for transportation. A wall or a curtain to stand behind is required. Choose the timing of the performance carefully. Find out when the children, women and men are free. Make sure the performances are well-publicised in advance.

      

Impact
Puppets have maximum impact when the community participates in the preparation of the programme, in performing the show and discusses it afterwards.

1.5.3 Patient-DP-community interaction meeting
Objectives
    To develop a good rapport and reduce social distance between DOT providers, patients and other programme personnel. To review the knowledge and activities of DOT providers and patients regarding TB as a disease and provision under RNTCP. To interact with irregular and defaulter cases and identify their problems and needs for counselling towards retrieval. To promote sharing of experiences between DOT providers and patients on their problems and success and agree on action for improvement, keeping the gender component in view. To maintain and promote the motivation level of DOT providers. To facilitate the practice of good counselling and communication skills.

 

Process
 A meeting is likely to be held in a PHI twice a year. A calendar is prepared by the DTO for every round of the meeting. Once the calendar is circulated by the CDMO/DTO to all PHCs, it is the responsibility of the concerned MO-PHI to intimate the DOT providers to attend the meeting.

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The BEE is the convenor of the meeting and will assist the MO PHI in organising and conducting the meeting.

Venue
PHI/PHC headquarters or any other suitable central place convenient to all participants.

Sitting arrangement
The meeting preferably takes place under a tree, except in the rainy season. All participants should sit on a common mat on the floor in a circle/semi-circle.

Duration
One day.

Participants
     DOT providers, both medical and non-medical Patients under treatment (male/female) Cured former TB patients (male/female) Defaulters, all Other programme personnel like BEE, MO-PHI, LT, STS, STLS, MO-TU and ICDS supervisor

Selection of patients and DOT providers
To ensure better participation and interaction, patients and providers are limited to a total of 40-50. Preference is given to all smear positive and defaulter patients, both male and female, to motivate them for regular treatment. Similarly, DOT providers who need orientation are called in on a priority basis.

Agenda of discussion
            Re-orientation of knowledge component in RNTCP Introduction of gender components Review of the activities of each DOT provider Interaction with each patient Review points of patient counselling which includes diet and regular sputum follow-up Experience of DOT provider and suggestion for improvement Narration of experience by patients Patient awareness regarding the disease Patient as educator/motivator in referred cases Interaction with defaulters Cross-checking and updating patient cards Role-play

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Method
    Mainly participatory through discussion Sharing of experiences Role-play Quiz

Evaluation and follow-up
The meeting is evaluated at the end of the session through a developed format in terms of participation, food, venue, defaulter retrieval etc. In the field, DOT providers and STSs monitor the regularity of the treatment among patients, and STSs monitors improvement of knowledge on the programme and fills the treatment cards.

1.5.4 Trialogue approach
Success of any health communication strategy depends largely on the close interaction and coordination between stakeholders. In RNTCP, this can be done through the trialogue approach. This is a community-based activity. In this approach there are three ‘p’s—the patients, the providers and the people. In this meeting the participants spend a whole day together, siting on a mat and eating from a common plates. This meeting gives an opportunity for people to air their feelings. It also provides an excellent opportunity for women to participate. Irregular and defaulter cases are specially addressed to identify their problems and needs, for counselling. Influential people from the community such as panchayati raj members are encouraged to actively participate in spreading awareness about TB diagnosis and DOTS. The trialogue approach reduces the gap between patients, providers and the community through informal, interactive meetings.

Objectives
    To develop a good rapport and reduce social distance between DOT providers, patients and other programme personnel To review the knowledge and activities of DOT providers and patients regarding TB as a disease and provision under RNTCP To interact with irregular and defaulter cases, identify their problems and needs for counselling towards retrieval To promote sharing of experiences between DOT providers and patients on their problems and success and agree on action for improvement, keeping the gender component in view To maintain and promote the motivation level of DOT providers To facilitate the practice of good counselling and communication skills

 

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Process
 A meeting is likely to be held in a PHI twice a year. A calendar is prepared by the DTO for every round of the meeting. Once the calendar is circulated by the CDMO/DTO to all PHCs, it is the responsibility of the concerned MO-PHI to intimate the DOT providers to attend the meeting. The BEE is the convenor of the meeting and will assist the MO-PHI in organising and conducting the meeting.

Venue
PHI/PHC headquarters or any other suitable central place convenient to all participants.

Sitting arrangement
The meeting preferably takes place under a tree, except in the rainy season. All participants should sit on a mat on the floor in a circle/semi-circle.

Duration
One day.

Participants
     DOT providers, both medical and non-medical Patients under treatment (male/female) Cured former TB patients (male/female) Defaulters, all Other programme personnel like BEE, MO-PHI, LT, STS, STLS, MO-TU and ICDS supervisor

Selection of patients and DOT providers
To ensure better participation and interaction, patients and providers are limited to a total of 40-50. Preference is given to all smear positive and defaulter patients, both male and female, to motivate them for regular treatment. Similarly, DOT providers who need orientation are called in on a priority basis.

Agenda of discussion
        Re-orientation of knowledge component in RNTCP. Introduction of gender components. Review of the activities of each DOT provider. Interaction with each patient. Review points of patient counselling which includes diet and regular sputum follow-up. Experience of DOT provider and suggestion for improvement. Narration of experience by patients. Patient awareness regarding the disease.

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   

Patient as educator/motivator in referred cases. Interaction with defaulters. Cross-checking and updating patient cards. Role-play.

Method
    Mainly participatory through discussion. Sharing of experiences. Role-play. Quiz.

Evaluation and follow-up
The meeting is evaluated at the end of the session through a developed format in terms of participation, food, venue, defaulter retrieval etc. In the field, DOT providers and STSs monitor the regularity of the treatment among patients and STSs monitors improvement of knowledge on the programme and fills the treatment cards.

1.5.5 Orientation of tribal link workers
Objectives
To improve timely diagnosis and regular treatment of TB cases through a coordinated effort by involving all partners in community development blocks.

Specific objectives
     To improve awareness regarding TB and RNTCP in the entire block area. To identify and extend block-level partnership for mobilising resources and for accelerating awareness activities on RNTCP. Capacity-building of different partners/stakeholders. To improve the quality of RNTCP services. To improve the case detection and cure rates.

Target group
      All sarpanches, samiti members, zila parishad members. Selected health workers from different sub-centres (4-5). Selected AWWs from the block (4-5). Selected traditional healers (3-4). NGO/CBO representatives (3-4). One male and one female volunteer from each gram panchayat.

Venue
Generally, an open-air venue under a tree at the block headquarters is selected for the training programme. In special circumstances, like rainy weather, the venue is shifted to a big well-ventilated room, if possible.

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Sitting arrangement
All participants, observers and resource persons sit on the floor on a mat in a circle/semi-circle.

Process of organisation
First, district health authorities like the CDMO and DTO are contacted and requested to organise the orientation programme in a particular block. A request letter is then issued to the BDO for arranging the activity under intimation to the concerned PHC MO and SDMO. A formal meeting is convened of the stakeholders listed below to decide the date and develop a plan for implementing the orientation programme.  SDMO  MO-PHC  BEE  BDO  Chairman, panchayat samiti  Representatives of one or two active NGOs  CDPO  Two or three sarpanches, if possible. In the presence of all the above stakeholders, the purpose of the orientation, selection of participants, logistic arrangements, distribution of responsibility, selection of date and the venue are discussed. A formal letter mentioning the date, time and venue of the orientation meeting is issued by the BDO to all participants and observers.

Resource persons
    CDMO/DTO/SDMO MO-PHC/sector STS/LT/BEE CDPO/supervisors

Training session
At the outset, a brief introduction about the orientation session is given by the CDMO/DTO or SDMO, highlighting the necessity of such orientation, followed by self-introduction of participants, resource persons and observers. The technical session then follows.

Content
Highlighting of RNTCP, TB, its cause, mode of spread, signs and symptoms, categories of treatment, availability of diagnostic and treatment facilities and the role of link workers. This session is continued till lunch break.

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It is conducted through question-answer sessions, discussions, sharing of experiences, demonstrations (patient, medicine box, sputum container) and quizzes. Initially, a number of questions written on a piece of paper are distributed among the participants. They are encouraged to answer those questions serially, which are then summarised by the resource person. Likewise, all the topics are covered by answering all questions, followed by a quiz among the participants, and a street theatre performance. After lunch, the participants and the resource person plan the orientation session at the gram panchayat (GP) level and dissemination of information to every household through IPC. Dates are finalised among the participating sarpanches for the training and conduction of IPC. Resource persons like MO-PHC, DTO, SDMO and DANTB personnel share the responsibility to facilitate the training camp at gram panchayat level. A detailed calendar of the gram panchayat level orientation activities is finalized on that day.

Writing and IEC materials used
Writing pads, pens, folders, leaflets, pamphlets, booklets and posters are distributed among the participants for future reference. Posters, banners, flipbooks and OHPs are used for training purposes.

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Outcome
   Increase of awareness on RNTCP in the community Involvement of people’s representatives in RNTCP Increase in the utilisation of RNTCP services

1.5.6 Orientation of cured, former patients as RNTCP advocates
Objective
Capacity-building of cured TB patients to disseminate appropriate information for better utilisation of RNTCP services in the community.

Duration
One day.

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Venue
Block headquarters or any other suitable place that is centrally-located

Participants
Cured, former TB patients, both male and female.

Facilitators
MO-PHI, BEE, STS and LT.

Process of organisation
BEE, STS and LT prepare a list of participants in consultation with the MO-PHI and fix a suitable date for the orientation. A letter is then issued to all participants requesting them to attend the programme.

Session content
       Objective of orientation. Brief introduction on technical aspects of TB. Target groups in RNTCP. Important talking points for different target groups. Scope of disseminating information. Use of different IEC materials. Use of NLDP card.

Aids to be used
Banners, posters, pictorial folder, booklets, pictorial pamphlet and pocket folders.

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Outcome
    Increase of awareness about TB and RNTCP in the community. Reporting of suspected TB cases increased at outpatient departments (OPDs). Reduction of defaulters. Increase of cure rate.

1.5.7 Orientation for NGOs at district-level
Objective
To apprise NGOs about RNTCP and help them identify their partnership role in performing specific activities for the promotion of the programme.

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Venue
District headquarters/conference hall/community hall.

Duration
One day.

Participants
President and secretary from each NGO.

Resource person
CDMO/DTO/MO-PHI/STS/BEE

Process of organisation
Collect the list of NGOs from the CDMO office and compile a profile of NGOs who are working in the field of health with the government sector. CDMO/DTO and DANTB staff make the selection of NGOs to be invited. Date, time and venue are decided by CDMO in consultation with DTO, MO-TU, MO-PHI, STS, BEE and DANTB staff. CDMO then invites the participants (NGO secretary and president) by a letter to the orientation meeting.

Session content
   RNTCP as a programme Achievements of the RNTCP district Technical aspects of TB such as its cause, mode of spread, signs and symptoms, diagnosis and treatment, diet pattern of TB patient, side-effect of the medicines, availability of treatment facilities and IEC on the gender component

Teaching methodology
      Discussion Group work Demonstration Quiz Role-play Snakes and ladders game

Health communication materials
OHP slides, folder, leaflets, booklets, posters, banners and games. ,

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

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Follow-up
DTO/MO-PHI contacts the presidents/secretaries of the NGOs who attended the orientation. A date is decided by DTO/MO-PHI in consultation with the NGO secretary who selects a suitable venue and informs the participants for orientation at grassroots level.

Evaluation
After six months, MO-PHI, STS and BEE evaluate the orientation of NGO members in terms of  no. of NGOs involved in RNTCP activities,  no. of NGOs providing DOT,  no. of NGOs carrying out awareness activities and  no. of NGOs referring suspects.

Documentation
A report on NGO activities is prepared by BEEs

Outcome
     Increase of symptomatic cases reporting to nearest PHI. Increased awareness about TB among community. Reduced number of defaulters. Increase in number of NGO DOT providers. Increase in cure rate.

1.5.8 Sensitisation meeting for PRI members
Objective
To ensure the support of panchayati raj institution (PRI) members for the successful implementation of RNTCP in their area.

Duration
Half day

Venue
Block headquarters

Participants
     Chairman, panchayat samiti Samiti members Sarpanches BDO and other extension officers DOT providers, patients

124 | A Health Communication Strategy for RNTCP

Facilitators
   MO-PHI/PHC BEE STS

Process of organisation
MO-PHI discusses with BDO and Chairman of panchayat samiti and fixes a suitable date. The Chairman of the panchayat samiti informs all participants to attend the meeting.

Session content
     Objective of the meeting Technical aspects of TB Facilities under RNTCP Status of TB in the block Role of PRI members in the promotion of RNTCP

Health communication materials
Banners, posters, flipbooks, folders and pictorial pamphlets .

Outcome
  Discussion about RNTCP in monthly gram panchayat meetings Involvement of PRI members in referring suspects and motivating defaulters.

Follow-up
BEEs and DPs attend gram panchayat-level monthly meetings and discuss TB problems there.

1.5.9 Orientation of SHGs
Objectives
 To ensure involvement of SHGs in the dissemination of information on RNTCP to the community.  To enable SHGs to refer symptomatic cases for sputum examination.  To enable SHGs to motivate defaulter patients for regular treatment.

Venue
School building/AWW/community centre/under a tree or any other suitable place

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Duration
Half day

Participants
Two to three representatives from each SHG (50 to 60 participants).

Resource persons
MO-PHI/STS/BEE

Process of organisation
    CDMO to contact CDPO to discuss the orientation meeting for SHG members and fix a date. CDPO to discuss with supervisor in the monthly meeting and select the venue and time for the orientation. Supervisor selects the most active presidents and secretaries of SHGs. Supervisor informs the participants about the orientation meeting or asks AWWs to do so.

Session content
  Session starts with success story Discussion of roles and responsibilities of SHG members towards the programme, such as  creating awareness about TB/RNTCP during monthly meetings,  organise meetings for women’s groups,  refer chest symptomatic cases to PHI,  be active in defaulter retrieval and  if necessary, act as a DOT provider.

Teaching contents
TB as a disease, cause, mode of spread, signs and symptoms, diagnosis and treatment availability, DOTS strategy, diet of patient and side-effects of medicines.

Teaching methodology
Story-telling, discussions, role-plays and demonstrations.

Health communication materials
Folders, leaflets , booklets, posters, banners, flipbooks, flash cards and cassette player with a cassette.

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

126 | A Health Communication Strategy for RNTCP

Outcome
    Increase of symptomatic cases reporting to the PHI Increased awareness on TB among SHG members Reduced number of defaulters Examination of sputum at regular intervals

Follow-up
Review activities and re-orientation of knowledge during monthly meetings by HWs (male/female), AWWs and BEEs.

Evaluation
Responsibility of HW (male/female), AWW and BEE to evaluate every half year:  How many symptomatic cases referred to PHI?  How many TB patients cured?  How many defaulter patients motivated for regular treatment?  How many patients died of TB?  How many TB patients under treatment in their respective places (categorywise male/female)?

1.5.10 Orientation of volunteers, teachers, students and religious organisations
Objective
To ensure the support of NSS/NYK volunteers in disseminating RNTCP messages in the community.

Duration
Half a day to one day

Participants
NYK/NSS volunteers

Venue
NYK office/college campus/any other suitable place.

Group size
40–50 participants.

Resource persons
MO-TU/MO-PHI/STS/STLS/BEE/Dy. MEIO

Process of organisation
CDMO/DTO to discuss with youth coordinator of NYK and MO-PHI to discuss with NSS programme officer of college for organising the sensitisation meeting.

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Session content
Morning session
          Assess knowledge of participants about TB Discuss objectives of meeting Present status of TB in Orissa and districts What is TB, cause, mode of spread Signs and symptoms of TB Diagnosis procedure Duration of treatment, DOTS strategy, dangers in interruption of medicine Importance of the follow-up sputum test Prevention of TB Review of knowledge by quizzes

Post-lunch session
   DOTS implementation in the district Availability of free treatment at nearest PHC/CHC Discuss role of NSS/NYK volunteers towards RNTCP

Possible role and responsibility
   To disseminate messages through IPC/group discussions/camps/village meetings. Refer chest symptomatic cases to nearest PHI. Motivate defaulters for regular drug intake and regular sputum follow-up examinations.

Teaching methodology
Lectures, discussions, success stories, role-play, group discussions, snakes and ladders game and outdoor games (kabaddi)

Health communication materials
Banners, folders , flipbooks , exhibition sets, leaflets and booklets

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Outcome
     Increased awareness on TB in the community. Increased chest symptomatic cases reporting to nearest PHI. Reduced number of defaulters in their respective areas. Participants interested to act as DOT providers. Participants involved in various health communication activities organised by PHI and district-level RNTCP staff.

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Follow-up
     Monitoring chest symptomatic cases referred by participants. Technical/programme guidance provided to participants by concerned PHI personnel. Involved NYK/NSS volunteers in RNTCP activities whenever necessary in their PHI. Review activities and re-orient participants at suitable intervals. All activities to be documented by concerned PHI and programme personnel.

1.5.11 Orientation of traditional healers, traditional birth attendants and other indigenous practitioners
Objectives
   To enhance knowledge on TB and RNTCP. To ensure support of participants in the referring of chest symptomatics. To enable participants to motivate defaulters for regular drug intake.

Duration
Half day.

Venue
PHC/CHC building/school building/NGO office.

Resource persons
MO-TU/MO-PHI/BEE/STS/LT.

Participants
Traditional healers and indigenous practitioners/VHGs/TBAs.

Process of organisation
Health workers send a list of traditional healers in their respective areas to the MO-PHC. The BEE prepares a consolidated list of traditional healers in the block. The lists of VHGs and TBAs are usually available at the primary health centre. The MO-PHC decides the date of the sensitisation meeting in consultation with the DTO/ADMO incharge of TB. The participants are then informed through the health workers about the date, time and venue of the meeting.

Session content
  Facts about TB like cause, mode of spread and signs and symptoms of TB. Diagnostic procedures, importance of regular treatment and timely sputum follow-up under DOTS strategy.

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Roles and responsibilities of traditional healers/VHGs TBAs in RNTCP such as  disseminating messages in the community,  referring chest symptomatic cases to the nearest PHI and  counselling patients for regular anti-TB drug intake. Review of knowledge by quiz.

Teaching methodology
Discussions, role-plays, live success stories and snakes and ladder game.

Health communication materials
Banners , posters , flipbooks, folders, leaflets, booklets and games (indoor and outdoor)

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Follow-up
    Chest symptomatic cases referred by traditional healers to be recorded by BEE. Monitoring the number of defaulter/irregular cases counselled by traditional healer. Problems associated with TB and programme to be clarified by HW/AWW/ BEE. After six months, review the activities and re-orientate about knowledge component.

Outcome
  Chest symptomatic cases increased in their respective area. Reduced defaulter and irregular patients.

Responsibility
   Organising meeting and follow-up action by MO-PHI. Recording and report-writing by BEE. Supervising the activities of traditional healers by STS/HW worker/AWW.

1.5.12 Orientation of members of CBOs
CBOs are usually small voluntary social groups who aim to serve the local community, especially the under-privileged groups.

Objective
Capacity building of CBOs in organising awareness activities, referring suspects and retrieving defaulters for promotion of RNTCP.

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Duration
One day

Venue
CBO headquarters or any other suitable place decided by them.

Participants
All active members of the CBO.

Facilitators
MO-PHI, BEE, STS

Process of organization
A list of CBOs who are actively involved in other health programmes is available at the PHC. The BEE/STS, sometimes DANTB personnel, in consultation with the MO-PHI, contacts concerned CBO and fix a suitable date and place. The president/secretary of concerned CBO informs the members regarding the date, time and place of such orientation.

Session content
      Objective of the orientation. Technical/social aspects of TB. Places where diagnosis and treatment facilities are available. Possible causes of defaulting treatment and ways to retrieve defaulters. Different types of awareness activities and their scope. Review of knowledge by quiz.

Health communication materials
Banners, posters, flipbooks, pictorial folder and pictorial pamphlet, snakes and ladders game and outdoor games (kabaddi)

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Outcome
    CBOs disseminate information on TB and RNTCP in their locality. CBOs refer symptomatic cases to PHI. CBOs retrieve defaulters. CBOs act as DOT providers.

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1.5.13 Training/workshop for CDPOs/supervisors at district-level
Objective
To ensure greater involvement of supervisory staff to encourage and support AWWs in acting as DOT providers.

Duration
Two days (residential).

Venue
A suitable conference hall/meeting hall.

Participants
CDPO/project officer/supervisors (15 – 20). Ensure participants from each block by District Social Welfare Officer (DSWO).

Facilitators
   Trainer in RNTCP CDMO/ADMO/DTO/MEIO STS

Process
A letter is issued by the CDMO/DTO requesting the Collector or DSWO to spare the ICDS officer and supervisors for the training. After subsequent discussion, a suitable date and venue is finalised after which DSWO issues a letter to the ICDS officer and supervisors to attend the training programme.

Session content
     Brief introduction of RNTCP. Status of TB in India, Orissa and concerned districts. Technical aspects of TB like cause, mode of spread, type of disease, diagnostic procedure, treatment under DOTS strategy and timely sputum follow-up. Gender disparities and IEC in RNTCP. Role of ICDS officials in the promotion of RNTCP.

Teaching methodology
Lectures, participatory discussions, group discussions, role-plays, quizzes, demonstrations/return demonstrations, ice-breakers, sputum collection procedures, medicine strips (no. of days and doses), experience-sharing of cured patients and follow-up of treatment cards (exercise).

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Methodology Contents
Lecture and discussion Introduction of RNTCP Technical aspects of TB Gender IEC in RNTCP Medicine boxes for treatment Sputum collection procedure Narration of experiences by patients Treatment card filling up Street theatre in IEC Role of ICDS officials in promotion of RNTCP Counselling of patients for regular anti-TB drug intake Supervision of DOT provider Assessment of knowledge

Demonstration

Group work

Role-play

Quiz

Health communication materials
Banners, posters, flipbooks, leaflets, booklets, TV, VCR, tape recorder, OHP, writing materials, folders, mela kits, pocket folders, writing pads, pens, pencils, erasers, snakes and ladders game, exhibition model.

Outcome
    Monthly review meeting of AWW at block level. Routine supervision during field visit of AWWS activities in RNTCP. Discussion on RNTCP during awareness meeting at project/PHC level. Involvement in RNTCP activities like workshops/trainings organised by PHIs.

Report-writing
Report preparation by Dy. MEIO/BEE/MO-TU.

Evaluation
At the end of the training, an evaluation is carried out using developed question formats to assess whether the objective of the training has been achieved.

Follow-up
 Monthly meeting of ICDS where RNTCP is discussed; health communication activities planned with responsibility for specific activities shared MO-PHI to attend the meeting.

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During field visits, interaction with AWWs to assess the planned activities implemented by STSs and BEEs.

1.5.14 Group discussion
Group discussion is a face-to-face interaction between members of a small group where ideas, thoughts, experiences and feelings are shared.

Participants
Women and men, usually within the reproductive-age-group, who hail from the same locality and share a common socio-cultural background. The number of participants usually ranges between 30 and 50. It is a big group for a short discussion, usually one hour, which is convenient to the group members.

Objective
Objectives will differ from group to group, according to their health-seeking behavioural practices based on their knowledge. One example is to build group consciousness on a selected topic, e.g. the effects of proper utilisation of RNTCP health facilities.

Venue
Panchayat office/school/community hall/open-air platform.

Facilitator
BEE/STS/Health Assistant (male/female)/HW (male/female), NGO, volunteers.

Process and Content
The facilitator meets village leaders/PRI members/youth club members/elders and fixes the date, time and venue for discussion. The topic is also made known in advance.

Role of the facilitator
  Ensure a relaxed and friendly environment for the discussion. Seating people in a circle in an open-air atmosphere, on the ground is the best way for discussion. In a circle, there is no ‘head’ and everyone is equal. Sitting in a ‘U’ shape is the next-best thing. Tell the group at the outset that each one of them must participate. Decide on the objective of the discussion in advance and ensure that each one of the participants understands the issues to be discussed. Begin with easy questions, with what people will feel free to talk about. This builds up people’s confidence. If no one answers a question, ask it again, using slightly different and simpler language. Give examples.

   

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 

Do not give up if answers are slow in coming. It will take people time to ‘warm up’ to this new way of learning. Always respond politely and with enthusiasm to any answer. Praise participants when they do respond, even if the answer is wrong: “Well done.” “Thank you for your thoughts.” “That’s really interesting.” Be sure to look at every member in the group. Do not look at only those who talk - as others will feel discouraged. If someone puts a question to you, you can direct it to another member by saying: “That’s an interesting question. Ms. Pushpa, could you respond to Ms. Leela?” Help keep the discussion focused on the objective. Keep and use audio-visual aids whenever required. Ensure equal participation of all, never allowing one or a few members to dominate the discussion. Encourage members to share opinions (even if wrong), information and experiences. From time to time, summarize important points. The best discussions are those that leave people wishing for more. After an hour or so, people’s minds begin to wander and not much more learning can take place. Complete the process by a quick review of important points and make someone responsible for a follow-up action.

 

     

Evaluation by facilitators and organisers
       How well was the group discussion organised? Attendance (male/female) Nos. Physical facilitators Good/Adequate/Poor Was the objective achieved? Yes/No If No, reasons? Participation of members – Good/Fair/Poor If ‘Poor’, reasons?

1.5.15 Kalyani clubs
Kalyani clubs have been formed under the GoI scheme in nine Doordarshan kendras all over India. The members of the club watch health programmes like Kalyani on television and spread health messages amongst people living in remote areas with no television access. Besides watching these episodes on television, members of Kalyani clubs are also informed about RNTCP and DOTS, enhancing their knowledge about TB.

Annexure 1 | 135

Club members organise dance programmes and plays with TB as the focus. The performances provide information to patients, providers and the community in an entertaining way. These performances are telecast on Doordarshan as a part of the Kalyani episode, spreading awareness about TB amongst a larger audience. The Kalyani club members are motivated to write about the problems faced by people in remote areas, for telecast through the Kalyani episodes.

Objective
To create awareness among youth to enhance timely detection, treatment adherence and general knowledge about TB and DOTS.

Target audience
Community—particularly youth.

Venue
Generally, an open air venue near a village is selected for the programme.

Duration
Three to four hours.

Process of organization
District health authorities like the CDMO and DTO are contacted and requested by Kalyani clubs to organise the programme in a particular block. A request letter is then issued to the BDO for arranging the activity under intimation to the concerned MO-PHC Medical Officer and the SDMO. A formal meeting of all these stakeholders is convened to decide the date and develop a plan for implementing the programme. Finally, the Doordarshan officer is informed about the date and venue of the programme and requested to televise.

Resource persons
   CDMO/DTO/SDMO MO-PHC/sector STS/LT/BEE

Health communication materials
Banners, posters, flipbooks, leaflets, booklets, story boards, tape recorder, outdoor material.

136 | A Health Communication Strategy for RNTCP

Follow-up
After the programme, the concerned Kalyani club members are met and their views ascertained about the success of the programme and possibilities for organising such events in neighbouring villages.

1.5.16 Workshop on culture and communication
There are several districts in India where a large section of the population do not have access to basic RNTCP services in spite of the wide coverage network. The cure rate in these districts may also be low compared to the national norm of 85 per cent. This could be attributed to varied geographical and ethno-cultural reasons. In order to motivate patients for continuation of treatment, bridging the cultural divide is indeed vital. The workshop on ‘Culture and Communication’ for service providers serves this purpose. The intent is to make providers internalise the importance of understanding the culture of the local people and hence to make a conscious effort for improvement in service delivery.

Objective
Sensitising service providers about geographical and ethno-cultural issues in order to bridge the cultural divide.

Duration
Two days

Venue
A suitable conference hall/meeting hall.

Participants
Traditional healers, STLS, pharmacists, LHV, BEE, MO, ADMO, ADEO, MPHS, STS, surgeons

Facilitators
   Trainers in RNTCP CDMO/ADMO/DTO STS

Process
   Planning meeting at district level involving CDMO/DTO/Collector for finalisation of date, venue and participants. Request letter is issued to all participants to participate in the meeting CDMO arranges all logistical requirements

Annexure 1 | 137

Session content
         Inauguration Introductory session where traditional healers introduce themselves Role play Lecture on ‘Culture and its Various Connotations’ by a resource person Training game Group sessions Presentation of findings by groups Story exercise and sharing experiences Concluding session and feedback from participants

Workshop methodology
Lectures, group exercises, training games, role plays, quizzes, ice-breakers, exercises.

Health communication materials
Banners, posters, tape recorder, register to record comments of participants.

Outcome
Increased sensitivity to cultural issues among service providers and programme staff.

1.6 Involvement of Other Organisations and Individuals
1.6.1 Orientation of industrial workers
Objective
To ensure early reporting of symptomatic cases by industrial workers and dissemination of information to other people

Venue
Community hall/club or any other suitable place

Duration
Two to three hours

Participants
Managers/officers/workers

Resource persons
DTO/MO-PHI/STS/BEE and DANTB officer

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Process of organisation
   CDMO/DTO informs the general manager of company. General manager of company decides the venue, time and date in consultation with CDMO/DTO. Company general manager informs the participants about the sensitisation meeting.

Session content
Technical aspects of TB, its cause, mode of spread, signs and symptoms, diagnosis and treatment, diet of the patient, side-effects of the medicine and availability of treatment facility.

Teaching methodology
   Discussions Demonstrations Quizzes

Health communication materials
Banners, posters, flash cards, flipbooks and leaflets

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Follow-up
MO-PHI/STS to keep regular contact with the MO of the concerned company regarding  referral of chest symptomatic cases and  regular drug intake and timely sputum follow-up where patients are under DOTS.

Outcome
  Increased awareness on TB among industrial workers and their family members and friends Increased reporting by suspected cases for sputum examination

1.6.2 Orientation of jail inmates and employees
RNTCP has been implemented in 14 districts of Orissa in a phased manner. Community awareness and education is one of the important components of RNTCP Efforts are on to make every section of the community aware about the . services provided under RNTCP so that it may avail them.

Annexure 1 | 139

Jail inmates who do not know about the happenings outside the four walls of the jail need to be sensitised about the new TB programme. Many inmates are released within a short period of time, either because they committed minor offences or because they are granted bail. Hospitals/dispensaries have been set up in district/central jails and designated jail MOs are available in smaller jails to provide medical care to the inmates.

Objectives
   To sensitise jail inmates regarding the signs and symptoms of TB and the necessity of early reporting for diagnosis and treatment. To sensitise jail employees to take timely action in referring chest symptomatic cases To persuade patients in jail for regular drug intake and sputum follow-up.

Duration
Half a day.

Venue
District/sub-district jail/under a tree in the jail premises.

Participants
All jail inmates, employees, jail MOs, pharmacists.

Date
A convenient date for participants and facilitators.

Facilitators
   District/PHI District level—MO-TU, STS, Dy. MEIO, STLS, LT PHI level—MO-PHI, LT, BEE

Process of organisation
     Planning at district level for finalising date, venue and selection of facilitators by CDMO Letter to jail superintendent at district-and sub-district levels by CDMO. Finalisation of date, time and number of participants to attend by jail superintendent. Information to jail employees—Jail Superintendent. Logistics arrangement for participants—MO-TU, STS, Dy. MEIO, BEE, LT.

Session content
 Cause of TB, mode of transmission, symptoms, diagnostic procedure and treatment facilities available.

140 | A Health Communication Strategy for RNTCP

    

Importance of regular medicine intake, sputum follow-up and normal diet. Identification of defaulter/irregular patient, if any. Health check-up for symptomatic cases. Sputum collection. Role of jail employees for taking timely action in relation to TB.

Teaching methodology
Lectures, participatory discussions, group discussions, role-plays, demonstration of sputum collection procedure and quizzes

Health communication materials
Banners, posters, flipbooks, leaflets, booklets on RNTCP messages and folders.

Video-based training modules
While planning your activity view the ‘Orientation’ module in the accompanying CD.

Outcome
   Regular discussion on RNTCP among jail inmates and employees, including jail MO, jail pharmacist and BEE. Identification of symptomatic cases. Cases referred for sputum examination.

Report-writing
BEE/Dy. MEIO/MOTU.

1.6.3 Sensitisation workshop for journalists
Workshop for journalists can be organised at state, district and block levels.

Objectives
  To raise the media’s awareness about issues pertaining to TB. To enhance the quality of reporting and seek the media’s cooperation in disseminating news and views on TB and spreading awareness that DOTS is effective and free.

Participants
      Journalists from leading newspapers with an interest in developmental and health issues. Programme providers of RNTCP. Patients who can narrate their experiences or who are DPs. DOT providers (health and non-health). NGO representatives. Key stakeholers such as, Director (IEC)/District MEIO/DIPRO/BDO/zila parishad chairman/panchayat samiti members.

Annexure 1 | 141

Venue
Panchayat office/block office/DRDA/Collectorate/SIH&FW

Duration
Half a day to one day

Facilitators
 State-level—Director/Dy. Director, IEC, Jt. Dir./Dy. Dir (TB), DANTB staff, Asst. Prof. ATD&TC, Director, AIR, Director, Doordarshan, zila parishad Chairman. District-level—CDMO, MO-TU, ADMO (Med./TB), MEIO, DIPRO, Station Director (Doordarshan/AIR), DANTB staff, STS. Block-level—ADMO (Med./TB), MO-TU, MO-PHI, BEE, BDO, Chairman of panchayat samiti.

 

Process of organisation
  Contact the State Press Bureau personally to obtain a list of editors of important dailies/magazines/news agencies. Make personal visits to editors/sub-editors after making appointments. Explain objectives clearly, speak about RNTCP and expectations in the area of developmental journalism. Request for suitable participants to attend the workshop. Thank them in anticipation. Letter of invitation should be sent from the head of the health system:  Dir. of Health Services, State level  CDMO, district-level  MOTU, block-level As part of the media workshop, prepare a written document of RNTCP activities in the relevant area, with attention-getting headlines. This may be on different sheets of paper, all put into a folder that will stimulate reading. Give an address/telephone number of someone who could be contacted if they need further information.

Session content
     Technical and social aspects of TB Interaction with patients and DPs Interaction with programme personnel Street theatre performance Identify role of journalists in the promotion of RNTCP

Suggestions to be discussed and noted for follow-up.

142 | A Health Communication Strategy for RNTCP

Health communication materials
 Mela kits, exhibition models, posters, leaflets, banners, folders and story book.

Outcome
   Interviews with DPs/patients/programme personnel and other information and news on RNTCP published in newspapers/magazines. Visits to PHIs/interaction meetings of DPs, patients and providers for regular press releases. Meetings at intervals for continuous update of activities.

1.7 Monitoring, Evaluation and Research
1.7.1 RNTCP programme documentation
The successes and failures of a programme must be documented for others to make use of the experiences gained in other contexts. Innovative approaches and activities which lead a programme to achieve its goal must be shared with other agencies and possibly replicated in similar programme.

Objective
To present an overview of programme objectives, approaches and achievements to different stake-holders.

Target audience
    Policy-makers Administrators All health staff in government, private and public sectors Donor agencies

Format
  Publication Video documentary

Contents
     RNTCP background Extent of TB problem Process of documentation pertaining to activities in focus Innovative approaches used Success in RNTCP

Annexure 1 | 143

Process of documentation
  Relevant operational research, evaluation or documentation techniques tailor-made to the specific issue/problem. Consultancy to professional film-maker with adequate experience in video documentation in government and public sector. Script developed in collaboration with programme staff.

Issues for documentation
Activities and issues for documentation should be identified through discussions with DHS, DDHS, DANTB and CDMO/DTOs of the concerned districts. A number of examples are given below:  Reporting of symptomatic cases and diagnosis of TB  DOTS at grassroots level  Different health communication activities  Monitoring and supervision  Views and perspectives of relevant programme staff

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Annexure 2

IEC Resource Centre of Central TB Division User Guidelines
Background
The Government of India and partners supporting TB interventions have long felt the need for a web-based Resource Centre for IEC material related to TB control for the benefit of those involved in RNTCP. As a response to this need an IEC Resource Centre has been set up by the Central TB Division, Ministry of Health and Family Welfare with the support of DANTB and Danida.

Highlights
The RNTCP IEC Resource Centre is accessible as a link from the CTD website, www.tbcindia.org. The Resource Centre houses specifications and digital formats of representative TB-IEC material being used in the programme. It is a useful tool in information sharing that is crucial to strengthen IEC activities in TB control in India. Users (STOs, NGOs, RNTCP staff, researchers, CBOs and others) can register themselves at the website and access the TB-IEC material database. A search facility has been provided for easy selection of material using a set of simple criteria. A help link is provided on the website to guide users.

Rationale of the IEC Resource Centre
 The IEC Resource Centre houses a selection of IEC materials for RNTCP available online for inspiration and replication at local levels. Online users will be able to access material produced at national, state- and district levels for a wide range of different target groups using different types of media. The IEC Resource Centre will help to strengthen the capacities of programme staff in the adaptation and usage of IEC material.

Features of the Resource Centre
The Resource Centre houses specifications and digital formats of representative TB IEC material. The user can navigate the website, register as a member, view

Annexure 2 | 145

and search the database of existing materials using keywords and download images and text. Users of the Resource Centre are encouraged to submit their e-mail ID while signing in and registering as members so that they may receive updates on the Resource Centre as and when such updates are available. The IEC material database, which is the backbone of the Resource Centre, stores information about each IEC material, specifying the nature of the IEC material, languages available, target audience, type of use and other information relevant to the appropriate use of the material. The material can be downloaded in digital format in medium resolution (not print quality). All material in regional languages is accompanied with translations/synopses in English and Hindi. Images of all print material such as posters, flipbooks and leaflets, are available in portable digital format. Other non-print material such as audio tapes and video films have a synopsis of the material. All IEC materials are uploaded through a single point administrator at the CTD to maintain the integrity of the Resource Centre.

Using the Resource Centre
Users can search for a particular IEC material by using either the simple or the advanced search facility. The simple search facility allows the user to search for IEC material based on media type, target audience and type of material. The advanced search allows the user to search using other criteria, in addition to the ones mentioned above, such as title, language, area of use etc.

Simple search
An example is search for a poster on symptoms of TB. To find samples of posters on symptoms of TB, first conduct a simple search. Under ‘Media/Media Type’ click on the ‘Print’ dropdown menu and select ‘Poster’. Under ‘Target Audience’ select ‘General Public’ and then click ‘Submit’. The simple search is generally very broad and gives search results that will include all print material for general awareness.

Advanced search
The advanced search helps in defining the parameters and produces more focused results. The advanced search has additional parameters that include type and area of use and language. The ‘Material Title’ and ‘Produced by’ fields give more precise results.

Search results
The results page will display thumbnail icons of the materials along with titles

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and brief descriptions. Click on the result that fits the requirements best.

Specific results
On clicking the result, a fresh page will open. It will have the title of the material above the visual. The information matrix gives the details including objectives, message route format, target group, year of production and the producer.

Modification/Adaptation of Material from Resource Centre
Users who are interested in reproducing the material should check the suggested modifications/other remarks. A significant objective of the Resource Centre is to facilitate standardisation of IEC messages and material across the country without compromising the contextual and cultural needs of different regions and target groups. Users of the Resource Centre can freely modify or adapt the material for use in their area. While modifying or adapting the material, care should be taken to use the standard RNTCP logo and messages and the latest RNTCP data.

Pre-testing of Material
After modifying or adapting material from the IEC Resource Centre, it is strongly advised that they be pre-tested among the intended target audience. Pre-testing means field-testing IEC material before they are mass-produced. It is

Annexure 2 | 147

an important yet often neglected aspect of developing IEC materials. Pre-testing is a cost-effective mechanism to prevent expensive mistakes. There is often a gap between the communicators who develop the IEC material and the target groups for whom the material is intended. Pre-testing helps to assess the effectiveness and relevance of the material for the target group. The focus on pre-testing should be on attention, comprehension, relevance, credibility and acceptability. To be effective, pre-testing must be accurate, well-planned and executed. The pre-test results should be analysed, assessed and critically reviewed. Based on the pre-test findings the material should be modified to make it more relevant and effective to the target group.

Submitting Material to the Resource Centre
The Resource Centre is a dynamic site. The CTD will be reviewing and updating IEC material produced by different agencies all over the country. If you wish to submit the IEC material you have produced recently for inclusion, please send samples (two copies) to the CTD at the following address. Please also provide the month/year of production, details of pre-testing and contact address. Plesae address your mail to IEC Consultant Central TB Division Directorate General of Health Services Ministry of Health and Family Welfare Nirman Bhavan New Delhi e-mail: postmaster@tbcindia.org www.tbcindia.org

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Annexure 3

Index of Materials Available in the Central TB Division’s Web-based IEC Resource Centre
ID No. Type of Material Material Title Area of Use Target Audience Language Objective 1, 3-5 Brochure TB: A Guide for the Health Provider Rural, Urban Service Providers English, Gujarati, Malyalam, Telugu To educate health service providers on TB, types of TB, diagnosis, treatment process under DOTS, drug administration and side effects. To guide health service providers on messages to be conveyed to the patients 6 Flipbook/chart Tuberculosis Control Rural, Urban Patients, Community, Service Providers English Spread awareness about TB and DOTS

ID No. Type of Material Material Title Area of Use Target Audience Language Objective

ID No. Type of Material Material Title Area of Use Target Audience Language Objective

8, 9-10 Booklet Use DOTS, Stop TB Urban Patients English, Hindi, Marathi Provide complete information about DOTS and encourage the patient to complete treatment

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ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

11, 12-21 Poster My wife is second to none Rural, Urban Community, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To spread the message that women TB patients should not be discriminated against 22, 23-32 Poster DOTS System Rural, Urban Patients, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu DOTS services are available free at your nearest health centre for free 33, 34-43 Banners Adopt DOTS if test confirms TB Rural, Urban Community, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To spread awareness about TB and its cure through DOTS 44, 45-54 Sticker DOTS System Rural, Urban Patients, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To spread awareness about DOTS strategy

ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

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ID No. Type of Material Material Title Area of Use Target Audience Language Objective

55, 56-57 Booklet Now Free TB Treatment Through Your Own Doctor! Urban Patients, General Public English, Hindi, Marathi To inform potential patients about DOTS and free treatment 58, 59-60 Flipbook/chart TB: A Communication Aid for Health Providers Urban Patients English, Hindi, Tamil To help health service provider in communicating effectively with the patient 61, 62-71 Poster “Towards Freedom from TB…” series (Zaheer Khan) Rural, Urban Patients, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To spread the message that TB is a widespread disease but is completely curable with DOTS—diagnosis and treatment process is free

ID No. Type of Material Material Title Area of Use Target Audience Language Objective

ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

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ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

72, 73-82 Poster TB can be cured with DOTS (Rahul Dravid) Rural, Urban Patients, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To advocate DOTS and that TB is completely curable with DOTS and diagnosis and treatment process is free

ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

83-84, 88-96 Poster Leaving TB treatment incomplete can… Rural, Urban Patients, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To spread awareness about dangers of incomplete treatment

ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

97-107 Poster DOTS—sure cure for TB (Rahul Dravid) Rural, Urban Community, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To advocate DOTS as the best system for treatment

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ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

108-118 Poster “We adopted DOTS and lost nothing” Rural, Urban Patients, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To spread the message that DOTS is the best strategy for sure cure of TB

ID No. Type of Material Material Title Area of Use Target Audience Language

Objectives

119-129 Poster “I completed TB treatment and gained a happy life” Rural, Urban Patients, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To spread the message that completing the treatment is very important and DOTS is the best strategy for sure cure of TB

ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

130-140 Poster Do’s and Don’ts Rural, Urban General public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To spread awareness about TB

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ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

141-151 Poster Facts about Tuberculosis Rural, Urban General public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To spread awareness about TB

ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

152-162 Poster Towards Freedom from TB Rural, Urban Patients, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To spread awareness about TB, its main symptoms, diagnosis, DOTS and treatment 163-173 Poster Myths and Realities Rural, Urban Community, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To dispel myths related to TB

ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

174-184 Poster DOTS system now closer to you Rural, Urban Opinion leaders, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To show the rapid increase in DOTS coverage

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ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

185-195 Poster Service to you is our responsibility Rural, Urban Patients, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To convey that health service providers in RNTCP are approachable

ID No. Type of Material Material Title Area of Use Target Audience Language

Objective

196-206 Balloon DOTS—sure cure for TB Rural, Urban Community, General Public English, Hindi, Gujarati, Bengali, Kannada, Malyalam, Marathi, Oriya, Punjabi, Tamil, Telugu To spread awareness about TB and its cure through DOTS

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Annexure 4

Index of Health Communication Materials Used in Orissa
Annexure 2 provides further details about each IEC material developed for RNTCP Orissa. It is hoped that this would facilitate the replication of materials elsewhere. Please note that Annexure 1 refers to the numbered items of Annexure 2, so that it can easily be inferred which IEC activities need which IEC materials. No. Type of Material Title in Oriya Title in English Content Language Target Audience Remarks 1 Pictorial folder Chabitia Katha Tia One Picture —One Message Cause, mode of spread, signs and symptoms of TB Oriya Specially developed for illiterate audiences Developed by a tribal group and based on the perception of tribals

No. Type of Material Title in Oriya Title in English Content Language Target Audience

2 Folder Jakhma Rogamukta Samaj Gathana Pain Eka Nibadana Appeal for control of TB to people’s representatives Role of people’s representatives in the promotion of RNTCP Oriya People’s representatives

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No. Type of Material Title in Oriya Title in English Content Language Target Audience

3 Booklet Saria Deichi Chithi Saria writes a letter RNTCP and TB messages in story form Oriya Neoliterate groups

No. Type of Material Title in Oriya Title in English Content Language Target Audience Remarks

4 Booklet Jakhma Roga Bhala Hoi Paruchi Ma TB is now curable All facts on TB including symptoms, diagnosis and treatment procedure Oriya Patients and general community Mainly for patient education

No. Type of Material Title in Oriya Title in English Content Language Target Audience

5 Leaflet Jakhma Roga Samparkare Keteka Janib a Katha Some important information about TB Facts on TB, availability of diagnosis and treatment under RNTCP Oriya General community

No. Type of Material Title in Oriya Title in English Content Language Target Audience Remarks

6 Pictorial pamphlet Jakhma roga arogya sadhya TB is curable Symptoms of TB and availability of diagnosis and treatment Oriya and Alchick General and tribal communities Specially developed for IPC

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No. Type of Material Title in Oriya Title in Alchick Title in English Content Language Target Audience

7 Poster Jhara, funka, guni, tuni se yugara katha Ran murgan omkhari agli halflam ktha DOTS cures TB To undertake DOTS for TB Oriya and Alchick Patients and general/tribal community

No. Type of Material Title in Oriya Title in English Content Language Target Audience

8 Poster Heu pachhe ma tara jakhma rogitia sisu pain ma khira amruta parai Encouraging breast-feeding even if mother is under DOTS Value of breast-feeding during DOTS Oriya Patients and general community

No. Type of Material Title in Oriya Title in English Content Language Target Audience

9 Poster Tinee hapta dahari jadi lagirahe kasa kapha parakhiba jai dakatar pase Get your sputum examined if you are coughing for three weeks Symptoms of TB Oriya General community

No. Type of Material Title in Oriya Title in English Content Language Target Audience

10 Poster Tinee hapta hela na chhade kasa ebe jiba dakatar pase Go to the doctor if cough persists for three weeks Encouraging early diagnosis of TB Oriya General community

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No. Type of Material Title in Oriya Title in English Content Language Target Audience No. Type of material Title in Oriya Title in English Content Language Target Audience

11 Poster Enetene chepa pakantu nahin Do not spit any- and everywhere Precaution for sputum disposal Oriya Patients and family members 12 Poster Amara lakhya ati kaamre 85 vage jakhma roginku rogamukta ariba Our objective is to cure at least 85% TB cases Objective of RNTCP Oriya Health personnel

No. Type of Material Title in English Content Language Target Audience Remarks

13 Poster Tre a t m e n t re g i m e n , s p u t u m examination Treatment category and sputum follow-up English Medical officers and laboratory technicians Reproduced from key concept, to display in OPDs and laboratories

No. Type of Material Title in English Content Language Target Audience Remarks

14 Poster Treatment Types of patients under different treatment categories English Medical officers and laboratory technicians Reproduced from key concept, to display in OPDs and laboratories

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No. Type of Material Title in English Content Language Target Audience Remarks

15 Poster Diagnosis Diagnostic procedure English Medical officers and laboratory technicians Reproduced from key concept, to display in OPDs and laboratories 16 Game Sapa and Sidi Snakes and Ladders Right answers go up the ladder, wrong answers fall into the mouth of the snake For SHGs, youth groups and mahila mandals

No. Type of Material Title in Oriya Title in English Content Target Audience

No. Type of Material Title in Oriya Title in English Content Language Target Audience

17 Flipbook (two types) TB/jakhma roga bisayare kichi jani ba katha Facts about TB Different aspects of TB with related pictures Oriya Health workers and trainees

No. Type of Material Title in Oriya Content Language Target Audience

18 Flash card Training Guide Different aspects of TB with related pictures Oriya Health workers and trainees

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No. Type of Material Title in Oriya Title in English Content Language Target Audience Remarks

19 Cloth banner (10’ x 3’) Apana Janichhanti ke? Jakhma roga arogya sadhya Do you know? TB is curable Curability of TB Oriya Patients and general community One set containing 10 pieces used during group discussions and other small training programmes.

No. Type of Material Title in Oriya Title in English Content Language Target Audience

20 Cloth banner (10’ x 3’) Mane rakhantu - Chikicha majhir jadi Apana ousda sabana banda karanti, tebe rogo sangatik akara dharana karipara Please remember - if you stop treatment the consequences can be dangerous Danger of irregular treatment Oriya Patients and general community

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No. Type of Material Title in Oriya Title in English Content Language Target Audience

21 Cloth banner (10’ x 3’) Nija ghara rahi adhunika ousad bebahara kari Jakhma rogaru mukta huantu Take drugs at home and be cured TB patients can be treated at home Oriya Patients and general community

No. Type of Material Title in Oriya

Title in English Content Language Target Audience

22 Cloth banner (10’ x 3’) Jdi apanku kramagata bhabe tinee hapta kasa lagi rahithya ba jyar hoithya, sanga sanga dakatarnka sa paramrsa karntu o kapha ra tinoti namuna parikhya karai niontu If you are coughing for three weeks, get three specimens of sputum examined Symptoms of TB and examination of three samples of sputum Oriya Patients and general community

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No. Type of Material Title in Oriya Title in English Content Language Target Audience

23 Cloth banner (10’ x 3’) Jani rakhantu - Jakma rogara niyamita chikicha samatha sarakari swasthya kendrare bina mulyare karajeithya Free diagnosis and treatment of TB is provided at all PHIs Diagnosis and treatment of TB available free of cost in health institutions Oriya Patients and general community

No. Type of Material Title in Oriya Title in English Content Language Target Audience

24 Cardboard poster Eha gurutua purna This is really important Regularity of treatment Oriya Patients and general community

No. Type of Material Title in Oriya Title in English Content Language Target Audience

25 Cardboard poster Bastabata True facts Measures to prevent spread of TB Oriya Patients and general community

No. Type of Material Title in Oriya Title in English Content Language Target Audience

26 Cardboard poster Jani rakhantu Remember some inportant facts Preventive measures for TB Oriya Patients and general community

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No. Type of Material Title in Oriya Title in English Content Language Target Audience

27 Cardboard poster Jani rakhantu Remember some important facts Diagnosis of TB Oriya Patients and general community

No. Type of Material Title in Oriya Title in English Content Language Target Audience

28 Cardboard poster Apna kana jananti? What do you know? Problem of TB Oriya Patients and general community

No. Type of Material Title in Oriya Title in English Content Language Target Audience

29 Cinema slide Apananku tini saptaha kasa heuchiki? Are you coughing for three weeks? How to suspect TB and what to do Oriya Patients and general community

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No. Type of Material Title in Oriya Title in English Content Language Target Audience

30 Video cassette Sabitri Sabitri A film about a TB patient who died due to negligence Oriya Patients and general community

No. Type of Material Title in Oriya Title in English Content Language Target Audience No. Type of Material Title in Oriya Title in English Content

31 Audiocassette (rural) No title No title Songs about TB symptoms, diagnostic procedure, importance of regular treatment etc. Oriya Patients and general community 32 Exhibition set (wooden) Raimani takes DOTS and is cured A Success Story Songs about TB symptoms, diagnostic procedure, importance of regular treatment, etc. Oriya, English Patients and general community One set containing 15 storyboards

Language Target Audience Remarks

No. Type of Material Title in English Content Language Target Audience Remarks

33 Mela kit Mobile exhibition unit Various information materials on different aspects of TB Oriya Patients and general community Folding stall with information on TB

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No. Type of Material Title in English Content Language Target Audience No.

34 Bounded cloth board World – India Statistics of TB Statistical information on TB in India English/Oriya Health personnel/trainers/NGOs 35

Type of Material Title in Oriya Title in English Content Language Target Audience Remarks

Folding cloth banner Adharu ausadha band karaktu nahin Do not stop treatment in the middle of a course Symptoms, diagnostic procedure, importance of regular treatment etc. Oriya Patients One set five

No. Type of Material Title in English Content Language Target Audience

36 Video cassette Shanta – Model Community Mobiliser IEC activities in RNTCP English Community health providers, IEC staff

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No. Type of Material Title in Oriya Title in English Content Language Target Audience

37 Video cassette Jakhma - prana binasakari hele madhya arogyo sadhya Tuberculosis—A curable killer Introduction of RNTCP and DOTS strategy in Orissa English Health administrators/donor agencies/trainers

No. Type of Material Title in Oriya Title in English Content Language Target Audience

38 Pocket folder Paribartita jatiya jakhma niantran karyakram (sankhipta suchana) Revised National TB Control Programme Basic information on TB Oriya Political representatives PRI members NGOs teachers

No. Type of Material Content Language Target Audience

39 Audiocassette for the Santhal tribe Songs about TB symptoms, diagnosis procedure, importance of regular treatment etc. Alchick Patients and general community

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No. Type of Material Title in Oriya

Title in English

Content Language Target Audience No. Type of Material Title in Oriya Title in English Language Target Audience

40 Folder with success stories Sabo muhon re hasso Jhauli lata re phoolo Moo Ethiru kano pauchi tume kano bujhibo Ghanti phuni bajilani Ae kano sathore kimia na kano Tanka gudiko panire pakai dele sinna… Koti kare gotia Nijo jibho nijo hato re kati deli Sato kahibaku kiyan daribi Mu para eveready battery To be happy and make others happy Happiness regained Noble investment Preaching DOTS DOTS - the saviour Paid a price to learn a lesson One in a million Duped by a quack Want to hear my story? Yours always Small case narratives of patients who suffered from TB Oriya and English Providers and patients 41 Paper belts Baidya/DP Traditional Healer/DOT Provider Oriya General community (this belt is used by participants in a mock kabaddi game, one side representing traditional healers and the other side representing DOT provider)

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No. Type of Material Title in Oriya Title in English Content Language Target Audience No. Type of Material Title in Oriya Title in English Language Target Audience

42 Apron Pratyakha tattwabadhanare ausadha khai mun Jakhama rogoru arogya hoichi I was cured of TB by taking the medicines under direct observation Used by participants in rallies Oriya General community 43 Cap TB safala chikitsha ra sathika jawab DOTS DOTS—sure cure for TB Oriya General Community

No. Type of Material Title in Oriya Title in English Content Language Target Audience

44 Pocket Folder DOTS subidha apanantu, Jakhma rogoru mukti huantu Adopt DOTS and get rid of TB A brief outline of DOTS and precautions to be taken during treatment Oriya Patient

No. Type of Material Title in Oriya Title in English Content Language Target Audience

45 Poster Laboratory technician kaan pain keteka manerakhiba katha Few things for the Laboratory Technicians to remember Information on sputum microscopy Oriya Laboratory technicians

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No. Type of Material Title in Oriya Title in English Content Language Target Audience No. Type of Material Title in Oriya Title in English Content

46 Certificate of recognition Priya DOT Provider Dear DOT Provider This is given to DOT providers in recognition of their work Oriya DOT providers 47 Booklet Chaalo aabe aame gaaonku jiba, Jakhma rogo katha bujhai deba Come lets go to our village and give the message about TB to everybody Description of signs and symptoms of TB the importance of DOTS and RNTCP in a nutshell. Oriya General community 48 Flipbook DOT Provider kaan pain sankhipta talim pathyakrama A brief curriculum for the DOT Providers Detailed description of the symptoms of TB, the role of DOT providers and the importance of adopting DOTS. Oriya General community

Language Target Audience No. Type of Material Title in Oriya Title in English Content

Language Target Audience

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No. Type of Material Title in Oriya Title in English Content Language Target Audience

49 Banner Aangyan tike sunantu Kindly listen This pictorial banner aptly describes how a person is cured of TB, in the words of the cured patient Oriya General community

No. Type of Material Title in Oriya Title in English Content Language Target Audience No. Type of Material Title in Oriya Title in English Content Language Target Audience

50 Poster DOTS pradanakari kaan pain ketoti suchana Some information for the DOT Provider Brief information about the role of DOT providers. Oriya General community 51 Poster DOTS pradatire hin Jakhma arogya sadhya The only cure for TB is DOTS Adopt DOTS under the supervision of one person Oriya General community

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No. Type of Material Title in Oriya

Title in English Content Language Target Audience

52 Poster TB parikhya abang chikitsha saamasta sarakari swastya kendra re maaganare mile Free treatment for TB is available in all government medical centres Signs and symptoms of TB and the importance of DOTS Oriya General community

No. Type of Material Title in English Content Language Target Audience

53 TV spots (two) DANTB DOTS Messages on DOTS and TB Oriya General community

No. Type of Material Title in English Language Target Audience

54 Badge DOTS—sure cure for TB English General community

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Annexure 5

User Guidelines for the Health Communication Video Modules CD
Learning from past experience, the RNTCP is currently engaged in strengthening IEC activities and institutionalising successful models through further training and dissemination of the communication strategy, and developing mass media campaigns for the entire country. This series of IEC video modules has been developed with this requirement in focus. The modules are in VCD and VCR format. So, they are appropriate for viewing by small audiences consisting of about 20 members. They can be viewed on a television or on a computer screen. The modules capture the essential elements of implementing a particular communication activity in RNTCP. The modules are organised as follows:

Module 1 – Introduction
1. 2. 3. 4. RNTCP-DOTS TB situation in Orissa IEC strategy—goals, target, audiences, components, responsibilities The trialogue approach

Module 2 – Orientation
1. 2. 3. 4. 5. 6. 7. 8. Orientation of SHGs Orientation of traditional healers Orientation of students and teachers Orientation of PRIs Orientation of cured patients Orientation of NGOs Orientation of industrial workers Orientation of jail inmates

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Module 3 – Advocacy and Social Mobilisation
1. 2. 3. 4. 5. 6. 7. Exhibitions Mass rallies Interactive stalls Puppet show Training on street theatre technique Performances of street theatre groups Group discussions

Module 4 – Types of Health Communication Material and Their Use
1. 2. 3. 4. IEC material development workshop Pre-testing of IEC material Media workshop Use of IEC material          Posters Storyboards Pamphlets, booklets, folders Banners Audio/video cassettes Games, quizzes Flipbooks, flash cards Mela kits Exhibition sets

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Annexure 6

Suggested Format for Planning IEC Activities at State and District
Permissible Budget as per Norms
Target Group/ Objective Activities Planned at District-/State-level Activity (all activities to be planned as per local needs, catering to the target groups specified) Outdoors • Wall paintings • Hoardings • Tin plates • Banners • Others Outreach activities • Patient-provider interaction meetings • Community meetings • Mike publicity • Others Puppet shows/street plays etc. School activities Print publicity • Posters • Pamphlets • Others Media activities on cable/ local channels/radio Any other activity Opinion leaders/NGOs for advocacy Sensitisation meetings No. of Activities Held in Last Four Quarters No. of Activities Proposed in the Next Financial Year, Quarter-wise AprJun JulySep OctDec JanMar Responsible Officer for These Activities Estimated Cost per Activity Unit Total Cost

Patients and General Public/ For awareness generation and social mobilisation

Media activities PowerPoint presentations/ one-to-one interaction Information booklets/ brochures World TB Day activities Any other public event Healthcare providers • Public and private • CME programmes • Interaction meetings • One-to-one interaction meetings • Information booklets • Any other Any other activities proposed Total Budget

Annexure 6 | 175

Annexure 7

IEC Reporting Formats
Reporting Format of DOT Patient-provider Interaction Meeting
Name of the PHI 1. Date of Meeting 3. Time Started 2. Place 4. Time Ended

1. Attendance (please write the number of persons attending)
Type of Participant Patients Female Male

                

Category I Category II Category III Cured/treatment completed Irregulars/defaulters Relatives of patients

DOT providers (DPs) Multi-purpose Health Workers Laboratory technicians Pharmacists Anganwadi workers Balwadi workers/balwadi teachers Village Health Guides Panchayat members NGO workers Cured patients working as DPs Teachers Others (specify)

176 | A Health Communication Strategy for RNTCP

Supervisory Staff/Health Authorities

Present

Not present

      

DTO MO-PHI STS STLS MPHS CDPO, Anganwadi supervisor Others (please specify)

2. Activities Conducted (please tick  the appropriate columns)
YES Activities Updating knowledge regarding: Lecture Group Discussion Role-play Quiz Individual Counselling No

           

Different categories of patients and associated treatment How TB is caused and spread Number and timings of sputum examinations required and reason Dangers associated with defaulting Diet Maintenance of cards How to handle side-effects Responsibilities of DPs Other (specify) Delay in diagnosis Stigma/fear of rejection Other (specify)

Raising gender issues

Cross-checking of patient cards Review of each DP’s activities Individual interaction between DP and her/his patients Sharing of DP’s experiences

  

How to ensure timely sputum examination How to ensure timely drug pouch collection for new patients How to promote regular drug intake

Annexure 7 | 177

    

Problems in getting support from supervisors Others (specify) Problems encountered in accessing RNTCP services Benefits from regular treatment Others (specify)

Sharing of patient’s experiences

3. Problems, Solutions and Responsibilities
Fill in these three columns during the meeting Name and address of defaulter Who will visit? When?

3.1 Defaulter retrieval (to be carried out within seven days of meeting)
Fill these two columns after visit to patient (enter code no.) What action was taken? Patient counselling Family counselling Involved village leaders Involved cured patient What was the outcome? Patient resumed treatment Patient refused

3.2 DOT providers
1. Is there a need for a special refresher course for this PHIs’ DOT providers? If ‘Yes’, why? When should it be held? Who should conduct it? 2. Is there a need to train additional DPs for this PHI? If ‘Yes’, how many? Why? Yes/No Yes/No

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4. Please comment on the following aspects of the meeting.
Good Attendance Participation by patients in activities Participation by DPs in activities Punctuality, keeping to time schedule Meeting hall arrangements Drinking water arrangements Quality of food Transport arrangements Average Poor

4.1 Did patients, DPs and supervisory staff eat together?

Yes/No

5. Do you have any other comments regarding this interaction meeting? Please mention positive and negative observations.

6. Please give suggestions for improving the interaction meetings.

Name, designation and signature of the reporter with date:

Annexure 7 | 179

Reporting Format on Street Theatre Performance
1. Date and time of performance 2. Place of performance Village Sub-centre/gram panchayat District 3. Approx. no. of audience Male Female Children 4. Name and designation of local health staff present

5. Local popular persons witnessed the show (obtain their signature and comments)

6. No. of symptomatics reported at the end of show (if any). Mention their names and addresses.

7. Technical queries compiled by

Name Designation Signature of reporter (Street theatre team)

180 | A Health Communication Strategy for RNTCP

A Health Communication Strategy for RNTCP

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