Example 6: Talaku - Fighting TB in the Maasai Community

This example was contributed by Ithar Hassaballa through a World Health Organization (WHO) Health Promotion Internship (summer 2012).

BACKGROUND: THE STORY BEHIND TALAKU

Tuberculosis (TB) is an infectious, airborne disease that is caused by strains of mycobacteria. Most TB infections remain inactive; only about 10% become active. In 2011, 8.7 million had TB and 1.4 million died of the disease that year (WHO, 2012).

Timpiyian, a young Maasai woman, founded Talaku—a Community Based Organization (CBO) after surviving TB. Having almost lost the battle to the disease, she wanted to improve the health of her community by providing treatment and supports to those affected by the disease, and to also take preventive measures so less community members are infected. Timpiyian underwent five operations in the Nairobi Hospital; she adhered to 6 months of medications, survived TB, and is now cured. Timpiyian made a promise to her mother saying, “If I survive this disease, my life will be dedicated to preventing TB, educating about TB, and helping those who are infected with TB survive their illness.” Those who develop TB are isolated from the community because people believe that TB is a derivative of HIV, it cannot be cured, and can kill everyone at home. Talaku has made an effort to educate people that TB is not a derivative of HIV, it can be cured, and with home ventilation it will not infect others.

After establishing Talaku, Timpiyian and her colleagues focus most of their efforts on reducing stigma, providing early TB detection services, and supporting those who are ill through support groups. TB is a major health problem in Kenya, but the Maasai are the most affected by this disease. According to Talaku, diet practices and adverse living conditions increases the prevalence of both lung and stomach TB among the Maasai people.

JUSTIFY THE CHOICE OF THE PRIORITY PROBLEM/ GOAL TO BE ADDRESSED:

Talaku chose to address TB because it is highly prevalent within the Maasai community. Although the exact number of those affected is unknown, the Maasai community has higher cases of TB than other ethnic groups in Kenya. The effects of TB are severe and if not treated, can cause a slow and painful death. The problem is seen as important to the community members and officials, but many are hesitant to test for TB or seek treatment because of fearing social isolation from community members.

FRAME THE PROBLEM TO BE ADDRESSED.

Too many people in the Maasai community are infected with both lung and stomach TB.

REVIEW THE NAMING AND FRAMING OF THE PROBLEM.

The main issue is that too many Maasai are being infected with TB in Kajiado. TB is easily transferred to others and can lead to death if not treated. The goal is to reduce the cases infected by the disease by implementing preventive measures. The second goal is to provide early detection, supports, and treatment services for those already infected with the disease.

ASK QUESTIONS ABOUT THE PROBLEM TO IDENTIFY KEY BEHAVIORS, ACTORS, AND CONSEQUENCES.

What behaviors contribute to the problem?

Talaku identified several factors that contribute to TB infections. The Maasai community has cultural traditions that are directly related to the spread of stomach and lung TB. For the longest time, the Maasai people have lived in Manyatas—small, single-room homes made of mud that are completely enclosed, except for a small view port. This housing style contributes to the spread of TB in a number of ways. First, there are no windows for ventilation, which allows TB to spread quickly from one family member to the next through the air. The smoke from cooking further aggravates the lungs. Another problem is the diet of the Maasai people and its contribution to TB of the stomach. Stomach TB is caused by bacteria in raw milk or meat that’s not fully cooked—which are diet essentials to the Maasai people. Increasing community understanding to the relationship between cultural practices and TB is needed to change the conditions that contribute to the problem. Changing the practice of consuming raw milk and uncooked meat by the Maasai people will reduce the prevalence of stomach TB among those in this community. Additionally, adding windows to the Manyata homes will improve ventilation and reduce the likelihood of transmitting airborne TB among family members. The disease also spreads among Maasai communities because they are nomads. They move with their cattle depending on the season (environmental migrants) and can infect other communities without knowing.

Who is affected by the problem?

All people in Kajiado are affected by the problem, including children, parents, elders, and neighbors. The total number of those who are affected is unknown, but the TB cases among the Maasai are much higher than other ethnic groups in Kenya. All community members are at risk for developing the disease through the air or through their diet.

How are people affected by the problem?

The consequences of TB are severe and can be deadly. According to the CDC, the symptoms of TB include a loss of appetite, weight loss, vomiting, night sweats, coughing (TB of the lung), and enlargement of the stomach (TB of the stomach). A person testing positively for TB typically takes 6 months to be cured, if and only if they adhere to their medication, which often consists of receiving shots for 2 months and 4 months of oral medication. Poor treatment adherence may result in multi-drug resistance, which may extend treatment for as long as 2 years. Timpiyian noted that many people end up losing the battle against multi-drug resistance due to the length of the treatment process as well as side effects from the medicine. “Evidence suggests that TB medications are also linked to liver dysfunction and pneumonia” Timpiyian articulates. Like HIV, there is much stigma surrounding TB because of the lack of understanding the disease. Often times, people think that there is no cure and many fear social isolation because they can spread the disease through the air. Being socially isolated in a community-oriented society is difficult and can lead to depression among those affected by the disease. Combatting TB is of great importance to the community as well as health experts.

Mobile Clinic: A tent in the Kajiado Market for TB testing

ANALYZE “ROOT CAUSES” TO IDENTIFY THE ENVIRONMENTAL CONDITIONS AND RELATED BEHAVIORS THAT MIGHT CONTRIBUTE TO THE PROBLEM.

Too many people in the Maasai community are infected with both lung and stomach TB.

• But, why? Because TB is widespread among the Maasai community.
• But, why? Because the disease is easily transferred among family members and through nomadic practices; and through eating uncooked foods that lead to infection. Also social isolation prevents many Maasai from getting tested or treated for TB.
• But, why? Because Manyata homes do not allow ventilation and Maasai diets consist of raw meat and un-boiled milk.
• But, why? Because of a long history of cultural practice.

Based on this root cause analysis, some specific conditions and behaviors related to improvement include increasing ventilation within the Manyata homes and the ways in which the Maasai prepare their food. Additionally, promoting early detection of TB and increasing screening efforts can set the conditions for reducing stigma associated with TB. There are promising interventions—TB testing availability in local markets and education in schools/markets—that might contribute to health improvement in places like Kajiado.

IDENTIFY RESTRAINING AND DRIVING FORCES THAT AFFECT THE PROBLEM. 

Forces keeping the situation the same include:

• The cultural practices of the Maasai regarding their diet consisting of uncooked foods and traditional, unventilated dwellings.
• The stigma surrounding TB prevents those with the disease from seeking treatment.
• The Maasai are a traditional people with deep, cultural practices, making it difficult to adopt new behaviors that challenge their traditional way of life.
• Many people rely on their livestock for food (some may not have much money to for vegetables, but most do not like to eat vegetables).

Forces that are causing the problem to change include:

• Talaku has been conducting an education campaign regarding TB to increase people’s awareness of the factors that contribute to the disease and the importance of treatment.
• A public TB screening campaign increases the opportunity for those infected to receive treatment and to reduce stigma surrounding those with the disease by drawing attention to the widespread problem.

FIND RELATIONSHIP BETWEEN THE COMMUNITY'S PROBLEMS.

The priority issue in the Maasai community is to increase the number of people that receive TB screenings, increase the adherence of TB treatment, and to decrease the number of those that contract the disease.

This figure describes the relationship between the traditional Maasai diet and living conditions with TB and the effect of the Talaku intervention on social isolation that prevents many from seeking treatment.

THESE FACTORS CONTRIBUTE TO THE PROBLEM WITHIN KAJIADO COMMUNITY.

Knowledge and skill

• Knowledge: Many within the community have misconceptions about TB, incorrectly believing that it is a derivative of HIV. Those with HIV are more likely to become infected with TB as a result of a weakened immune system. Few people know that TB can be cured.
• Beliefs: The Maasai  diet and living conditions are based in a deep, cultural tradition.
• Skills: The Maasai have outstanding social skills and those social skills can catalyze knowledge about TB, ways to prevent it, and ways to treat it.
• Education: Many of the community members are not formally educated and are unable to read and write; however, they are traditionally educated through African teachings by family members, relatives, and the entire community. They learn skills like respectful communication, herding animals, bringing food on the table, and other essential skills for survival.

Experience and custom

• Experience: The Maasai have little experience with primary care due to limited access to health care facilities.
• Cultural norms and practices: Living in Manyatas and eating uncooked meat and drinking raw milk are traditional Maasai customs.
• Social status: The Maasai are highly regarded in Kenya for their strong traditional practices. They also mistrust the healthcare system and are more likely to seek traditional healing.

ENVIRONMENTAL FACTORS THAT MY CONTRIBUTE TO THE PROBLEM.

Support and services

There is very limited support in Kajiado. Talaku is the only organization that is creating social support for TB patients along with the collaboration of a local ACK (Anglican Church of Kenya) Clinic in the area. Talaku has been creating awareness about TB, visiting schools, as well as screening in local markets for TB cases. Additional resources would allow Talaku to have transportation to reach remote places to provide information, TB screening services, and treatment.

Access, barriers, and opportunities

Primary care clinics are located at great distances from the community members they serve, requiring residents to walk as much as 6 to 7 hours to receive medical treatment. Mobile phones have aided monitoring progress of those who are infected with TB. Health workers call patients to prompt them to take their medicine and to also pick up their medications on a weekly or monthly basis for those living far away.

Consequences of these efforts

Talaku had positive consequences within Kajiado. Talaku increased access to care for those with TB, reduced social isolation by educating people about the disease and its treatment. The consequences of the effort were positive and have began to change the way people think about the disease.

Policies effecting the issue

The Kenyan government provides free TB medication for those diagnosed with the infection. However, if a person with TB develops another infection, they may need to treat that infection first before continuing the medications; an issue that can place financial difficulty on the individual’s family. In addition, some of those infected with stomach TB may need surgery, further straining the family financially.

THE TARGETS AND AGENTS OF CHANGE FOR ADDRESSING THE COMMUNITY PROBLEM 

The targets of change are those who live in the community of Kajiado, those who live in Manyatas, and those whose diet consists of uncooked meat or raw milk. Although TB is a big problem in Maasai land, there are those who can influence the behaviors and conditions that relate to the problem; agents of change include the chief, Talaku, community health workers, clinic staff, teachers, and community members. Those with the power to bring about needed change are TB survivors like Timpiyian.

Changing Living Conditions in Kajiado.

There has been an effort by Talaku to change the living conditions of the Maasai people in Kajiado. Manyatas are now being designed in a way in which windows are included to increase ventilation. This new design is being discussed between Talaku and local officials. If the chief and others agree, this invention will be proposed to the community for consideration. It will be up to the Kajiado residents to make the changes that they think are essential to reducing the disease. Many Kajiado residents are changing their cooking styles, but others are sticking to their traditional ways of cooking, which proves challenging to organizations like Talaku.

RESOURCES AND ACKNOWLEDGEMENTS:

Centers for Disease Control and Prevention (CDC).
Talaku (Timpiyian)
The Maasai community of Kajiado
WHO office in Nairobi, Kenya (TB Team)
World Health Organization (WHO)