Consultancy to develop intervention package for reducing structural TB Stigma

KNCV Tuberculosis Foundation

KNCV Tuberculosis Foundation is an international non-profit organization dedicated to the fight against tuberculosis (TB), still the second most deadly infectious disease in the world. KNCV is an international center of expertise for TB control that promotes effective, efficient, innovative and sustainable tuberculosis control strategies in a national and international context.  We are an organization of passionate TB professionals, including doctors, researchers, training experts, nurses and epidemiologists. We aim to stop the spread of the worldwide epidemic of TB and to prevent the further spread of drug-resistant TB. Over the past century we have built up a wealth of knowledge and expertise, initially by successfully controlling TB in the Netherlands. Since the 1970s, we have also shared our knowledge and expertise with the rest of the world. We operate from a central office in The Hague in the Netherlands, a regional office in Central Asia and country offices worldwide. KNCV raises funds from private, institutional, corporate, and government donors.

Official structures of TB control may foster distrust, suspicion, and often infantilize or even violate the rights of persons with TB. We invite brief proposals to develop tools and approaches to reduce TB stigma within structures and systems in society.

Hatzenbuehler and Link (2014, p. 2) define structural stigma as “societal-level conditions, cultural norms, and institutional practices that constrain the opportunities, resources, and wellbeing for stigmatized populations.”

By reducing structural TB stigma we mean a set of actions designed to:

  • Catalyze the reforming of laws, policies, penalties and protections to improving
  • Ensure the equitable enforcement of existing processes
  • Revisit labels, categories, and discursive frames that name, blame, shame or exclude
  • Challenge dogmas and mantras (established practices) of TB control that stigmatize.

Structural change requires the ability to reimagine the status quo and question the underlying logic and evidence upon which much of TB control is built. Often structures serve seemingly competing interests and reconciling them is not a trivial task. Effective approaches prompt critical reflection and long-term change that disrupt chains of events that reduce the life chances of people with TB.  Crucially, effective structural change requires knowing when to modify versus destroy systems.

Successful applications need not include all possible stigmatizing structures and systems. However, applications are encouraged to consider these priorities areas:

  • Local, national, and international health governance systems
  • The judicial system and associated disciplining structures
  • The labor, employment systems – including regulation and compensation structures
  • The international migration system

An effective intervention package will vary the exposures, channels, and address stigma at its roots (i.e. drivers). Efforts at institutional change should anticipate and address different levels of motivation to change, learning styles, and tailor the “dosage” and type of intervention to specific audiences.

Many TB patients are disadvantaged by social, economic, and political inequalities that are beyond the locus of control of a national TB program or a community-based organization. Applicants should acknowledge the intersectional and pervasive nature of structural stigmas but privilege addressing structural barriers with a demonstrable and direct link to the well-being of people with TB, including:

  • Structures that may increase risk of TB or hinder TB care seeking by particular groups or classes
  • Structures that contribute to the delay or denial of an accurate TB diagnosis through unequal access or quality
  • Health or legal structures that hamper economic interests, education or survival of those exposed to TB
  • Health or legal structures that infringe upon rights of individuals exposed to or burdened by TB.
  • TB treatment structures that encumber people unduly, curtailing their life pursuits (e.g. legal obstacles barring people with TB from marriage, education or migration).

Concretely we envision a set or package of tools that help community activists, national TB programs, and technical partners to build skills to:

  • Improve the understanding of international legal conventions
  • Operationalize Human Rights and Ethics guidance in practical settings
  • Re-examine habitus (taken-for-granted practices) and discourses (rhetoric).
  • Clarify implicit values and beliefs embedded in policies, architectures, and messaging
  • Improve the alignment between practices and available scientific evidence

Proposals stressing standard “chalk and talk” didactic trainings (where learners are lectured by an instructor as opposed to engaged in participatory adult learning) are discouraged.  Technical knowledge acquisition can be a small part of the intervention package, but successful proposals will engage both cognitive and affective levels.

Illustrative structural TB Stigma Reduction activities could include:

  • Sensitization exposures for political, judicial, education, or health authorities designed to build empathy and catalyze reform of (or reinforcement of supportive) polities, guidelines, and norms.
  • Interventions to increase the eligibility for, access to, and utilization of economic, psychological, housing, employment opportunities and support for persons affected by TB.
  • Structural reforms to decrease the social burden of TB diagnosis and treatment, particularly those that help to prevent deductive disclosure, elevate the decision-making power and autonomy of persons with TB, and reframe the partnership between those with TB and those who serve them.
  • Working with architects, patients, and infection control engineers to re-design TB treatment spaces to better balance the needs of families affected by TB and the air safety needs of health workers.


KNCV Tuberculosis Foundation is reaching out to scientists, creative change-makers, community leaders, innovators, and justice-seekers to help create the tools to dismantle TB stigma in people with TB, communities with a high TB burden, institutions where TB stigma thrives, and in structures that support TB stigma.

KNCV seeks to develop a series of new interventions to tackle stigmatizing messages, behaviors, and social structures using a heart+head+hands approach.  We believe that to dismantle TB stigma we need to:

  1. a) CHANGE HEARTS: by growing empathy and solidarity
  2. b) CHANGE MINDS: by shifting cognitive processes and improving knowledge, and
  3. c) ALL HANDS: by engaging all stakeholders in the daily labor of making the world more just and healthy for people with TB.

We seek collaborators who can help us to build impactful intervention packages that can be adapted to different settings.  Our tool box will contain clear evidence-based, multi-level stimuli to shift hearts and minds, policies and practice.

Applicants are strongly encouraged to leverage ideas that have worked in reducing other kinds of stigma. In this case, applicants should be able to adapt those existing interventions to address TB and KNCV will provide support on how best to do that, if appropriate.

Leveraging the science of stigma reduction, we seek social and scientifically informed approaches that can be readily adapted and deployed in countries such as: Afghanistan, Bangladesh, Botswana, Cambodia, Democratic Republic of Congo, Ethiopia, Georgia, India, Indonesia, Kyrgyzstan, Malawi, Mozambique, Myanmar, Namibia, Nigeria, Philippines, Romania, Tajikistan, Tanzania, Ukraine, Uzbekistan, Vietnam, Zambia, or Zimbabwe.

Passive learning (e.g. listening, watching) should be limited in favor of more active forms of behavior and attitude change (e.g. doing, discovering, problem solving). The over-use of power point is discouraged.

The package described in the application must reflect a specific behavioral change theory or theory-driven community mobilization approach. We are looking for an individual or organization that understands how to connect behavioral theory to an overall intervention design which leads to outcomes that are measurable and effective in the reduction of TB stigma.


  1. Applicants should build their package around a clear theoretically -informed, evidence-based framework that specifies which domains of stigma are being addressed and what is the hypothesized mechanism of stigma reduction for each module. The intervention package must be informed by both theory and practice of TB stigma reduction. Authors should provide citations to any studies supporting the theories underlying the intervention and reasons why it is expected to be effective in reducing stigma.
  2. Applicants should include a prominent role for persons with TB or persons with a history of TB as technical partners in the development of the interventions to ensure the quality and relevance of the interventions.
  3. All intervention packages should include a module specific to the stigmatization of people with multi-drug resistant TB (MDR-TB). Stigma toward people with MDR/XDR TB are likely fostered and sustained by distinct sets of underlying factors.
  4. The intervention package will eventually include an appropriate monitoring & evaluation envelope- (i.e. with measures and stigma scales that map to the specific stigma domains in the intervention). The M&E content will be developed by KNCV in collaboration with authors and is not required as part of the application or the full package.
  5. If interventions need to follow a specific sequence – these implementation guidelines should be specifically explained. The authors should indicate the minimum dosage of the intervention expected to be required to detect any noticeable changes in the expected outcomes and the preferred manner of implementation. Optional or advanced modules of the intervention should be specifically defined.
  6. All TB stigma reduction interventions must be gender-aware and informed by region-specific literature on TB and gender.
  7. In many communities TB stigma may be temporized or potentialized by other powerful stigmas.1,2 So addressing TB stigma, even successfully, will not reduce the suffering of people with TB very much. Applicants should therefore indicate how this intervention could be combined with other anti-stigma efforts.


The materials developed under this contract would be co-owned and co-branded (by the author and KNCV TB Foundation). KNCV would reserve the right to make modifications to the work such as translation, copy editing, and combination with other content. End-users would also be encouraged to tailor to the interventions to the needs of their setting. If the applicants consider aspects of the intervention package to be original works of art ( i.e. not modifiable), this should  be clearly specified.


The proposed budget should not exceed $7,000. Budgets should include the time needed to craft the package by an expert or very small team. Successful applications will likely be those that have already developed similar materials in the past, which need only modify existing materials.

Additional Information

This RFA does not require the applicant to provide graphic design competency as this will be provided. An Instructional Designer and Social Scientist will be available to contribute to ensure the logical coherence between the behavioral theory employed, the interventions developed, the materials developed, and the measurement metrics used (M&E).


8 September Annotated outline off the full intervention package (scope of work)
22 September Rough draft of half of the intervention package
6 October Full draft of the intervention package
13 October Technical review feedback from KNCV
27 October Revised draft of the intervention package
3 November Final draft of the intervention package to copy editors and lay out


The final published version of the TB Stigma reduction Tool Box will be presented by the authors in The Hague December 13-14th, 2017. Travel expenses for 1 author will be paid by KNCV TB Foundation.

Please note the deadline for submission of the final materials is: November 3rd , 2017

Application Instructions

Interested applicants should supply:

  • A complete application form (three to ten-page) including:
    1. Conceptual framework (Figure 1)
    2. Matrix of Intervention Modalities and Aims (Figure 2)
    3. Matrix of Intervention Delivery mechanisms (Figure 3)
    4. Budget proposal
  • 1 or 2 page track record of the individual or organization in related efforts
  • CVs of the main content developer(s) – highlighting track record in TB and stigma reduction.

Please use the template provided to submit your application.

KNCV TB Stigma Reduction Application Template Final Draft

Reducing TB stigma among health care workers- Sample_Application


Proposals will be evaluated by a multidisciplinary team. Proposals will be rated according to:

  • The track record of the applicant.
  • The coherence of the link between the theory, tools, and specific outcomes
  • The transformative potential of the package
  • The balance between affective, cognitive, and active change efforts.
  • The likelihood that the applicant can complete the work in the short time period.

Proposals that are impactful and comprehensive in scope will be preferred over proposals that privilege feasibility, incremental improvement, or traditional chalk+talk methods.


  1. Bond V, Nyblade L. Supportive Social Context and Intentions for Civic and Political Participation: An Application of the Theory of Planned Behaviour. J Community Appl Soc Psychol. 2006;61:452–61.
  2. Bond V, Nyblade L. The Importance of Addressing the Unfolding TB-HIV Stigma in High HIV Prevalence Settings. J Community Appl Soc Psychol [Internet]. 2006;16(January):452–461. Available from: