Health Communication Insights: The Role of Communication in Peru's Fight Against Tuberculosis

Published by the Health Communication Partnership (HCP), this 29-page report examines Peru's use of health communication as an integral component in its successful efforts to turn back a mounting tuberculosis (TB) epidemic.

The World Health Organization (WHO) set a global target of detecting 70% of infectious cases and curing 85% of those by the year 2005 through the use Directly Observed Therapy-Short Course (DOTS). The authors explain that, between 1983 and 1988, 30,000 deaths in Peru were due to TB, with half occurring among those between 25 and 65 years. A 1999 study showed that the economic cost of TB was between $67 million and $108 million per year. The tuberculosis incidence rate reached 243 cases per 100,000 before Peru's National Tuberculosis Control Program (NTCP) succeeded in turning the trend around. Specifically, in the first half of the 1990s, the extensive national effort to detect cases caused TB incidence to reach 243 per 100,000. Then, due to the successful case detection and treatment efforts, the incidence rate dropped gradually to reach about 133 cases per 100,000 in the year 2000. The number of patients who began and then abandoned treatment dropped from 12.1% in 1991 to 2.8% in 2000. According to WHO, Peru fell off the list of high burden countries in 2000 and TB cases are now falling at a rate of 6% per year.

How did Peru's NTCP accomplish its TB control and prevention goals? According to this evaluation, communication was key. Communication activities were developed to respond to the barriers operating in the Peruvian context; formative research found that stigma against TB patients in Peru is deep and passed down from generation to generation. To combat this, NTCP aired several television and radio spots to raise community awareness about TB, correct common misconceptions, motivate patients to seek care, and encourage the public to participate in Peru's fight against TB. Among the messages developed to encourage the public to help others seek care, the widely recognised slogan "If you cough for more than 15 days, you should go to the health center" was integrated at various programme levels. One strategy was to use the word "free" to appeal to low-income groups. The consistent and widespread use of the NTCP logo in television and printed media (in local Quechua and Aymara languages) amounted to "branding", which "led to wide recognition that helped the public easily identify TB service sites."

This evaluation describes another finding of the NTCP's formative research: widespread misconceptions among health workers about how TB is transmitted. To correct health care providers' misperceptions about TB and TB patients, the NTCP trained all health staff in interpersonal communication and counseling skills. One female nurse quoted here comments, "When it was explained to us that we can't get infected when we shake hands with a patient, we were at ease to do it." The NTCP developed a counseling flipchart, adapted it for urban and rural audiences, and then disseminated it to clinics to guide staff and volunteers on how to counsel patients, families, and the general public. Video spots about TB were designed, and then distributed to health care providers to show in health care facility waiting areas, and then to supplement with follow-up conversations with patients. Several incentive programmes to motivate health care workers to participate in the programme were also created.

This report shares of the lessons learned in Peru's national TB control programme, suggesting implications for other infectious disease initiatives. These lessons include:

• Political commitment is essential, especially when combined with increased resources - NTCP engaged political leaders through advocacy activities such as seminars and presentations organised with international experts. It also raised
  awareness about the issue and used locally organised groups, such as the Association of TB Patients, to exert pressure on political leaders to address patients' needs.
• Communication activities should be strategically timed to correspond with improvements in clinical services - The training of health care workers in interpersonal communication and counseling skills was timed to correspond to the increasing coverage of clinical and laboratory services.
• Integrate communication activities into all programme activities at all levels - Advocacy, mass media, training activities, and community mobilisation were "seamlessly integrated into all of the NTCP's activities as needed".
• Formative research can unlock key communication challenges - "The NTCP in Peru benefited from the results of socio-anthropologic studies to inform and guide the development of advocacy and communication activities."
• Communication programmes are more effective when consistent messages are conveyed through a mix of mass media and interpersonal communication - "This approach helps emphasize and reinforce messages and enables the program to reach different sectors of the population, who may be more receptive to one form of communication over the other".
• Involve the community and local health care providers, including private practitioners - Efforts included recruiting community volunteers, organising and engaging local community groups, such as Community Surveillance Units (CSUs) and Mothers' Groups, and encouraging home visits by the health staff. "The program also built the communication capabilities of local staff and volunteers. As a result, local staff designed some of the most innovative print materials used in the program."
• Create partnerships at all levels - One partnership between the national programme and the pharmaceutical industry helped distribute TB control materials to private practitioners.
• Put some effort into reaching the hard-to-reach, especially if they have high prevalence rates - NTCP worked closely with local authorities and health clinics located in TB "hot spots" to organise theatre performances, card games with questions and answers, and focus group discussions using flipcharts to disseminate TB messages.
• Create a positive and encouraging culture - "Before the program started, the predominant feeling among the Peru's health workers was that working in TB control was a sort of punishment. NTCP's communication program transformed this negative feeling into one of proud achievement and competitiveness among health
  teams".
• Simple and consistent messages can help the public recognise TB cases - "The slogan 'Treatment of one is prevention for all' motivated the community to become involved".

Click here for the full evaluation in PDF format.

See also: "Health Communication Insights Summary: The Role of Health Communication in Achieving Global TB Control Goals - Lessons from Peru, Vietnam and Beyond" [PDF].