1. Cough to Cure: Applying a Pathway of Ideal Behaviors in TB Control AED: Dr. Silvio Waisbord Dr. Susan Zimicki Stop TB Partnership: Thaddeus Pennas

2. Overview of Presentation Introduction: The “Cough to Cure Pathway” - a diagnostic and planning tool The "Cough to Cure Pathway“ - six steps to ideal TB treatment Applying the Pathway: 4 diagnostic steps

3. Overview of Presentation Introduction: The “Cough to Cure Pathway” is a diagnostic and planning tool. – Why another tool? – What is new about the tool? – How was it developed? The "Cough to Cure Pathway” Applying the Pathway: 4 diagnostic steps

4. Why another tool? Response to expressed need. Countries and technical programs request support and guidance regarding advocacy, communication and social mobilization (ACS): This diagnostic and planning tool supports cost- effective implementation of ACS support and services.

5. What is new about this tool? Frame of reference – way of conceptualizing problems – Think about communication by thinking about behaviors – Behaviors instead of logistics and structure Focus – People (patients and providers) View of system – Enabling environment

6. How was it developed? AED working with Stop TB: Defined the steps in the pathway “from cough to cure” from the patient’s care-seeking practices Identified the social and behavioural barriers to completing each of these steps (through literature review and interviews) Mapped possible ACS entry points drawing on lessons from other behavioural change interventions

7. Overview of Presentation Introduction: The “Cough to Cure Pathway” is a diagnostic and planning tool. The "Cough to Cure Pathway” – How does it work? – Basic structure – six steps – Barriers (individual, group, system) – Examples Applying the Pathway: 4 diagnostic steps

8. How does it work? This pathway was developed to serve as a road map to understand the interrelationship of behaviour, DOTS services and other societal structures on treatment-seeking behaviour and compliance. The pathway focuses on the patient, and how the system can facilitate patients’ “going through” the ideal steps.

9. The Pathway – basic structure Six steps to ideal TB treatment behavior : 1) Seek timely care 2) Go to a DOTS facility 3) Get accurate diagnosis 4) Begin treatment 5) Persist in getting treatment 6) Complete treatment Case detection Goal: 70% Current average: 44% Treatment completion Goal: 85% Current average: 82%

10. Ideal vs reality In an ideal world, for every 100 infected people, all 100 would: – Seek timely care – Go to a DOTS facility either directly through referral – Be correctly diagnosed – Begin treatment – Persist with treatment for more than 2 months – Complete treatment These are the six steps that form the basic structure of the pathway As the following slide shows, things are far from ideal

11. Pathway Steps

12. The Pathway – List of barriers At each step, the pathway also lists the common barriers to completion of the step Barriers can occur at the level of the – Individual – Group – System The current list of barriers is based on AED’s literature review and interviews; it will be updated as program experience accrues

14. Barriers - individual and group level Step 2 – Go to DOTS Common reasons for non-completion are that the individual – Prefers to go to a provider s/he knows, and fears going to someone unknown – Believes attending DOTS facility will be expensive – Doesn’t prioritize TB over other health issues – Low-risk perception of TB symptoms And that the group (community/family) – Stigmatizes people with tuberculosis and, by extension, anyone attending a TB clinic

15. Barriers – system level Step 2 – Go to DOTS Few DOTS facilities, so that people live relatively far away and traveling to the facility takes time and money Lack of linkages between non-DOTS and DOTS facilities = providers do not refer patients with possible TB to DOTS facilities; = providers do not consider TB (e.g., treat HIV patients only for HIV & acute illnesses)

16. Barriers - individual and group level Step 5 (Persist with treatment) Common reasons for drop-out are that the individual and his/her social support group (family, neighbors) – Do not know how long treatment takes – Do not understand or accept the importance of continuing treatment even after the patient feels better or despite side effects – Cannot financially support the cost of distant treatment or “good food” – Stigmatize those with TB

17. Barriers – system level Step 5 (Persist with treatment) Lack of medicines Lack of DOTS facilities - trouble (time, money) to attend Providers fail to give adequate information about length of treatment, importance of persistence, side effects Poor quality of services (e.g., non-supportive or abusive providers)

19. Overview of Presentation Introduction: The “Cough to Cure Pathway” is a diagnostic and planning tool. The "Cough to Cure Pathway"—six steps to ideal TB treatment Applying the Pathway: 4 diagnostic steps – Description – Examples

20. Applying the Pathway: 4 Steps 1. Identify the steps that patients are not completing 2. Examine the reasons for non-completion at the individual, group and systems levels 3. Decide which barriers to address. Need to weigh relative importance of factors 4. Choose an intervention based on understand of motivating factors, and likely effectiveness and impact

21. How to examine step completion Obtain information about step completion from a variety of sources – Routine information – Special studies – Key informants Chart out the data and let it guide the decision making process Important: be clear about denominators – Make sure all your percents refer to the same base population

22. Step 2. Examine reasons for missed steps In this case, the program should examine individual, group and systems barriers that are likely to be problems for both step 1 and for step 2.

23. Example: for Step 2 (Go to DOTS) Possible reasons include – Individual: Misperceptions of costs of diagnosis and treatment; Reluctance to go to an unknown provider – Group Stigma – System Distance to DOTS provider No or weak links between non-DOTS and DOTS providers; non-referral

24. How to examine reasons Use both qualitative and quantitative research Examples of some questions relevant to individual and group-level barriers for Step 2: – Where should someone go to find out if she or he has TB? – How much does it cost to be tested? – Can TB be cured? – How much does it cost? – How long does it take? – How would your family and neighbors react if they knew that you went to a DOTS clinic?

25. Step 3. Decide which barrier(s) to address What is the relative importance of this barrier compared to others? How feasible is to reduce this barrier within a short-to-medium period? How much will it cost (cost/benefit analysis)? Does the program have the right expertise to tackle the problem (human resource analysis) ?

26. Step 4. Choose an intervention What kinds of interventions will best address the identified barrier(s)? – Systems improvement (e.g., logistics) – Behavioural change of patients and/or providers – Mixed (what is the sequence?) What kind of communication strategy is best adequate to address barriers?

27. Core questions for communication interventions Who is the primary and secondary audience? What is it that they are expected to do? What will it take to get people to do it? – What do they need to know? – What do they value? – How will they overcome perceived and existing barriers? – What factors promote their doing it? these come from the BEHAVE model; many other models exist: NCI Pink Book, P-Process, Combi, CDCynergy, …)

28. Thank you Academy for Educational Development and the Stop TB Partnership Secretariat