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ORIGINAL ARTICLETHE COMBI (COMMUNICATION FOR BEHAVIOURAL IMPACT ) PROGRAM IN THEPREVENTION AND CONTROL OF DENGUE – THE HUL...
The propagation of Aedes mosquitoes         control, and enforcement activities as well asowes as much to the practices an...
The number of nations incorporating          the course was the identification of dengueCOMBI into their indigenous commun...
(Interpersonal Communication), Advertising              statement was formulated as follows : “To(Massive, Repetitive, Int...
Volunteer Teams” who would visit the premises          establishing a Residents COMBI Committeeon foot fortnightly to impa...
the teams prior to departure in order to i) focus                    inspected on the final Aedes Survey onon problem area...
6                                        5                         5     Aedes Index                         4            ...
50                                                                                            A. Aegypti                  ...
Numbe r Of Sample s Of Outdoor Bre e ding                              De te cte d Pe r Ae de s Surv e y                  ...
Fig. 8 describes the attendance of                        so long as volunteers produced their Identityvolunteers as recor...
ADVTs, rather than eager acceptance of the new         strengthen the case for the approach adopted bybehaviour. Despite t...
redefine     campaign     goals,    without    the   observation, for continued confirmation that theencumbrance of centra...
Surveilance (CDS)/Communicable Disease    Prevention, Eradication and Control (CPE)    Social    Mobilization      and    ...
Communication for behavioral impact(COMBI)
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Communication for behavioral impact(COMBI)

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  1. 1. ORIGINAL ARTICLETHE COMBI (COMMUNICATION FOR BEHAVIOURAL IMPACT ) PROGRAM IN THEPREVENTION AND CONTROL OF DENGUE – THE HULU LANGAT EXPERIENCES Rozhan 1 , M Jamsiah 1 , A. Rahimah 2 and K.T. Ang 21 Department of Community Health, Faculty of Medicine, Universiti and 2 Department of Health State SelangorABSTRACT Background: The COMBI concept is a novel approach by the WHO to control communicablediseases which are influenced by community behaviour. The Ministry of Health is currently evaluating itsuse against dengue in selected areas throughout Malaysia. COMBI doctrine differs from previous denguecampaigns. It acknowledges that the factors contributing to dengue proliferation may differ betweenareas. Factors for a given area are analysed, then a single precise behavioural goal to overcome thoseproblems is formulated. To inculcate this behavioural change, the target community is subjected to anintensive campaign using Integrated Marketing Communication techniques adapted from the advertisingindustry, particularly involving volunteers from the community itself. Methodology: In Selangor the pilot project was implemented in Section 3 and Section 4 of BandarBaru Bangi, in the district of Hulu Langat. Here, Aedes breeding was found to occur mainly in watercontainers of semi permanent nature (eg. ‘kolah’, aquatic plant jars, flower pot bases etc). A total of 172volunteers were recruited to disperse the message of “Suluh – Suluh, Basuh - Basuh” whilst distributingleaflets and flashlights to 2666 homes. Residents were instructed to illuminate such water containers twiceweekly and scrub any containers found to contain larvae. The program commenced on 23/5/2004 andlasted 16 weeks. Results : During this period, the initial Aedes Index of 5 was reduced to 0.96 while combinedcases of Dengue Fever / Dengue Haemorraghic Fever in Sections 3 and 4 reported to the Hulu LangatDistrict Health Office also dropped to 1 (unconfirmed). Conclusion : The COMBI approach in Hulu Langat successfully demonstrated that correctproblem identification synergized with community engagement can potentially reduce Aedes proliferationand dengue morbidity.Keywords : COMBI, Community, Behavioural Approach, Dengue Fever, Aedes IndexINTRODUCTION 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 casesMalaysia 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 ain 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, isdisease 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 aconcern to the Ministry of Health (MOH), as suitable dengue virus vaccine, all disease controlwell as the Ministry of Housing and Local efforts necessarily focus on eradication ofGovernment. breeding habitats of these mosquitoes. Studies conducted by the Institute of Medical ResearchCorrespondence to: M Jamsiah, Department of (IMR) have long shown that both these subtypesCommunity Health, Faculty of Medicine, Universiti favour breeding in shaded containers or waterKebangsaan Malaysia retaining structures of almost any type whereTel: 03-91702540, Fax: 03-91737825(e-mail: jamsiah_jkm@yahoo.com) rain or any other clear water can stagnate 2.
  2. 2. The propagation of Aedes mosquitoes control, and enforcement activities as well asowes 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 awarenessdoes to the existing architectural and campaigns conducted by the RKPBV nationwideinfrastructural conditions. Urban buildings and via posters, banners and media ads alldwellings, slum and squatter areas, construction homogenously implore a decades-old, genericsites, refuse sites, storage yards and domestic and unchanging theme ie. appropriate refusehouseholds 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 inculcaterefuse, blocked gutters and unused tyres 3, as in the general public some basic knowledge andwell as domestic, commercial and industrial a sense of responsibility in reducing the breedingjunk, static machinery, landed and strata property of mosquitoes. While this is rightly so, thewater storage tanks 4 are frequently incriminated. relevance (and thus appeal) of such traditionalAny attempt to resolve the problem of Aedes exhortations in today’s diverse modern livingcum dengue proliferation by addressing certain deserves timely scrutiny. The ministry has takenissues in isolation is unlikely to attain long term cognizance of this fact through the adoption ofsuccess. the COMBI concept, which amongst others, While improvements involving demands not just the disease but also the peoplelegislation and personnel, urban renewal and involved be studied beforehand prior to anyresettlement, better city structural and landscape campaign 4.designs, improved drainage and council refuse There is also now a shift towardsdisposal services are actions within the community empowerment as evidenced by thegovernment’s prerogative, there is a recognized trial of community based programs such asneed for a fresh approach to action at community COMFOG (Community based Fogging) inlevel. This recognition and issues related to it Perak, Selangor and Pahang, and again COMBIwere discussed at great length by speakers and whose area of scope is progressively beingparticipants at the MOH-organized COMBI expanded in various states 1.training course in Melaka in September 2003, This paper provides an abbreviatedand some of the salient comments are reiterated background of COMBI, the observation of thein the following paragraphs. unifying characteristics of Aedes breeding in the Although in general, most states in target community of Section 3 and Section 4 ofMalaysia often exhibit common patterns of urban Bandar Baru Bangi, the assessment of communaldengue endemicity, it is only recently that the makeup, traits and routines, the application ofmore subtle differences in breeding COMBI marketing principles and finally, thecircumstances among different communities perceived impact on dengue incidence within thehave begun to be explored in the hope of finding said community. It is not intended to be analternative 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 thewas introduced to Malaysia, with the aim of RKPBV unit at federal level.using its unique methodology to identify socialtraits in dengue affected communities and tailor COMBI (COMMUNICATION FOReradication programs accordingly 4. BEHAVIOURAL IMPACT ) In Malaysia, the responsibility fordengue control activities (eg: fogging, Aedes COMBI is a new approach towardssurveys) in most major cities and towns is tackling communicable diseases espoused by theincreasingly being assumed by the local World Health Organization (WHO). The officialauthorities. The Ministry of Health maintains its WHO Communicable Diseases Programmerole in non – council areas whilst retaining its description of COMBI reads “..the task ofadvisory capacity in training and assisting the mobilizing all societal and personal influenceslocal councils. Through its Vector Borne on an individual and family to prompt individualDiseases Control Unit (RKPBV) of the and family action.” It incorporates the lessons ofInfectious Disease Control Division, the ministry the past 50 years in health education andremains the main government agency responsible communication while drawing substantially fromfor monitoring dengue disease incidence and the experience of the private sector in consumerbreeding indices, evaluation of eradication, communication (advertising) 5.
  3. 3. The number of nations incorporating the course was the identification of dengueCOMBI into their indigenous communicable problem localities amenable to subsequentdisease control programs is growing COMBI amelioration.exponentially. Since 2001, COMBI has been The Hulu Langat District Health Officeapplied in the elimination of leprosy in was directed by the Selangor State HealthMozambique 5, the control of tuberculosis (TB) Department to spearhead the program. Based onin India and Nepal 6, lymphatic filariasis control its own 2002 data, the Hulu Langat Districtin Zanzibar 7 and the control and prevention of Health Office Vector Unit selected the Bandardengue in Lao People’s Democratic Republic Baru Bangi area for the pilot project. The reasonsand Johor Bahru, Malaysia 8 . Since 2003, the list for selection were threefold : i) high number ofhas 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 Baruinformation-education-comunication (IEC) , Bangi itself, Section 3 and Section 4 weremarket research , advertising techniques and identified as the focus of the program as thesecommunity mobilization in an effort to achieve two sections had been classified as Denguethe 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 ofmaintain healthy behaviours. A basic mantra of 2666 household premises in the area, which wasCOMBI dictates “Do Nothing…make no t-shirts, considered an appropriate and manageable figureno posters, no pamphlets until the precise single in terms of manpower available and time for abehavioural goal has been formulated ” 5. pilot project. For example, in the fight againstlymphatic filariasis in Zanzibar, the single Methodology Of COMBIbehavioral goal was to ensure that at a given timeon a given date, all members of the population The design of a COMBI plan beginsswallowed the diethylcarbamazine (DEC) tablets with identifying the behavioural objectives. Thisprovided 7. In the fight against TB, COMBI has takes the form of a statement of the overall goalbeen used to ensure the attendance TB patients at followed by a statement of the behavioural goalDOTS clinics, as well the provision of sputum which must be specific, appropriate, measurablesamples in suspect cases 6. and time bound. In contrast, formulating a single The next step is known as thebehavioural goal for combating Aedes and Situational Market Analysis (SMA) which is thedengue is a more complicated proposition, given observation and analysis of factors influencingthat i) there is no specific treatment or vaccine to the attainment of the overall goal and theform the basis of intervention ii) any preventive behavioural goal. Existing and new data onmeasures have to take into account the disparate factors causing or contributing to the diseasemultitude of contributory factors involved. In problem are studied. The strategy and choice ofdengue, it is difficult to single out any one communication techniques will also besolution as being the best. Proponents of determined by the SMA. The SMA involvescommunity fogging and applying abate might listening to people and learning about theirbalk at the cost, while homeowners living next to perceptions and obstacles to the proposedabandoned / neglected houses can do little except behaviour through techniques common to thereport it to the authorities. Hence it is inherently advertising world such as TOMA (Top Of themore 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 NOSAstandalone tool 4. (Number Of Steps Away). Following the success of the COMBI Next, the overall strategy and plan ofprogram in Johor Bahru in 2001, the program action is drawn up. This comprises a broadwas expanded to other states in Peninsular outline of the proposed actions for achieving theMalaysia. 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 ActionsMelaka by visiting WHO Communications which consists of Public Relations / PublicAdvisor Dr. N. Everold Hosein for health Advocacy / Administrative Mobilization,representatives from selected states. Central to Community Mobilization, Personal Selling
  4. 4. (Interpersonal Communication), Advertising statement was formulated as follows : “To(Massive, Repetitive, Intensive, Persistent @ M- reduce the incidence of Aedes breeding asRIP) 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 Bandaractual implementation can begin. A Baru Bangi by the end of the 16 weekmultidisciplinary team is appointed, which will campaign”. Next, the behavioural goal statementcollaborate with other agencies. Adherence to the was outlined in the following statement : “Toplanned time schedule (eg. Gant Charts etc) and prompt household members in 80 - 90% ofbudget is critical. As the program progresses, homes in Sec. 3 & 4, Bandar Baru Bangi startingevaluation of progress via data collection and 25th 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 bothSections 3 dan 4, Bandar Baru Bangi was inside and outside, for mosquito larvae, byprimarily 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 bathroomwas 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 thethat the main sources of Aedes breeding in the rim and insides of the container to get rid ofhousehold premises were bathroom water unhatched eggs ” .troughs (kolah), flower pot bases, aquatic plant The underlying idea was to impose asjars, urns, vases, disused aquariums / fish minimally as possible upon people’s dailyenclosures, multitiered motorized mini routines while effectively disrupting the Aedeswaterfalls, corridor gutters, refrigerator breeding cycle. To improve the appeal, thecondensation 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 subjectivitydiscard or bury was somewhat absurd. of self reporting methods of assessment, it was Socioeconomically, the neighbourhood decided that Aedes and Breteau Indices obtainedis rather homogenous, consisting mainly of through the fortnightly Aedes Surveys wouldMalay middle class families with corresponding serve as tracking indicators of success of theeducational attainment, with a number of affluent program.households and conversely factory workers / The overall strategy of COMBI instudents occupying respective ends of the tackling dengue in Sections 3 and 4 Bandar Baruspectrum. The main dwellings are double storey Bangi was implemented as follows:link houses, with a substantial number of With regard to Public Relations andbungalows as well as apartment/ factory hostel Advocacy cum Administrative Mobilization, thetype of accommodation. Hulu Langat Medical Officer of Health ordered Bandar Baru Bangi arose in the past 3 the mobilization of district health staffdecades with the opening and development of the particularly the Health Inspectors and PublicUniversiti Kebangsaan Malaysia (UKM) Health Assistants to assist the volunteers.campus. Hence the vast majority of residents are Government agencies with related interests incareer people from various parts of Malaysia dengue prevention in Bandar Baru Bangi such aswhose days are normally engaged in work the Kajang Municipal Council (the localcommitments throughout the Klang Valley, and authority responsible for sanitation and denguewhose weekends are spent away from home. control) and Selangor State DevelopmentHence time is at a premium, a factor which Corporation (as the area developer and landweighed heavily in our DILO and MILO controller) were informed and invited todeliberations. participate. Consent was sought from the District Most of the residents were familiar with Education Office in order to enlist thethe association between dengue and their cooperation of 4 local schools. We also liasedneighbourhood, and had a rudimentary grasp of with the local police regarding securitythe how dengue occurred, which helped assistance.tremendously in our TOMA, NOSA and other As part of our Community Mobilisationanalyses. efforts, we commenced the selection of After considering the above factors and approximately 150 – 200 local volunteers fromstudying the Aedes life cycle, the overall goal the target community to form 20 “Anti Dengue
  5. 5. Volunteer Teams” who would visit the premises establishing a Residents COMBI Committeeon foot fortnightly to impart the novel anti was achieved on 1st March 2004 where 20 localdengue message and inspect for breeding (Aedes residents were briefed by the Hulu LangatSurveys). A further contingent was invited to Medical Officer of Health. Training of a total ofform 1 – 2 roving “Anti Dengue Scooter Teams” 172 volunteers was completed on 18th Aprilto promote the same message. To recruit and 2004.oversee the activities of these volunteers, we After several postponements due tocanvassed for certain highly committed national elections and various holidays, thevolunteers to form a Residents’ COMBI Aedes Surveys finally commenced on 23rrd MayCommittee. 2004. The distribution of student worksheets and In keeping with COMBI experience placement of advertising media waselsewhere, we concurred that students would be implemented concurrently. Volunteersideal for Personal Selling within their own accompanied by health staff visited homes inhomes and circle of friends. Hence the their respective areas every 2nd and 4th Sunday ofinvolvement of the 4 local schools ; teachers the month. Volunteers were issued uniforms andwould distribute worksheets to students in Year identification cards. Their mission was to4 and 5, as well as Form 1 and 2 who would act distribute pamphlets and torches whileas ‘personal sellers’ to spread the message in instructing residents on the new practice, as welltheir respective families as well as perform the as to inspect the premises for larvae samplesdesired ‘suluh & basuh’ practices. which would be sent for official analysis and For advertising and promotion media, confirmation. To enhance receptiveness towardswe used pamphlets, bunting, t-shirts, newspaper the program, a temporary halt on compoundinserts, mobile public announcements etc. We fines for detected breeding was announced. Thealso planned an Inauguration Ceremony, to be front doors of premises visited were tagged withofficiated 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 thewas of a significantly much smaller scale. In Inauguration Ceremony held in a local schoolterms of client volume , the most convenient and field for high visibility on 7th August 2004. Apartprominent place frequented by the residents of from the presence of the local MP, addedSections 3 and 4 was simply the local health publicity was gained through the hosting of aclinic. We therefore used Klinik Kesihatan colourful themed run “Larian Suluh Suluh,Bandar Baru Bangi for our Point –of- Sale Basuh Basuh” involving t-shirt cladPromotion ie. incidental promotion of the schoolchildren running escorted through theirCOMBI message to patrons coming for other neighbourhood, chanting the slogan and wavingreasons. slogan embossed balloons. Having determined the overall strategyand specific behavioural goals, the next step was RESULTSdesigning the appropriate logo and selecting theappropriate media to carry the message. This and Over the 16 weeks, a total of 2458other budgetary considerations was purview of premises or 92.2% of the total available werethe Vector Unit, Selangor State Health visited and inspected at least once. Of those, aDepartment. The purchase of bunting (danglers), further 1923 (78.2%) were visited andstickers, t-shirts, pamphlets, caps, vests, kitbags, reinspected a second time. Premises nottorchlights, batteries, student worksheets and inspected were mainly locked vacant premisesstationery for distribution among an estimated awaiting tenants or buyers, while premises not3000 households and program volunteers was reinspected were those whose occupants wereaccomplished from November 2003 to January out. Fig. 1 illustrates the number of premises2004. visited per Aedes Survey. Next, a working committee at district The reduction in the number ofhealth office level and chaired by the Hulu premises inspected during the second, third andLangat Medical Officer of Health was set up on fourth surveys (on 23.5.04, 6.6.04 and 27.6.0425th February 2004. This committee was tasked respectively) as compared to the first survey (onwith 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
  6. 6. the teams prior to departure in order to i) focus inspected on the final Aedes Survey onon problem areas arising during preceding 12.9.2004 as the survey was concluded early tosurveys and ii) to ensure equal manpower in the allow for a farewell gathering of volunteer.event of absenteeism. Only 312 premises were Ae de s Surv e y 1000 898 916 No. Of Premises 800 695 566 574 600 420 400 312 200 0 23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04 Sur ve y Date Fig.1: Number of premises inspected on each Aedes Survey 50 43 No. Of Premises 40 30 18 20 13 15 8 10 3 3 0 23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04 Su r ve y Date Fig.2: Number of premises with larvae breeding detected per Aedes SurveyFig. 2 demonstrates a gradual reduction in reduction is most marked between the first andpremises found to have larvae breeding. The second surveys.
  7. 7. 6 5 5 Aedes Index 4 3.2 3 3 2.6 2 0.87 1 0.96 1 0 23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04 Sur ve y 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 3trend of the Aedes Index with successive and 4 of Bandar Baru Bangi closely mirrored thesurveys. Aedes Index . 6 5 5 Breteau Index 4 3.5 3 3 3 2 0.87 1 0.96 1 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.4: Reduction in Breteau Index in COMBI program area during program periodFig. 5 provides a breakdown on number of larvae Surveillance program in Section 3 Bandar Baruby 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 abovewas obtained by the concommitant epidemiologic distribution of Aedes species.implementation of the Ovitrap Sentinel
  8. 8. 50 A. Aegypti 40 15 A. Albopictus 30 20 2 28 10 5 20 16 3 2 8 9 0 23.5.04 6.6.04 27.6.04 1 .7.04 1 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 No. Of Samples 10 8 7 6 4 4 2 2 1 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 distributionof breeding within the visited households. Totalnumber of breeding cases was 107. Of these,24.3 % (n = 26) or 1 in 4 affected householdshad breeding inside the house. Examples of thetypes of containers implicated are provided byTables 1 and 2.
  9. 9. Numbe r Of Sample s Of Outdoor Bre e ding De te cte d Pe r Ae de s Surv e y 35 31 30 No. Of Samples 25 20 16 15 11 9 9 10 2 3 5 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 LandscapeContainer Unused Bases / Storage Items Painting / Mini Others Type Tyres Aquatic Containers (various) Items waterfall Plants (various) (various) No. OfBreeding 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 RefrigeratorContainer water / Bases / Toilet Storage Condensation Others Type trough Aquatic Cisterns Containers Trays (kolah) Plants (various No. OfBreeding 13 6 3 2 1 1 Cases % of Total 50.0 23.0 11.5 7.7 3.8 3.8 (n=26
  10. 10. Fig. 8 describes the attendance of so long as volunteers produced their Identityvolunteers as recorded at each survey. Note that Cards for registration and were attired in thethe figures do not necessarily represent the same official uniform.people each week as substitutions were allowed Atte ndance Of ADVT M e mbe rs Pe r Ae de s Surv e y 160 149 135 140 121 No. Of Attendees 120 101 97 100 82 71 80 60 40 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 SurveyDISCUSSION 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 forto be able to compare the Aedes Index trend in dengue control which is universal enough to beSections 3 and 4 during the specific 16 week applicable to as wide a range of premises and aprogram period with the Aedes Index trend for large a geographical area as possible is athe same sections during the same period in 2003 mammoth challenge. We were fortunate in beingor 2002. However, there had been no previous able to identify a fairly common theme recurringAedes Survey pertaining specifically to Sections throughout the target households and use it to3 and 4 for that particular 16 week period to good effect. Although we believe it is possible toproduce such data. extend the same, unmodified goal to other Likewise, it was not possible to obtain sections of Bandar Baru Bangi, the same maydata on Aedes Indices for the other neighbouring not necessarily be true of the entire Hulu Langatsections of Bandar Baru Bangi for purposes of district, especially in industrial andcomparison against sections 3 and 4 during the manufacturing areas, where high rates of workerprogram 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 wouldfeasible to assemble additional teams for be difficult to discount the possibility of theancillary purposes. This takes into account other confounding properties of the Hawthorne Effect 10ongoing labour intensive activities including as being partially responsible for the initialfogging, Food Quality Control operations and decline in breeding indices. The HawthorneSanitary Water Supply and Environmental Effect in its simplest form states that whenHygiene activities. people know they are being measured, they In terms of VEKPRO data for clinically modify their behaviour. The sharp decline inreported cases of dengue fever/ dengue number of premises found to have larvae withhaemorrhagic fever, it was not possible to each subsequent week (see Fig. 2), particularlyretrospectively 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 be16 week period in 2003 or 2002. This is because due to people hastily ridding their homes ofall cases from individual sections, once reported larvae in anticipation of the arrival of the
  11. 11. ADVTs, rather than eager acceptance of the new strengthen the case for the approach adopted bybehaviour. Despite the moratorium on the the “Suluh Suluh, Basuh Basuh” theme.issuing of compound fines, the perceived One of the greatest difficultiesembarrassment of having one’s volunteer encountered with such a major community-basedneighbour discovering Aedes in one’s home volunteer-dependent program lasting over awould motivate most people. However it is protracted period is regular attendance. At noviewed though, the final indisputable outcome time was the program able to muster its fullremains 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 thirdsomething 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 demandssuccinctly reflected in Figs. 4 and 5. The total heavily on the sacrifices of those involved. Whenreduction in breeding incidence at the one considers that the majority of Bandar Baruculmination of the 16 week period was Bangi residents are extremely busy citizens forapproximately 80%, far in excess of the 30% whom weekends especially Sundays may be thetarget set out as the initial goal. While the short only leisure time available to spend with lovedterm success of COMBI appears to be amply ones, visiting relatives or pursuing somedemonstrated, its sustainability in the long term recreation, then the sacrifice of 3 – 4 alternateremains to be seen. It is premature to draw any Sundays appears generous indeed. When thelong term conclusions from the Bandar Baru distractions of intervening school and publicBangi experience. However, given the holidays are factored into the 16 week period, thereceptiveness of the community to the program ability of the program to maintain its momentumthus far, it should be fair to presume that the deserves acknowledgement.campaign has had a positive influence on the The frequent migration of temporaryawareness threshold of the residents, and only residents such as college students, factoryoccasional reminders in the form of periodic contract workers, and young working adults inannouncements, flyers or ADVT visits are and out of the Bandar Baru Bangi remains aneeded to prompt the continuation of the “Suluh threat to the long term viability of COMBI. SuchSuluh, 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 suchCOMBI program period, there was a total of 50 unavoidable attrition, the message of the COMBIcases of clinically suspected dengue fever/ program would have to redelivered to thesedengue hemorrhagic fever reported from the particular groups at scheduled intervals, in orderBandar Baru Bangi area. The surrounding to sensitize the newly arrived individuals.residential sections all had several cases reported Given this scenario, it is conceivablein each but only one was reported from Section 4 that the regular repetition of the COMBIand none from Section 3. This correlates message via periodic campaigns will beexceedingly well with the reduction of the Aedes necessary to ‘keep the flame alive’ in theand Breteau Indices in these two sections. targeted community. Such activity would need to Confirmation regarding the commonest become an obligatory component of the calendarsource 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 thatTables 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 awas the main source followed by plastic water tremendous degree of autonomy. Because eachstorage containers (n = 24 or 29.6%). The need district’s COMBI solution is supposedly uniqueto store water in such containers by the residents to itself, each HEU can and should actis the result of past experience with the proactively, without recourse to state or centraldisruption in water supply. For indoor breeding, impetus. Being ground level personnel, thethe kolah accounted for half of all cases (n = 13 HEUs can observe any changing trends andor 50%) followed by flower pots/ bases /aquatic detect waning enthusiasm in the communityplants (n = 6 or 23%). These figures further early, and thus adapt their COMBI message and
  12. 12. redefine campaign goals, without the observation, for continued confirmation that theencumbrance 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 ACKNOWLEDGEMENTSevidence that what they’re doing is making adifference will wither support. Because COMBI The authors wish to acknowledge thein essence is affirmative action at the individual cooperation and generosity of the followinghousehold level, there must exist a means to agencies and bodies in the implementation ofrelay information in understandable form to this program :those individual households that lives are being The Kajang Municipal Council, Thespared and morbidity reduced. The traditional Selangor State Development Corporation, Thechannel of Village / Neighbourhood Health and Public Works Department, The Bandar BaruSafety Committees (JKKK / JKKT) has been Bangi Police Station, The Hulu Langat Districtused 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. Jalanperhaps a more direct route in the form of Empat, Sek. Kebangsaan Jalan Empat, Themailbox leaflets and such, containing monthly Bandar Baru Bangi Fire and Rescue Station anddisease figures (and breeding cases if available) finally the Honourable Chairman and Membersshould be considered in future. In order to of the Residents’ COMBI Committee Bandarpreserve the sensitivity of such data, explicit Baru Bangi.details such as dates, addresses and names couldremain classified. REFERENCES Any one effort spearheaded by aparticular government agency needs to be given 1. Kementerian Kesihatan Malaysia. 2003.solid support by other government bodies with Garispanduan Projek Fogging Olehvested interests in the same field. Public Komuniti – Ogos 2003. Cawangan Penyakitconfidence 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 PenyakitThe 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 Ucapanto surmounted before the public can be asked to "UTAMAKAN KEBERSIHAN DANtoil further. Community effort must be matched HAPUSKAN NYAMUK" oleh YABif not exceeded by prompt sanitary services. Timbalan Perdana Menteri Malaysia padaCommunity receptiveness to campaigns will Majlis Pelancaran Kempen Anti-Nyamukonly be commensurate to the level of Dan Kempen Kebersihan Nasional.responsiveness to comment and criticism 20.4.1999 Kuala Lumpurdisplayed by the authority in question. 4. Kursus Latihan Kebangsaan Dalam Communication-for Behavioural-ImpactCONCLUSION (COMBI) Untuk Pencegahan Denggi. 14 -20 September 2003 Emperor Hotel Melaka In its immediate assessment, the organized by Kementerian KesihatanCOMBI program in the prevention and control Malaysia. Discussion notes.of dengue in Sections 3 and 4 of Bandar Baru 5 World Health Organiztion. 2001. IntegratedBangi was successfully implemented. The Marketing Communication For Behaviouralreduction in number of larvae breeding cases Results In Health And Social Developmentwithin the targeted premises was successfully – Summary Of Concepts. New Yorkachieved, as evidenced by the decline in Aedes University /WHO Integrated MarketingIndex 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 Ofdescribed above must now be the subject of TB. WHO Communicable Disease
  13. 13. 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

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