ENGAGE-TB: Integrating community-based TB activities into the work of NGOs and other CSOs
Frequently Asked Questions
What is ENGAGE-TB?
ENGAGE-TB is a WHO-recommended approach for the integration of community-based TB activities into the work of NGOs and other CSOs.
Why the need for ENGAGE-TB?
The implementation and scaling up of community-based TB activities remains weak, despite the clear need, the documented cost-effectiveness of community-based TB activities and the tremendous efforts that have been expended in recent years. Lack of effective collaboration between NTPs and NGOs and other CSOs and the absence of joint strategic planning, monitoring and evaluation are more the norm than the exception. Difficulties in measuring the impact of community-based TB activities and the lack of standard indicators have also been noted. The absence of operational guidance on engaging NGOs and other CSOs in TB prevention, diagnosis, treatment and care, including community-based TB activities, has been mentioned as a barrier. NTP managers and representatives of NGOs and other CSOs requested WHO to develop an operational guidance based on existing WHO norms and guidelines.
ENGAGE-TB: who is it for?
ENGAGE-TB Operational Guidance is intended for NGOs and other CSOs working on health and other development initiatives (e.g. education, agriculture and income-generation schemes) that intend to integrate TB prevention and care services into their field work. Within government, this guidance is intended for NTPs or their equivalents in ministries of health and other line ministries (e.g. ministries of justice for prison health services and ministries of mining or labour for workplace health services) providing TB services. Patients and communities affected by TB and related co-morbidities (e.g. HIV infection, noncommunicable diseases) could use the guidance to generate demand for TB services. Funding agencies and researchers (especially involved in operational and implementation research) could also benefit from this guidance to support community-based TB activities.
Who are NGOs and other CSOs?
NGOs and other CSOs are non-profit organizations that operate independently from the state and from the private for-profit sector. They include a broad spectrum of entities such as international, national and local NGOs, community-based organizations (CBOs), faith-based organizations (FBOs), patient-based organizations and professional associations. CBOs are membership-based non-profit organizations that are usually self-organized in specific local areas (such as a village) to increase solidarity and mutual support to address specific issues. For example, these include HIV support groups, women’s groups, parent–teacher associations and micro-credit village associations. CBO membership is comprised entirely of community members themselves, so these organizations can be considered to represent the community most directly. NGOs and other CSOs engage in activities that range from community mobilization, service delivery, and technical assistance to research and advocacy.
What are community-based TB activities?
Community-based TB activities cover a wide range of activities contributing to prevention, diagnosis, improved treatment adherence and care that positively influence the outcomes of drug-sensitive, drugresistant and HIV-associated TB. The activities also include community mobilization to promote effective communication and participation among community members to generate demand for TB prevention, diagnosis, treatment and care services. While diagnostic tests for TB continue to be performed in clinical settings, for lack of simpler diagnostic methods, community-based TB activities are conducted outside the premises of formal health facilities (e.g. hospitals, health centres and clinics) in community-based structures (e.g. schools, places of worship, congregate settings) and homesteads. Such community-based TB activities could and should be integrated with other community-based activities supporting primary health care services, including those for HIV infection, maternal and child health and noncommunicable diseases to improve synergy and impact. Community-based TB activities utilize community structures and mechanisms through which community members, CBOs and groups interact, coordinate and deliver their responses to the challenges and needs affecting their communities.
What are the examples of integrated community-based TB activities?
NGOs and other CSOs could integrate TB into their community-based work in many ways, without trained medical staff. It is particularly important for them to do so when they are working with high-risk populations (such as people living with HIV and the very poor), people living in congested environments (urban slums and prisons), people who use drugs, sex workers and migrant workers.
Examples of TB activities that can be integrated:
- Assisting early case finding: Encouraging people who present with symptoms of TB such as chronic cough, weight loss, night sweats and fever to contact a health worker or visit a health facility. Sputum examination is the mainstay of TB investigation in many settings. In community meetings (e.g. women’s groups, health clubs, farmers’ groups), the main symptoms of TB could be explained. People with symptoms could be helped to have their sputum examined by transporting either the person or the sputum sample to the nearest health facility.
- Providing treatment support: Patients being treated for TB may require support to take their drugs and finish their treatment. Family members and community-based volunteers and workers can be trained as treatment supporters by NGOs and other CSOs. Patients can also be provided with nutritional and psychosocial support, if needed.
- Preventing the transmission of TB: Covering the mouth and nose when coughing and sneezing is a simple behaviour change that can help to limit the spread of infected sputum particles and so reduce the risk to others of being infected. NGOs and other CSOs could spread this message using their various social communication media.
- HIV programmes and projects: Encouraging every person living with HIV to be screened for TB and, depending on the result, helping them receive TB prevention treatment (isoniazid preventive therapy) or further examination for TB disease.
- Maternal and child health programmes and projects: Encouraging all pregnant women to test for HIV and to be screened for TB symptoms at the nearest facility. Children under five are particularly vulnerable to TB infection if an adult in the home has TB. Health workers should be made aware of this and keep watch for any symptoms and signs of TB in households with young children.
- Education programmes and projects: Incorporating messages of TB prevention and care into curricula and classroom learning. Schoolchildren should be able to recognize TB symptoms and the importance of sputum examination so that they can encourage those at home who might have TB to get tested.
- Agriculture and income-generation programmes and projects: Raising awareness about TB symptoms and signs among organized groups (such as farmers’ groups and savings and credit groups). Members with symptoms of TB could be encouraged to get their sputum examined. Those being treated for TB could be supported to complete their course of treatment. Nutritional and psychosocial support will improve the outcome of TB treatment.
What are the core principles of ENGAGE-TB?
ENGAGE-TB emphasizes three core principles in order to improve collaboration and foster effective partnership between NGOs and other CSOs and the NTPs or their equivalents. Respect for these principles will help to remove barriers and bottlenecks affecting implementation of integrated community-based TB activities. Their importance should be recognized and efforts made to ensure their integration into the six components of the ENGAGE-TB approach described later. The principles are:
- Mutual understanding and respect recognizing differences and similarities in background, functions and working culture.
- Due consideration and respect for local contexts and values while establishing collaborative mechanisms and scaling-up integrated community-based TB activities.
- A single national system for monitoring implementation of activities by all actors with standardized indicators.
Efforts must be inclusive rather than exclusive so that more and more NGOs and other CSOs can become engaged TB stakeholders through closer collaboration and partnership with NTPs and their equivalents based on these principles.
Are there standardized indicators for ENGAGE-TB?
One of the main challenges of monitoring the implementation of community-based TB activities has been the lack of standardized indicators. The following are suggested core indicators to measure the implementation of community-based activities that need to be included in the TB monitoring system of all stakeholders and linked with the national monitoring and evaluation system of the NTP or its equivalent.
- Indicator 1: Referrals and new notifications Definition: Number of new TB patients (all forms) diagnosed and notified with TB who were referred by community health workers and community volunteers expressed as a percentage of all new TB patients notified in the basic management unit (BMU) during a specified period
- Indicator 2: Treatment success Definition: New TB patients (all forms) successfully treated (cured plus completed treatment) who received support for treatment adherence from community health workers or community volunteers among all new TB patients (all forms) provided with treatment adherence support by community health workers or community volunteers (number and percentage)