View metadata, citation and similar papers at core.ac.uk brought to you by CORE

provided by UKM Journal Article Repository

ORIGINAL ARTICLE

THE COMBI (COMMUNICATION FOR BEHAVIOURAL IMPACT ) PROGRAM IN THE PREVENTION AND CONTROL OF DENGUE – THE HULU LANGAT EXPERIENCE

S Rozhan 1 , M Jamsiah 1 , A. Rahimah 2 and K.T. Ang 2

1 Department of Community Health, Faculty of Medicine, Universiti and 2 Department of Health State

ABSTRACT

Background: The COMBI concept is a novel approach by the WHO to control communicable diseases which are influenced by community behaviour. The Ministry of Health is currently evaluating its use against dengue in selected areas throughout . COMBI doctrine differs from previous dengue campaigns. It acknowledges that the factors contributing to dengue proliferation may differ between areas. Factors for a given area are analysed, then a single precise behavioural goal to overcome those problems is formulated. To inculcate this behavioural change, the target community is subjected to an intensive campaign using Integrated Marketing Communication techniques adapted from the advertising industry, particularly involving volunteers from the community itself . Methodology : In Selangor the pilot project was implemented in Section 3 and Section 4 of Bandar Baru Bangi, in the district of Hulu Langat. Here, Aedes breeding was found to occur mainly in water containers of semi permanent nature (eg. ‘kolah’, aquatic plant jars, flower pot bases etc). A total of 172 volunteers were recruited to disperse the message of “Suluh – Suluh, Basuh - Basuh” whilst distributing leaflets and flashlights to 2666 homes. Residents were instructed to illuminate such water containers twice weekly and scrub any containers found to contain larvae. The program commenced on 23/5/2004 and lasted 16 weeks. Results : During this period, the initial Aedes Index of 5 was reduced to 0.96 while combined cases of Dengue Fever / Dengue Haemorraghic Fever in Sections 3 and 4 reported to the Health Office also dropped to 1 (unconfirmed). Conclusion : The COMBI approach in Hulu Langat successfully demonstrated that correct problem identification synergized with community engagement can potentially reduce Aedes proliferation and dengue morbidity.

Keywords : COMBI, Community, Behavioural Approach, Dengue Fever, Aedes Index

INTRODUCTION In 1992 there were 5,473 reported cases (incidence rate of 29.38/100,000 population) Dengue fever (DF) was first recorded in while in 2001 there were 16, 363 reported cases Malaysia in 1902 while the first case of Dengue (incidence rate of 68.78/100,000 population) 1. Haemorrhagic Fever (DHF) was first described In Malaysia, dengue is predominantly a in 1962 during an epidemic in Pulau Pinang. disease of urban and rapidly developing areas, Since then, dengue has remained an endemic whose vector, the Aedes mosquito species, is disease with sporadic outbreaks and fatalities, found in two subtypes, A. Albopictus and A. whose control remains a major public health Aegypti. Pending the commercial availability of a concern to the Ministry of Health (MOH), as suitable dengue virus vaccine, all disease control well as the Ministry of Housing and Local efforts necessarily focus on eradication of Government. breeding habitats of these mosquitoes. Studies conducted by the Institute of Medical Research Correspondence to: M Jamsiah, Department of (IMR) have long shown that both these subtypes Community Health, Faculty of Medicine, Universiti favour breeding in shaded containers or water Kebangsaan Malaysia retaining structures of almost any type where Tel: 03-91702540, Fax: 03-91737825 rain or any other clear water can stagnate 2. (e-mail: [email protected]) The propagation of Aedes mosquitoes control, and enforcement activities as well as owes as much to the practices and behaviours of health promotion and education programs 2 . convenience of the affected communities as it The anti dengue and public awareness does to the existing architectural and campaigns conducted by the RKPBV nationwide infrastructural conditions. Urban buildings and via posters, banners and media ads all dwellings, slum and squatter areas, construction homogenously implore a decades-old, generic sites, refuse sites, storage yards and domestic and unchanging theme ie. appropriate refuse households have all been implicated with flower disposal, burying potential breeding containers, pot bases, bathroom water troughs, discarded putting abate etc. The aim as ever, is to inculcate refuse, blocked gutters and unused tyres 3, as in the general public some basic knowledge and well as domestic, commercial and industrial a sense of responsibility in reducing the breeding junk, static machinery, landed and strata property of mosquitoes. While this is rightly so, the water storage tanks 4 are frequently incriminated. relevance (and thus appeal) of such traditional Any attempt to resolve the problem of Aedes exhortations in today’s diverse modern living cum dengue proliferation by addressing certain deserves timely scrutiny. The ministry has taken issues in isolation is unlikely to attain long term cognizance of this fact through the adoption of success. the COMBI concept, which amongst others, While improvements involving demands not just the disease but also the people legislation and personnel, urban renewal and involved be studied beforehand prior to any resettlement, better city structural and landscape campaign 4. designs, improved drainage and council refuse There is also now a shift towards disposal services are actions within the community empowerment as evidenced by the government’s prerogative, there is a recognized trial of community based programs such as need for a fresh approach to action at community COMFOG (Community based Fogging) in level. This recognition and issues related to it Perak, Selangor and Pahang, and again COMBI were discussed at great length by speakers and whose area of scope is progressively being participants at the MOH-organized COMBI expanded in various states 1. training course in Melaka in September 2003, This paper provides an abbreviated and some of the salient comments are reiterated background of COMBI, the observation of the in the following paragraphs. unifying characteristics of Aedes breeding in the Although in general, most states in target community of Section 3 and Section 4 of Malaysia often exhibit common patterns of urban Bandar Baru Bangi, the assessment of communal dengue endemicity, it is only recently that the makeup, traits and routines, the application of more subtle differences in breeding COMBI marketing principles and finally, the circumstances among different communities perceived impact on dengue incidence within the have begun to be explored in the hope of finding said community. It is not intended to be an alternative solutions. It is with such exhaustive treatise of COMBI doctrine per se, considerations in mind that the COMBI concept the details of which can be obtained through the was introduced to Malaysia, with the aim of RKPBV unit at federal level. using its unique methodology to identify social traits in dengue affected communities and tailor COMBI (COMMUNICATION FOR eradication programs accordingly 4. BEHAVIOURAL IMPACT ) In Malaysia, the responsibility for dengue control activities (eg: fogging, Aedes COMBI is a new approach towards surveys) in most major cities and towns is tackling communicable diseases espoused by the increasingly being assumed by the local World Health Organization (WHO). The official authorities. The Ministry of Health maintains its WHO Communicable Diseases Programme role in non – council areas whilst retaining its description of COMBI reads “..the task of advisory capacity in training and assisting the mobilizing all societal and personal influences local councils. Through its Vector Borne on an individual and family to prompt individual Diseases Control Unit (RKPBV) of the and family action.” It incorporates the lessons of Infectious Disease Control Division, the ministry the past 50 years in health education and remains the main government agency responsible communication while drawing substantially from for monitoring dengue disease incidence and the experience of the private sector in consumer breeding indices, evaluation of eradication, communication (advertising) 5. The number of nations incorporating the course was the identification of dengue COMBI into their indigenous communicable problem localities amenable to subsequent disease control programs is growing COMBI amelioration. exponentially. Since 2001, COMBI has been The Hulu Langat District Health Office applied in the elimination of leprosy in was directed by the Selangor State Health Mozambique 5, the control of tuberculosis (TB) Department to spearhead the program. Based on in India and Nepal 6, lymphatic filariasis control its own 2002 data, the Hulu Langat District in Zanzibar 7 and the control and prevention of Health Office Vector Unit selected the Bandar dengue in Lao People’s Democratic Republic Baru Bangi area for the pilot project. The reasons and Johor Bahru, Malaysia 8 . Since 2003, the list for selection were threefold : i) high number of has grown to include Bangladesh, Kenya, Sri dengue cases (30% of total for district) ii) Lanka , Sudan and a host of Latin American increasing number of dengue cases (39% countries 9. increase from the previous year) iii) consistently COMBI integrates health education, high Aedes Index (> 5). Within Bandar Baru information-education-comunication (IEC) , Bangi itself, Section 3 and Section 4 were market research , advertising techniques and identified as the focus of the program as these community mobilization in an effort to achieve two sections had been classified as Dengue the ultimate goal of behavioural impact in health Priority 1 Areas after experiencing severe : “someone doing something” to adopt and outbreaks in the past. Also there was a total of maintain healthy behaviours. A basic mantra of 2666 household premises in the area, which was COMBI dictates “Do Nothing…make no t-shirts, considered an appropriate and manageable figure no posters, no pamphlets until the precise single in terms of manpower available and time for a behavioural goal has been formulated ” 5. pilot project. For example, in the fight against lymphatic filariasis in Zanzibar, the single Methodology Of COMBI behavioral goal was to ensure that at a given time on a given date, all members of the population The design of a COMBI plan begins swallowed the diethylcarbamazine (DEC) tablets with identifying the behavioural objectives. This provided 7. In the fight against TB, COMBI has takes the form of a statement of the overall goal been used to ensure the attendance TB patients at followed by a statement of the behavioural goal DOTS clinics, as well the provision of sputum which must be specific, appropriate, measurable samples in suspect cases 6. and time bound. In contrast, formulating a single The next step is known as the behavioural goal for combating Aedes and Situational Market Analysis (SMA) which is the dengue is a more complicated proposition, given observation and analysis of factors influencing that i) there is no specific treatment or vaccine to the attainment of the overall goal and the form the basis of intervention ii) any preventive behavioural goal. Existing and new data on measures have to take into account the disparate factors causing or contributing to the disease multitude of contributory factors involved. In problem are studied. The strategy and choice of dengue, it is difficult to single out any one communication techniques will also be solution as being the best. Proponents of determined by the SMA. The SMA involves community fogging and applying abate might listening to people and learning about their balk at the cost, while homeowners living next to perceptions and obstacles to the proposed abandoned / neglected houses can do little except behaviour through techniques common to the report it to the authorities. Hence it is inherently advertising world such as TOMA (Top Of the more useful to view COMBI as part of an overall Mind Analysis), DILO (Day In the Life Of), multifaceted anti-dengue effort rather than a MILO (Moment In the Life Of) and NOSA standalone tool 4. (Number Of Steps Away). Following the success of the COMBI Next, the overall strategy and plan of program in Johor Bahru in 2001, the program action is drawn up. This comprises a broad was expanded to other states in Peninsular outline of the proposed actions for achieving the Malaysia. From 14 – 20 September 2003, a behavioural results. At the core of this is the 5- week-long training course was conducted in Pointed Star of Integrated Marketing Actions Melaka by visiting WHO Communications which consists of Public Relations / Public Advisor Dr. N. Everold Hosein for health Advocacy / Administrative Mobilization, representatives from selected states. Central to Community Mobilization, Personal Selling (Interpersonal Communication), Advertising statement was formulated as follows : “ To (Massive, Repetitive, Intensive, Persistent @ M- reduce the incidence of Aedes breeding as RIP) and finally Point – of – Service Promotion. determined via the Aedes Index (AI), by 30 % in When the strategy and plan is in place, the designated locality of Sec.3 & 4 Bandar actual implementation can begin. A Baru Bangi by the end of the 16 week multidisciplinary team is appointed, which will campaign ”. Next, the behavioural goal statement collaborate with other agencies. Adherence to the was outlined in the following statement : “ To planned time schedule (eg. Gant Charts etc) and prompt household members in 80 - 90% of budget is critical. As the program progresses, homes in Sec. 3 & 4, Bandar Baru Bangi starting evaluation of progress via data collection and 25 th April for 16 weeks, for approximately 10 – analysis is carried out. 15 minutes on every Sunday morning and The situational market analysis of Wednesday evening, to inspect their homes both Sections 3 dan 4, Bandar Baru Bangi was inside and outside, for mosquito larvae, by primarily based on Aedes breeding site data for simply shining a torch into flower pot bases, the period of September to October 2003 which aquatic plant jars, urns, vases and bathroom was supplied by the Vector Unit of the Hulu water troughs. Should they notice any larvae, Langat District Health Office. This revealed they are to get rid of the water, then scrub the that the main sources of Aedes breeding in the rim and insides of the container to get rid of household premises were bathroom water unhatched eggs ” . troughs ( kolah ), flower pot bases, aquatic plant The underlying idea was to impose as jars, urns, vases, disused aquariums / fish minimally as possible upon people’s daily enclosures, multitiered motorized mini routines while effectively disrupting the Aedes waterfalls, corridor gutters, refrigerator breeding cycle. To improve the appeal, the condensation trays etc. As these were aesthetic memorable slogan “ Suluh Suluh, Basuh Basuh ” items of value and of a permanent / semi was coined. permanent nature, the traditional message of Due to the inherent bias and subjectivity discard or bury was somewhat absurd. of self reporting methods of assessment, it was Socioeconomically, the neighbourhood decided that Aedes and Breteau Indices obtained is rather homogenous, consisting mainly of through the fortnightly Aedes Surveys would Malay middle class families with corresponding serve as tracking indicators of success of the educational attainment, with a number of affluent program. households and conversely factory workers / The overall strategy of COMBI in students occupying respective ends of the tackling dengue in Sections 3 and 4 Bandar Baru spectrum. The main dwellings are double storey Bangi was implemented as follows: link houses, with a substantial number of With regard to Public Relations and bungalows as well as apartment/ factory hostel Advocacy cum Administrative Mobilization, the type of accommodation. Hulu Langat Medical Officer of Health ordered Bandar Baru Bangi arose in the past 3 the mobilization of district health staff decades with the opening and development of the particularly the Health Inspectors and Public Universiti Kebangsaan Malaysia (UKM) Health Assistants to assist the volunteers. campus. Hence the vast majority of residents are Government agencies with related interests in career people from various parts of Malaysia dengue prevention in Bandar Baru Bangi such as whose days are normally engaged in work the Municipal Council (the local commitments throughout the Valley, and authority responsible for sanitation and dengue whose weekends are spent away from home. control) and Selangor State Development Hence time is at a premium, a factor which Corporation (as the area developer and land weighed heavily in our DILO and MILO controller) were informed and invited to deliberations. participate. Consent was sought from the District Most of the residents were familiar with Education Office in order to enlist the the association between dengue and their cooperation of 4 local schools. We also liased neighbourhood, and had a rudimentary grasp of with the local police regarding security the how dengue occurred, which helped assistance. tremendously in our TOMA, NOSA and other As part of our Community Mobilisation analyses. efforts, we commenced the selection of After considering the above factors and approximately 150 – 200 local volunteers from studying the Aedes life cycle, the overall goal the target community to form 20 “Anti Dengue Volunteer Teams” who would visit the premises establishing a Residents COMBI Committee on foot fortnightly to impart the novel anti was achieved on 1 st March 2004 where 20 local dengue message and inspect for breeding ( Aedes residents were briefed by the Hulu Langat Surveys). A further contingent was invited to Medical Officer of Health. Training of a total of form 1 – 2 roving “Anti Dengue Scooter Teams” 172 volunteers was completed on 18 th April to promote the same message. To recruit and 2004. oversee the activities of these volunteers, we After several postponements due to canvassed for certain highly committed national elections and various holidays, the volunteers to form a Residents’ COMBI Aedes Surveys finally commenced on 23 rrd May Committee. 2004. The distribution of student worksheets and In keeping with COMBI experience placement of advertising media was elsewhere, we concurred that students would be implemented concurrently. Volunteers ideal for Personal Selling within their own accompanied by health staff visited homes in homes and circle of friends. Hence the their respective areas every 2 nd and 4 th Sunday of involvement of the 4 local schools ; teachers the month. Volunteers were issued uniforms and would distribute worksheets to students in Year identification cards. Their mission was to 4 and 5, as well as Form 1 and 2 who would act distribute pamphlets and torches while as ‘personal sellers’ to spread the message in instructing residents on the new practice, as well their respective families as well as perform the as to inspect the premises for larvae samples desired ‘suluh & basuh’ practices. which would be sent for official analysis and For advertising and promotion media, confirmation. To enhance receptiveness towards we used pamphlets, bunting, t-shirts, newspaper the program, a temporary halt on compound inserts, mobile public announcements etc. We fines for detected breeding was announced. The also planned an Inauguration Ceremony, to be front doors of premises visited were tagged with officiated by the local Member of Parliament adhesive cards which were replaced in different (MP) as further means of publicity. colours monthly, to denote successive visits and In comparison to the COMBI program aid coverage. in Johor Bahru, the Bandar Baru Bangi program The climax of the campaign was the was of a significantly much smaller scale. In Inauguration Ceremony held in a local school terms of client volume , the most convenient and field for high visibility on 7 th August 2004. Apart prominent place frequented by the residents of from the presence of the local MP, added Sections 3 and 4 was simply the local health publicity was gained through the hosting of a clinic. We therefore used Klinik Kesihatan colourful themed run “Larian Suluh Suluh, Bandar Baru Bangi for our Point –of- Sale Basuh Basuh” involving t-shirt clad Promotion ie. incidental promotion of the schoolchildren running escorted through their COMBI message to patrons coming for other neighbourhood, chanting the slogan and waving reasons. slogan embossed balloons. Having determined the overall strategy and specific behavioural goals, the next step was RESULTS designing the appropriate logo and selecting the appropriate media to carry the message. This and Over the 16 weeks, a total of 2458 other budgetary considerations was purview of premises or 92.2% of the total available were the Vector Unit, Selangor State Health visited and inspected at least once. Of those, a Department. The purchase of bunting (danglers), further 1923 (78.2%) were visited and stickers, t-shirts, pamphlets, caps, vests, kitbags, reinspected a second time. Premises not torchlights, batteries, student worksheets and inspected were mainly locked vacant premises stationery for distribution among an estimated awaiting tenants or buyers, while premises not 3000 households and program volunteers was reinspected were those whose occupants were accomplished from November 2003 to January out. Fig. 1 illustrates the number of premises 2004. visited per Aedes Survey. Next, a working committee at district The reduction in the number of health office level and chaired by the Hulu premises inspected during the second, third and Langat Medical Officer of Health was set up on fourth surveys (on 23.5.04, 6.6.04 and 27.6.04 25 th February 2004. This committee was tasked respectively) as compared to the first survey (on with the distribution of the program related items 23.5.04) was attributed to late starting times. and training of volunteers. The critical step of This in turn resulted from the need to redistribute the teams prior to departure in order to i) focus inspected on the final Aedes Survey on on problem areas arising during preceding 12.9.2004 as the survey was concluded early to surveys and ii) to ensure equal manpower in the allow for a farewell gathering of volunteer. event of absenteeism. Only 312 premises were

Aedes Survey

1000 898 916

800 695 566 574 600 420 400 312

200 No.Of Premises 0 23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04 Surve y Date

Fig.1: Number of premises inspected on each Aedes Survey

50 43 40 30 18 20 13 15 8 10 3 3 No. Of Premises 0 23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04 Surve y Date

Fig.2: Number of premises with larvae breeding detected per Aedes Survey

Fig. 2 demonstrates a gradual reduction in reduction is most marked between the first and premises found to have larvae breeding. The second surveys.

6 5 5 4 3 3.2 3 2.6 2 0.87 1 0.96 AedesIndex 1 0 23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04 Survey Date

Fig.3 Reduction in Aedes Index in COMBI program area during program period

Fig. 3 displays the obvious downward The Breteau Index (Fig.4) in sections 3 trend of the Aedes Index with successive and 4 of Bandar Baru Bangi closely mirrored the surveys. Aedes Index .

6 5 5 4 3.5 3 3 3 2 0.87 1 0.96

Breteau Index Breteau 1 0 23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04 Survey Date

Fig.4: Reduction in Breteau Index in COMBI program area during program period

Fig. 5 provides a breakdown on number of larvae Surveillance program in Section 3 Bandar Baru by species type. A. Albopictus appears to Bangi. Ovitrap samples despatched to the Sg. predominate. Further verification of specie types Buloh Public Health Lab confirmed the above was obtained by the concommitant epidemiologic distribution of Aedes species. implementation of the Ovitrap Sentinel

50 A. Aegypti 40 15 A. Albopictus 30

20 2 2 8 10 5 2 0 16 3 2 8 9 0 23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04 Survey Date

Fig.5: Number of samples of Aedes larvae (by species) detected per Aedes Survey

14 12 12 10 8 7 6 4 4 2 1 No. Of Samples Of No. 2 0 0 0 23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04 Survey Date

Fig.6: Number of samples of indoor breeding detected per Aedes Survey

Figs. 6 and 7 illustrate the distribution of breeding within the visited households. Total number of breeding cases was 107. Of these, 24.3 % (n = 26) or 1 in 4 affected households had breeding inside the house. Examples of the types of containers implicated are provided by Tables 1 and 2.

Number Of Samples Of Outdoor Breeding Detected Per Aedes Survey 35 31 30 25 20 16 15 11 9 9 10 3

No. Of Samples Of No. 5 2 0 23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04 Survey Date

Fig. 7: Number of samples of outdoor breeding detected per Aedes Survey

Table 1. Number Of Outdoor Breeding Cases By Type Of Container

Flower Plastic Hardware Pots / Water Gardening And Landscape Container Unused Bases / Storage Items Painting / Mini Others Type Tyres Aquatic Containers (various) Items waterfall Plants (various) (various)

No. Of Breeding 33 24 7 6 4 3 4 Cases

% of Total 40.7 29.6 8.6 7.4 4.9 3.7 4.9 (n=81)

Table 2. Number Of Indoor Breeding Cases By Type of Container

Plastic Bathroom Flower Pots Water Refrigerator Container water / Bases / Toilet Storage Condensation Others Type trough Aquatic Cisterns Containers Trays (kolah ) Plants (various

No. Of Breeding 13 6 3 2 1 1 Cases

% of Total 50.0 23.0 11.5 7.7 3.8 3.8 (n=26

Fig. 8 describes the attendance of so long as volunteers produced their Identity volunteers as recorded at each survey. Note that Cards for registration and were attired in the the figures do not necessarily represent the same official uniform. people each week as substitutions were allowed

Attendance Of ADVT Members Per Aedes Survey 160 149 135 140 121 120 101 97 100 82 71 80 60 40 No. Of Attendees Of No. 20 0 23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04 Survey Date

Fig. 8 Attendance of ADVT members per Aedes Survey

DISCUSSION and investigated, are recorded generically under the general category of Bandar Baru Bangi only. Ideally, it would have been appropriate Devising a single behavioural goal for to be able to compare the Aedes Index trend in dengue control which is universal enough to be Sections 3 and 4 during the specific 16 week applicable to as wide a range of premises and a program period with the Aedes Index trend for large a geographical area as possible is a the same sections during the same period in 2003 mammoth challenge. We were fortunate in being or 2002. However, there had been no previous able to identify a fairly common theme recurring Aedes Survey pertaining specifically to Sections throughout the target households and use it to 3 and 4 for that particular 16 week period to good effect. Although we believe it is possible to produce such data. extend the same, unmodified goal to other Likewise, it was not possible to obtain sections of Bandar Baru Bangi, the same may data on Aedes Indices for the other neighbouring not necessarily be true of the entire Hulu Langat sections of Bandar Baru Bangi for purposes of district, especially in industrial and comparison against sections 3 and 4 during the manufacturing areas, where high rates of worker program period. This is because, with most transmigration and different infrastructure / available manpower committed to Aedes Surveys building composition exist. in the two sections every fortnight, it was not In accounting for human nature it would feasible to assemble additional teams for be difficult to discount the possibility of the ancillary purposes. This takes into account other confounding properties of the Hawthorne Effect ongoing labour intensive activities including 10 as being partially responsible for the initial fogging, Food Quality Control operations and decline in breeding indices. The Hawthorne Sanitary Water Supply and Environmental Effect in its simplest form states that when Hygiene activities. people know they are being measured, they In terms of VEKPRO data for clinically modify their behaviour. The sharp decline in reported cases of dengue fever/ dengue number of premises found to have larvae with haemorrhagic fever, it was not possible to each subsequent week (see Fig. 2), particularly retrospectively isolate the number of cases between the first Aedes Survey (23.5.04, n = 43) specifically from Sections 3 and 4 for the same and the second (6.6.04, n = 13) may indeed be 16 week period in 2003 or 2002. This is because due to people hastily ridding their homes of all cases from individual sections, once reported larvae in anticipation of the arrival of the ADVTs, rather than eager acceptance of the new strengthen the case for the approach adopted by behaviour. Despite the moratorium on the the “Suluh Suluh, Basuh Basuh” theme. issuing of compound fines, the perceived One of the greatest difficulties embarrassment of having one’s volunteer encountered with such a major community-based neighbour discovering Aedes in one’s home volunteer-dependent program lasting over a would motivate most people. However it is protracted period is regular attendance. At no viewed though, the final indisputable outcome time was the program able to muster its full remains that the there was a persistent decline in complement of 172 volunteers. As shown in Fig. breeding detected after the first survey because 8, attendance began declining after the third something motivated the residents to inspect survey onwards. The final attendance (n = 71) their homes, and continue inspecting for 15 was less than half of that on the first day (n = weeks afterwards, as per the stated goal. 149). Most volunteers averaged 3 – 4 surveys. Therefore only sustainability remains the issue. The fact of the matter is that any COMBI The near term success of the program is program is a long drawn out affair and demands succinctly reflected in Figs. 4 and 5. The total heavily on the sacrifices of those involved. When reduction in breeding incidence at the one considers that the majority of Bandar Baru culmination of the 16 week period was Bangi residents are extremely busy citizens for approximately 80%, far in excess of the 30% whom weekends especially Sundays may be the target set out as the initial goal. While the short only leisure time available to spend with loved term success of COMBI appears to be amply ones, visiting relatives or pursuing some demonstrated, its sustainability in the long term recreation, then the sacrifice of 3 – 4 alternate remains to be seen. It is premature to draw any Sundays appears generous indeed. When the long term conclusions from the Bandar Baru distractions of intervening school and public Bangi experience. However, given the holidays are factored into the 16 week period, the receptiveness of the community to the program ability of the program to maintain its momentum thus far, it should be fair to presume that the deserves acknowledgement. campaign has had a positive influence on the The frequent migration of temporary awareness threshold of the residents, and only residents such as college students, factory occasional reminders in the form of periodic contract workers, and young working adults in announcements, flyers or ADVT visits are and out of the Bandar Baru Bangi remains a needed to prompt the continuation of the “Suluh threat to the long term viability of COMBI. Such Suluh, Basuh Basuh” habit. migrations would dilute the pool of initial It is interesting to note, that during the responders to the program. To allow for such COMBI program period, there was a total of 50 unavoidable attrition, the message of the COMBI cases of clinically suspected dengue fever/ program would have to redelivered to these dengue hemorrhagic fever reported from the particular groups at scheduled intervals, in order Bandar Baru Bangi area. The surrounding to sensitize the newly arrived individuals. residential sections all had several cases reported Given this scenario, it is conceivable in each but only one was reported from Section 4 that the regular repetition of the COMBI and none from Section 3. This correlates message via periodic campaigns will be exceedingly well with the reduction of the Aedes necessary to ‘keep the flame alive’ in the and Breteau Indices in these two sections. targeted community. Such activity would need to Confirmation regarding the commonest become an obligatory component of the calendar source containers of breeding larvae as identified and budget for the Health Education Unit (HEU) during our situational market analysis is given in of the district health office in charge of that Tables 1 and 2. For outdoor breeding, flower selected area or locality. Seen in a positive vein, pots / bases /aquatic plants (n = 33 or 40.7%) COMBI confers upon each district HEU a was the main source followed by plastic water tremendous degree of autonomy. Because each storage containers (n = 24 or 29.6%). The need district’s COMBI solution is supposedly unique to store water in such containers by the residents to itself, each HEU can and should act is the result of past experience with the proactively, without recourse to state or central disruption in water supply. For indoor breeding, impetus. Being ground level personnel, the the kolah accounted for half of all cases (n = 13 HEUs can observe any changing trends and or 50%) followed by flower pots/ bases /aquatic detect waning enthusiasm in the community plants (n = 6 or 23%). These figures further early, and thus adapt their COMBI message and redefine campaign goals, without the observation, for continued confirmation that the encumbrance of central bureaucratic machinery. stated behavioural goal has truly been adopted as Communities require motivation to desired by the targeted community. perform, such is the effort – reward equation. Failure to provide the community with tangible ACKNOWLEDGEMENTS evidence that what they’re doing is making a difference will wither support. Because COMBI The authors wish to acknowledge the in essence is affirmative action at the individual cooperation and generosity of the following household level, there must exist a means to agencies and bodies in the implementation of relay information in understandable form to this program : those individual households that lives are being The , The spared and morbidity reduced. The traditional Selangor State Development Corporation, The channel of Village / Neighbourhood Health and Public Works Department, The Bandar Baru Safety Committees (JKKK / JKKT) has been Bangi Police Station, The Hulu Langat District used to varying degrees of success. However, in Education Office, Sek. Men. Keb. Jalan Tiga, keeping with the proactive nature of COMBI, Sek. Keb. Jalan Tiga, Sek. Men Keb. Jalan perhaps a more direct route in the form of Empat, Sek. Kebangsaan Jalan Empat, The mailbox leaflets and such, containing monthly Bandar Baru Bangi Fire and Rescue Station and disease figures (and breeding cases if available) finally the Honourable Chairman and Members should be considered in future. In order to of the Residents’ COMBI Committee Bandar preserve the sensitivity of such data, explicit Baru Bangi. details such as dates, addresses and names could remain classified. REFERENCES Any one effort spearheaded by a particular government agency needs to be given 1. Kementerian Kesihatan Malaysia. 2003. solid support by other government bodies with Garispanduan Projek Fogging Oleh vested interests in the same field. Public Komuniti – Ogos 2003. Cawangan Penyakit confidence and cooperation for a campaign such Bawaan Vektor. as COMBI by one agency will be undermined if 2. Kementerian Kesihatan Malaysia. 1986. their basic needs have yet to be met by another. Panduan Pencegahan Dan Kawalan Penyakit The common complaint of dissatisfaction Demam Denggi / Demam Denggi Berdarah. regarding the efficiency of council services for Cawangan Penyakit Bawaan Vektor. which rates or assessments have been levied has 3. Abdullah, A.B. 1999. Teks Ucapan to surmounted before the public can be asked to "UTAMAKAN KEBERSIHAN DAN toil further. Community effort must be matched HAPUSKAN NYAMUK" oleh YAB if not exceeded by prompt sanitary services. Timbalan Perdana Menteri Malaysia pada Community receptiveness to campaigns will Majlis Pelancaran Kempen Anti-Nyamuk only be commensurate to the level of Dan Kempen Kebersihan Nasional. responsiveness to comment and criticism 20.4.1999 displayed by the authority in question. 4. Kursus Latihan Kebangsaan Dalam Communication-for Behavioural-Impact CONCLUSION (COMBI) Untuk Pencegahan Denggi. 14 -20 September 2003 Emperor Hotel Melaka In its immediate assessment, the organized by Kementerian Kesihatan COMBI program in the prevention and control Malaysia. Discussion notes. of dengue in Sections 3 and 4 of Bandar Baru 5 World Health Organiztion. 2001. Integrated Bangi was successfully implemented. The Marketing Communication For Behavioural reduction in number of larvae breeding cases Results In Health And Social Development within the targeted premises was successfully – Summary Of Concepts. New York achieved, as evidenced by the decline in Aedes University /WHO Integrated Marketing Index from 5 to 0.96. In addition, there were no Communiation /COMBI – Malaysia Doc #1. clinically confirmed cases of dengue fever and WHO Geneva. dengue haemorrhagic fever reported in these two 6. World Health Organization 2002. sections throughout the program period. Communication-for Behavioural-Impact The sustainability of the achievements (COMBI) In The Prevention and Control Of described above must now be the subject of TB. WHO Communicable Disease Surveilance (CDS)/Communicable Disease Prevention, Eradication and Control (CPE) Social Mobilization and Training Programme. 7. World Health Organization 2002. Communication-for Behavioural-Impact (COMBI) In The Prevention and Control Of TB. WHO Communicable Disease Surveilance (CDS)/Communicable Disease Prevention, Eradication and Control (CPE) Social Mobilization and Training Programme. 8. World Health Organization 2002. Mobilizing for Action – Communication for Behavioural Impact (COMBI). WHO Communicable Disease Surveilance (CDS)/Communicable Disease Prevention, Eradication and Control (CPE) Social Mobilization and Training Programme. 9. World Health OrganizationMediterranean Centre, Tunisia. 2003. A Manual For Designing A Communication For Behavioural Impact (COMBI) Plan 0f Action – July 2003 Draft. World Health Organization Communicable Disease Surveillance (CDS) Division. 10. Draper,S.W. 2004. The Hawthorne Effect and Other Expectancy Effects. www.psy.gla.ac.uk/~steve/hawth.html. on 1.6.2004