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COMBI) in the Prevention and Control of Dengue in Johor Bahru, Johore, Malaysia

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COMBI) in the Prevention and Control of Dengue in Johor Bahru, Johore, Malaysia Case Study 8 Applying Communication-for-Behavioural-Impact (COMBI) in the Prevention and Control of Dengue in Johor Bahru, Johore, Malaysia Mohd. Raili Suhaili*#, Everold Hosein**, Zuraidah Mokhtar***, Nyamah Ali***, Kevin Palmer+ and Marzukhi Md. Isa*** *Medical Development Division, Ministry of Health, Malaysia **WHO Mediterranean Centre for Vulnerability Reduction, Tunis, Tunisia ***Vector Borne Diseases Control Unit, Johor Health Department, Johor Bahru, Malaysia +WHO Western Pacific Regional Office, Manila, Philippines Abstract The Ministry of Health in Malaysia has used a variety of mass media interventions and community-based actions to prevent and control dengue fever in the past but with only limited success. In 2001, an innovative approach to planning and implementing social mobilization, known as Communication-for- Behavioural-Impact (COMBI), was piloted in Johor Bahru District, Johore State, with assistance from the World Health Organization. This paper provides highlights of the COMBI Plan. Results from intensive monitoring and evaluation suggest that the pilot project has contributed towards positive behavioural outcomes in Johor Bahru. COMBI has now been adopted as the national approach to social mobilization and communication for dengue fever prevention and control. Keywords: DF/DHF control, social mobilization, COMBI, positive behavioural outcomes, national approach, Johor Bahru, Malaysia. Country setting and Bahru, the second largest city in Malaysia after Kuala Lumpur. The estimated background metropolitan population in 2000 was Johore state is located at the southern end 1,264,547 with an estimated growth of of the peninsula and shares a common 4.2% per annum. The population growth is boundary with Pahang and Malacca to the partially due to the influx of people from north. To the south, separated by the Strait other countries and other parts of Malaysia. of Tebrau, is the island state of Singapore. Dengue fever/dengue haemorrhagic 2 Covering an area of 18,986 km , the state of fever (DF/DHF) imposes a significant social, Johore is divided into eight administrative economic, and medical burden in Malaysia. districts. The state’s capital city is Johor Since 1994, the incidence of DF/DHF has #E-mail: [email protected] Dengue Bulletin – Vol 28, 2004 (Suppl.) 39 COMBI in the Prevention and Control of Dengue in Johor Bahru, Malaysia been on the rise[1]. Johore state is of their homes both inside and outside particularly affected with the district of Johor for potential mosquito larva sites over Bahru reporting more than half of the State’s 12 weeks (August – September, 2001) cases in 2000. The Ministry of Health in (2) To prompt, in every village/community/ Johor Bahru (MOHJB) has used a variety of block in JB, the formation of a Dengue mass media interventions and community- Volunteer Inspection Team (DVIT) based actions to prevent and control which will conduct a weekly larva site DF/DHF in the past but with limited inspection of the community [2,3] success . In January 2001, MOHJB surroundings (not within the definition decided to try a fresh approach to social of homes) and take specific action to rid mobilization and communication for the area of these breeding sites. dengue prevention and control in the city of (3) To prompt every individual with a fever Johor Bahru. The Social Mobilization and during the 12 weeks of the Plan’s Training Team (SMT) of the World Health implementation to presume that it is DF Organization provided technical assistance and to come immediately (at least in the production of a Communication-for- within a day) to the nearest health clinic Behavioural-Impact (COMBI) Strategic Plan. for diagnosis and treatment. The pilot project was launched in August 2001 and lasted for 12 weeks. This paper Two simple but important messages provides highlights of the COMBI Plan containing the desired behavioural together with results from intensive project outcomes were composed and were to be monitoring and evaluation. repeated over and over again throughout the 12-week campaign: (i) INSPECT YOUR HOME. GET RID OF AEDES BREEDING Planning innovation for SITES; and (ii) IF YOU HAVE FEVER SEEK dengue prevention IMMEDIATE TREATMENT. A minimum budget of US$ 100,000 was agreed upon. and control The WHO Regional Office for the Western COMBI is an integrated marketing approach Pacific (WPRO), provided three-quarters of to social mobilization based on lessons this budget with the remainder borne by the learnt from over 100 years of consumer Ministry of Health. communication and 50 years of public health communication. The overall goal of Implementation of the new the COMBI Plan in Johor Bahru (JB) was to: “contribute to the dramatic reduction in the approach incidence of dengue fever (DF) and deaths The following are highlights of the integrated due to dengue haemorrhagic fever (DHF) in approach: the state of Johor Bahru, Malaysia in the year 2001.” The Plan focused efforts on the (1) Advocacy/public relations/administrative achievement of three behavioural goals: mobilization. Advocacy and public relations activities (e.g., meetings and (1) To prompt family members in every press conferences) rather than formal home in the city of JB to conduct a directives were applied to engage key weekly, 30-minute Sunday inspection stakeholders including local politicians. 40 Dengue Bulletin – Vol 28, 2004 (Suppl.) COMBI in the Prevention and Control of Dengue in Johor Bahru, Malaysia (2) Community mobilization. (i) Dengue on dengue. Listeners were encouraged Volunteer Inspection Teams (DeVITs) to call in to ask questions. (v) All doctors, were formed in 48 localities. Volunteers nurses and other staff in government were either selected by their local clinics carried out “point-of -service community or came forward on their promotion” by explaining the own accord. They were responsible for behavioural goals of the project to every inspecting areas beyond the home such patient who came to the clinic for as vacant lots and community halls, and whatever reason. Private doctors were also encouraged house owners to carry also encouraged to do this. out weekly house inspections. (ii) Local youths formed bicycle riding teams (D’RIDERS) to undertake promotional Monitoring and evaluating tours of the district each Sunday the new approach morning, accompanied by a van equipped with a public announcement Project progress and impact was measured system. At each location the team was by various means. Two monitoring and greeted by the local community leaders evaluation processes and their associated and residents. results are worth highlighting. (3) Communication. (i) Two thousand (1) Pre- and Post-COMBI KAP survey. A vertical buntings measuring two by six post-intervention structured questionnaire feet were hung on the posts along survey was carried out at the end of the selected streets of Johor Bahru. (ii) A 12-week campaign with results single, two-sided self-instructional compared against baseline data worksheet/checklist on how to deal with collected before the intervention. The Aedes breeding sites at home were survey used a multistage stratified prepared in four major languages sample. Respondents were either (Malay, Chinese, English, and Tamil). household heads or anyone over 18 Worksheets were distributed to years. Out of 1712 post-intervention schoolchildren every week to take respondents, only 926 were considered home to their parents. The worksheet “paired” respondents i.e., they were the encouraged families to inspect their same respondents who were home for mosquitoes breeding sites. interviewed during the baseline survey. (iii) Radio advertisements (30 seconds Selected results include: almost all and 60 seconds) were broadcast in (99%) the respondents interviewed in Malay and Chinese on four radio the post-survey claimed that they had channels throughout the 12 weeks. The carried out Sunday household advertisements contained the two inspections compared to 71% in the behavioural messages. Four mainstream pre-survey (p<0.01). Caution is needed, newspapers also carried a series of half- however, when interpreting whether page and quarter-page advertisements this impact can be attributed to the containing the two behavioural campaign for two reasons. First, survey messages. (iv) Radio talk shows responses are self-reports, not presented by local doctors promoted observations. Second, many of those COMBI and gave listeners information who self-reported carrying out Dengue Bulletin – Vol 28, 2004 (Suppl.) 41 COMBI in the Prevention and Control of Dengue in Johor Bahru, Malaysia household inspections had not heard cases reported in the study area did not specific campaign messages. show a dramatic reduction, there was a Nevertheless, field reports from decline in the number of cases in areas members of DeVITs and local health where DeVITs were established. No workers who monitored the activities of decline was measured in the non- residents in areas assigned to them DeVIT areas. indicate that the “majority” of the residents did carry out Sunday house inspections as promoted by the Lessons learned campaign. Many lessons have been learnt from the (2) Treatment-seeking surveys. Short Johor Bahru experience. First, a small group questionnaires were developed to elicit of committed and dedicated people can responses on treatment-seeking plan and execute a project as well as, if not behaviours among patients admitted better, than a large committee. Second, and diagnosed with dengue in all communities and households will readily get government hospitals throughout Johore involved if the behavioural targets set are State. Patients admitted to Sultanah reasonable and achievable. Third, sustaining Aminah Hospital and Kulai Hospital the interest of the volunteers is fundamental. (government hospitals serving Johor There were noticeable differences in areas Bahru district) were considered as where the volunteers are active compared “cases” while those admitted in to those where they were less active. Lastly, hospitals in other districts served as measuring behavioural impact and trying to “controls”. It was assumed that people determine the role of COMBI are not who resided in other districts did not straightforward.
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