Social networks in tuberculosis in Pereira, Colombia
Taking in account general epidemiology of TB in Colombia and particularly at a municipality where this strategy of social networking was developed, social conditions were analyzed (Collazos et al. 2010, Jalil-Paier & Donado 2010, Ascuntar et al. 2010, Mateus-Solarte & Carvajal-Barona 2008, Jaramillo 1999). Also, in the scenarios were considered the recent impacts of the health sector reform (Carvajal et al. 2004, Ayala & Kroeger 2002), that also have influenced the TB control programs from a national to a local perspective. Pereira is the capital municipality of the Department of Risaralda (Figure 2). It stands in the center of the western region of the country, located in a small valley that descends from a part of the western Andes mountain chain. Its strategic location in the coffee producing area makes the city an urban center in Colombia, as does its proximity to Bogotá, Cali and Medellín. For 2011, Pereira municipality has an estimated population of 459,690. Official reported records for TB in Risaralda registered a disease incidence for 2011 of 66 cases per 100,000 pop (as 15 December) (which is above the national average rate of 24 cases per 100,000 pop). Pereira is divided into 19 urban submunicipalities: Ferrocarril, Olímpica, San Joaquín, Cuba, Del Café, El oso, Perla del Otún, Consota, El Rocío, El poblado, El jardín, San Nicolás, Centro, Río Otún, Boston, Universidad, Villavicencio, Oriente y Villasantana. Additionally also has rural townships which include Altagracia, Arabia, Caimalito, Cerritos, La Florida, Puerto Caldas, Combia Alta, Combia Baja, La Bella, Estrella- La Palmilla, Morelia, Tribunas. The municipality of Pereira has a diversified economy: the primary sector accounts for 5.7% of domestic product, the secondary sector shows a relative weight of 26.2%, while the tertiary sector is the most representative with a 68.1%. The GDP of Pereira grew by 3.7% in 2004. For 2010, Pereira reported 301 cases of TB (incidence rate of 65.85 cases per 100,000pop). In Pereira, previously reported interventions have been developed and working intersectorially with the academia in order to increase the impact of activities in TB control (Castañeda-Hernández et al. 2012b).
Fig. 2. Relative location of Pereira, Risaralda, Colombia, South America.
In the country, the strategic plan "Colombia Libre de Tuberculosis para la Expansión y Fortalecimiento de la Estrategia Alto a la TB, 2010-2015" (Colombia Free of TB for the Expansion and Enhancement of the Strategy Stop TB, 2010-2015), define as goal the achievement of notifications of new positive baciloscopy cases in more than 70% and a curation rate of at least 85%. In this context the routine surveillance allow to follow management and measurement of the impact of the realized actions by the control programs at municipal, departmental and national level, in order to generate interventions that contribute to achievement of the established goals to stop the advance of TB in the country. Those considered strategies in the referred plan include the previously mentioned pursue advocacy, communication and social mobilization (ACMS), from the WHO Global Plan to STOP TB (World Health Organization 2011). In the context of wide-ranging partnerships for TB control, advocacy, communication and social mobilization (ACSM) embrace: advocacy to influence policy changes and sustain political and financial commitment; two-way communication between the care providers and people with TB as well as communities to improve knowledge of TB control policies, programmes and services; and social mobilization to engage society, especially the poor, and all allies and partners in the campaign to Stop TB. Each of these activities can help build greater commitment to fighting TB.
Advocacy is intended to secure the support of key constituencies in relevant local, national and international policy discussions and is expected to prompt greater accountability from governmental and international actors. Communication is concerned with informing, and enhancing knowledge among, the general public and people with TB and empowering them to express their needs and take action. Equally, encouraging providers to be more receptive to the expressed wants and views of people with TB and community members will make TB services more responsive to community needs. Social mobilization is the process of bringing together all feasible and practical intersectoral allies to raise people’s knowledge of and demand for good-quality TB care and health care in general, assist in the delivery of resources and services and strengthen community participation for sustainability. Thus, ACSM is essential for achieving a world free of TB and is relevant to all aspects of the Stop TB Strategy. ACSM efforts in TB control should be linked with overarching efforts to promote public health and social development (World Health Organization 2011).
Fig. 3. SNA for Tuberculosis Network in Pereira, Colombia (developed with the Software SocNETV 0.81).
With these considerations in mind, in Pereira a social network for TB was developed. This network include the participation of ex-patients with TB, also healthy general population participated. All of them through the creation of nodes of the network, which were considered for this purposes as communitarian organizations constituted for a common objective and which are present regularly at neighborhoods in the municipality. Nodes were located at the 7 most highly prevalent areas of the municipality, previous to epidemiological analyses of those areas. Then, these locations were oriented to focalize the actions through the impact that, once established, this network would have on the control activities for TB in the areas of the municipality where most cases are concentrated.
In Pereira, with coordination of the TB control program on the top of the organization, a social network was developed with 7 strategically located and voluntary participation nodes (Figure 3). This social network included more than 100 people supporting the program of TB in the municipality, then strengthening the control and surveillance activities necessary to reduce and to impact more the actions against the disease.
The nodes were constituted as communitarian organization, recognized by the communities and by the different related institutions, seen as long-lasting entities, with clear objectives and work plans for continued activity at the community. In all cases the participation was completely voluntary and non-profit.
As one of the key aspects of this network, multiple programmed activities were developed, including regularly meetings for discussions and for education on TB, giving multiple and different type of incentives in order to increase the interest on participation, helding workshops and different age-oriented designed activities that include games and handy-craft works, but in every case taking in consideration an structured and varied programation to include activities for TB education.
With this social TB network the municipal TB control program pursue to improve case detection and treatment adherence, combat stigma and discrimination, empower people affected by TB and mobilize political commitment and resources for TB.
Further implications of this social network, however, should be analyzed in the long term in order to measure its impact of epidemiological indicators of TB in the municipality.
Conclusions
Tuberculosis control in the XXI century requires new approaches and interventions, particularly those based in education and prevention with a community-based orientation. Programs such as the social network developed in Pereira TB control program, should performed in other highly endemic places. As the WHO recommends to pursue the ACMS (advocacy, communication and social mobilization), strategies as the social network allow to enhance particularly the communication and social mobilization components. Unfortunately at many national plans of TB control, how translate the ACMS in specific actions is not well defined in most occasions.
As has been previously stated, in the establishment of a social network for TB, previous diagnosis, including geo-referenced characterization, it is necessary to select the areas where the nodes will be established, taking also in consideration the suitability as the willingness of the potential participants of the network in each area and node. Finally, with the mining of the activities described, but also beginning with the idea of raise the awareness about the disease, taking in consideration a high level of diversity on the activities, as has been stated in order to warrant the continuous interest and participation of the network members on it. In the future, in order to enhance the function and structure of the whole social network, further meetings between the nodes are expected. As now, only nodes interact internally, but the idea for the future activities in this setting is increase the links internally, but also between the main nodes in order to potentially increase the participation in the whole network.
Activities such as the development of social network of TB in Pereira will enhance the prevention, education and surveillance in the community, allowing a better integrated approach to the TB control in these scenarios and increasing the health profile in the community decreasing the lost opportunities for diagnosis and treatment of TB cases, finally leading to an improvement of the TB prevention and control.
