Cough to Cure: Applying a

Pathway of Ideal Behaviors in TB Control

AED: Dr. Silvio Waisbord

Dr. Susan Zimicki
Stop TB Partnership: Thaddeus Pennas
Overview of Presentation

Introduction: The Cough to Cure Pathway

- a diagnostic and planning tool

The "Cough to Cure Pathway - six steps to

ideal TB treatment

Applying the Pathway: 4 diagnostic steps

Overview of Presentation

Introduction: The Cough to Cure Pathway

is a diagnostic and planning tool.
Why another tool?
What is new about the tool?
How was it developed?
The "Cough to Cure Pathway
Applying the Pathway: 4 diagnostic steps
Why another tool?

Response to expressed need.

Countries and technical programs request support
and guidance regarding advocacy, communication
and social mobilization (ACS):

This diagnostic and planning tool supports cost-

effective implementation of ACS support and
services.
What is new about this tool?

Frameof reference way of conceptualizing

problems
Think about communication by thinking about
behaviors
Behaviors instead of logistics and structure
Focus
People (patients and providers)
View of system
Enabling environment
How was it developed?

AED working with Stop TB:

Defined the steps in the pathway from cough to
cure from the patients care-seeking practices
Identified the social and behavioural barriers to
completing each of these steps (through literature
review and interviews)
Mapped possible ACS entry points drawing on
lessons from other behavioural change
interventions
Overview of Presentation

Introduction: The Cough to Cure Pathway

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

Thispathway was developed to serve as a road

map to understand the interrelationship of
behaviour, DOTS services and other societal
structures on treatment-seeking behaviour and
compliance.

The pathway focuses on the patient, and how the

system can facilitate patients going through the
ideal steps.
The Pathway basic structure

Six steps to ideal TB

treatment behavior :
Case detection
1) Seek timely care
Goal: 70%
2) Go to a DOTS facility
Current average: 44%
3) Get accurate diagnosis

4) Begin treatment Treatment completion

5) Persist in getting treatment Goal: 85%
6) Complete treatment Current average: 82%
Ideal vs reality

In an ideal world, for every 100 infected people, all 100 would:
Seek timely care
Go to a DOTS facility either directly through referral
Be correctly diagnosed
Begin treatment
Persist with treatment for more than 2 months
Complete treatment
These are the six steps that form the basic structure of the
pathway

As the following slide shows, things are far from ideal

Pathway Steps
The Pathway List of barriers

Ateach step, the pathway also lists the

common barriers to completion of the step
Barriers can occur at the level of the
Individual
Group
System
The current list of barriers is based on AEDs
literature review and interviews; it will be
updated as program experience accrues
Barriers - individual and group level
Step 2 Go to DOTS

Common reasons for non-completion are that the

individual
Prefers to go to a provider s/he knows, and fears going to
someone unknown
Believes attending DOTS facility will be expensive
Doesnt prioritize TB over other health issues
Low-risk perception of TB symptoms
And that the group (community/family)
Stigmatizes people with tuberculosis and, by extension, anyone
attending a TB clinic
Barriers system level
Step 2 Go to DOTS

Few DOTS facilities, so that people live

relatively far away and traveling to the facility
takes time and money
Lack of linkages between non-DOTS and DOTS
facilities
= providers do not refer patients with possible TB to
DOTS facilities;
= providers do not consider TB (e.g., treat HIV patients
only for HIV & acute illnesses)
 Barriers - individual and group level
Step 5 (Persist with treatment)

Common reasons for drop-out are that the

individual and his/her social support group
(family, neighbors)
Do not know how long treatment takes
Do not understand or accept the importance of
continuing treatment even after the patient feels
better or despite side effects
Cannot financially support the cost of distant
treatment or good food
Stigmatize those with TB
Barriers system level
Step 5 (Persist with treatment)

Lack of medicines
Lack of DOTS facilities - trouble (time, money)
to attend
Providers fail to give adequate information
about length of treatment, importance of
persistence, side effects
Poor quality of services (e.g., non-supportive
or abusive providers)
Overview of Presentation

Introduction: The Cough to Cure Pathway

is a diagnostic and planning tool.
The "Cough to Cure Pathway"six steps to
ideal TB treatment
Applying the Pathway: 4 diagnostic steps
Description
Examples
Applying the Pathway: 4 Steps

1. Identify the steps that patients are not

completing
2. Examine the reasons for non-completion at
the individual, group and systems levels
3. Decide which barriers to address. Need to
weigh relative importance of factors
4. Choose an intervention based on
understand of motivating factors, and likely
effectiveness and impact
How to examine step completion
Obtain information about step completion from a variety
of sources
Routine information
Special studies
Key informants

Chart out the data and let it guide the decision making
process

Important: be clear about denominators

Make sure all your percents refer to the same base population
Step 2. Examine reasons for missed
steps

In this case, the program should examine

individual, group and systems barriers that
are likely to be problems for both step 1 and
for step 2.
Example: for Step 2 (Go to DOTS)

Possible reasons include

Individual:
Misperceptions of costs of diagnosis and treatment;
Reluctance to go to an unknown provider

Group
Stigma

System
Distance to DOTS provider
No or weak links between non-DOTS and DOTS providers;
non-referral
How to examine reasons
Use both qualitative and quantitative research
Examples of some questions relevant to individual
and group-level barriers for Step 2:
Where should someone go to find out if she or he has TB?
How much does it cost to be tested?
Can TB be cured?
How much does it cost?
How long does it take?
How would your family and neighbors react if they knew
that you went to a DOTS clinic?
Step 3. Decide which barrier(s) to address

What is the relative importance of this barrier

compared to others?
How feasible is to reduce this barrier within a
short-to-medium period?
How much will it cost (cost/benefit analysis)?
Does the program have the right expertise to
tackle the problem (human resource
analysis) ?
Step 4. Choose an intervention

What kinds of interventions will best address

the identified barrier(s)?
Systems improvement (e.g., logistics)
Behavioural change of patients and/or
providers
Mixed (what is the sequence?)

Whatkind of communication strategy is best

adequate to address barriers?
Core questions for communication
interventions

Who is the primary and secondary audience?

What is it that they are expected to do?
What will it take to get people to do it?
What do they need to know?
What do they value?
How will they overcome perceived and existing
barriers?
What factors promote their doing it?

these come from the BEHAVE model; many other models exist: NCI Pink
Book, P-Process, Combi, CDCynergy, )
Thank you

Academy for Educational

Development and the
Stop TB Partnership
Secretariat