Since 2015, the World Health Organization has annually reported Thailand as one the 14 countries with high tuberculosis (TB) burden. Sigma against TB and poverty hinder the effort to end TB epidemic. A multisectoral approach and engaging civil society are needed to end TB. However, research to reduce TB stigma and study to engage civil society are lacking. This operational research program composed of 2 projects implemented in Central district, Chiang Rai between 24 June 2019 – 23 December 2020. The program developed and evaluate tools and innovations to reduce stigma against TB and enhance multisectoral collaboration to end TB epidemic. Project 1: Communication for reducing stigma against TB and to enhance participation in End TB 1.1 Developing and evaluating the effectiveness of the videos for reducing stigma against TB and to enhance participation in End TB
Based on the previous TB research and anecdotal evidences, the project developed 3 videos for different target audiences. 1.1.1 The video entitled “End TB Chiang Rai” and “Love overcomes the secret of tuberculosis” were used in the training for ten groups of people. The pre and post-test were used to evaluate TB knowledge and stigma. 1.1.2 The video entitled “Happy Ending with TB” was used as an intervention in a randomized control study with 170 TB patients They were randomly assigned to an intervention and a control group, each with 85 participants. The TB awareness and stigma level before watching the video of the intervention group were not different from the control group. However, in the intervention group, the mean tuberculosis knowledge after watching the video increased from 7.3 to 9.0 (p<0.001). The mean scores for stigma were reduced from 20.6 to 11.5, (p<0.001). The 6 month follow of the individual patient revealed that the median adherence rate of the intervention group was significantly higher than the control group 99.6% (IQR 3.3) and 96.9% (IQR 9.2) (p<0.001). The proportion of patients achieving 100% adherence of the intervention group was significantly higher than the control group (49.3%, 19.7%, p<0.001) 1.2 Curriculum development and conducting training to mitigate stigma against TB and enhance ending TB through multisectoral approach Based on the previous TB research and anecdotal evidences, the curriculum is composed of updated global, Thailand and local TB situation, essential TB knowledge and social aspects of TB. The training methods include lecture, discussion, watching the videos and group works. The training evaluation is based on the pre and post-test for TB knowledge and level of stigma against TB. Project 2: End TB through a multisectoral approach 2.1 Engaging civil society to End TB Ten different groups of people were identified and invited to the first meeting. These included medical doctors from private clinics, pharmacists from drugstores, nurses from TB clinic and admission wards, teachers, student leaders, religion leaders, charity organizations, local government administration, justice and legal sector, business sector. The selection emphasized persons or organizations locating in the area with highest TB notification for 5 consecutive years. Number of persons attended the first meeting ranged between 13 - 32 persons, Coverage of participation to attend the meeting was 19.5% - 90.3%, the lowest participation is medical doctors from clinics and the highest participation is the group of student leaders. The average participation rate is 51.2%. The pre-posttest of the 10 groups show that post-test score for TB knowledge significantly increased (p< 0.001) in every group, except the group of nurse (p=0.605). Level of stigma against TB significantly reduced (p< 0.001) in every group, except the group of private clinic physicians (p=0.08). After the first training, the project created 10 groups of communication networks through the Line application and weekly reported the records of new TB cases. The post training follow up found the End TB activities as follows: drugstores and clinics screen and referred persons with TB symptoms; The provincial education office disseminated End TB information to every school; The Christian group organized TB training for community religion leaders and updated weekly TB report; The provincial probation office organized TB information corner for pardoned inmates visiting the office. 2.2 Development and utilization of a mobile phone application for screening and referring persons with tuberculosis symptoms in drugstores and private clinics A mobile phone application entitled “TB-REFER” was developed and used in drugstores and private clinics. The clients whose symptoms meet the TB referral criteria will be referred to the hospital via the application. The referred persons received compensation for travel when they arrived the hospital. The drugstores and clinics did not receive any incentives. The one-year implementation shows 36 drugstores 20 clinics with medical doctors and 9 clinics with professional nurse totally 65 voluntarily participated in the project. Eighteen drugstores and clinics (27.7%) referred 38 clients but only 24 (63.2%) went to the hospital. Six clients were diagnosed as TB. Five cases were pulmonary TB (one smear-positive and 4 smear-negative sputum) and one extra-pulmonary TB. The 36.8% (14/38) of clients did not visit the hospital because they needed to work, no person to accompany and unable to bare for hospital cost. The clients who did not go to the hospital had higher proportion of coughing with blood (35.7% vs 12.5%) and higher average TB symptom scores than the clients who visit the hospital (4.5 vs 4.1 scores). A self-administered questionnaire with 81.3 response rate (52/65) revealed that 67.3% of drugstores and clinics did not refer clients because no clients reaching the criteria of referral. As for the clinics and the drugstores with referrals, they felt the TB-REFER application is easy to use (mean scores of easiness 9.5 out of 10 scores. The shortest, the longest and the average time spent with clients and the application are 5, 15 and 10 minute respectively. The impact of Covid-19 on the research implementation and TB patients The research project could not organize the World TB day on 24th March which is a highlighted research activity to campaign TB awareness by engaging all groups of civil society in the public for the first time. Moreover, the project could not organize face to face meetings to follow up the progress from the first training. The internet-based meetings were not practical. A rapid assessment with drug stores and private clinics show that Covid-19 reduced more than half of their clients. Persons with fever and cough also significantly reduced. Strict infection control measures were practiced by most clinics and drugstores. A rapid survey with 81 TB patients living with poverty found 70.8% lost their income. Hand washing and wearing mask in the public were regularly practiced by 95% of the patients. Female patients significantly washes hands more than male patients (97%, 78%, p=0.027). Utilization of research findings The TB-REFER mobile application and the referral pattern have been applied to HIV prevention and care program at the Thai-Myanmar border and the sexually transmitted infection (STI) clinic in local setting. Engaging drug stores and private clinic in TB case finding will be expanded to the whole region in 8 northern provinces. Conclusions The videos and the training curriculum for civil societies improved tuberculosis knowledge and reduced stigma against TB in various groups. The video for TB patients enhanced TB awareness, reduced stigma and promoted adherence to treatment. It was possible to engage drug stores and private clinics to screen TB symptoms and used the TB-REFER mobile application to refer patients to the hospital with high yield of TB case detection. However, only 61% of referred patients accessed the hospital. Other social protection measures are needed to enhance vulnerable people to access the hospital service. Policy Recommendations 1. The videos are low cost intervention for reducing stigma and enhance treatment adherence. Every tuberculosis clinic and primary care health center should be informed about these videos. The newly diagnosed tuberculosis patients should watch the video. 2. Provincial Health Office, regional hospitals and community hospitals should engage drug stores and private clinics in screening and referring persons with tuberculosis symptoms for definite diagnosis at the hospital. and 3. The community grant funded by the National Health Security Office should play role to support the vulnerable persons to access TB diagnosis.