1. ORIGINAL ARTICLE
THE COMBI (COMMUNICATION FOR BEHAVIOURAL IMPACT ) PROGRAM IN THE
PREVENTION AND CONTROL OF DENGUE – THE HULU LANGAT EXPERIENCE
S Rozhan 1 , M Jamsiah 1
, A. Rahimah 2 and K.T. Ang 2
1
Department of Community Health, Faculty of Medicine, Universiti and 2 Department of Health State Selangor
ABSTRACT
Background: The COMBI concept is a novel approach by the WHO to control communicable
diseases which are influenced by community behaviour. The Ministry of Health is currently evaluating its
use against dengue in selected areas throughout Malaysia. COMBI doctrine differs from previous dengue
campaigns. It acknowledges that the factors contributing to dengue proliferation may differ between
areas. Factors for a given area are analysed, then a single precise behavioural goal to overcome those
problems is formulated. To inculcate this behavioural change, the target community is subjected to an
intensive campaign using Integrated Marketing Communication techniques adapted from the advertising
industry, particularly involving volunteers from the community itself.
Methodology: In Selangor the pilot project was implemented in Section 3 and Section 4 of Bandar
Baru Bangi, in the district of Hulu Langat. Here, Aedes breeding was found to occur mainly in water
containers of semi permanent nature (eg. ‘kolah’, aquatic plant jars, flower pot bases etc). A total of 172
volunteers were recruited to disperse the message of “Suluh – Suluh, Basuh - Basuh” whilst distributing
leaflets and flashlights to 2666 homes. Residents were instructed to illuminate such water containers twice
weekly and scrub any containers found to contain larvae. The program commenced on 23/5/2004 and
lasted 16 weeks.
Results : During this period, the initial Aedes Index of 5 was reduced to 0.96 while combined
cases of Dengue Fever / Dengue Haemorraghic Fever in Sections 3 and 4 reported to the Hulu Langat
District Health Office also dropped to 1 (unconfirmed).
Conclusion : The COMBI approach in Hulu Langat successfully demonstrated that correct
problem identification synergized with community engagement can potentially reduce Aedes proliferation
and dengue morbidity.
Keywords : COMBI, Community, Behavioural Approach, Dengue Fever, Aedes Index
INTRODUCTION In 1992 there were 5,473 reported cases
(incidence rate of 29.38/100,000 population)
Dengue fever (DF) was first recorded in while in 2001 there were 16, 363 reported cases
Malaysia in 1902 while the first case of Dengue (incidence rate of 68.78/100,000 population) 1.
Haemorrhagic Fever (DHF) was first described In Malaysia, dengue is predominantly a
in 1962 during an epidemic in Pulau Pinang. disease of urban and rapidly developing areas,
Since then, dengue has remained an endemic whose vector, the Aedes mosquito species, is
disease with sporadic outbreaks and fatalities, found in two subtypes, A. Albopictus and A.
whose control remains a major public health Aegypti. Pending the commercial availability of a
concern to the Ministry of Health (MOH), as suitable dengue virus vaccine, all disease control
well as the Ministry of Housing and Local efforts necessarily focus on eradication of
Government. breeding habitats of these mosquitoes. Studies
conducted by the Institute of Medical Research
Correspondence to: M Jamsiah, Department of (IMR) have long shown that both these subtypes
Community Health, Faculty of Medicine, Universiti favour breeding in shaded containers or water
Kebangsaan Malaysia retaining structures of almost any type where
Tel: 03-91702540, Fax: 03-91737825
(e-mail: jamsiah_jkm@yahoo.com)
rain or any other clear water can stagnate 2.

2. The propagation of Aedes mosquitoes control, and enforcement activities as well as
owes as much to the practices and behaviours of health promotion and education programs 2 .
convenience of the affected communities as it The anti dengue and public awareness
does to the existing architectural and campaigns conducted by the RKPBV nationwide
infrastructural conditions. Urban buildings and via posters, banners and media ads all
dwellings, slum and squatter areas, construction homogenously implore a decades-old, generic
sites, refuse sites, storage yards and domestic and unchanging theme ie. appropriate refuse
households have all been implicated with flower disposal, burying potential breeding containers,
pot bases, bathroom water troughs, discarded putting abate etc. The aim as ever, is to inculcate
refuse, blocked gutters and unused tyres 3, as in the general public some basic knowledge and
well as domestic, commercial and industrial a sense of responsibility in reducing the breeding
junk, static machinery, landed and strata property of mosquitoes. While this is rightly so, the
water storage tanks 4 are frequently incriminated. relevance (and thus appeal) of such traditional
Any attempt to resolve the problem of Aedes exhortations in today’s diverse modern living
cum dengue proliferation by addressing certain deserves timely scrutiny. The ministry has taken
issues in isolation is unlikely to attain long term cognizance of this fact through the adoption of
success. the COMBI concept, which amongst others,
While improvements involving demands not just the disease but also the people
legislation and personnel, urban renewal and involved be studied beforehand prior to any
resettlement, better city structural and landscape campaign 4.
designs, improved drainage and council refuse There is also now a shift towards
disposal services are actions within the community empowerment as evidenced by the
government’s prerogative, there is a recognized trial of community based programs such as
need for a fresh approach to action at community COMFOG (Community based Fogging) in
level. This recognition and issues related to it Perak, Selangor and Pahang, and again COMBI
were discussed at great length by speakers and whose area of scope is progressively being
participants at the MOH-organized COMBI expanded in various states 1.
training course in Melaka in September 2003, This paper provides an abbreviated
and some of the salient comments are reiterated background of COMBI, the observation of the
in the following paragraphs. unifying characteristics of Aedes breeding in the
Although in general, most states in target community of Section 3 and Section 4 of
Malaysia often exhibit common patterns of urban Bandar Baru Bangi, the assessment of communal
dengue endemicity, it is only recently that the makeup, traits and routines, the application of
more subtle differences in breeding COMBI marketing principles and finally, the
circumstances among different communities perceived impact on dengue incidence within the
have begun to be explored in the hope of finding said community. It is not intended to be an
alternative solutions. It is with such exhaustive treatise of COMBI doctrine per se,
considerations in mind that the COMBI concept the details of which can be obtained through the
was introduced to Malaysia, with the aim of RKPBV unit at federal level.
using its unique methodology to identify social
traits in dengue affected communities and tailor COMBI (COMMUNICATION FOR
eradication programs accordingly 4. BEHAVIOURAL IMPACT )
In Malaysia, the responsibility for
dengue control activities (eg: fogging, Aedes COMBI is a new approach towards
surveys) in most major cities and towns is tackling communicable diseases espoused by the
increasingly being assumed by the local World Health Organization (WHO). The official
authorities. The Ministry of Health maintains its WHO Communicable Diseases Programme
role in non – council areas whilst retaining its description of COMBI reads “..the task of
advisory capacity in training and assisting the mobilizing all societal and personal influences
local councils. Through its Vector Borne on an individual and family to prompt individual
Diseases Control Unit (RKPBV) of the and family action.” It incorporates the lessons of
Infectious Disease Control Division, the ministry the past 50 years in health education and
remains the main government agency responsible communication while drawing substantially from
for monitoring dengue disease incidence and the experience of the private sector in consumer
breeding indices, evaluation of eradication, communication (advertising) 5.

3. The number of nations incorporating the course was the identification of dengue
COMBI into their indigenous communicable problem localities amenable to subsequent
disease control programs is growing COMBI amelioration.
exponentially. Since 2001, COMBI has been The Hulu Langat District Health Office
applied in the elimination of leprosy in was directed by the Selangor State Health
Mozambique 5, the control of tuberculosis (TB) Department to spearhead the program. Based on
in India and Nepal 6, lymphatic filariasis control its own 2002 data, the Hulu Langat District
in Zanzibar 7 and the control and prevention of Health Office Vector Unit selected the Bandar
dengue in Lao People’s Democratic Republic Baru Bangi area for the pilot project. The reasons
and Johor Bahru, Malaysia 8 . Since 2003, the list for selection were threefold : i) high number of
has grown to include Bangladesh, Kenya, Sri dengue cases (30% of total for district) ii)
Lanka , Sudan and a host of Latin American increasing number of dengue cases (39%
countries 9. increase from the previous year) iii) consistently
COMBI integrates health education, high Aedes Index (> 5). Within Bandar Baru
information-education-comunication (IEC) , Bangi itself, Section 3 and Section 4 were
market research , advertising techniques and identified as the focus of the program as these
community mobilization in an effort to achieve two sections had been classified as Dengue
the ultimate goal of behavioural impact in health Priority 1 Areas after experiencing severe
: “someone doing something” to adopt and outbreaks in the past. Also there was a total of
maintain healthy behaviours. A basic mantra of 2666 household premises in the area, which was
COMBI dictates “Do Nothing…make no t-shirts, considered an appropriate and manageable figure
no posters, no pamphlets until the precise single in terms of manpower available and time for a
behavioural goal has been formulated ” 5. pilot project.
For example, in the fight against
lymphatic filariasis in Zanzibar, the single Methodology Of COMBI
behavioral goal was to ensure that at a given time
on a given date, all members of the population The design of a COMBI plan begins
swallowed the diethylcarbamazine (DEC) tablets with identifying the behavioural objectives. This
provided 7. In the fight against TB, COMBI has takes the form of a statement of the overall goal
been used to ensure the attendance TB patients at followed by a statement of the behavioural goal
DOTS clinics, as well the provision of sputum which must be specific, appropriate, measurable
samples in suspect cases 6. and time bound.
In contrast, formulating a single The next step is known as the
behavioural goal for combating Aedes and Situational Market Analysis (SMA) which is the
dengue is a more complicated proposition, given observation and analysis of factors influencing
that i) there is no specific treatment or vaccine to the attainment of the overall goal and the
form the basis of intervention ii) any preventive behavioural goal. Existing and new data on
measures have to take into account the disparate factors causing or contributing to the disease
multitude of contributory factors involved. In problem are studied. The strategy and choice of
dengue, it is difficult to single out any one communication techniques will also be
solution as being the best. Proponents of determined by the SMA. The SMA involves
community fogging and applying abate might listening to people and learning about their
balk at the cost, while homeowners living next to perceptions and obstacles to the proposed
abandoned / neglected houses can do little except behaviour through techniques common to the
report it to the authorities. Hence it is inherently advertising world such as TOMA (Top Of the
more useful to view COMBI as part of an overall Mind Analysis), DILO (Day In the Life Of),
multifaceted anti-dengue effort rather than a MILO (Moment In the Life Of) and NOSA
standalone tool 4. (Number Of Steps Away).
Following the success of the COMBI Next, the overall strategy and plan of
program in Johor Bahru in 2001, the program action is drawn up. This comprises a broad
was expanded to other states in Peninsular outline of the proposed actions for achieving the
Malaysia. From 14 – 20 September 2003, a behavioural results. At the core of this is the 5-
week-long training course was conducted in Pointed Star of Integrated Marketing Actions
Melaka by visiting WHO Communications which consists of Public Relations / Public
Advisor Dr. N. Everold Hosein for health Advocacy / Administrative Mobilization,
representatives from selected states. Central to Community Mobilization, Personal Selling

4. (Interpersonal Communication), Advertising statement was formulated as follows : “To
(Massive, Repetitive, Intensive, Persistent @ M- reduce the incidence of Aedes breeding as
RIP) and finally Point – of – Service Promotion. determined via the Aedes Index (AI), by 30 % in
When the strategy and plan is in place, the designated locality of Sec.3 & 4 Bandar
actual implementation can begin. A Baru Bangi by the end of the 16 week
multidisciplinary team is appointed, which will campaign”. Next, the behavioural goal statement
collaborate with other agencies. Adherence to the was outlined in the following statement : “To
planned time schedule (eg. Gant Charts etc) and prompt household members in 80 - 90% of
budget is critical. As the program progresses, homes in Sec. 3 & 4, Bandar Baru Bangi starting
evaluation of progress via data collection and 25th April for 16 weeks, for approximately 10 –
analysis is carried out. 15 minutes on every Sunday morning and
The situational market analysis of Wednesday evening, to inspect their homes both
Sections 3 dan 4, Bandar Baru Bangi was inside and outside, for mosquito larvae, by
primarily based on Aedes breeding site data for simply shining a torch into flower pot bases,
the period of September to October 2003 which aquatic plant jars, urns, vases and bathroom
was supplied by the Vector Unit of the Hulu water troughs. Should they notice any larvae,
Langat District Health Office. This revealed they are to get rid of the water, then scrub the
that the main sources of Aedes breeding in the rim and insides of the container to get rid of
household premises were bathroom water unhatched eggs ” .
troughs (kolah), flower pot bases, aquatic plant The underlying idea was to impose as
jars, urns, vases, disused aquariums / fish minimally as possible upon people’s daily
enclosures, multitiered motorized mini routines while effectively disrupting the Aedes
waterfalls, corridor gutters, refrigerator breeding cycle. To improve the appeal, the
condensation trays etc. As these were aesthetic memorable slogan “Suluh Suluh, Basuh Basuh”
items of value and of a permanent / semi was coined.
permanent nature, the traditional message of Due to the inherent bias and subjectivity
discard or bury was somewhat absurd. of self reporting methods of assessment, it was
Socioeconomically, the neighbourhood decided that Aedes and Breteau Indices obtained
is rather homogenous, consisting mainly of through the fortnightly Aedes Surveys would
Malay middle class families with corresponding serve as tracking indicators of success of the
educational attainment, with a number of affluent program.
households and conversely factory workers / The overall strategy of COMBI in
students occupying respective ends of the tackling dengue in Sections 3 and 4 Bandar Baru
spectrum. The main dwellings are double storey Bangi was implemented as follows:
link houses, with a substantial number of With regard to Public Relations and
bungalows as well as apartment/ factory hostel Advocacy cum Administrative Mobilization, the
type of accommodation. Hulu Langat Medical Officer of Health ordered
Bandar Baru Bangi arose in the past 3 the mobilization of district health staff
decades with the opening and development of the particularly the Health Inspectors and Public
Universiti Kebangsaan Malaysia (UKM) Health Assistants to assist the volunteers.
campus. Hence the vast majority of residents are Government agencies with related interests in
career people from various parts of Malaysia dengue prevention in Bandar Baru Bangi such as
whose days are normally engaged in work the Kajang Municipal Council (the local
commitments throughout the Klang Valley, and authority responsible for sanitation and dengue
whose weekends are spent away from home. control) and Selangor State Development
Hence time is at a premium, a factor which Corporation (as the area developer and land
weighed heavily in our DILO and MILO controller) were informed and invited to
deliberations. participate. Consent was sought from the District
Most of the residents were familiar with Education Office in order to enlist the
the association between dengue and their cooperation of 4 local schools. We also liased
neighbourhood, and had a rudimentary grasp of with the local police regarding security
the how dengue occurred, which helped assistance.
tremendously in our TOMA, NOSA and other As part of our Community Mobilisation
analyses. efforts, we commenced the selection of
After considering the above factors and approximately 150 – 200 local volunteers from
studying the Aedes life cycle, the overall goal the target community to form 20 “Anti Dengue

5. Volunteer Teams” who would visit the premises establishing a Residents COMBI Committee
on foot fortnightly to impart the novel anti was achieved on 1st March 2004 where 20 local
dengue message and inspect for breeding (Aedes residents were briefed by the Hulu Langat
Surveys). A further contingent was invited to Medical Officer of Health. Training of a total of
form 1 – 2 roving “Anti Dengue Scooter Teams” 172 volunteers was completed on 18th April
to promote the same message. To recruit and 2004.
oversee the activities of these volunteers, we After several postponements due to
canvassed for certain highly committed national elections and various holidays, the
volunteers to form a Residents’ COMBI Aedes Surveys finally commenced on 23rrd May
Committee. 2004. The distribution of student worksheets and
In keeping with COMBI experience placement of advertising media was
elsewhere, we concurred that students would be implemented concurrently. Volunteers
ideal for Personal Selling within their own accompanied by health staff visited homes in
homes and circle of friends. Hence the their respective areas every 2nd and 4th Sunday of
involvement of the 4 local schools ; teachers the month. Volunteers were issued uniforms and
would distribute worksheets to students in Year identification cards. Their mission was to
4 and 5, as well as Form 1 and 2 who would act distribute pamphlets and torches while
as ‘personal sellers’ to spread the message in instructing residents on the new practice, as well
their respective families as well as perform the as to inspect the premises for larvae samples
desired ‘suluh & basuh’ practices. which would be sent for official analysis and
For advertising and promotion media, confirmation. To enhance receptiveness towards
we used pamphlets, bunting, t-shirts, newspaper the program, a temporary halt on compound
inserts, mobile public announcements etc. We fines for detected breeding was announced. The
also planned an Inauguration Ceremony, to be front doors of premises visited were tagged with
officiated by the local Member of Parliament adhesive cards which were replaced in different
(MP) as further means of publicity. colours monthly, to denote successive visits and
In comparison to the COMBI program aid coverage.
in Johor Bahru, the Bandar Baru Bangi program The climax of the campaign was the
was of a significantly much smaller scale. In Inauguration Ceremony held in a local school
terms of client volume , the most convenient and field for high visibility on 7th August 2004. Apart
prominent place frequented by the residents of from the presence of the local MP, added
Sections 3 and 4 was simply the local health publicity was gained through the hosting of a
clinic. We therefore used Klinik Kesihatan colourful themed run “Larian Suluh Suluh,
Bandar Baru Bangi for our Point –of- Sale Basuh Basuh” involving t-shirt clad
Promotion ie. incidental promotion of the schoolchildren running escorted through their
COMBI message to patrons coming for other neighbourhood, chanting the slogan and waving
reasons. slogan embossed balloons.
Having determined the overall strategy
and specific behavioural goals, the next step was RESULTS
designing the appropriate logo and selecting the
appropriate media to carry the message. This and Over the 16 weeks, a total of 2458
other budgetary considerations was purview of premises or 92.2% of the total available were
the Vector Unit, Selangor State Health visited and inspected at least once. Of those, a
Department. The purchase of bunting (danglers), further 1923 (78.2%) were visited and
stickers, t-shirts, pamphlets, caps, vests, kitbags, reinspected a second time. Premises not
torchlights, batteries, student worksheets and inspected were mainly locked vacant premises
stationery for distribution among an estimated awaiting tenants or buyers, while premises not
3000 households and program volunteers was reinspected were those whose occupants were
accomplished from November 2003 to January out. Fig. 1 illustrates the number of premises
2004. visited per Aedes Survey.
Next, a working committee at district The reduction in the number of
health office level and chaired by the Hulu premises inspected during the second, third and
Langat Medical Officer of Health was set up on fourth surveys (on 23.5.04, 6.6.04 and 27.6.04
25th February 2004. This committee was tasked respectively) as compared to the first survey (on
with the distribution of the program related items 23.5.04) was attributed to late starting times.
and training of volunteers. The critical step of This in turn resulted from the need to redistribute

6. the teams prior to departure in order to i) focus inspected on the final Aedes Survey on
on problem areas arising during preceding 12.9.2004 as the survey was concluded early to
surveys and ii) to ensure equal manpower in the allow for a farewell gathering of volunteer.
event of absenteeism. Only 312 premises were
Ae de s Surv e y
1000 898 916
No. Of Premises
800 695
566 574
600
420
400 312
200
0
23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04
Sur ve y Date
Fig.1: Number of premises inspected on each Aedes Survey
50 43
No. Of Premises
40
30
18
20 13 15
8
10 3 3
0
23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04
Su r ve y Date
Fig.2: Number of premises with larvae breeding detected per Aedes Survey
Fig. 2 demonstrates a gradual reduction in reduction is most marked between the first and
premises found to have larvae breeding. The second surveys.

7. 6
5
5
Aedes Index
4 3.2
3
3 2.6
2
0.87 1 0.96
1
0
23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04
Sur ve y Date
Fig.3 Reduction in Aedes Index in COMBI program area during program period
Fig. 3 displays the obvious downward The Breteau Index (Fig.4) in sections 3
trend of the Aedes Index with successive and 4 of Bandar Baru Bangi closely mirrored the
surveys. Aedes Index .
6
5
5
Breteau Index
4 3.5
3 3
3
2 0.87 1 0.96
1
0
23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04
Surve y Date
Fig.4: Reduction in Breteau Index in COMBI program area during program period
Fig. 5 provides a breakdown on number of larvae Surveillance program in Section 3 Bandar Baru
by species type. A. Albopictus appears to Bangi. Ovitrap samples despatched to the Sg.
predominate. Further verification of specie types Buloh Public Health Lab confirmed the above
was obtained by the concommitant epidemiologic distribution of Aedes species.
implementation of the Ovitrap Sentinel

8. 50
A. Aegypti
40
15 A. Albopictus
30
20 2
28
10 5 20
16 3 2
8 9
0
23.5.04 6.6.04 27.6.04 1 .7.04
1 25.7.04 15.8.04 12.9.04
Survey Date
Fig.5: Number of samples of Aedes larvae (by species) detected per Aedes Survey
14 12
12
No. Of Samples
10
8 7
6 4
4 2
2 1
0 0
0
23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04
Survey Date
Fig.6: Number of samples of indoor breeding detected per Aedes Survey
Figs. 6 and 7 illustrate the distribution
of breeding within the visited households. Total
number of breeding cases was 107. Of these,
24.3 % (n = 26) or 1 in 4 affected households
had breeding inside the house. Examples of the
types of containers implicated are provided by
Tables 1 and 2.

9. Numbe r Of Sample s Of Outdoor Bre e ding
De te cte d Pe r Ae de s Surv e y
35 31
30
No. Of Samples
25
20 16
15 11
9 9
10
2 3
5
0
23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04
Survey Date
Fig. 7: Number of samples of outdoor breeding detected per Aedes Survey
Table 1. Number Of Outdoor Breeding Cases By Type Of Container
Flower Plastic Hardware
Pots / Water Gardening And Landscape
Container Unused
Bases / Storage Items Painting / Mini Others
Type Tyres
Aquatic Containers (various) Items waterfall
Plants (various) (various)
No. Of
Breeding 33 24 7 6 4 3 4
Cases
% of
Total 40.7 29.6 8.6 7.4 4.9 3.7 4.9
(n=81)
Table 2. Number Of Indoor Breeding Cases By Type of Container
Plastic
Bathroom Flower Pots
Water Refrigerator
Container water / Bases / Toilet
Storage Condensation Others
Type trough Aquatic Cisterns
Containers Trays
(kolah) Plants
(various
No. Of
Breeding 13 6 3 2 1 1
Cases
% of
Total 50.0 23.0 11.5 7.7 3.8 3.8
(n=26

10. Fig. 8 describes the attendance of so long as volunteers produced their Identity
volunteers as recorded at each survey. Note that Cards for registration and were attired in the
the figures do not necessarily represent the same official uniform.
people each week as substitutions were allowed
Atte ndance Of ADVT M e mbe rs Pe r Ae de s
Surv e y
160 149
135
140 121
No. Of Attendees
120 101 97
100 82
71
80
60
40
20
0
23.5.04 6.6.04 27.6.04 11.7.04 25.7.04 15.8.04 12.9.04
Survey Date
Fig. 8 Attendance of ADVT members per Aedes Survey
DISCUSSION and investigated, are recorded generically under
the general category of Bandar Baru Bangi only.
Ideally, it would have been appropriate Devising a single behavioural goal for
to be able to compare the Aedes Index trend in dengue control which is universal enough to be
Sections 3 and 4 during the specific 16 week applicable to as wide a range of premises and a
program period with the Aedes Index trend for large a geographical area as possible is a
the same sections during the same period in 2003 mammoth challenge. We were fortunate in being
or 2002. However, there had been no previous able to identify a fairly common theme recurring
Aedes Survey pertaining specifically to Sections throughout the target households and use it to
3 and 4 for that particular 16 week period to good effect. Although we believe it is possible to
produce such data. extend the same, unmodified goal to other
Likewise, it was not possible to obtain sections of Bandar Baru Bangi, the same may
data on Aedes Indices for the other neighbouring not necessarily be true of the entire Hulu Langat
sections of Bandar Baru Bangi for purposes of district, especially in industrial and
comparison against sections 3 and 4 during the manufacturing areas, where high rates of worker
program period. This is because, with most transmigration and different infrastructure /
available manpower committed to Aedes Surveys building composition exist.
in the two sections every fortnight, it was not In accounting for human nature it would
feasible to assemble additional teams for be difficult to discount the possibility of the
ancillary purposes. This takes into account other confounding properties of the Hawthorne Effect
10
ongoing labour intensive activities including as being partially responsible for the initial
fogging, Food Quality Control operations and decline in breeding indices. The Hawthorne
Sanitary Water Supply and Environmental Effect in its simplest form states that when
Hygiene activities. people know they are being measured, they
In terms of VEKPRO data for clinically modify their behaviour. The sharp decline in
reported cases of dengue fever/ dengue number of premises found to have larvae with
haemorrhagic fever, it was not possible to each subsequent week (see Fig. 2), particularly
retrospectively isolate the number of cases between the first Aedes Survey (23.5.04, n = 43)
specifically from Sections 3 and 4 for the same and the second (6.6.04, n = 13) may indeed be
16 week period in 2003 or 2002. This is because due to people hastily ridding their homes of
all cases from individual sections, once reported larvae in anticipation of the arrival of the

11. ADVTs, rather than eager acceptance of the new strengthen the case for the approach adopted by
behaviour. Despite the moratorium on the the “Suluh Suluh, Basuh Basuh” theme.
issuing of compound fines, the perceived One of the greatest difficulties
embarrassment of having one’s volunteer encountered with such a major community-based
neighbour discovering Aedes in one’s home volunteer-dependent program lasting over a
would motivate most people. However it is protracted period is regular attendance. At no
viewed though, the final indisputable outcome time was the program able to muster its full
remains that the there was a persistent decline in complement of 172 volunteers. As shown in Fig.
breeding detected after the first survey because 8, attendance began declining after the third
something motivated the residents to inspect survey onwards. The final attendance (n = 71)
their homes, and continue inspecting for 15 was less than half of that on the first day (n =
weeks afterwards, as per the stated goal. 149). Most volunteers averaged 3 – 4 surveys.
Therefore only sustainability remains the issue. The fact of the matter is that any COMBI
The near term success of the program is program is a long drawn out affair and demands
succinctly reflected in Figs. 4 and 5. The total heavily on the sacrifices of those involved. When
reduction in breeding incidence at the one considers that the majority of Bandar Baru
culmination of the 16 week period was Bangi residents are extremely busy citizens for
approximately 80%, far in excess of the 30% whom weekends especially Sundays may be the
target set out as the initial goal. While the short only leisure time available to spend with loved
term success of COMBI appears to be amply ones, visiting relatives or pursuing some
demonstrated, its sustainability in the long term recreation, then the sacrifice of 3 – 4 alternate
remains to be seen. It is premature to draw any Sundays appears generous indeed. When the
long term conclusions from the Bandar Baru distractions of intervening school and public
Bangi experience. However, given the holidays are factored into the 16 week period, the
receptiveness of the community to the program ability of the program to maintain its momentum
thus far, it should be fair to presume that the deserves acknowledgement.
campaign has had a positive influence on the The frequent migration of temporary
awareness threshold of the residents, and only residents such as college students, factory
occasional reminders in the form of periodic contract workers, and young working adults in
announcements, flyers or ADVT visits are and out of the Bandar Baru Bangi remains a
needed to prompt the continuation of the “Suluh threat to the long term viability of COMBI. Such
Suluh, Basuh Basuh” habit. migrations would dilute the pool of initial
It is interesting to note, that during the responders to the program. To allow for such
COMBI program period, there was a total of 50 unavoidable attrition, the message of the COMBI
cases of clinically suspected dengue fever/ program would have to redelivered to these
dengue hemorrhagic fever reported from the particular groups at scheduled intervals, in order
Bandar Baru Bangi area. The surrounding to sensitize the newly arrived individuals.
residential sections all had several cases reported Given this scenario, it is conceivable
in each but only one was reported from Section 4 that the regular repetition of the COMBI
and none from Section 3. This correlates message via periodic campaigns will be
exceedingly well with the reduction of the Aedes necessary to ‘keep the flame alive’ in the
and Breteau Indices in these two sections. targeted community. Such activity would need to
Confirmation regarding the commonest become an obligatory component of the calendar
source containers of breeding larvae as identified and budget for the Health Education Unit (HEU)
during our situational market analysis is given in of the district health office in charge of that
Tables 1 and 2. For outdoor breeding, flower selected area or locality. Seen in a positive vein,
pots / bases /aquatic plants (n = 33 or 40.7%) COMBI confers upon each district HEU a
was the main source followed by plastic water tremendous degree of autonomy. Because each
storage containers (n = 24 or 29.6%). The need district’s COMBI solution is supposedly unique
to store water in such containers by the residents to itself, each HEU can and should act
is the result of past experience with the proactively, without recourse to state or central
disruption in water supply. For indoor breeding, impetus. Being ground level personnel, the
the kolah accounted for half of all cases (n = 13 HEUs can observe any changing trends and
or 50%) followed by flower pots/ bases /aquatic detect waning enthusiasm in the community
plants (n = 6 or 23%). These figures further early, and thus adapt their COMBI message and

12. redefine campaign goals, without the observation, for continued confirmation that the
encumbrance of central bureaucratic machinery. stated behavioural goal has truly been adopted as
Communities require motivation to desired by the targeted community.
perform, such is the effort – reward equation.
Failure to provide the community with tangible ACKNOWLEDGEMENTS
evidence that what they’re doing is making a
difference will wither support. Because COMBI The authors wish to acknowledge the
in essence is affirmative action at the individual cooperation and generosity of the following
household level, there must exist a means to agencies and bodies in the implementation of
relay information in understandable form to this program :
those individual households that lives are being The Kajang Municipal Council, The
spared and morbidity reduced. The traditional Selangor State Development Corporation, The
channel of Village / Neighbourhood Health and Public Works Department, The Bandar Baru
Safety Committees (JKKK / JKKT) has been Bangi Police Station, The Hulu Langat District
used to varying degrees of success. However, in Education Office, Sek. Men. Keb. Jalan Tiga,
keeping with the proactive nature of COMBI, Sek. Keb. Jalan Tiga, Sek. Men Keb. Jalan
perhaps a more direct route in the form of Empat, Sek. Kebangsaan Jalan Empat, The
mailbox leaflets and such, containing monthly Bandar Baru Bangi Fire and Rescue Station and
disease figures (and breeding cases if available) finally the Honourable Chairman and Members
should be considered in future. In order to of the Residents’ COMBI Committee Bandar
preserve the sensitivity of such data, explicit Baru Bangi.
details such as dates, addresses and names could
remain classified. REFERENCES
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