Every message counts: scientific analysis of tuberculosis communication materials in Gujarat

BACKGROUND: TB-IEC is central to India's TB elimination efforts through print and digital outputs for care-seeking, adherence, prevention, and stigma reduction. However, IEC portfolios expand without checks on whether messages are behaviorally enabling, actionable, and culturally resonant. Gujarat has produced diverse TB-IEC through government channels, creating an opportunity to examine content alignment with behavior-change constructs. This study evaluates the content, behavioral fidelity, clarity, and cultural relevance of TB-IEC materials in Gujarat, and compares performance across issuer, language, and format. METHODS: A cross-sectional content analysis was performed after IRB and State TB-Cell approvals on 375 TB-IEC items (2017-2025), compiled from state repositories, online media, and archives. Items were cataloged under National TB Elimination Programme (NTEP) thrust areas, coded using a 40-item checklist from seven behavioral and communication frameworks (COM-B, HBM, TPB, SCT, TTM, WHO-COMBI, and CDC-CCI; binary scoring), with two 5-point ratings for clarity and cultural adaptation. Descriptive and comparative analyses (chi-square tests, t-tests, one-way ANOVA, correlations) were performed in MS Excel and SPSS version 25 (p < 0.05). RESULTS: Materials were primarily print-based (84.5%), followed by video (14.4%) and audio (1.1%), with posters comprising 68.0%. Items were issued by state and central agencies in Gujarati (52.3%) and Hindi (39.5%), targeting the general public (91.2%). Mean Total Behavioral Breadth was 11.41/40. Topics covered symptoms (44.0%) and diagnosis (53.6%), while prevention topics were less common (preventive therapy 4.3%; vaccination 0.3%); stigma reduction appeared in 13.6%. Items were assessed for calls to action, credibility cues, audience testing signals, skill demonstrations, and barrier-addressing content. Format analysis showed significant differences in clarity and action-cue ratings between video and print, with format differences in adherence and social acceptance themes. Cultural adaptation and clarity ratings varied by issuer and language, while Total Behavioral Breadth remained consistent across issuers. CONCLUSIONS: Gujarat's TB IEC output during 2017-2025 was mainly print-based, with limited prevention and stigma content across formats, languages, and issuers. These findings support framework-guided IEC audits, rebalancing toward prevention and stigma reduction, and audience-tailored messaging. Expanding effective formats with clear action cues, alongside pre-testing and monitoring, may strengthen TB communication products.