STS: Guidelines and Protocols for ACSM activities

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.

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