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Wednesday, September 16th, 2009 - 5 comments

When it comes to Tuberculosis, testing isn’t exactly free

We must understand the barriers that plague even the most well-intentioned campaigns to promote health. The actual cost of a Tuberculosis test is free, but there are indirect costs: one week of lost wages; and emotional and physical stress.

When it comes to health campaigns, there are many barriers. Let me give you an example from the real world with a focus on Tuberculosis (TB). TB is one of the great causes of morbidity and mortality in the world today, with the World Health Organization estimating that one third of the world’s population is infected with the TB bacteria.

A day in the life of a man getting tested for TB

One evening, a man working for a farmer in a community is visited by a community health worker in a door-to-door campaign aimed at preventing the spread of TB.

The aim is to raise awareness, and encourage individuals to be tested and treated for TB. The skin test is free and provided by a health clinic in a rural agricultural region.

This well-intentioned health worker who lives in the community is invited into the home of this man, and has an opportunity to educate him and his family on Tuberculosis. The health worker concludes the presentation by encouraging the family to be tested for TB at the free clinic in town. The man, not wanting to put his family at risk, and having been compelled by the presentation of this neighbor, plans to visit the clinic the following week.

On Monday, following a 14 hour day at work, he takes the bus from the farm where he works into town to attend the free clinic. He arrives shortly after 7pm and is dismayed to find a large sign indicating the clinic is closed and hours of operation are 8am to 5pm. After some negotiation with his boss the following morning he plans to visit the clinic first thing the following morning and then head back to work after the testing is complete.

The next morning he takes the bus directly into town and arrives at 8am at the opening of clinic, after 20 minutes navigating the building to find the TB testing area he is only met with more bad news- the free testing takes place from 11am-1pm only.

Having lost a morning’s worth of work he stays until 11am is tenth in line and finally at 12:00noon he is next in line, finally he is called forward and the 5 minute test is completed. He is then told to get the results he will need to come back in two days time between the hours of 11am and 1pm. He heads back to work in time to work the final two hours in the field and then journeys on home.

Use your imagination to hypothesize how this story continues.

Victims of false advertising

It is not until we venture into a ‘Day in the Life Of’ or DILO (a term shared with me by Dr. Everold Hosein) that we truly understand the barriers both individual and systemic that plague even the most well-intentioned campaigns to promote health and other social programs.

Now, the clinic did have some important aspects to their campaign that were culturally sensitive and responsive to the needs of the particular community:

  • they utilized key opinion leaders from the neighborhood to implement the door-to-door campaign and
  • they eliminated the financial cost of TB testing to encourage participation.

However, there were some crucial elements of the program that were not dissected and thus resulted in loss of income, and physical and emotional stress:

  • the health center did not boast clear signage, and therefore potential patients were left roaming around a large building trying to locate the specific TB clinic area.
  • the health center was open ‘business hours’, which was totally incompatible with the population they were trying to reach- mostly farmers working 14 hour day.
  • the free testing was only available during the middle of the day and almost certainly required the patient to take an entire day off work to get to the clinic, receive testing, and return home.

The way forward?

The story and context detailed above could be equally applied in most communities in the world, switching farm worker for fisherman, and switching TB for HIV/AIDS and so on. We oft move too quickly in our planning to focus on the outcomes we wish to achieve, and spend frighteningly too little time understanding our intended audience of our campaign to create an intervention that is both meaningful to the consumer and appeals to their needs and desires, while also reducing barriers to encourage participation.

While, I cannot offer a comprehensive solution or technique that will insulate the most well meaning campaigns from the challenges that have been touched on above, I endeavor that in our respective fields and roles as advocates and professionals within public health, and international development that we remain mindful of the DILO. This perhaps will reduce health disparities and promote equitable access to health and social programs and services.

The views expressed in this blog-post are solely those of the author.

Comments (5)

kim Yi Dionne
Wednesday 16th September, 2009, 4:47pm

I work with a group of researchers conducting a longitudinal study in rural Malawi. We collect demographic and health data, including results of an HIV test. More than 90% of respondents accepted HIV testing when offered in the comfort of their own home. Why not train the community health workers campaigning to increase TB testing to give TB screening tests? (Better yet, why not train them on how to ask the series of questions to determine whether the person is high risk before giving them a screening test?) My hunch is that Community Health Workers would welcome new training, an opportunity to be in the capital (or some other metropolitan location) for the duration of the training, and they are the ones who know best how to reach people in far-flung areas. I'm unfamiliar with the testing logistics for TB (perhaps there are supply chain issues, refrigeration requirements?), but when it comes to HIV testing, mobile door-to-door testing is welcomed by those who we would propose are the intended beneficiaries of such a public health intervention.

Jennifer Jenkins
Wednesday 16th September, 2009, 10:41pm

As a health care professional for 25 years the story I read above rings true on many levels. We often schedule health for the compromised/ at risk population from 9-5 ,not acknowledging this does not fit well with their way of life. Bravo on this article; and lets look at policy , procedure and organization of health so that it truley benefits those most at risk!

Thursday 17th September, 2009, 11:43am

Great article. I thought of the times I had to contemplate taking off work to go see the OB while I was pregnant because shes open only certain days and hours of the week, it is difficult especially for those relying on public transportation or other means and having to take time off work, especially in economic difficulties today where a lot of people make hourly wages can't afford a couple hours off or as some other employers dictate that you have to take a half day off regardless of how long you are going to be away from work. There was an article on the internet I believe on yesterday saying that if peoples paychecks were one week late many would miss payments and go into credit and financial ruin.

Thursday 17th September, 2009, 10:44pm

Great posts, and thank-you for engaging in the conversation. I hope to continue this dialogue about health disparities in different posts and from different perspectives. While my work in Public Health is focused on chronic disease prevention- non-communicable chronic diseases, the TB example is just that, an example of the barriers that exist in as fundamental design flaws in our health and social development interventions. A truly person-centered approach is absolutely more expensive, and time intensive, the outcomes are however qualitative and quantitative. I certainly agree training would better prepare the health workforce to ensure they are inclusive in their approach. Additionally a socio-ecological approach would include policies to support inclusive and equitable program design, through to organizational culture that supports the time required to go through the 'DILO', and to the individual professional making a commitment to remove all barriers for all clients. Also appreciate the comments from Jennifer and Leila in that this analogy could be equally applied within the context of the Global North or 'developed world' and that care must be taken to remove barriers in all programs to serve the most at risk.

Isobel Hoskins
Friday 9th October, 2009, 8:26am

I think this DILO account shows the importance of knowing your potential patients and their priorities. It brings to life ‘cost’ and distance’ often cited in papers about healthcare access and shows what they could mean. And I entirely agree this is a global issue, rural and poor populations worldwide have issues with accessing care.

As well as organisational and cultural issues there are technical ones that if overcome could help. TB is a good example for this. Tests for TB take a long time -days or weeks- or they are not very accurate. Simple testing while you wait would be a great step forward, saving repeat trips to distant clinics. The bibliographic database I work on- Global Health- shows that a lot of research on rapid diagnosis of TB is in progress especially using PCR and ELISA. Unfortunately these methods need labs to do. I saw one exciting idea - breath testing- - see this abstract in Tuberculosis (

My second comment is that the problems of accessing healthcare don’t stop with testing. Testing may be 'free' but is treatment? If the man Tanya describes was diagnosed positive he likely wouldn’t be able to comply with the treatment if the tablets cost money and he might still have to travel somewhere daily to be observed taking his tablets possibly for months.

What is the ethics if you offer free testing but then the affordability/accessibility of treatment is beyond the patient?

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Guest Editor

Tanya Rumble

Health Promoter, Halton Public Health


Tanya Rumble is a public policy professional committed to creating social change, with demonstrated project management and knowledge brokering experience in the government relations; public health; non-profit; public administration; and research sectors. She incorporates her diverse upbringing in the United Arab Emirates, and travels to over 60 countries in her work. Tanya posses technical expertise in the areas of Health Promotion, Public Health, and Integrated Marketing Communication for Behavioural Impact (COMBI). She spent the month of July 2009 as a participant in the Integrated Marketing Communication for Behavioural Impact (COMBI) in Health & Social Development certificate program at New York University in collaboration with the World Health Organization, and was a member of the Winning COMBI Plan Team. Her current professional positions include Project Manager-Healthy Weights Halton Takes Action at Halton Region Health Department; Executive Member at Health Promotion Ontario; Reviewer-Halton Peel Grant Review Team at Ontario Trillium Foundation; Consultant-Food For The Poor at Endeavour Volunteer Consulting For Non-Profits.

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