The COMBI (Communication for Behavioural Impact) Program in the Prevention and Control of Dengue - The Hulu Langat Experience

This 14-page report examines the COMBI (Communication for Behavioural Impact) approach - developed by the World Health Organization (WHO) to control communicable diseases which are influenced by community behaviour - as applied to dengue fever (DF) in Malaysia. COMBI is an approach including: health education; information, education, and communication (IEC); market research; advertising techniques; and community mobilisation in an effort to inspire people to adopt and maintain healthy behaviours. Wherever possible, efforts are made to involve volunteers from the community itself.

As explained here, the anti-dengue and public awareness campaigns conducted by the Ministry of Health's Vector Borne Diseases Control Unit (RKPBV) of the Infectious Disease Control Division nationwide had previously been centred around posters, banners, and media ads, which "all homogenously implore a decades-old, generic and unchanging theme ie. appropriate refuse disposal, burying potential breeding containers, putting abate etc. The aim as ever, is to inculcate in the general public some basic knowledge and a sense of responsibility in reducing the breeding of mosquitoes. While this is rightly so, the relevance (and thus appeal) of such traditional exhortations in today's diverse modern living deserves timely scrutiny." In light of such observations, the Ministry moved to adopt the COMBI concept.

The design of a COMBI plan begins with identifying the behavioural objectives. A basic mantra of COMBI dictates "Do Nothing...make no t-shirts, no posters, no pamphlets until the precise single behavioural goal has been formulated." As explained here, formulating a single behavioural goal for combating Aedes and dengue is complicated, given that i) there is no specific treatment or vaccine to form the basis of intervention ii) any preventive measures have to take into account the disparate multitude of contributory factors involved. In dengue, it is difficult to single out any one solution as being the best. Hence, it is inherently more useful to view COMBI as part of an overall multifaceted anti-dengue effort rather than a standalone tool.

Acknowledging that the factors contributing to dengue proliferation may differ among areas analysed, a Situational Market Analysis (SMA) is carried out. Existing and new data on factors causing or contributing to the disease problem are studied. The SMA involves listening to people and learning about their perceptions and obstacles to the proposed behaviour through techniques common to the advertising world such as TOMA (Top Of the Mind Analysis), DILO (Day In the Life Of), MILO (Moment In the Life Of), and NOSA (Number Of Steps Away).

Next, the overall strategy and plan of action is drawn up. This comprises a broad outline of the proposed actions for achieving the behavioural results. At the core of this is the 5-Pointed Star of Integrated Marketing Actions which consists of: Public Relations / Public Advocacy / Administrative Mobilisation; Community Mobilisation; Personal Selling Interpersonal Communication; Advertising (Massive, Repetitive, Intensive, Persistent, or MRIP); and Point-of-Service Promotion.

In Selangor, the pilot project was implemented in Section 3 and Section 4 of Bandar Baru Bangi, in the district of Hulu Langat. After considering the above factors, studying the Aedes life cycle, and formulating the overall goal and behavioural goal statements, organisers implemented the programme. It commenced on May 23 2004 and lasted 16 weeks.

First, the Hulu Langat Medical Officer of Health ordered the mobilisation of district health staff. Government agencies with related interests in dengue prevention in Bandar Baru Bangi were informed and invited to participate. Consent was sought from the District Education Office in order to enlist the cooperation of 4 local schools. Organisers also liased with the local police regarding security assistance.

Then, 172 local volunteers from the community were selected to form "Anti Dengue Volunteer Teams" and roving "Anti Dengue Scooter Teams". Dressed in uniforms and carrying identification cards, these volunteers visited homes in their respective areas every 2nd and 4th Sunday of the month to disperse the message of "Suluh - Suluh, Basuh - Basuh". Their mission was to distribute pamphlets and torches while instructing residents on the new practice - to illuminate water containers twice weekly and scrub any containers found to contain larvae - as well as to inspect the premises for larvae samples which would be sent for official analysis and confirmation. To enhance receptiveness towards the programme, a temporary halt on compound fines for detected breeding was announced. The front doors of premises visited were tagged with adhesive cards, which were replaced in different colours monthly, to denote successive visits and aid coverage. They visited a total of 2,666 homes.

Teachers at 4 local schools distributed worksheets to students who would act as "personal sellers" to spread the message in their respective families as well as perform the desired "suluh and basuh" practices. Advertising and promotion media included pamphlets, bunting, t-shirts, newspaper inserts, and mobile public announcements.

The climax of the campaign was the inauguration ceremony, held in a local school field for high visibility, on August 7 2004. Apart from the presence of the local Minister of Parliament (MP), added publicity was gained through the hosting of a colourful themed run called "Larian Suluh Suluh, Basuh Basuh" involving t-shirt-clad schoolchildren running escorted through their neighbourhood, chanting the slogan and waving slogan-embossed balloons.

In conclusion, the COMBI approach in Hulu Langat demonstrated that correct problem identification - synergised with community engagement - can potentially reduce Aedes proliferation and dengue morbidity.

An excerpt from the Discussion section of the report follows:

"...The total reduction in breeding incidence at the culmination of the 16 week period was approximately 80%, far in excess of the 30% target set out as the initial goal. While the short term success of COMBI appears to be amply demonstrated, its sustainability in the long term remains to be seen....It is interesting to note, that during the COMBI program period, there was a total of 50 cases of clinically suspected dengue fever/dengue hemorrhagic fever reported from the Bandar Baru Bangi area. The surrounding residential sections all had several cases reported in each but only one was reported from Section 4 and none from Section 3. This correlates exceedingly well with the reduction of the Aedes and Breteau Indices in these two sections.

...One of the greatest difficulties encountered with such a major community-based volunteer-dependent program lasting over a protracted period is regular attendance. At no time was the program able to muster its full complement of 172 volunteers....The fact of the matter is that any COMBI program is a long drawn out affair and demands heavily on the sacrifices of those involved....The frequent migration of temporary residents such as college students, factory contract workers, and young working adults in and out of the Bandar Baru Bangi remains a threat to the long term viability of COMBI....Given this scenario, it is conceivable that the regular repetition of the COMBI message via periodic campaigns will be necessary..."