BackgroundSouth Africa, with an estimated number of 490,000 new tuberculosis (TB) cases in 2009, ranks fourth among the 22 high-burden TB countries in the world. Multi-drug resistant (MDR) TB is largely caused by patients’ non-adherence to drug regimens, inappropriate drug regimens, and increasingly by direct transmission. Direct transmission has more than tripled – from 2,000 cases in 2005 to 7,343 cases in 2009 – and is further exacerbating the epidemic.1 TB HIV/AIDS co-infection rates are high, with approximately 73 percent of new TB patients co-infected with HIV. TB patients with HIV are almost twice as likely to get MDR TB and have high mortality rates due to TB and HIV co-infection.

South Africa’s management of TB has improved significantly over the last years: all districts have implemented the core DOTS components, though with varying coverage; the quality and access to TB services has improved leading to increased case detection and success in treatment outcomes; the TB defaulter rate has fallen; and the cure rate has increased.

However, substantial work still needs to be done to achieve South Africa’s Millennium Goal 6: to halt and reverse the incidence of TB by 2015. In July 2009, the World Health Organization and partners conducted a review of the TB Control Programme in South Africa. Among other recommendations, the report advocates health systems strengthening and intensifying the National TB Control Program’s Advocacy, Communication, and Social Moblisation (ACSM) strategy.2

University Research Co., LLC (URC), with funding from USAID, has been working since 2004 with the National TB Control Program (NTCP) and other partners to strengthen TB prevention, treatment and control in South Africa. In 2009, USAID awarded a new five-year TB Project to URC for continued support of the national TB program. The TB Project’s communications strategies are receiving technical and implementation support from Johns Hopkins Health

Technical Brief | South Africa

February 2011

Advocacy, Communication, and Social Mobilization (ACSM) to Strengthen TB Prevention, Treatment, and Control

Children play at the bottom of a play pump depicting a treatment adherence message. As they play on the roundabout, clean water is pumped for the community.

“These adverts help a lot because a lot of people don’t speak about TB, they keep it hidden so it is good to see it in a public space and it gets people talking about it”– Commuter at Mabopane Taxi Rank in Pretoria

and Education in South Africa (JHHESA), Health Systems Trust, along with a large number of local NGOs and CBOs. The mass media campaign is being supported by Matchboxology and Mediology with market research done by Millward Brown.

Communication ApproachThe USAID-funded TB Project’s ACSM strategy draws upon the Socio-Ecological Model.3 The model recognizes that diverse factors affect human behavior and that it is essential to understand and address barriers and constraints to behavior change at multiple levels. Individuals’ behaviors cannot be changed without impacting upon their social networks, communities, and societies (see Figure 1). To address all spheres of influence, the project’s ACSM strategy incorporates various types of communication programming, including mass media, interpersonal communication, community mobilization, and advocacy. URC’s approach relies firmly on engaging local South African partners to design, adapt, and develop appropriate messages and communication strategies.

Several organizations – with expertise in media design, development, and implementation – have been employed to carry out many of the project’s ACSM activities.

Communication ActivitiesMass MediaThe TB Project is working on a national TB Awareness Campaign, with specific regional weightings (Johannesburg, East London, Port Elizabeth, and Durban) in the country. The primary target audiences for this campaign are previously disadvantaged populations – the majority of which are adult Black South Africans (ages 16-64). This is a group at high risk of TB transmission due to poor living conditions, migration, limited education, and unemployment. The secondary audiences are Black South African children of school going age. Due to their potential as change agents, children are targeted to help them make informed decisions to take preventative measures.

Communication for Participatory Development

DialogueCommunity MobilizationEntertainment-Education

Peer education

Engagement Mass Media

DialogueCounseling

Peer Education

Advocacy

To strengthen policy and systems

Types of Communication

INDIVIDUALbehavior and intention;

knowledge and skills; beliefs and values; emotion; perceived risk; self-efficacy; self-image;

subjective norms

SOCIAL NETWORKSPartner and family relationships (communication, trust, understanding, agreement, and power), peer influence, gender equity, bounded normative influence

COMMUNITYLeadership; level of participation; information equity; access to resources; shared ownership; collective efficacy; social capital; value for continual improvement

SOCIETYNational leadership; per capita income; income inequality; health policy and infrastructure; mass media; religious and cultural values; gender norms

Physical Environment and Infrastructure Burden of disease; climate and seasonality; transportation and

communication networks, access to health care facilities, access to water, sanitation, and household technologies; etc.

Figure 1: Social Ecology Model of Communication and Behavior

The project supports TV public service announcements; TB messaging through popular TV shows and radio dramas; radio PSAs; radio talk shows and interviews; dissemination of periodical press releases to newspapers, journals, magazines, and other publications; and IEC materials such as pamphlets, fact sheets, and posters, to be widely distributed to health facilities, non-governmental organizations, faith based organizations, sports clubs, health facilities, schools, taxi ranks, bus stops and libraries.

The project is using mass media to help people recognize the symptoms of TB and HIV, and test early. It focuses on the following three message areas across mediums:

1. Infection Control: This message is broadcast during the winter months when people are more susceptible and conscious of airborne diseases. The message encourages people to open their windows, cover their coughs, and wash their hands after sneezing or coughing.

2. Treatment adherence: This message communicates the necessity of completing treatment with the full course of medication. “180 to #1 OK” is a catchphrase for the need to adhere to 180 doses of TB drugs.

3. TB/HIV: This message encourages testing for HIV as well as screening for TB and emphasizes that TB is curable even among people living with HIV and AIDS.

AdvocacyThe project is encouraging visible public leaders (e.g., religious leaders, politicians, celebrities, and decision makers) to support TB awareness, prevention, and control. In addition, provincial and district dialogues with community leaders and stakeholders are being organized in partnership with the National Department of Health

Children receiving their “We Beat TB” lap desks at school

(NDOH) in identified districts to engage them around the key drivers of the epidemic, the challenges being faced with TB service uptake, and to develop community action plans in their communities. The project also works with journalists to ensure accurate and consistent coverage of the epidemic through annual media workshops, fact sheets, mapping of media in priority districts, and technical assistance for ACSM managers on how to engage with local media.

Community mobilizationThe project is working with provincial and district level health departments as well as local partners to encourage communities to participate actively in TB control and to empower TB patients to take responsibility for their own health. Activities include building partnerships with local NGOs/CBOs, public stakeholders, and local businesses; door to door campaigns with health facilities and NGOs to share information with families; school activations (interactive sessions where health promoters engage school children using entertainment education materials on TB and distribute lap desks at selected schools), community dialogues, community media and special events. All these activities are undertaken to raise public awareness in order to improve case detection and treatment adherence, combat stigma and discrimination, empowering people affected by TB, and to mobilize political commitment and resources for TB. In addition, TB/HIV support groups will be formed to encourage uptake of ioniazid preventive therapy (IPT) among people living with HIV/AIDS (PLWHAs) and of antiretroviral therapy (ART) in TB patients.

Children at Kusa Kusa Primary school in Kwa-Zulu Natal watch an educational DVD as part of the KICK TB Campaign.

University Research Co., LLC • Block B, Rigel Park Offices • 446 Rigel Avenue • South Erusmasrand 0181 [Pretoria suburb] • South AfricaTel: 27-12-484-9300 • www.urc-chs.com

Improving systems to empower communities

URC supported the “Kick TB Campaign”, developed by Stellenbosch University and the NDOH. This campaign – linked to the FIFA World Cup 2010 – fuses soccer and social mobilization to create a platform through which TB appropriate messages are conveyed to school aged youth ages 5 to 14. The campaign seeks to roll out to 300 health promoting schools across South Africa. Approximately 115,000 learners drawn from diverse schools and backgrounds (gender, race, language, socio-economic status, disability status and geographic location [rural/urban]) will participate directly in the campaign. Special attention is being given to schools in the 18 priority districts identified by the Department of Health for accelerated interventions and TB hotspots (e.g., schools in mining areas and those in close proximity to hostels).

Training of health care workersThe TB Project is training health promoters and district TB Directorates (Communication Directorates and TB managers) on ACSM.

A TB awareness billboard erected at a busy taxi rank in Johannesburg. The message tells people that TB is curable and that medication and testing are free of charge.

Key Achievements to date¡ 72% of Black South Africans, ages 16-64, and 62% of

children ages 5 to 14 have been reached through TV commercials.

¡ 64% of Black South Africans, ages 16-64, and 49% of children ages 5 to 14 have been reached through radio spots.

¡ 150 play pumps depicting TB adherence messages created in 5 provinces.

¡ 12m² giant screens have been installed in 13 of the biggest taxi ranks in the country and reach 1.7 million unduplicated viewers daily. 775 audio visual spots were played at taxi ranks in 5 provinces.

¡ 17,500 children have been reached in Gauteng, Kwa-Zulu Natal, Limpopo, North West provinces through the Kick TB Campaign.

¡ Design, development and production of 40, 000 posters in 7 languages for TB/HIV; infection control; treatment adherence; ventillation.

¡ ACSM training of 84 personnel from TB Directorates in the Eastern Cape and Free State provinces.

¡ Development of a community dialogue guide. Conducted community dialogue in Eastern Cape, Amatole District attended by 68 people.

¡ Conducted public TB knowledge awareness campaigns in North West Province and Limpopo Province reaching 3,000 people.

Sources1. World Health Organization (2010). Global Tuberculosis Control.

Geneva, Switzerland.

2. World Health Organization South Africa (2009). Annual Report.

3. http://en.wikipedia.org/wiki/social_ecological_model (accessed February 4, 2011).