Increasing TB testing and treatment with the elderly

Despite significant progress in recent years, Cambodia remains one of the 30 high-burden Tuberculosis (TB) countries in the world. Roughly 40% of TB cases go undiagnosed, and the biggest population to be impacted is men over the age of 65. The USAID-funded Promoting Healthy Behaviors Project (PHB) sought to understand, what might encourage the elderly to go for testing and complete their full course of treatment, so that there are lower rates of TB in Cambodia?

The intervention was designed to focus on Battambang and Pailin provinces, which account for 13% of all TB cases nationwide despite representing just 7% of the population. The team spoke with past and present patients, their family members, community leaders, and health care workers. It became clear that rural elderly populations did not know that coughing for more than two weeks was a symptom of TB, nor that stopping treatment before completion can reactivate TB in a patient.

Tapping into the Cambodian culture of appreciation and respect for elders

The research uncovered that, because parents often migrated for work, grandparents and grandchildren had a strong caretaking and family bond. We ideated and tested a variety of solutions with the elderly and the “If You Love Me…” concept ultimately saw the strongest emotional response. The concept connects getting tested for TB and completing the course of treatment with expressing one’s love for family members.

Woman at community event in a breathing exercise to raise awareness about lung’s health, while thinking of her loved ones. 

Reducing barriers and creating habits

A main barrier to testing is travelling to the clinics. Using the behavior change principle of incentives, the intervention encouraged potential patients with undiagnosed TB to get tested by offering a small payment to cover their transportation costs. If their test came back positive, they received an additional payment, to ensure future transportation costs were covered.

To improve the completion of long-course medication, the TB Care Kit, which includes a medicine tracker booklet, water cup, sticker, and mints, was developed to instill a habit loop among patients. The medicine tracker booklet broke the long treatment period into 30 day blocks with motivating messages and images as patients progress through the treatment journey. The water cup, sticker, and mints facilitate a habit loop: the water cup and sticker remind them to take their medicine in the morning, and the mints are a nominal reward for practicing the behavior. Robocalls were used as automated prompts for medication continuation.

Convening communities as a sustainable solution

A series of community-led training sessions at 24 health centers across Battambang and Pailin equipped local healthcare workers with the knowledge and resources they need to utilize the TB Care Kit effectively. Local pharmacies were recruited into the “If you love me” campaign and became referral points for potential patients. 

Local pharmacies took part in the campaign.

This project had extensive technical oversight and assistance from CENAT, who has supported design, strategy, and implementation, and is now working with partners to ensure sustainability and longevity of the project. Working in partnership with CENAT ensures not only sustainability, but also encourages government institutions to mobilize HCD and behavior change thinking when reaching patients.

As project delivery continues in 2021, to-date 58 community sessions have engaged 1,182 at-risk participants. Thus far, 121 people have been tested for TB, and 60 new TB cases have been identified. These results are promising considering the high positive rate as compared to the incidence of disease. The early positive results of this intervention show that when NGOs , government entities and small local businesses work together they can lower the TB rate in Cambodian communities.

Participants at community event miming tuberculosis symptoms.