John Elder, Ph.D., MPH
Publication Date
February 14, 2006

San Diego State University

This evaluation was carried out through a series of interviews, group meetings, and visits to various communication for behavioural impact (COMBI) programme sites meant to address tuberculosis (TB) in Nairobi, Kenya, and the state of Kerala, India, which the author visited in January and early February of 2006. This process involved meetings with World Health Organization (WHO) and Ministry of Health (MOH) officials.

One communication-related element to emerge from the "process" element of the evaluation relates to what is described here as the complex behaviours and negative images involved in designing TB communications. The author, Dr. John Elder, points to the negative image of this disease (similar to cancer or AIDS) and the concurrent dearth of positive messages that indirectly promote testing. In both Kenya and Kerala, he says, COMBI implementers were challenged by the negative stigma that people have regarding TB. For instance, in India, it is often viewed as a disease of the lower class or even a symptom of destitution; in Kenya, the image of TB is inextricably linked to HIV/AIDS, and both are viewed quite negatively. Dr. Elder notes that, for effective promotion of TB control, communicators have to deal with the stigmatisation of TB, whether directly (a de-stigmatisation campaign), or indirectly (the promotion of screening services or treatment).

Also, related to the "cough, cough, cough" message to promote symptom recognition and subsequent seeking of services, the author notes that one expert in India felt that this message was far too non-specific to TB, as coughing over a long period of time is viewed as very common and not necessarily unhealthy. "TB communication planners, therefore, must continue to explore both alternative target behaviors for the three aspects of TB control (getting tested, beginning treatment, staying in treatment) and messages that will best promote these behaviors."

With regard to the "implementation" element of this evaluation process, the author describes the India and Kenya launches, and then points to the importance of pilot projects. He notes that neither of these programmes was considered a pilot, nor preceded by one. Also, with regard to the monitoring-feedback loop, Dr. Elder found that, "neither country collected information suitable for modifying approaches or making mid-course corrections, or if monitoring did occur, it was not used for this purpose."

Looking at project management, Dr. Elder found that "no high-profile program champions emerged within the MOH structures for COMBI. Serious reservations about COMBI constrained such levels of support at the higher levels..." Also, he cites as a weakness of the COMBI TB effort the fact that volunteers and frontline health workers were not integrated into the effort.

In the area of impacts and outcomes, the author states that "with minimal or no evaluation data and no obvious impact, it would have to be said that the COMBI TB projects in Kerala and Kenya are not sustainable nor certainly generalizable."

Dr. Elder concludes that refinements and new iterations of the COMBI TB programme should include more detailed instruction of the communications approach at all levels in the administrative hierarchy and should involve all other stakeholders in participating sectors. Furthermore, he suggests that specific and sensitive data should be collected and that monitoring, evaluation, and feedback based on these data should form the core of ongoing planning and mid-course correction.

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Email from John Elder to The Communication Initiative on August 31 2010.