STS: ACSM and Community Engagement

In ACSM, "A" stands for Advocacy. "Advocacy" is an activity by an individual or a group that aims to influence the decisions within political, economic and social institutions. 

Advocacy focuses on influencing policy-makers, funders and international decision-making bodies through a variety of channels:

• Conferences, summits and symposia
• Celebrity spokespeople, press conferences, news coverage
• Meetings between various levels of government and civil society organizations
• Official Memoranda of Understanding (MoU), parliamentary debates and other political events
• Partnership meetings, patients’ organizations, private physicians, radio and television talk shows, and service providers.

Types of advocacy

• Policy advocacy: Mainly targets policy-setting, influencing policymakers to incorporate the latest evidence and informs senior politicians and administrators how an issue will affect the country, and outlines actions to take for improving the laws and policies.
• Programme advocacy: Targets opinion leaders at the community level on the need for local action.
• Media advocacy: Validates the relevance of a subject, puts issues on the public agenda and encourages the media to cover TB-related topics regularly and in a responsible manner so as to raise awareness of possible solutions and problems.

 

Resources

1. Advocacy, Communication & Social Mobilization (ACSM) for Tuberculosis Control - A Handbook for Country Programmes, WHO, 2007.
2. Operational Handbook on Advocacy, Communication & Social Mobilization for RNTCP, Central TB Division, MoHFW, GoI, 2014.

 

 

Assessment:

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
News reports on World TB day celebrations are an example of which of the following types of advocacy?	Policy advocacy	Programme advocacy	Media advocacy	None of the above	3	Media advocacy encourages the media to cover TB-related topics regularly and in a responsible manner so as to raise awareness of possible solutions and problems.	​	Yes	Yes

Communication aims to favourably change knowledge, attitudes and practices among various groups of people. 

Types of communication in healthcare are:

• Oral/verbal communication- by word of mouth (speech/talk)
• Written communication- exchange of facts, ideas and opinions through the use of written materials
• Non verbal communication- through gestures, body language or posture, facial expressions, and eye contact 
• Visual communication- exchange of ideas through visuals

Health communication aims to influence and empower individuals, populations and communities to make healthier choices. It frequently informs the public of the services that exist for diagnosis and treatment and relays a series of messages about the disease. It aims to inculcate behaviour change for healthy life choices.

E.g.: “Seek treatment if you have a cough for more than two weeks”, “TB hurts your lungs” or “TB is curable”.

Approaches to health communication

1. Informative communication

Provides information about a new idea and makes it familiar to people.

2.Educative communication

A new idea on health behaviour is explained, including its strengths and weaknesses.

3.Persuasive communication 

Usually in the form of a message that promotes a positive change in behaviour and attitudes, and which encourages that audience to accept the new idea. This approach to message development involves finding out what most appeals to a particular audience. Persuasive approaches are more effective than coercive approaches in achieving behaviour change.

4.Prompting communication

Messages are designed so that they are not easily ignored or forgotten they can be used to remind the audience about something that reinforces earlier messages.  

Behaviour Change Communication (BCC)

• Behaviour Change Communication (BCC) is an interactive process of any intervention with individuals, groups or communities to develop communication strategies to promote positive health behaviours which are appropriate to the current social conditions and thereby help the society to solve their pressing health problems.
• BCC creates an environment through which the affected communities can discuss, debate, organize and communicate their own perspectives on TB.
• It aims to change behaviour – such as persuading people with symptoms to seek treatment – and to foster social change, supporting processes in the community or elsewhere to spark a debate that may shift social mores and/or eliminate barriers to new behaviour.

 

                                                                                           Figure: Behaviour Change Communication

 

 

 

Resources

1. Advocacy, Communication & Social Mobilisation (ACSM) for Tuberculosis Control - A Handbook for Country Programmes, WHO, 2007.
2. Operational Handbook on Advocacy, Communication & Social Mobilisation for RNTCP, Central TB Division, MoHFW, GoI, 2014.

 

 

 

Assessment:

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
What does the environment created by behaviour change communication encourage the TB-affected communities to do?	Discuss, debate, organize, communicate	Discuss, organize, implement, communicate	Organize, enforce, communicate	None of the above	1	Behaviour change communication creates an environment through which the affected communities can discuss, debate, organize and communicate their own perspectives on TB.	​

Social Mobilisation (SM) is the process of bringing together different stakeholders and building partnerships to prevent, detect and cure TB. It generates dialogue, negotiation and consensus among a range of players that includes decision-makers, the media, Non-government Organisations (NGOs), opinion leaders, policy-makers, the private sector, professional associations, TB-patient networks and religious groups.

At the heart of social mobilisation is the need to involve people who are either living with active TB or have suffered from it at some time in the past.

 

Aims of Social Mobilisation

• Increase awareness of the disease (TB) and the demand for diagnosis and treatment services

• Expand service delivery through community-based approaches

• Enhance sustainability, accountability and community ownership of TB services

 

Activities for Social Mobilisation

• Group and community meetings - Engaging yuva/ mahila mandals, village health sanitation and nutrition committees under the National Rural Health Mission (NRHM), sensitization of local and religious leaders on TB and related stigma in the community. Regular meetings at the village level to address myths and misconceptions and help people with TB symptoms seek timely and appropriate care or referrals.
• School activities - Conducting TB awareness campaigns in schools by addressing the school assembly/ class, painting competitions, rallies, road shows, essay competitions, drawing competitions, exhibitions, dramas, pictorial presentations, quizzes, puzzles, puppet shows, leaflet distributions etc.
• Traditional media group performances - Performing entertainment-centred folk performances, street plays with scripts centred around TB awareness messages.
• Rallies and road shows - Spreading TB related messages on World TB day.
• Home visits - Encouraging interpersonal communication and empowering former TB patients and TB champions to become Directly Observed Treatment, Short-course (DOTS) providers.

Here, inter-personal communication and group communication are the main channels of communication for disseminating TB-related key messages.

 

In the National TB Elimination Programme (NTEP), partner NGOs play an important role in social/ community mobilisation. It generates dialogue, negotiation and consensus, engaging a range of players in interrelated and complementary efforts while taking into account people’s needs.

 

Resources

 

1. Advocacy,Communication & Social Mobilisation (ACSM) for Tuberculosis Control - A Handbook for Country Programmes, WHO, 2007.
2. Operational Handbook on Advocacy, Communication & Social Mobilisation for RNTCP, Central TB Division, MoHFW, GoI, 2014.

 

Assessment:

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
A roadshow was conducted by local PHC in a village on World TB day with message to End TB. This is an example of:	Policy making	Social mobilisation	Institutional strengthening	Diagnostics	2	Roadshow is one of the activities of social mobilisation strategy which aims at increasing awareness about the disease, involving major stakeholders.	​

 

 

 

 

 

Advocacy, Communication and Social Mobilization (ACSM) strategies are directed at achieving specific goals in terms of TB elimination.

They are:

• Setting and developing the policy based on the latest evidence
• Mobilizing political commitment and resources for TB
• Improving case detection and treatment adherence
• Widening the reach of services
• Combating stigma and discrimination
• Empowering people affected by TB and the community at large

It is useful to determine how ‘ideal behaviour’ in the community relates to these goals. The ‘ideal behaviour’ which is promoted through messages and ACSM strategies should be connected to the overall goal of the TB control programme. A few examples of this are:

• For the general public: Going to a healthcare provider at the first signs of possible TB infection (ideal behaviour) relates directly to the National TB Elimination Programme (NTEP) goal of increasing the case-detection rate for TB.
• For healthcare providers: Following the standards set for the treatment of TB – includes knowing what regimen, how to administer anti-tubercular therapy and what treatment path to take in case of multidrug-resistant or extensively drug-resistant TB. This relates to treatment adherence and outcomes.

The ACSM goals are planned in such a way as to achieve/ address:

• Structural or systemic issues (such as the lack of community Direct Observation Treatment, Short-course (DOTS) programmes)

• Communication interventions (such as behaviour change)

• Individual and social barriers (such as stigma, risk perception and knowledge among populations and health staff)

• Social mobilization activities that promote changes throughout a community or priority group.

 

Resources

 

1. Advocacy, Communication & Social Mobilization (ACSM) for Tuberculosis Control - A Handbook for Country Programmes, WHO, 2007.
2. Operational Handbook on Advocacy, Communication & Social Mobilization for RNTCP, Central TB Division, MoHFW, GoI, 2014.

 

Assessment:

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
Seeking healthcare at the earliest symptom of TB directly relates to which goal of NTEP?	Mobilizing political commitment and resources for TB	Improving case detection	Widening the reach of services	Combating stigma and discrimination	2	Improving case detection is an important goal of NTEP and seeking health care early helps in the detection of more number of cases.	​	Yes	Yes

 

 

Identifying target audience is a key step in the process of developing Advocacy, Communication and Social Mobilisation (ACSM) strategy.

Specific target audience need to be addressed to prevent hinderances in achieving the programme objectives.

Figure: Steps in Identifying Target Audience for ACSM Activities 

 

Target Audience for ACSM Activities

1. Advocacy

• Decision-makers at national, regional and district levels (National Health Mission officials, District Magistrate, National TB Elimination Programme leadership)

• Policy-makers

• Professional groups

• Funders

• Media

 

2. Communication

• General public, including different vulnerable groups, healthcare workers (i.e., primary healthcare providers, Allopathic and Ayurvedic, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) doctors, private healthcare providers, traditional healers, etc.)

• TB patients currently on treatment as well as cured TB patients

• Contacts of patients with active TB

• People at high risk of developing TB

 

3. Social mobilisation

• Communities

• Community groups, e.g., mahila mandals, youth groups

• National and local level leaders

• Local Non-government Organisations (NGOs), Youth organizations, Community-based Organisations (CBOs)

 

Resources

• Operational Handbook on Advocacy, Communication & Social Mobilisation for RNTCP, Central TB Division, MoHFW, GoI, 2014.

 

Assessment  Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​
Identifying target audience is crucial in the process of developing ACMS strategy.	True	False			1	Specific target audiences need to be addressed to remove the causes/ reasons that are hindering programme objectives.

 

Once Advocacy, Communication and Social Mobilisation (ACSM) objectives are designed, linking them with activities strengthens the overall programme effectiveness. Several ACSM approaches can be considered for TB. Decisions on which approach or combination of approaches to use should take into account the benefits and risks, the time frame and the expertise and financial resources needed for effective implementation.

 

There are two parameters to determine:

(1) What ACSM activities to conduct?

(2) Which channels of communication to use?

 

Following are the various ACSM approaches relevant to the National TB Elimination Programme (NTEP) and the activities included in it:

 

NTEP Goal	ACSM Approaches	Activities & Channels
Gaining political commitment to TB elimination	Educate national policy-makers and political leaders about the health and economic benefits of TB elimination. Aim to have TB declared a national health priority. Educate local and community level authorities to encourage them to contribute to TB elimination efforts. Solicit the support of international and national partners.	Seminars and briefing meetings Print information (letters, fact sheets) Events around World TB Day and other occasions
Improving case detection	Raise public awareness about TB. Reduce stigma against people with TB and correct misconceptions about TB infection by actively involving current and former TB patients. Help health workers, communities and individuals identify TB cases. Encourage individuals to seek care from appropriate sources. Target hard-to-reach populations (prisoners, urban poor, homeless).	Formative research to determine the best messages and approaches Mass media including radio and television Distribution of print materials at community meetings or events Interpersonal communication and counselling training for health workers Community mobilisation activities
Increasing treatment success and discouraging the spread of Multidrug-resistant TB (MDR-TB)	Give people with TB hope of complete cure. Encourage people with TB to seek treatment from appropriate sources. Provide materials to counsellors. Encourage people with TB to complete treatment even if they improve before treatment ends. Make people with TB aware of possible side effects, and where to seek care, if present. Encourage health workers, family and community members to directly observe people with TB taking their medicine. Engage people who are fully recovered to encourage people currently affected by TB to complete treatment.	Interpersonal communication and counselling training for health workers Mass media, including radio and television Extensive distribution of print materials at healthcare facilities Community mobilisation activities Peer education at community or interest group meetings

 

 

Resources

 

1. Advocacy, Communication & Social Mobilisation (ACSM) for Tuberculosis Control - A Handbook for Country Programmes, WHO, 2007.
2. Operational Handbook on Advocacy, Communication & Social Mobilisation for RNTCP, Central TB Division, MoHFW, GoI. 2014.

 

 

Assessment:

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
Factors to be considered while adopting an ACSM approach include:	Risks & benefits	Time frame	Expertise & financial resources	All of the above	4	Decisions on which ACSM approach or combination of approaches to use should take into account the benefits and risks, the time frame and the expertise and financial resources needed for effective implementation.	​	Yes	Yes

 

 

 

There are several communication channels for the effective dissemination of messages.

Below are various channels with their advantages and disadvantages listed.

Channels/ Tools	Audiences Reached	Advantages	Disadvantages
Mass media channels
Television	Households, families	Wider reach in urban and rural areas Maximum impact due to audiovisual elements	Expensive production costs Less reach among rural and migrant populations, who are vulnerable to TB.
Radio	Individuals, households, families	Radio production is simple and much less expensive than TV. Relatively wider reach than TV among rural and migrant populations. Accessible even on mobile phones	Radio listening is no more popular; TV viewing/online portals are more popular.
Newspapers and magazines	Educated individuals, households	Timely and fixed schedule of dissemination. Pictorial description of message.	Not useful for the illiterate population People read newspapers for news about political developments, crime, etc., and not for advertisements per se, unless the advertisement is attractive and eye-catching enough.
Mid-Media - Outdoor Publicity Materials and Folk Arts/ Dramas
Posters	Individuals	Strong pictorial description of the message. Useful in high-traffic areas	Brief messages Short lifespan
Pamphlets	Individual	Good for communicating core messages with illustration/ visual support. Mass distribution and a kind of take-home message. Not very expensive. Can be used for repeated exposure and to reinforce messages broadcasted through mass media.	Useful for the literate population, but can be used by the illiterate people as well If the pamphlet looks attractive enough, it is taken home and contents are deciphered with the help of literates or children at home/ in the neighbourhood.
Brochures	Individuals, groups	Detailed information/ instructions with illustrations/ visuals/ graphs etc.	Production costs may be relatively high.
Flip charts	Individuals	Good support in counselling sessions.	Production costs may be relatively high.
Wall writings/ hoardings	Individuals, households	Useful in high-traffic areas. Good for identification, pictorial description and reinforcement of message	Only for the literate population. Message retention is low
Kiosks	Individuals	Face-to-face communication along with audio-visual communication for better message retention. Useful in dispelling myths and practices.	Expensive to scale up. Requires trained staff. Relatively small reach.
Mobile vans and videos on wheels	Groups, community	Entertaining and can grab audience attention and better message retention	Expensive to implement and scale up Relatively small reach Requires precision of timing
Folk dramas	Groups, community	Entertaining and can grab audience attention and better message retention Can touch an emotional chord with individuals/ households; useful for sensitisation.	Relatively small reach. Expensive to scale up. Requires precision of timing. Requires good artists with prior training.
Interpersonal Communication (IPC)
Counselling	Individuals	Credible source due to face-to-face communication. Allows detailed explanation of key health messages. Can help dispel myths and check wrong practices.	Time-taking to build reach. Small reach (individual). Costly to scale up. Requires special training.
Home visits	Households	Credible source due to face-to-face communication. Allows detailed explanation of key health messages. Can help dispel myths and check wrong practices. Useful for rapport building.	Time-taking to build reach. Small reach to the target audience. Requires adequate capacity building.
Community Dialogue
Seminars, workshops, and Parliament questions	Policy-makers, implementers, urban population	Brainstorming of key stakeholders. Identification of key communication challenges, Key inputs from experts and academicians.	Not timely. High cost of implementation. Time-taking to bring about change. Difficulty in mobilizing key stakeholders.
Public meetings and gatherings	Key influencers, individuals, households	Emphasis on key messages by influencers/ stakeholders. Useful for addressing different segments of the target audience together.	Intermittent in occurrence. High organising cost. Only verbal communication involved. Reach is relatively small.
Working with groups	Households, individuals	Dissemination of key messages among communities. Word-of-mouth communication.	Low frequency. Only verbal communication involved.
Social Media
Facebook, Blogs, YouTube, SMS	Individuals	Targets individuals but has a wide/ mass reach. An effective method of reaching a large number. High visibility among decision-makers.	Only limited people have access to internet accounts on Facebook, and an even smaller number have blogs.

 

Resources

1. Advocacy, Communication & Social Mobilisation (ACSM) for Tuberculosis Control - A Handbook for Country Programmes, WHO, 2007.
2. Operational Handbook on Advocacy, Communication & Social Mobilisation for RNTCP, Central TB Division, MoHFW, GoI, 2014.

 

Assessment

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
Home visits for communication are an example of:	Mass media	Interpersonal communication	Community dialogue	Mid-media approach	2	A home visit is a form of Interpersonal Communication (IPC). Credible source due to face-to face communication Allows detailed explanation of key health messages Can help dispel myths and check wrong practices Useful for rapport building	​	Yes	Yes

 

Advocacy, Communication and Social Mobilization (ACSM) activities must place the individual at the centre and bring in the family, community and society to bring about sustained changes in TB perceptions and behaviours. ACSM activities must target these 4 groups accordingly:

 

1. Individual: Specific interventions that ensure sustained engagement of people or individuals in maintaining positive behaviours/ changing to desired behaviours. E.g., counselling, use of positive TB messages, message by TB champions, etc.
2. Family: Interventions that create an enabling environment for promoting positive behaviour change and developing necessary skills for a person affected by TB. E.g., counselling of the entire family.
3. Community: Mobilizes groups toward a common goal, raises local resources and fosters support and awareness for TB-related issues. E.g., conducting TB awareness campaigns in public meeting places, melas, street dramas, etc. 
4. Society: Advocates for rights-based and socially inclusive approaches and seek support for the TB programme. E.g., workshops and seminars to drive change in legislation, policy, partnerships and resource allocation.

 

Aimed at individuals, families, communities, and the society, varied ACSM activities are undertaken at the national, state, district and community levels to:

• Create awareness and an enabling environment
• Build capacities to bring about desired changes in TB-related health behaviour
• Sustain positive behaviour

 

These are shown in the figure below.

Figure: ACSM Activities Spanning Across All Levels

Resources

• Operational Handbook on Advocacy, Communication, and Social Mobilization (ACSM), NTEP, 2014.
• NTEP Training Modules 5-9 for Programme Managers & Medical Officers, 2020.

Assessment

 

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
ACSM activities span across which levels?	Individual only.	Individual, family, community, society and from central down to the village level.	Individual and family levels only.	ACSM activities do not span across any level.	2	ACSM activities must span across the individual, family, community, societal levels, and from the central down to the village level.	​

 

 

Components of Advocacy, Communication and Social Mobilisation (ACSM) Planning Format

• Activity - The number of planned activities is mentioned against the timeline (for every quarter). Common activities listed in the format include community meetings, patient-provider meetings, school activities and outreach activities.
• Timeline - Timelines are divided into four quarters, but one must ensure that activities are spread across all the quarters and not aggregated in the last quarter of January–March.
• Budget - Budgeting for ACSM activities should cover materials, events, training, monitoring, evaluation, etc.
• Justification - The reason/ purpose for undertaking the ACSM activities is recorded.

The planning format also collects historical budgets proposed, allotted and spent for previous years to see if allotted budgets were properly utilised. The current allocation depends on the historical trend of spending. 

Table: Example of ACSM Implementation Plan Format  

 

Activity	Timeline				Budget	Justification/ Remarks
	Q1	Q2	Q3	Q4
	(Apr - June)	(July - Sep)	(Oct - Dec)	(Jan - Mar)

 

 

1. State Level

2. District Level

 

Advocacy, Communication and Social Mobilisation								Justification/ Remarks
Activity	Budget Proposed in last annual action plan (2012 – 2013)	Amount available in this Head (2012 – 2013)	Amount spent by district (2012 - 2013)	Approved ACSM Plan for 2013 -2014	Amount spent in 2013-2014 (till Sep 2013)	Permissible Budget as per population norm for 2014 - 2015	Budget proposed for 2013 - 2014
Total						0

 

 

 

 

Name of Activity	Number of activities undertaken in 2012-2013	Number of activities undertaken in 2013-2014 (till Sep 2013)	Number of Activities Proposed in 2014-15					Budget Proposed for Next FY 2014-2015
			Apr-Jun	Jul-Sep	Oct-Dec	Jan-Mar	Total
Community meeting							0
Patient – provider meeting							0
School activity							0
Outreach activity							0
CME							0
							0
							0
							0
Total	0	0	0	0	0	0	0	0

 

Resources

• Operational Handbook on Advocacy, Communication & Social Mobilisation for RNTCP, Central TB Division, MoHFW, GoI, 2014.

Assessment

 

Question​	Answer  1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​
How many components are there in the ACSM planning format?	3	4	5	2	2	Activity, Timeline, Budget and Justification are the key components of PIPs for ACSM.

Three Levels of Advocacy, Communication and Social Mobilisation (ACSM) Activities 

 

• Preparation of district- and state-level Project Implementation Plans (PIPs) is an important component of the National TB Elimination Programme (NTEP) under the umbrella of the National Health Mission (NHM).
• State PIP is prepared annually which helps states in identifying and quantifying their targets for programme implementation during the year.
• This takes a bottom-up participatory approach that promotes need-based and decentralised planning.

 

Figure 1: Bottom-up approach used in developing ACSM annual action plan

Steps in Planning ACSM PIP

• Draft of district PIPs are discussed in groups of 4–5 districts and ‘finalised’ as district PIPs.
• The district PIPs are consolidated into one document as the draft of state PIP by the IEC officer, in consultation with the STO and other concerned staff.
• In the process, the district PIPs and the state PIP are finalised and sent to Central TB Division (CTD) for approval.
• Once the state ACSM PIP and budget are approved by the CTD, the State IEC Officer (SIECO) should rework the state and district PIPs to reprioritise ACSM activities based on the allotted budget.

 

Community meetings are organised by the Senior Treatment Supervisor (STS) or the partner Non-Government Organisation (NGO) under the supervision of the Medical Officer.

• These meetings are conducted to create awareness about TB among the general population, community leaders, people’s representatives, Self-help Groups (SHGs), community volunteers, traditional healers, etc.
• These meetings are organised in a community centre or any other suitable place at the village and slum level.
• To maximise the output, the community meetings should be planned appropriately.

Following are the steps involved in planning a community meeting:

 

Resources

• Operational Handbook on Advocacy, Communication and Social Mobilisation (ACSM) for RNTCP, Central TB Division, Ministry of Health and Family Welfare.

 

Assessment

 

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
Who supervises the conduct of community meetings?	DTO	STO	MO	STLS	3	Community meetings are organised by the STS or the partner NGO under the supervision of the Medical Officer.		YES	YES

 

Community or peer-led measures penetrate better into the intricate layers of key population and facilitate Intensive Case Finding (ICF). Peer group support helps patients deal with challenges that they face during the treatment period. Several Tuberculosis (TB) patients find their treatment period stressful and having a peer to talk to, who has undergone similar challenges, and a doctor or counsellor to answer their questions, helps build confidence and realization that they are not alone in this journey.

 

 

Figure 1: Characteristics of a Peer Group

 

 

 

Figure 2: Peer group interventions has an influence on the knowledge, attitude, and quality of life of the pulmonary tuberculosis patients

 

• Peer group intervention is human centered approach as it involves perspectives from the patients and their care givers encouraging them to openly discuss their concerns. Peer group intervention builds collective strength and solidarity among patients attending the group meeting and improve their treatment experience by learning from experience of peers. Talking to others in support groups reduces anxiety, improves self-esteem, and helps members' sense of well-being overall.

 

• Peers are an underused resource for strengthening TB control among socially excluded populations. There is a need for further research into the contribution of peers to TB control, including analyses of economic effectiveness.

 

 

Peer group interventions for TB patients are:

 

• Conducting patient support group meetings where patients and care givers can discuss their concerns and invite other patients who have addressed similar issues in their treatment. Social support from family and friends, helps in patient’s adherence to treatment. Treatment adherence is a key to the completion of TB treatment. The support is part of an external stimulus which can develop a particular behavior in human.

 

• Peer group members can facilitate linkages to nutrition and other forms of support for TB patients – Patients or caregivers can be linked to support services like counselling, nutrition and social entitlements, either from the NTEP or through other public schemes or community structures.

 

• Peer group members can help each other by sharing their knowledge to create linkages with the medical support systems – TB patients who develop side effects due to medication, should be linked for medical support during the meetings. Medical Doctor/STS/TBHV/CHO shall provide counselling to patients regarding side effects of the TB treatment and how to address the issues. Members act as role models for each other. Seeing others who are contending with the same adversity and making progress in their lives is inspiring and encouraging.

 

• Peer group members can facilitate interactions of family members with Medical officer (M.O.)/National TB Elimination Programme  (NTEP) staff – Peer group meetings can be used to counsel the caregivers on how to take care of the patient at home. A support group is a safe place for someone who needs to talk about intensely personal issues, experiences, struggles, and thoughts.

 

 

 

Resources

 

Guidance document on community engagement under NTEP Central TB Division, MoHFW, GoI September 2021

 

Operational handbook on Advocacy, Communication & Social Mobilization for RNTCP, Central TB Division, MoHFW, GoI 2014  

 

NTEP Training Modules 5 to 9, Central TB Division, MoHFW, GoI 2020

 

 

Assessment

 

Question	Answer   1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation
Peers are an underused resource for strengthening TB control among socially excluded populations. There is a need for further research into the contribution of peers to TB control, including analyses of economic effectiveness.	True	False			1	Community or peer-led measures penetrate better into the intricate layers of key population and facilitate Intensive Case Finding (ICF).

 

 

 

 

In order to create awareness and mobilise young students to fight against TB, the National TB Elimination Programme (NTEP) encourages TB awareness campaigns in schools.

Common school activities undertaken to create awareness about TB among children include the following:

• Addressing the school assembly/ classes
• Holding painting competitions
• Holding rallies and road shows
• Holding essay competitions
• Holding slogan competitions
• Reading TB leaflets during prayers
• Organising quizzes
• Puzzle games
• Pictorial presentations (presenting TB-related information in the form of pictures)
• Organising exhibitions (posters, models etc.)
• Katputli shows
• Distributing leaflets containing information about TB

 

Steps for Organising School Activities

School activities could prove very effective, provided they are well planned. Following are the steps for effective organisation of school activities:

 

 

Resources

• Operational Handbook on Advocacy, Communication and Social Mobilisation (ACSM) for RNTCP. Central TB Division, Ministry of Health and Family Welfare.

Assessment

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
Training school teachers is a part of the ACSM activities in schools.	True	False			1	Training of school teachers, who will in turn conduct school activities in a planned manner is a part of ACSM activities in schools.		YES	YES

 

Tribal people (10.4 Cr, 8.6% of total population) have higher prevalence (703 per 100,000) of TB compared to national average (256 per 100,000).10.4% of all TB notified patients are from tribal communities. The National TB program has prioritized this subgroup of population through Tribal Action Plans since 2005.

As a part of the Multisectoral collaboration with various Ministries, a guidance note on the joint action plan was developed by Ministry of Health and Family Welfare (MoHFW) and Ministry of Tribal Affairs in October 2020 and shared with the Secretaries of all States/ UTs for field level implementation. Tribal TB initiative, a unique partnership between the Ministry of Health and Family Welfare and Ministry of Tribal Affairs was initiated to improve the cascade of TB care and support services among Tribal Populations in India. The technical assistance for this initiate will be provided by USAID.

Challenges in communities in tribal areas:

Access, availability, and utilization of TB care services of these communities are hindered by:

1. Geographical barriers
2. Poor state of social determinants
3. High impact of malnutrition, insufficient community involvement
4. Health system constraints including lack of trained human resources
5. Cultural and communication gaps between the care provider and the community, etc.
6. The COVID-19 pandemic has probably further worsened the situation.

 

Community mobilization strategies in tribal areas:

 

 

Various departments which play a role in community mobilization in Tribal areas:

1. National Program Management Unit (NPMU) provides technical assistance in monitoring and implementation of the Tribal TB Initiative.
2. Coordination among National Tuberculosis Elimination Programme (NTEP), National Health Mission (NHM), Ministry of Development of Northeastern Region, Ministry of Tribal affairs at National, state and district levels through national level Technical Support Unit.

 

 

3. Coordination with ‘Centre of Excellence’ within the Ministry of Tribal Affairs, with a key focus on TB.
4. Partnering with private sector players for leveraging resources for TB elimination in Tribal communities.
5. Documenting best practices, and commission tribal health research studies in collaborations with identified government institutions.
6. Various departments collaborate for improving the operational excellence of existing demand-side interventions such as Village Health Sanitation and Nutrition Days (and committees), Jan Arogya Samiti platforms, Jan Andolan initiatives, engaging TB-Champions, and training of faith healers and other community influencers.

 

Resource

1. Operational handbook on Advocacy, Communication & Social Mobilization for RNTCP, Central TB Division, MoHFW, GoI 2014  

 

2. Tribal TB Iniative

 

3. NTEP Training Modules 5to9

 

Assessment

 

Question	Answer   1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation
Community mobilization strategies in tribal areas include home visits.	True	False			1	Community mobilization is about seeking cooperation and support from different stakeholders in general and the community in specific. Home visits will improve awareness on various government schemes, provisions, facilities available for TB patients and to improve treatment literacy and adherence among TB patients in tribal areas.

 

 

 

 

Rural populations have more limited access to primary care physicians than residents of urban areas, and are older, sicker, and poorer than urban counterparts. Travel to reach a primary care provider may be costly and burdensome for patients living in remote rural areas, with subspecialty care often being even farther away. These patients may substitute local primary care providers for sub specialists, or they may decide to postpone or forego care. Many social determinants act as barriers for rural communities to access health services.

Challenges faced by communities in rural areas are:

• Higher poverty rates, which can make it difficult for participants to pay for services or programs
• Cultural and social norms surrounding health behaviors
• Low health literacy levels and incomplete perceptions of health
• Linguistic and educational disparities
• Limited affordable, reliable, or public transportation options
• Unpredictable work hours or unemployment
•     Poor primary healthcare and infrastructure in rural areas
•     Lack of access to tuberculosis testing and treatment centers in remote unreached areas
•     Unregulated indigenous system of medicine
•     Poor airborne infection control
•     Poor nutrition and Malnourishment 

 

Community mobilization strategies in rural areas include:

Various committees which play a role in community mobilization in rural areas:

•      Village Health Sanitation and Nutrition Committees (VHSNCs) - In each Gram Panchayat, Village Health Sanitation and Nutrition Committees (VHSNCs) have been formed at the village level under National Health Mission (NHM). These committees are entrusted with community-level planning and implementation of health and sanitation, and have representation from the local government, local health centre, and the local community. 

 

•      Panchayat Raj Institution (PRI) - Members of PRI refers to local self-government at the village level. The village pradhan (head) and members of the Panchayat are elected members of the Gram Panchayat. They are the key people who can, after sensitization, mobilize the community for TB care and control and make allocations for TB patients’ nutrition and travel requirements.

 

•      Yuva mandal/Mahila mandals (Youth/women’s clubs) - Community-level federations of young boys/girls/women, sometimes even comprising several women SHGs. 

 

•     Self-help groups (SHG) - An SHG is a group of individuals with a homogenous social and economic background, who voluntarily come together to regularly save small amounts of money and contribute to a local fund to meet the members’ emergency needs on a mutual help basis. These groups collectively manage their payments and ensure proper use of credits. Many NGOs currently engaged in the project are involved in formation/registration of these SHGs. It would be advisable to involve these NGOs for ease of implementation. 

 

•     Community-based organizations (CBO) - A CBO is a small group of people from a community, who come together for a particular purpose. It may be a local association of people mobilized around water conservation, mother and childcare, sustainable agriculture, education, or adolescent health; a group of social service persons; or any other such active group in a village. 

 

Resource: 

 

Operational handbook on Advocacy, Communication & Social Mobilization for RNTCP, Central TB Division, MoHFW, GoI 2014  

 

 

Assessment: 

 

Question	Answer   1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation
Community mobilization strategies in rural areas includes empowering key decision-makers, people affected by TB, and marginalized and vulnerable populations.	True	False			1	This leads to raising awareness of services available and general health literacy surrounding TB.    More people accessing public health services will lead to better utilization of services.

 

 

Information, Education and Communication (IEC) material for the Public has been made available on the Central TB Division official website. In the home page of https://tbcindia.gov.in under the ACSM/IEC option IEC materials like launch video on World TB Day, Posters on TB Arogya Sathi, Ni-kshay Poshan Yojana, Ni-kshay Patrika, Documentaries, Radio Spots, TV Spots/TVC’s, Script for Nukkad Natak’s and Exhibition Panels are available in the public domain. 

Figure 1: IEC Material available in Public Domain: Source: tbcindia.gov.in 

Information, Education and Communication (IEC) materials for the general public include:

1. Mid-Media  

• Banners
• Flip charts
• Wall writings
• Hoardings
• Posters
• Pamphlets
• Mobile vans and videos on wheels
• Folk performances
• Kiosks individuals - Face-to-face communication along with audio-visual communication for better message retention. Useful in dispelling myths and practices.

Figure 2: Poster for TB Arogya Sathi App: Source: tbcindia.gov.in

Figure 3: Poster for Nikshay Poshan Yojana: Source: tbcindia.gov.in 

2. Mass media

• Newspapers
• Television
• Radio
• Magazines

Figure 4: Snapshots from a TVC’s: Source: tbcindia.gov.in 

3. Social Media

• Facebook
• Blogs
• YouTube
• Twitter

Figure 5: Ni-kshay e-patrika: Source: tbcindia.gov.in 

4. Interpersonal Communication (IPC)

• Counselling
• Home-visits

 

5. Community Dialogue

• Public meetings and gatherings

Figure 6: Script for Nukkad Natak available on Central TB Division website: Source: tbcindia.gov.in 

 

Resources 

Operational Handbook on Advocacy, Communication & Social Mobilisation for RNTCP, Central TB Division, MoHFW, GoI, 2014.  

 

Assessment

Question​	Answer   1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​
Counselling and home visits are not part of the IEC materials/ tools available to the public.	False	True			1	Counselling and home visits are part of the interpersonal communication of the IEC strategy.

 

Information, Education and Communication (IEC) is defined as a comprehensive approach that spans across mass media, digital campaigns, strategic partnerships and inter-personal ground level activities. The strategies that could be utilised in IEC for government and private medical practitioners with regard to TB elimination can be categorised under both mass strategies and inter-personal strategies which include: 

Standardised training of practitioners

• All practitioners, government and private must  receive up-to-date training as and when the programme launches newer updates to the TB treatment and guidelines.
• The trainings shall be conducted through the use of standardised materials utilising the Swasth e-Gurukul Platform. 
• The IEC material developed for the practitioners must not only include TB symptoms but also focus on free diagnostics, free treatment, financial support available under the National TB Elimination Programme (NTEP).
• Only NTEP approved  IEC materials in the form of print media (pamphlets, posters) or digital media (videos, audios)  shall be provided to the private practitioners in the area by the District TB Officers (DTOs), for display in the health care establishments as well as for patient communication.
• All practitioners must be trained on the identification of Latent TB infection and importance of initiating TB preventive treatment.

Capacity building

• Use of Nikshay Sampark (Toll free number: 1800- 11-6666) for feedback/concerns should be promoted from providers as well as patients. 
• The training should also be provided to all the practitioners in order to be able to use the Ni-kshay digital application for TB notification and reporting all other related aspects.
• System should be set up to enable all practitioners to receive the government’s demi official (DO) letters as and when circulated.
• All government practitioners should be educated on how to build capacities of Mahila Arogya Samiti (MAS) and Accredited Social Health Activists (ASHA) in TB control at the community level.
• Capacities of District Programme Supervisors , District programme Co-ordinators, Senior Treatment Supervisors should be built under the leadership of the DTO to be able to extend support to the government medical practitioners in day to day TB control activities.
• Professional medical associations must  be sensitized to conduct regular Continued Medical Education (CMEs) programmes in TB care and elimination for the private sector providers

Involvement of Patient Provider Support Agencies (PPSAs) and Non-Governmental Organisations  (NGO’s)

• A list of contact details of local public health staff/officers and PPSA (where present) should be made available to all private providers. 
• Wherever possible PPSAs must be utilised to help the private sector establishments provide patient centric support by facilitating implementation of a single window for diagnostic and treatment services, notification, patient linkage with social welfare, contact investigation, TB preventive treatment and treatment adherence support. 
• DTOs should ensure coordination with PPSA for DR-TB services.
• NGOs functioning in the area may also be involved to support the practitioners in conducting IEC campaigns in the communities.
• Advocacy and policy support groups may be formed with the practitioners and medical associations to strengthen the TB control activities in the private sector.

 

Resource:

Training Modules (5-9) For Programme Managers & Medical Officers, CTD, MoHFW, India,2020.

National Strategic Plan For Tuberculosis Elimination 2017–2025, MoHFW, India, 2017

Training Strategy for in- service Capacity Building of a Community Health Officers, Ministry of Health and Family Welfare, India , 2019

Guidance Document on STEPS (System for TB Elimination in Private Sector) in Kerala.

Assessment

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation	Page id	Part of Pre-test	Part of Post-test
Information, Education and Communication (IEC) strategies for government & private medical practitioners includes only interpersonal communication.	True	False			1	Information, Education and Communication (IEC) strategies for government & private medical practitioners includes mass strategies as well as interpersonal communication		Yes	Yes

 

Information, Education and Communication (IEC) strategies for Senior Treatment Supervisor (STS)

STS holds a key responsibility in planning and implementing IEC activities in the Tuberculosis Unit (TU). STSs help the Medical Officer TB of the TU to plan IEC activities across the TU. 

STS should collaborate with the Block Education Officer or District IEC Officer in implementing the planned IEC activities. 

 

A few important IEC strategies advocated for STSs under the National TB Elimination Programme (NTEP) are:

 

1. Provide continuous training to the staff of health facilities under his/ her jurisdiction. 

2. Sensitise media and programme staff about language so as to avoid stigmatising. 

3. Engage with the media (print, TV, radio, digital) 

4. Expand Helpline (patients/ providers) of all states, mobile campaign (SMS/ voice SMS) 

5. Assess, revise and disseminate patient education literature 

6. Simplify messages so they are understood by the community – avoid programme/ medical jargon – e.g. DMC/ ICTC/ TU/ rapid molecular tests etc.  

7. Disseminate patients' charter at the community level

8. Educate the community regarding the use of TB Arogya Sathi 

 

Resources

• National Strategic Plan for Tuberculosis Elimination 2017–2025, CTD, 2017. 

Assessment 

Question	Answer   1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation
Providing continuous training to the staff of health facilities under the jurisdiction of STS is one of the IEC strategies.	False	True			2	Continuous training to the staff of health facilities is provided to keep them updated with the latest advancements so that they disseminate correct information to the patients.

Information, Education & Communication (IEC) strategies for community health volunteers (CHVs) are: 

 

Standardised TB training

• Training for all CHVs should be conducted through standardised training material approved and published under the Central TB Division (CTD)
• E – modules available on Swasth e-Gurukul platforms should be used in order to maintain uniformity of the training processes as well as for conducting pre and post training assessments
• Regular capacity building workshops for CHVs may be conducted along with CTD and partner organizations as per the need of the localities identified.

Dissemination of simplified IEC tools to all the CHVs

• NTEP’s IEC material must be simplified, translated to local language and must be provided to all CHVs through the programme.
• Program / medical jargon (e.g.: District Microscopy centre (DMC)/ rapid molecular tests) must be avoided for ease of understanding.
• All CHVs must be equipped with necessary permissions and facilities required to display these IEC materials across common access areas, public walls, canteens, factories entry/exit points etc.

TB related events and community engagement activities

• Under the supervision of District TB Officers (DTOs), the CHVs must be guided and supported for organising events on the occasion of World TB Day, Village Health and Nutrition Day etc., with a focus to increase understanding of the prevailing TB scenario and also their commitment towards TB elimination. 
• Community engagement activities must be conducted by the CHVs and should involve role plays, street plays (Nukkad Naatak on TB), video vans, group meetings, outdoor communications especially in the high-risk areas/vulnerable populations. 

Training on NTEP’s digital initiatives for TB elimination

• All CHVs must be trained on the functioning of TB Arogya Saathi - a citizen and patient application launched by the Ministry of Health & Family Welfare, India that connects patients to TB health care services.
• Ni-kshay Sampark the TB helpline (Toll free number: 1800- 11-6666) must be made accessible to all CHVs across various states through which they can seek reliable information.  
• CHVs must be well-informed about the Nikshay Poshan Yojana and other financial support schemes (travel support, tribal patient support etc.) available for TB patients under NTEP’s direct beneficiary transfer (DBT)

 

Resources: 

National Strategic Plan for Tuberculosis Elimination 2017–2025, CTD, 2017 

N Sharma, A Nath, D Taneja, G Ingle. A Qualitative Evaluation Of The Information, Education And Communication (IEC) Component Of The Tuberculosis Control Programme In Delhi, India. The Internet Journal of Tropical Medicine. 2007 Volume 4 Number 2.
 

Assessment: 

Question	Answer   1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation
Training through standardised training material available on CTD website and E – modules available on Swasth e-gurukul is an IEC strategy for Community Health Volunteers.	False	True			2	The community health volunteers can take the course and get certified, which can further aid them in managing TB patients.

+

Community engagement is a process of developing relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive health impact and outcomes.

Mobilize communities to engage them in TB care and to increase ownership of the Programme by communities.

Why Community Engagement?

Figure: Importance of Community Engagement

Community-based TB activities are conducted outside the premises of formal health facilities (e.g. hospitals and clinics) in community-based structures (e.g. schools and places of worship) and homesteads. Community health workers and community volunteers carry out community-based TB activities. Both can be supported by nongovernmental organizations and/or the government.

 

Community Engagement is a cost effective intervention to improve health service coverage and deliver accessible and people-centered integrated care.

Figure: Importance of Community Engagement

 

• Scaling up community participation in the National TB Elimination Programme through community-led activities and working with various community groups, especially TB survivors and key populations

 

• Empower TB survivors and affected populations to act as mentor’s/change agents and build their capacity for engaging them in programme planning, implementation and monitoring

 

• Working with community stakeholders to aid in early case identification amongst the vulnerable population

 

• Increasing accountability of the service delivery system through community participation

 

The TB forum for community engagement aims to empower and engage the TB-affected community. The forum acts as a bridge between the community, TB patients, the health system and civil society. In these forums, advocacy activities are undertaken to influence policy changes for accessible, affordable, supportive TB services to the entire population with a special focus on poor and vulnerable groups.

Under the National TB Elimination Programme (NTEP),  there are provisions for the constitution of state TB forums at the state level. The state TB forum consists of various stakeholders as shown in the table below. The meetings of these forums are to be convened at least every 6 months at the state level.

 

Table: Composition of the State TB Forum

Chairperson	Principal Secretary / Secretary Health & Family Welfare, State Govt.
Co-Chairperson	Mission Director (National Health Mission)
Members	Project Director, SACS Director Health Services WHO Representative – TB Consultant State Chairman/ Secretary, Tuberculosis Association of India Public Health Foundation of India/ any reputed public health institute State President, Indian Medical Association Professor of Pulmonary Medicine and Professor of Community Medicine of Medical Colleges	Two representatives of reputed local NGOs/ CSOs on a rotation basis One representative from NTEP partners on a rotation basis (REACH/ UNION/ CHAI/ PATH/ FIND/ WHP/ KHPT) Representative of PLHIV Networks Five TB patient representatives (past TB patients/ family members) Representative of Corporate Sector/ Industry/ PSU State TB Officer One representative each from SACS, NPCDCS, SPMU, RCH, NUHM
Abbr: SACS: State AIDS Control Society; WHO: World Health Organisation; NGOs/CSOs: Non-governmental and Civil Society Organisations; NTEP: National TB Elimination Programme; WHP: World Health Partners, PLHIV: People Living with HIV; PSU: Public Sector Undertaking; NPCDCS: National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke; SPMU: State Programme Management Unit; RCH: Reproductive Child Health; NUHM: National Urban Health Mission

 

Functions of the State TB Forum  

1. To advise on strategies for engaging communities affected by TB and increasing community participation in TB programs by forming a network of people affected by TB.
2. To periodically review the progress of community involvement and network of people affected by TB.
3. Highlight the concerns and needs of TB patients, work with the government and a broad range of individuals/ organisations to develop better and more responsive health services.
4. Advocate for greater and more equitable access to quality, accurate and independent information for patients. To focus on reducing health inequalities by campaigning for patients to have the right to be involved in decision-making.
5. Enable dialogue between all stakeholders involved in a TB patient’s care such as government (including local self-government), medical and paramedical associations, industry, medical insurance companies, private healthcare providers and diagnostic centres.
6. Create and manage resources to sustain and accelerate TB prevention, control, care and treatment services through community engagement and a network of people affected by TB.
7. Facilitate nutritional support, linkages with social welfare schemes, and rehabilitation of TB patients.
8. Perform grievance redressal.

 

Resources

• NTEP Training Modules (5-9) for Programme Managers & Medical Officers, 2020.

 

Assessment

 

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
Concerning the state TB forum, which of the following is false?	It is involved in engaging communities affected by TB at the state level.	It is chaired by the person affected by TB.	It has 33 stakeholders.	It convenes meetings biannually.	2	State TB forums are chaired by the Principal Secretary/ Secretary HFW, State Govt.	​	Yes	Yes

 

Local Self Government is the management of local affairs by local bodies who have been elected by the local people.

• The local self-Government includes both rural and urban government.

Figure 1: Types of local self government

Rural Local Governments:

• Panchayati Raj Institution (PRI) is a system of rural local self-government in India. PRI was constitutionalized through the 73rd Constitutional Amendment Act, 1992. The panchayat raj system in the entire country is not the same but, by and large, structure of LSG in most of the States have the three-tier structure:

Figure 2: Structure of Panchayati Raj

Urban Local Governments:

• An urban area is usually a compact and densely populated area. All types of urban local governments are democratically elected by the people based on electoral wards.

• Municipal administration is necessary to provide basic civic facilities like water supply, drainage, garbage disposal, public health, primary education, construction, and maintenance.

Figure 3: Types of Urban local bodies

• Other types of urban local governments in India - Notified Area Committee, Town Area Committee, Cantonment Board, township, Port trust, Special purpose agency.

 

Role of Local Self Government in Health.

• The common departments in the LSGs are General Administration, Finance, Public Works, Agriculture, Health, Education, Social Welfare, Information Technology, and others. Thus, LSG could play an important role in addressing the determinants of health.

• LSGs play an active role in preventive healthcare services like vaccination, controlling drinking water and foods, mother-child health, disease screening programs, sanitation precautions, controlling of wastes and animal diseases, controlling of  environmental  factors  that  have  disease  risks  such  as air  and  water pollution. They are seen as critical to the planning, implementation, and monitoring of the NHM. Implementation of the NHM in achieving its outcomes is significantly dependent on well-functioning gram, block and district level panchayats. 

• LSGs also deliver services toward health promotion.

• The other services provided by the LSGs are: Emergency and ambulance services, rehabilitation centers, elderly care centers and  home care  services 

• ASHA/USHA is one of the important functionary in health care service delivery and selected by the Gram Panchayat. 

 

Resources

• Structure of Government, National Institute of Open Schooling, Ministry of Education, GoI.

• Government Mechanisms, Ministry of Minority Affairs, GoI.

 

Assessment

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation
The fundamental objective of Panchayati Raj system is to ensure which among the following? 1. People’s participation in development 2. Political accountability 3. Democratic decentralisation 4. Financial mobilisation	1,2,3	2,3	1,4	1,3	4	Panchayat Raj Institution (PRI) was constitutionalised to build democracy at the grassroots level and was entrusted with the task of rural development in the country. Active participation and vigilance on the part of the rural public is a must for the sustenance of democratic de-centralisation.

 

Local Self Governance is the management of local affairs by local bodies who have been elected by the local people. There are 2 types of Local Self Government (LSG): panchayats in rural areas and municipalities in urban areas. Local self-government (LSG) has deep connections and linkages with local people.  Role of LSG in Tuberculosis (TB) elimination includes:   

Fig 1: Role of Local Self Government in TB Elimination 

 

  

1. Awareness generation activities 

With the participation of Panchayati Raj Institution (PRI) members in rural areas and municipalities in urban areas following awareness generation activities can be carried out:

• Health education on symptoms of TB, good cough etiquettes, available services for screening, diagnosis and treatment of TB, patient support/benefit schemes, TB in vulnerable groups (children, pregnant women, diabetic patients, patients on immunosuppressants, alcoholics and smokers) with emphasis on periodic screening for TB.
• Observance of World Tuberculosis Day on March 24
• Organize health-checkup camps and talks with the TB survivors
• Sensitize Panchayat Raj Institutions (PRI) members, faith leaders etc.
• Organize anti-stigma and non-discrimination campaigns

2. Advocacy interventions

Local administration or Panchayat Raj Institutions (PRI) can be engaged in advocacy interventions to promote healthy behaviours and leverage support of TB patients:

• To install spitting bins.
• To install signages on good cough etiquettes.
• Free distribution of masks/handkerchief/tissues to TB patients in the community.

3. Services for case finding (Active and latent TB Infection)

With the help of LSGs outreach activity can be planned and undertaken by community/non-governmental organizations (NGO) volunteers, Accredited Social Health Activist (ASHA) and Multi-Purpose Worker (MPW-Male)/ Auxiliary Nurse Midwife (ANM) under the supervision of the Community Health Officer (CHO)/Medical Officer- Urban Primary Health Centre (MO-UPHC), for case finding. These activities include:

• Vulnerability assessment
• Screening for symptoms of TB using Community Based Assessment Checklist (CBAC)
• Periodic active case finding among identified vulnerable populations
• Prompt referral of persons with TB symptoms to health center

4. Treatment support and monitoring

• Local self governments can engage in formation and conducting meetings of treatment support groups.
• Health education for TB patients and their household contacts can be conducted on TB symptoms, treatment, managing adverse drug reactions, nutrition during house visits and treatment support group meetings.
• Counselling for TB patients and caregivers can be organised by PRI members and local administration.
• LSGs can mobilise funds from philanthropists to support the TB Patients, to supplement and augment healthcare facilities, screening and testing requirements, buying diagnostics and any other resources that might be required.

5. TB preventive measures

• Under supervision of LSGs screening can be conducted of household/workplace contacts and other contacts of TB patients as eligible in the local context and identified vulnerable population for TB/latent TB infection.
• LSG can promote airborne infection control at workplaces and community settings.

6. Interventions to ensure community participation

• LSGs can participate in identifying and training TB Champions and facilitate their participation in Village Health Sanitation Nutrition Committees (VHSNCs), Mahila Arogya Samitis (MASs), Jan Arogya Samitis and TB forum meetings.
• VHSNCs and MASs can discuss TB related issues in their meetings, conduct awareness programmes and extend support to case finding and treatment.

Resources 

• Operational Guidelines for TB Services at Ayushman Bharat Health and Wellness Centres Central TB Division, Ministry of Health and Family Welfare (MoHFW), Government of India 2020  
• Pradhan Mantri Khanij Kshetra Kalyan Yojana (PMKKKY), Ministry of Mines, Government of India, 2015. 
• Training Modules (5-9) for Programme Managers and Medical Officers, Central TB Division, Ministry of Health and Family Welfare (MoHFW), Government of India, 2020. 

 

Assessment

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation
Local self-government can help in identifying and mapping socially and clinically vulnerable groups using available data from Municipal/ Block/ Taluka/ Zila Panchayats' records. Periodic drives can be conducted by them to identify and trace cases and link them to services provided under National Tuberculosis Elimination Programme (NTEP) and other social schemes.	True	False			1	Media advocacy by local self-government can engage the local media to disseminate information. With strategic communication and social mobilisation through Local self-government, the community members will help in gaining awareness about the services available in NTEP as well as other social schemes.

The district TB forum is a community-engagement modality that aims to empower and engage the TB-affected community. Constituted by TB patients (cured or on treatment), community leaders, government officials, experts and NGOs; it gives a voice to the affected community and advocates with the programme managers for the resolution of challenges faced by TB patients in accessing TB services.

District TB forum is composed of various stakeholders as shown in the table below and its meeting is to be convened at least every 6 months at the district level.

Table: Composition of the District TB Forum

Chairperson	District Magistrate
Co-Chairperson	Chief Executive Officer, Zilla Parishad
Members	District Development Officer Chief Medical/ Health Officer WHO Representative – TB Consultant Representative of Tuberculosis Association of India Pulmonologist and Professor of Community Medicine of Medical Colleges District President, Indian Medical Association Two representatives of reputed local NGOs/CSOs on a rotation basis	Representative from NTEP partners on a rotation basis (REACH/ UNION/ CHAI/ PATH/ FIND/ WHP/ KHPT) Five TB patient representatives (past TB patients/ family members) Representative of district-level PLHIV Network Representative Officer from RCH who manages NGOs District TB Officer PRI member (Zilla Parishad/ BDC/ Panchayat) Journalist Advocate Representative of the corporate sector
Abbr: WHO: World Health Organisation; NGOs/CSOs: Non-governmental and Civil Society Organisations; NTEP: National TB Elimination Programme; WHP: World Health Partners, PLHIV: People Living with HIV; RCH: Reproductive Child Health; PRI: Panchayati Raj Institutions; BDC: Block Development Council

 

Functions of the District TB Forum  

1. To advise on strategies for engaging communities affected by TB and increasing community participation in TB programs by forming a network of people affected by TB.
2. To periodically review the progress of community involvement and network of people affected by TB.
3. Highlight the concerns and needs of TB patients, and work with the government and a broad range of individuals/ organisations to develop better and more responsive health services.
4. Advocate for greater and more equitable access to quality, accurate and independent information for patients. To focus on reducing health inequalities by campaigning for patients to have the right to be involved in decision-making.
5. Enable dialogue between all stakeholders involved in a TB patient’s care such as government (including local self-government), medical and paramedical associations, industry, medical insurance companies, private healthcare providers and diagnostic centres.
6. Create and manage resources to sustain and accelerate TB prevention, control, care and treatment services through community engagement and a network of people affected by TB.
7. Facilitate nutritional support, linkages with social welfare schemes, and rehabilitation of TB patients.
8. Perform grievance redressal.

 

Resources

• NTEP Training Modules (5-9) for Programme Managers & Medical Officers, 2020.

 

Assessment

 

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
Concerning the district TB forum, which of the following is true?	It is involved in engaging communities affected by TB at the state level.	It is chaired by the person affected by TB.	It has only 3 stakeholders.	It convenes meetings biannually.	4	The district TB forum engages communities affected by TB at the district level is chaired by district magistrates, convenes meetings biannually, and comprises of various stakeholders.	​	Yes	Yes

 

A TB Champion is a person who has been affected by TB and successfully completed the treatment.

TB Champions, in their capacity as survivors, are role models and can provide valuable support to those with TB and their families.

Figure: Roles of TB Champion

 

Community Health Volunteers should identify TB Champions and engage them to provide their support to the patient in activities like:

Figure: Help to TB Patients by Community Health Volunteers

 

Patient-provider meetings are important to ensure patient support and improve case holding/ treatment adherence.

Objective: To orient the patients on the course of the treatment, the importance of adherence and the risk for close contact. It also provides a platform to discuss the difficulty in following treatment courses by the patients and the need for further counselling if required.

Purpose: The purpose of this meeting is to counsel patients in a group who are on treatment or who are about to begin treatment. This is an opportunity for free interaction between providers and patients and also an opportunity for patients to clarify their doubts, if any.

Facilitators: These meetings are organized by the treatment supporter/ Directly Observed Treatment (DOT) provider. The Senior Treatment Supervisor (STS)/ Medical Officer (MO) are to conduct these meetings.

Target Group: Patients on treatment or who are about to begin treatment. There could be 5-10 patients (minimum) in such meetings. (If there is a large number of patients at one centre, small groups of about 10 patients may be made so that better interaction takes place between patients and providers).

Participants: Block medical officer/ Medical Officer - TB Control (MO-TC), field staff (STS, TB Health Visitor (TBHV), Senior TB Lab Supervisor (STLS)), general health system staff, patients and their attendees.

Place: These meetings are to be organized at the health facility.

Duration and Frequency: These meetings can be organized once a month so that each patient who is on treatment has the opportunity to attend one such meeting during the intensive phase. The frequency of such meetings would be more than one in a month when there is a large number of patients at one health facility.

• Each meeting can be for half-hour to one hour.
• The patient may be provided refreshments (tea, snacks etc.)

Note:  Patient-provider interaction meetings are additional to, and are different from, interpersonal communication that the provider has with the patient while administering treatment.

Messages to be Provided to Patients

1. Basic information about tuberculosis, cough etiquette, etc.
2. Importance of completing treatment
3. Side-effects of drugs and how to manage these
4. Importance of follow-up sputum examination
5. Prophylaxis for children in the family
6. Do’s and don’ts including protective measures, the role of a nutritious diet, etc.

Health Communication Materials: Flip book, banner, posters on TB, etc., are to be provided and used during these meetings.

Report Writing: At the end of each meeting, a report may be prepared to state the date and time of meetings, number of patients, name of facilitators, presence of MO in the meeting, topics covered/ main points discussed in the meeting, along with major concerns mentioned by the patients.

• The report is to be prepared by the STS.
• The list of patients who attended the meeting may be attached to the report.
• It may be more convenient to have a register at each centre for such meetings, and patients can write their names in the same register.
• These may be submitted by STS to the MO-TC on a monthly basis for onward submission to the District TB Officer (DTO) to be included in the quarterly Performance Monitoring Report (PMR).

Resources 

• Training Modules (1-4) for Programme Managers and Medical Officers, 2020.
• Technical and Operational Guidelines for Tuberculosis Control, RNTCP, 2019.

Assessment 

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
How often should patient-provider meetings be conducted?	Everyday	Twice a year	Once every month	Once a year	3	Patient-provider meetings can be organised once a month so that each patient who is on treatment has the opportunity to attend one such meeting during the intensive phase. The frequency of such meetings would be more than one in a month when there is a large number of patients at one health facility.		Yes	Yes

Socio-economic factors affecting TB patients are: 

1. General socioeconomic conditions of the society, culture and environment. This includes:

• Gross Domestic Product (GDP)  

• Immigration  

• Urbanisation 

• Incidence of TB in the country   

• Labour policy 

• Access to healthcare 

2. Socioeconomic position of the individual. This includes:

• Income 

• Education 

• Occupation  

• Social class/ caste 

• Indigenous/ tribal population 

• Gender 

3. Living and working conditions. This includes: 

• Housing conditions (overcrowding and poor ventilation especially in night shelters, de-addiction centres, old age homes, prisons) 

• Employment conditions - Occupation with risk of developing TB (mines, coal industry, sand blasting industries, weaving & glass industries, stone-crushers, cotton mill workers, tea garden workers, rice mill workers, etc.,) 

• Homelessness  

• Hard to reach areas 

• Urban slums 

3. Psychosocial risk factors, such as:  

• Social exclusion 

• Depression  

4. Individual lifestyle risk factors, such as:  

• Smoking  

• Alcohol abuse  

• Tobbaco use 

• Drug abuse  

• Nutrition (malnutrition) 

• Co-morbidities like diabetes mellitus, malignancies, patients on dialysis and on long term immunosuppressant therapy HIV, past history of TB 

 

Resources

• NTEP Training Modules (1 to 4) for Programme Managers & Medical Officers, CTD, 2020. 
• Social Determinants of Tuberculosis Context Framework and the Way Forward to Ending TB in India, IPH, India, 2020. 

 

Assessment

Question​	Answer   1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​
Socio-economic factors affecting TB patients are: Housing  Income  Access to healthcare  Alcohol abuse	1,2	2,3,4	1,2,3,4	1,2,4	3	TB is one of the few diseases which reflects and expresses social inequalities. Living conditions, economic conditions, lifestyle, and access, affordability, and availability of healthcare are factors which affect TB patients.

TB can affect anyone but it is more prevalent in some communities which are vulnerable to TB disease due to various factors which are mentioned below:

Increased exposure of TB due to where they live or work

• prisoners
• slum dwellers
• miners
• hospital visitors
• healthcare workers

Limited access to Quality TB services

• Migrant workers
• Women in settings with gender disparity,
• Children
• Physically challenged
• Transgender population
• Tribal and population living in hard to reach areas
• Refugees or internally displaced people
• Illegal miners and undocumented migrants

 

Increased risk because of biological or behavioural factors that compromise immune functions in people who:

• People who live with HIV
• have diabetes or silicosis
• undergo immunosuppressive therapy
• are undernourished
• use tobacco
• suffer from alcohol use disorders.
• inject drugs 

Stigma is when someone sees you in a negative way.

Discrimination is when someone treats you in a negative way.

TB patients face various forms of stigma and discrimination in the community

Figure: Stigma towards TB Patients in the community

 

At Individual Level

• Lack of self-esteem and confidence
• Increased sense of emotional isolation, feeling of guilt and anxiety
• Physical as well as financial debilitation
• People, more often women, are forced to leave their homes
• Concealing symptoms and hesitancy in seeking medical care making disease management more difficult
• Delayed diagnosis, interrupted treatment that can lead to further transmission and DRTB
• Vulnerability increases, can lead to suicidal thoughts due to isolation and shame

 

At Family and Community Levels

• Loss of household earnings
• Exposure of caregivers to the risk of infection that lowers productivity and cycle of poverty further gets perpetuated
• Isolation and stigmatization of infected persons often by people of their community
• Deep-rooted lack of knowledge and misconceptions among the affected and infected within their cultural and religious environment
• Loss of status and negative impact on those with the disease, their caregivers, family, friends and communities
• Perceived and internalized stigma of the community due to socio-cultural values that TB is punishment for sins or transgression

Although more men are affected by TB, women and transgender persons experience the disease differently. Gender differences and inequalities play a significant role in how people of all gender access and receive healthcare services.

Gender difference in	Men	Women
Incidence of TB	Higher proportion of men(approximately- 2:1) are diagnosed with TB than women More likely to have microbiologically confirmed Pulmonary TB	More likely to have Clinically diagnosed pulmonary TB and extra – pulmonary forms of TB Prevalence of HIV-TB co-infection is higher among women who live in overcrowded houses and consume alcohol High Risk for developing TB – Pregnant women and women in the postpartum period
Exposure, Risk & Vulnerability	Smoking and alcohol consumption among men High risk for developing TB - employment in mining, quarrying, metals and construction industries	Undernutrition, their role as caretakers and the use of solid fuel for cooking puts women at risk for TB
Health Seeking & Health system factors	Fear of loss of income and the consequences of absence from work hinder care seeking.	Women face difficulties due to perceived stigma, prioritization of household chores, lack of money or financial dependence
Treatment Outcomes	Pressure to get back to work and lifestyle habits such as smoking or consumption of alcohol influence discontinuation of treatment in men Migrant workers, mostly men, often face difficulties in adherence to treatment in the face of extreme poverty and issues of daily survival	Women tend to have better adherence and treatment outcome as compared to men Stigma and discrimination are major impediments to treatment adherence, mainly among unmarried women, newly married women and the elderly

Transgender population often has low literacy, low education levels and are poor. A high proportion of transgender persons are known to smoke, consume alcohol and use drugs. All these factors make them vulnerable to TB.

Broad principles to address gender inequalities in TB care

1. Confidentiality of patient needs to be maintained
2. Non-discrimination and non-stigmatising behaviour to be promoted
3. Respect for all to be ensured
4. Informed consent and informed treatment
5. Accountability to be fixed for actions and inactions
6. Access for all health services
7. Rights-based approach
8. Empowered communities - Ensure representation of women, men and transgender persons in all forums
9. Work in partnership - Strengthen linkages between program, private sector and communities

 

Yoga

• Yoga aims at holistic functioning of the mind and body. It consists of various exercises and specific body positions and movements(yoga asana) which can be learnt and performed under the supervision of a yoga teacher.
• Yoga will help to clean the upper respiratory tract and the sinuses. The breathing exercise or pranayama induce relaxation and help to reduce the stress levels of the patients considerably.

 

Meditation

• Meditation is a practice where an individual uses a technique – such as mindfulness, or focusing the mind on a particular object, thought, or activity – to train attention and awareness, and achieve a mentally clear and emotionally calm and stable state.

 

Exercise

• Exercise is being recognized as an important modality for gaining good health and recovering from illness and disease.
• Exercise like cycling and walking are great ways to make sure that the TB infection that was once in your system has been completely eradicated. Once recovered, it is a good idea to keep up the exercise, as this is a factor in stopping the TB from returning at a later date.

• Rehabilitation Service to TB Patients

• Emotional support must be provided to patients with TB and their families during illness. Receiving TB diagnosis is often regarded by patients as a real stigma that isolates them from their family and society. Psychologists can support patients to help reduce misconceptions and socially integrate former patients.

 

• TB is a contagious disease that induces fear and social isolation and needs a long period of drug administration, sometimes with adverse effects. Therefore, therapeutic education is very important, which serves the purpose of explaining to patients and their families about the condition of the disease, the risks of contagiousness, the stages of treatment and prognosis.

 

• Exercise may be light initially, followed by assisted and active exercise. Once the patient’s condition is stable, a 6-minute walk test may be done in the room or corridor. The intensity should be progressively increased, depending on the patient’s tolerance.

 

• Nutrition: Weight loss is associated with fatigue and decreased exercise capacity. There is a risk for the patient not recovering body weight at the end of drug therapy, despite receiving correct TB treatment. Nutritional supplementation may play a positive role in the recovery of these patients.

 

• Tuberculosis Drug side effects: A proactive clinical approach is required to replace/stop the use of the concerned drugs.

 

• Providing Assistive devices Hearing aids, cochlear implants, tinnitus-masking devices, mobility aids, and prosthetic/orthotic devices improve the quality of life of patients.

 

• Corrective Surgery: May be required in TB of the bones, spine etc.

 

• Community and home-based care: This becomes important in severe neuromuscular deficits and movement disabilities.

 

• Physiotherapy: A trained physiotherapist may help through:
  • Sputum clearance technique for reduced sputum quantity, better ventilation and relief of symptoms
  • Cough education involving body positioning during coughing, control of breathing in coughing to achieve mobilization and secretions

 

• Counselling: Psychological support is required for facing long-term/permanent disabilities like loss of vision and hearing loss as side effects of the drugs, paralysis in TB meningitis, infertility in genital TB etc.

 

• Livelihood options: NGOs and support groups can create such options and/or facilitate treated patients to find various livelihood options

Who can provide Psychosocial support?

Family Members, Peer groups, treatment support groups, TB Champions, Community Health Volunteers(CHVs) and NGOs can provide psychosocial support to TB patients and their families by:

 

• Building a strong sense of community
• Helping the patients to contact a health worker or visit a health facility
• Providing treatment support to take their drugs and finish their treatment. Family members, community-based volunteers and workers can be trained as treatment supporters by NGOs
• Facilitating patients to access DBT for nutritional support under NPY
• Helping TB patients with comorbidities to visit the referral facility for treatment
• Treatment adherence support through peer support and education and individual follow up
• Home-based palliative care for TB
• Awareness generation, providing right information, behaviour change communication and community mobilisation for reducing stigma and discrimination
• Facilitating patients to join yoga/meditation/exercise groups once the active phase is over
• Facilitating and arranging rehabilitative services for problems/disabilities in TB patients
• Social and livelihood support
• Food supplementation
• Income-generation activities(NGO can start or facilitate patients to join activities like candle making, making festival-related goods)
• Sensitising PRIs to engage TB patients(who can work) through the Mahatma Gandhi National Rural Employment Guarantee Scheme(MGNREGS)

Palliative care is specialised medical care for people living with a serious illness.

• This type of care is focused on providing relief from the symptoms and stress of the illness.
• The goal is to improve the quality of life for both the patient and the family.
• Palliative care is based on the needs of the patient, not on the patient’s prognosis.

 

Need for Palliative Care for TB Patients

TB is, and should be, a curable disease; however, each year an increasing number of patients acquire or develop drug-resistant TB (DR-TB), which has a much lower cure rate.

While the expectations are to have increasing numbers of treatment success rates, DR-TB remains a life-threatening condition with high mortality.

The life-threatening nature of DR-TB and the burden of disease management in terms of symptoms, adverse treatment effects, adherence, stigma and subsequent discrimination and social isolation, clearly show the need for care that addresses physical, social and emotional suffering by patients.

Thus, the need for palliative care is being increasingly recognised as an important part of the continuum of care for DR-TB patients.

 

Challenges in Palliative Care

At present, there is a scarcity of trained health workers and local community-based palliative care resources in the settings that are most in need. Although clinical expertise in palliative care for patients who die in respiratory distress has developed considerably, individuals with DR-TB are yet to see the benefits.

 

Services under Palliative Care for TB

• Addressing pain and symptom control (including respiratory insufficiency)
• Nutritional support
• Medical intervention after treatment cessation
• Ensuring the appropriate place of care, preventive care, infection control and end-of-life care

 

Supportive Measures in Palliative Care

 

Resources

Guidelines for Programmatic Management of Drug-resistant Tuberculosis in India, March 2021, Central TB Division, Ministry of Health and Family Welfare, Government of India.

Assessment

 

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
Palliative care is based on a patient’s prognosis.	True	False			2	Palliative care is based on the needs of the patient, not on the patient’s prognosis.		YES	YES

The Patients’ Charter for Tuberculosis Care (the Charter) outlines the rights and responsibilities of people with TB. It empowers people affected by TB and their communities through this knowledge. Initiated and developed by persons affected by TB from around the world, the Charter makes the relationship with healthcare providers a mutually beneficial one.

The Charter sets out ways in which people affected by TB, the community, health providers (both private and public), and governments can work as partners in a positive and open relationship with a view to improve TB care and enhance the effectiveness of the healthcare process. 

It allows for all parties to be held more accountable to each other, fostering mutual interaction and a positive partnership.

 

Principles of the Patients’ Charter for TB Care

• The charter practices the principle of Greater Involvement of People with TB (GIPT).
• This affirms that the empowerment of people with the disease is the catalyst for effective collaboration with health providers and authorities and is essential to victory in the fight to end TB.

 

Parts of the Patients’ Charter for TB Care

There are two main parts in the patients’ charter for TB care which cover:

1. Patients’ rights 
2. Patients’ responsibilities

These parts are further delineated in Tables 1 and 2 below.

 

Table 1: Patient's Rights According to the Patient's Charter for TB Care

Rights	Explanation of rights: You, as the patient, have the right to:
Care	Free and equitable TB quality care meeting the International Standards of Tuberculosis Care (ISTC) Benefit from community-care programmes
Dignity	Be treated with respect and dignity Social support of the family, community and national programmes
Information	Information about available care services — be informed about condition and treatment, know drug names, dosage and side-effects Access your medical records in the local language Have peer support and voluntary counselling
Choice	A second medical opinion, with access to medical records Refuse surgery if drug treatment is at all possible Refuse to participate in research studies
Confidence	Have your privacy, culture and religious beliefs respected Keep your health conditions confidential Care in facilities that practice effective infection control
Justice	File a complaint about care, and have a response Appeal unjust decisions to a higher authority Vote for accountable local and national patient representatives
Organization	Join or organise peer support groups, clubs and Non-governmental Organisations (NGOs) Participate in policy-making in TB programmes
Security	Job security, from diagnosis through to cure Food coupons or supplements, if required Access to quality-assured drugs and diagnostics

 

Table 2: Patients' Responsibilities According to the Patients' Charter for TB Care

Responsibilities	Explanation of responsibilities: You, the patient, have the responsibility to:
Share information	Inform healthcare staff all about your condition Tell staff about your contacts with family, friends, etc. Inform family and friends and share your TB knowledge
Contribute to community health	Encourage others to be tested for TB if they show symptoms Be considerate of care providers and other patients Assist family and neighbours to complete treatment
Follow treatment	Follow the prescribed plan of treatment Tell staff of any difficulties with treatment
Solidarity	Show solidarity with all other patients Empower yourself and your community Join the fight against TB in your country

 

​​​​​Resources

• The Patients’ Charter for Tuberculosis Care, The Global Plan to Stop TB 2006-2015.
• Capacity-building of Affected Communities for Accelerated Response to Drug-resistant Tuberculosis in the South-east Asia Region, WHO, 2019.

 

Assessment 

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
According to the Patients' Charter for TB Care, it is not the patient’s responsibility to support other patients.	True	False			2	According to the Patients' Charter for TB Care, patients have a responsibility to support other patients, show solidarity and empower their communities.	​	Yes	Yes