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Archive for "CHW"



CHW &Integration &IPTi &IPTp &Malaria in Pregnancy &Maternal Health &Seasonal Malaria Chemoprevention Bill Brieger | 12 Dec 2022

Malaria Chemoprevention in 2021 as Seen in The World Malaria Report of 2022

Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, reminds us in this year’s edition of the World Malaria Report (WMR 2022) that, “Although hard hit, most countries held the line and were able to maintain services to prevent, detect and treat malaria – a remarkable feat in the midst of a pandemic. Nonetheless, more than 600 000 people still die of malaria every year – most of them children. Even with the heroic efforts to maintain services during the pandemic, malaria control efforts face many hurdles in addition to the already significant COVID-related disruptions and other health system challenges.”

Even though there was an increase in cases between 2020 and 2021, there are now more strategies in the malaria control and elimination toolkit than ever before. One in particular is an updated take on an old concept of chemoprophylaxis, which fell out of use due to mounting drug resistance. Years of research with pregnant women and young children led to the development over time of using regularly scheduled treatment doses of malaria medicines as chemoprevention. Intermittent Preventive Treatment for pregnant women (IPTp) and Seasonal Malaria Chemoprevention for young children, both targeted to appropriate epidemiological settings, are now common. Countries are also exploring IPT for children in other settings.

We were, therefore, curious what the current WMR shares on chemoprevention initiatives. Specifically, the WMR summarized WHO recommendations as follows: “Updated guidelines provide recommendations on intermittent preventive treatment of malaria in pregnancy (IPTp), perennial malaria chemoprevention (PMC) and seasonal malaria chemoprevention (SMC), intermittent preventive treatment of malaria in school-aged children (IPTsc), post-discharge malaria chemoprevention (PDMC), mass drug administration (MDA) and elimination.”

In summary, WMR 2022 notes that, “The average number of children treated per cycle of SMC increased from about 0.2 million in 2012 to almost 45 million in 2021,” and “Using data from 33 countries in the WHO African Region, the percentage of IPTp use by dose was computed. In 2021, 72% of pregnant women used ANC services at least once during their pregnancy. About 55% of pregnant women received one dose of IPTp, 45% received two doses and 35% received three doses.” This is not just progress over time, but also represents an expansion targets and work required for success. For pregnant women the increase represented a change in target from only two doses during pregnancy to a minimum of three. Starting with pilot efforts, SMC now covers children in 15 countries.

The targeted three doses for IPTp shows that two thirds of women who register for antenatal (prenatal) care (ANC), fail to achieve full coverage. Stronger collaboration is needed between malaria control and maternal health programs to ensure that pregnant women actually attend ANC and do so early and often enough to receive 3 monthly doses minimum in their second and third trimesters. More emphasis is needed on community IPTp distribution, since we know that community health workers have been crucial in achieving SMC as well as integrated community case management efforts.

Similar challenges exist for SMC as research looks into whether additional doses are needed based on mosquito breeding and malaria transmission season factors in endemic countries. Adding extra months to the program will tax resources, but also save lives.

Both maternal and child efforts at chemoprevention will need to address research that first shows increasing resistance to the common medicines used, and the potential for introducing new drug combinations in light of that resistance. Challenges here reflect another aspect of SMC, the need for CHWs to guarantee that on any given distribution round, three doses on medicine are required. Recent reports show that within any given round, community adherence to SMC has been good. We need to apply those lessons to IPTp when the regimen changes.

Ultimately, chemoprevention has proven to be an important life saving tool. The challenges of multiple contacts and doses that lead to success rely not only on having effective medicines, but also on culturally appropriate behavior change strategies and well-funded efforts to strengthen the health systems that deliver preventive treatments.

 

 

Antenatal Care (ANC) &CHW &IPTp Bill Brieger | 19 Nov 2021

Changes in ANC Attendance and IPTp Uptake after Introduction of Complimentary Community Interventions

The TiPToP malaria in pregnancy project of Jhpiego and Unitaid has been aiming to increase coverage of Intermittent Preventive Treatment of malaria in pregnancy. The abstract below shares experiences from Nigeria, one of 4 TiPToP countries, is being presented at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting. Described are Changes in antenatal care (ANC) attendance and uptake of intermittent preventive treatment of malaria in pregnancy (IPTp) after introduction of community-based distribution of IPTp in three local government areas (LGA) in Nigeria. See Author List below.

In Nigeria, community health workers (CHWs) from three LGAs were engaged to introduce community delivery of IPTp (C-IPTp) with quality-assured sulfadoxine-pyrimethamine to prevent malaria. This approach, which complements IPTp delivery during ANC visits, was carried out in Ohaukwu, Akure South, and Bosso LGAs. C-IPTp was introduced in September 2018 in Ohaukwu and in December 2019 in Akure South and Bosso.

A total of 1,062 CHWs were trained on early identification of pregnant women, referral to ANC, IPTp administration, and use of mobile phones to capture and report data. CHWs conduct household visits, provide malaria health education, refer and encourage pregnant women to attend ANC, and provide IPTp.

Routine facility data from 2017 before introduction of C-IPTp were compared with 2020 facility and CHW data to understand the effect of C-IPTp across the LGAs. Before C-IPTp, 43% of the estimated number of pregnant women in these areas attended at least one ANC visit as compared to 57% in 2020 (p<.05).

Attending at least four ANC (ANC4) visits increased in Ohaukwu by ten percentage points to 29% in 2020 (p<.05). In Akure South, ANC4 remained steady Bosso pre-C-IPTp data on ANC4 visits were of too poor quality to conduct a meaningful analysis. Though this project focused on C-IPTp, it also resulted in statistically significant increases in IPTp distribution during ANC visits.

From 2017 to 2020, coverage of IPTp doses 1, 2, and 3 all saw increases across the three sites: IPTp1 increased from 54%?to 57%; IPTp2 from 36% to 42%; and IPTp3 increased 20 percentage points from 5% to 25%. Of pregnant women receiving all doses of IPTp, 39% did so through ANC with 61% receiving IPTp from CHWs.

These data suggest that in addition to contributing to overall increases in IPTp coverage, C-IPTp may also contribute to increases IPTp delivery in ANC and ANC attendance.

AUTHORS LIST:

Herbert Enyeribe Onuoha1, Bartholomew Odio1, Christina Maly2, Lawrence Nwankwo3, Folayan Waheed Adewale4, Elizabeth Njoku1, Oniyire Adetiloye1, Orji Bright1, Emmanuel Dipo Otolorin1, Elaine Roman2 — 1Jhpiego, Abakaliki, Nigeria, 2Jhpiego, Baltimore, MD, United States, 3Ebonyi State Ministry of Health, Abakaliki, Nigeria, 4Ondo State Ministry of Health, Alagbaka, Akure, Nigeria

Antenatal Care (ANC) &Case Management &CHW Bill Brieger | 19 Nov 2021

The role of community health workers in malaria control in in Cote d’Ivoire

Save the Children is sharing a wealth of information on programs at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting. Here is an abstract from one of their malaria efforts. See Author List below.

Since the Alma Ata Declaration in 1978, international efforts to improve access to primary health care have shifted towards the deployment of various types of community health workers (CHWs). This study aimed to assess the contribution of CHWs and identify challenges faced, which may impede malaria control efforts in Cote d’Ivoire.

A mixed-methods assessment was conducted in 16 health districts. A total of 1,922 community members were surveyed using a structured questionnaire. Qualitative data was gathered through 48 focus group discussions with pregnant women and mothers of children under 5, women’s groups and men and 132 in-depth interviews with government and implementation stakeholders, community members, caregivers and community leaders. Thematic content analysis around the key themes of the project implementation was used.

Over 50% of participants knew the CHW. The reported services provided by the CHW were diagnosis and treatment (47.4%), referrals to the health center (17.3%), education (14.1%), other medicines (12.2 %), and support at the health center (6.4%).  The benefits to children U5 reported by the participants were home-based treatment (22.9%), children get less sick (20.4%) and are in good health (14.7%), children suffer less from malaria (14%), and families spend less money on treatment (12.8%).

Additionally, up to 53% of pregnant women who had stopped attending ANC started to go again after being sensitized by the CHW. The main challenges reported by community members in accessing CHW services were non-coverage of all households by CHWs (13.6%), stock-outs of ACTs (10.9%), treatment provided is mostly for children U5 (10.4%). Distances between the CHW and the households were a major barrier to malaria treatment by CHWs.

CHWs were well perceived by the communities they serve. Expanding CHW coverage as well as CHW’s role to diagnose and treat adults is necessary for malaria control. Additionally, the lack of consistent supplies necessary for day-to-day activities, like ACTs and RDTs, must be addressed at the system level. Supply chain strengthening in Cote d’Ivoire, including forecasting and monitoring, is vital for CHWs to be effective.

AUTHOR LIST

Edouard C. Balogoun1, Manasse N. Kassi1, Philomène A. Beda1, Serge B. Assi2, Jacob Y. Agniman1, Théodore D. Doudou3, Rodolphe H. Yao4, Adama Z. Ouattara5, Joel Koffi1, Aristide E. Kouadio1, Apollinaire N. Kouadio1, Paul Bouey6, Sara Canavati6, Eric Swedberg6 — 1Save the Children, Abidjan, Côte D’Ivoire, 2Le Programme Nationale de Lutte contre le Paludisme (PNLP), Abidjan, Côte D’Ivoire, 3Sociologue de la Santé CRD/UAO, Abidjan, Côte D’Ivoire, 4National Statistical Institute (INS), Abidjan, Côte D’Ivoire, 5Socio-Anthropologue de la Santé (CRD/UAO), Abidjan, Côte D’Ivoire, 6Save the Children, Washington, DC, United States

Capacity Building &CHW &Community &Elimination &Health Education &Indoor Residual Spraying &IPTp &ITNs &Malaria in Pregnancy &World Malaria Day &Zero Malaria Bill Brieger | 25 Apr 2021

Twenty Years of Malaria Day Observances: Jhpiego at the Forefront

In 2001 the first Africa Malaria Day (AMD) was observed. The opportunity to mark progress and exhort increased efforts for the continent continued through 2007. Then in 2008, the concept of World Malaria Day (WMD) took over, though it could not be denied that the bulk of malaria morbidity, mortality and intervention still was focused on African countries. Other countries have made progress such as the recent certification of malaria elimination in Argentina and El Salvador, but twenty years after the first AMD/WMD, Africa is still leading the way for creative, sustained intervention against the disease, despite threats to resources from economic downturns and new pandemic diseases.

Below we go straight to Africa to share activities and observances of WMD 2021 from Jhpiego’s African Malaria Technical Officers. After reading through, please watch “Jhpiego Leaves No One Behind | World Malaria Day, 2021″ on YouTube.

“Saramed” from Guinea reports that Guinea, like other countries in the world, celebrates World Malaria Day under the theme: ” Zero Malaria, Draw a Line on Malaria “. We are currently conducting the following activities:

  • Lectures and debates on malaria in medical faculties and health schools;
  • Animation of debate programs on malaria in public and private radios and televisions of the country,
  • Advocacy and sensitization of religious and other influential people
  • Carrying out a package of activities (administration of IPT to pregnant women who have missed their ANC appointment, community distribution of LLINs, screening and treatment of confirmed cases, awareness raising on malaria) in high incidence localities.

These activities is in line with the WHO approach of “high burden, high impact”.

Noella Umulisa reports that the WMD celebration took place in Eastern Province, in Bugesera district in the Mareba sector. Due to COVID-19 pandemic ,only 100 persons were invited to the event.This year’s the national theme is “Zero Malaria starts with me”.

Key activities during the event included …

  • Visit of breeding sites under sentinel surveillance
  • Visit of indoor residual spraying (IRS) sites
  • Launching of the Awareness of the population using drones on the ongoing IRS campaign in this time of COVID-19
  • Song by CHWs
  • Certificate to Integrated Vector Management (IVM) Training of Trainers who will train others up to village level
  • Speech of the Director General ,the guest of honor.

From Burkina Faso, Yousseff Sawadogo and Moumouni Bonkoungou shared photos of the celebration that featured a giant Insecticide-Treated  Net, a speech by the US Ambassador, a malaria song composed by a nurse, an official speech by the President of the National Assembly, and national recognition given to one of the current Jhpiego staff members, Thiery Ouedraogo, who at one time also served as director of the national malaria control program. He was decorated by the country’s authorities as a knight of the order of merit.

Bright Orgi from Jhpiego’s TiPToP malaria in pregnancy project in Nigeria ?? shared photos from a series of compound meetings in the community to mark WMD 2021. The meetings focused on malaria prevention and treatment. Provided opportunities to rural communities to ask questions on malaria issues. Here we can see that observance of WMD must be taken to the people who actually suffer from malaria and need to be actively involved in its solution. Deo Cibinda from the Democratic Republic of the Congo share photos of a national celebration, seen to the left.

Finally, As Kristen Vibbert noted, “These are such amazing World Malaria Day stories. I’m so heartened to see all of these great country efforts to remind everyone of how the fight against malaria must continue despite the Covid-19 pandemic.”  Charles Wanga tweeted, “We know how to defeat #malaria. But that’s not enough. We must do more to save pregnant women and children from the deadly scourge. This #WorldMalariaDay and everyday, because@Jhpiego leaves no one behind in our fight to #EndMalaria for good in Africa, and everywhere”

Agriculture &Case Management &CHW &Essential Medicines Bill Brieger | 17 Feb 2021

Frederick Olori Oshiname (1954-2021): Malaria and Tropical Health Researcher

Fred Oshiname has been my student, colleague and friend for 35 years. I was fortunate to supervise his MPH dissertation and PhD thesis when I was at the University of Ibadan. He has been a major partner in many tropical disease and malaria research projects over the years. His untimely passing deprives us of more fruitful years of malaria research in Nigeria.

Below is a brief summary of some of the malaria research projects/teams for which Fred was a partner. At his memorial service friends and colleagues commented on the valuable role he played in any team in helping the group focus, plan and produce quality work. The articles mentioned below are examples of such work.

One of Fred’s first contributions was designing and implementing training for patent medicine vendors, a major, though informal source of primary care for malaria and other diseases in Nigeria. This training demonstrated that medicine shops could become a reliable part of malaria treatment programs.

Subsequently, he was part of a team that helped develop a community-based essential medicine revolving fund for community health workers. CHWs were found to be another important component of malaria control.

Continuing on the theme of medicines for malaria, Fred was part of a team that examined how perceptions of medicine efficacy and appropriateness were influenced by the color of the drugs. This study aimed at determining perceptions of both consumers and sellers of medicines at the community level to learn about color likes and dislikes that might influence acceptance of new color-coded child prepacks of antimalarial drugs

As part of another team, Fred examined malaria knowledge and agricultural practices that promote mosquito breeding in two rural farming communities in Oyo State, Nigeria. The team learned of the urgent need to engage farmers in meaningful dialogue on malaria reduction initiatives including the modification of agricultural practices which favor mosquito breeding.

He also participated in a multi country team that studied the Feasibility of Malaria Diagnosis and Management at the community level in Burkina Faso, Nigeria, and Uganda: A Community-Based Observational Study. An important lesson learned by the group was that provision of diagnosis and treatment via trained CHWs increases access to diagnosis and treatment, shortens clinical episode duration, and reduces the number of severe cases.

That team went on to conduct Training Community Health Workers to Manage Uncomplicated and Severe Malaria: Experience From 3 Rural Malaria-Endemic Areas in Sub-Saharan Africa. The training and related supervision resulted in improved diagnosis and treatment of uncomplicated and severe malaria. Furthermore, this training was connected with greater acceptability of community health workers by the communities where they worked.

We trust that these endeavors have made a major contribution to knowledge and the field of malaria control.

Antenatal Care (ANC) &CHW &IPTp Bill Brieger | 16 Nov 2020

Increasing Access to Malaria in Pregnancy Services through Community Health Units and Enhanced Supportive Supervision of Community Health Volunteers

Donald Apat and colleagues address the importance of community health workers and appropriate supervision in their study from Kenya. This was presented today at the 69th Annual Meeting of American Society of Tropical Medicine and Hygiene which is virtual. See their findings below.

According to the 2018 Kenya malaria program review, the uptake of malaria in pregnancy interventions by rural communities in Kenya remains low due to late first presentation to antenatal care (ANC), leading to sub-optimal intermittent preventive treatment in pregnancy (IPTp) coverage. Poor healthcare provider-client communication and low investment in advocacy, communication, and social mobilization contribute to late ANC presentation.

Kenya is using community health volunteers (CHVs) supervised by community health assistants (CHAs) in community health units (CHUs) to increase demand for ANC services and uptake of IPTp but tracking of progress is hampered by a lack of accurate data on the number of estimated pregnancies at the sub-national level and poor household coverage by CHVs at the community level.

In July 2019, Impact Malaria supported malaria-endemic Teso South sub-county of Busia county with the reorientation of 354 CHVs (92%) and 14 CHAs (100%), to identify and track pregnant women at the household level within the government established CHUs, provide social and behavior change communication messages, and enhance monthly supervision and reporting by CHAs.

CHVs identified and tracked 917 pregnant women from 32,758 (89.6%) households and identified and referred 273 ANC defaulters. We compared the uptake of IPTp before intervention (January to June 2019) and during the intervention (July to December 2019) using programmatic and Kenya health information system (KHIS) data.

At pre-intervention, 32,898 (90%) households were visited, with 2,160 new ANC visits and 5,342 ANC revisits. During the intervention period, 35,910 (98.3%) households were visited with 1,934 new ANC visits and 5,904 ANC revisits. Uptake of IPTp1 increased from 83.6% to 92.6%; IPTp2 from 73.5% to 87%; and IPTp3 from 51.9% to 75.4%.

Enhanced supervision of CHVs by CHAs to conduct and improve household visits enabled identification and referral of ANC defaulters and contributed to increased IPTp uptake. Supportive supervision and optimal CHU coverage in tracking pregnant women if conducted routinely may provide accurate denominators to track IPTp coverage and inform targeted interventions.

Authors and Affiliations

Donald Apat1, Willis Akhwale1, Moses Kidi1, Edwin Onyango2, James Andati1, Hellen Gatakaa1, Augustine Ngindu1, Lolade Oseni3, Gladys Tetteh3, Daniel Wacira4
1PMI-Impact Malaria, Nairobi, Kenya, 2Department of Health, Busia County, Kenya, 3Jhpiego, Baltimore, MD, United States, 4PMI, Nairobi, Kenya

CHW &Community &IPTp &Malaria in Pregnancy Bill Brieger | 16 Nov 2020

Community health workers’ sex and variation in uptake of malaria in pregnancy services in Ebonyi State, Nigeria

Ebonyi members of Integrated Health Data Management Team (IHDTM) providing mentorship to HCWs during RDQA visit to Akpaka

Bartholomew Odio et al. work with CHWs who promote community delivery of intermittent preventive treatment for pregnant women in Ebonyi State, Nigeria for the UNITAID/Jhpiego TiPToP Project. They shared below some of their findings from the virtual 69th Annual Meeting of American Society of Tropical Medicine and Hygiene this week. (Photos are from Bright Orji)

In Nigeria, malaria remains a high burden disease and pregnant women are among the most vulnerable. According to the 2019, World Malaria Report only 31% of pregnant women received the World Health

CHWs at data validation meeting during COVID 19 pandemic social distancing

Organization recommended minimum of three doses of IPTp with Sulfadoxine-Pyrimethamine (SP) compared to 17% in Nigeria (DHS, 2018). In order to expand the coverage of this life-saving intervention, the Transforming Intermittent Preventive Treatment for Optimal Pregnancy project engaged community health workers (CHWs) to introduce the delivery of community IPTp (C-IPTp) to eligible pregnant women, in addition to women being able to access IPTp at antenatal care in Ohaukwu district of Ebonyi State, Nigeria.

Community meeting in Bosso

As findings from studies in Nepal and Uganda showed that the sex of CHWs were correlated with uptake of iCCM services, we examined routine project data to determine if the sex of the CHWs was correlated with uptake of IPTp. Of the 462 CHWs selected, 49% were male and 51% were female and were deployed at a ratio of one CHW to 27 pregnant women. All CHWs were trained on early identification of pregnant women, referral to antenatal care and provision of C-IPTp using SP.

A trained data analyst extracted routine data from the national community health management information system for 13,733 pregnant women who received IPTp from CHWs between June and November 2019. Data abstracted included CHW sex and number of PW that received IPTp. Findings showed that female CHWs distributed 60% of IPTp1, 65% IPTp2, and 61% IPTp3 (p-value=0.00 for all comparisons). The data suggest that trained female CHWs may reach more pregnant women than their male counterparts in community directed IPTp interventions.

Authors and Affiliations

Bartholomew Odio(1), Onyinye Udenze(1), Chinyere Nwani(1), Herbert Onuoha(1), Elizabeth Njoku(1), Lawrence Nwankwo(2), Oniyire Adetiloye(1), Bright Orji(1) 1.Jhpiego, Nigeria, Abuja, Nigeria, 2.State Ministry of Health, Nigeria, Abuja, Nigeria. This is part of the TiPToP Project funded by UNITAID.

Case Management &Children &CHW &Communication &COVID-19 &Education &Gender &ITNs &Politics Bill Brieger | 13 Sep 2020

Malaria News Today 2020-09-12/13 Weekend

Recent news over this weekend included efforts at school and peer education on bednets in Ethiopia, gender inequality effects of COVID-19 and pandemics, a reduction in severe malaria in Rwanda and increased use of home based case management, and the altering of scientific reports by political appointees. Links in these summaries take one to the full story.

Effectiveness of peer-learning assisted primary school students educating the rural community on insecticide-treated nets utilization in Jimma-zone Ethiopia

Abstract: Making insecticide-treated nets (ITNs) utilization a social norm would support the global goal of malaria eradication and Ethiopian national aim of its elimination by 2030. Jimma zone is one of the endemic settings in Ethiopia. This study aimed to report effects of malaria education, delivered by students, on community behaviours; particularly ITNs. The intervention engaged students from primary schools in participatory peer education within small groups, followed by exposing parents with malaria messages aimed at influencing perceptions and practices.

Over the intervention periods, the findings showed significant improvement in exposure to and content intensity of malaria messages delivered by students. Socio-demography, access, exposures to messages, and parental perception that students were good reminders predicted ITN utilization over the intervention periods with some changing patterns. Exposing the community to malaria education through students effectively supports behaviour change, particularly ITN usage, to be more positive towards desired malaria control practices. A school-based strategy is recommended to the national effort to combat malaria.

Melinda Gates calls on Leaders to Ensure that Women, Girls are Not Left Behind in the Global Response to COVID-19

Melinda Gates has launched a paper exploring how the COVID-19 pandemic has exploited pre-existing inequalities and drastically impacted women’s lives and livelihoods. In the paper, titled “The Pandemic’s Toll on Women and Girls,” Melinda makes the case that to recover fully from this pandemic, leaders must respond to the ways that it is affecting men and women differently. She puts forward a set of specific, practical policy recommendations that governments should consider in their pandemic response—to improve health systems for women and girls, design more inclusive economic policies, gather better data, and prioritize women’s leadership.Writing in the paper, Melinda describes how previous disease outbreaks, including AIDS and Ebola, tend to exploit existing forces of inequality, particularly around gender, systemic racism, and poverty.
Melinda concludes, “This is how we can emerge from the pandemic in all of its dimensions: by recognizing that women are not just victims of a broken world; they can be architects of a better one.

Severe malaria drops by 38% in Rwanda

In its annual Malaria and Neglected Tropical Diseases Report, the Ministry of Health says that the national malaria incidence reduced from 401 cases per 1,000-person in 2017-2018 fiscal year to 200 cases per 1,000-person in 2019-2020. According to the report, 4,358 cases of severe malaria (representing a 38 per cent reduction) were reported at the health facility level compared to 7,054 in 2018-2019. The decrease in malaria deaths is attributed to home based management interventions, the free treatment of malaria for Ubudehe Categories I and II and the quality of care at health facility level.

There has also been a steady increase of proportion of children under 5 and above plus adults who are seeking care from 13 per cent to 58 per cent in 2015-2016 and 2019-2020 respectively. “This indicates that interventions such home based treatment of children and adults that contributed to early diagnosis and treatment have been successful in decreasing the number of severe cases and consequently the number of malaria deaths,” the report indicates.

Political appointees sought to alter CDC scientific reports so they don’t contradict or undermine the president

Caputo (a US presidential appointee) and his communications staff have worked to delay CDC reports that contradict President Donald Trump’s rhetoric. One publication was held back for about a month, according to Politico, for recommending against the use of hydroxychloroquine, a malaria drug touted by the White House as a potential cure for COVID-19.

The reports, written by career scientists, are known as the Morbidity and Mortality Weekly Reports, and according to Politico, are used to “inform doctors, researchers, and the general public about how Covid-19 is spreading and who is at risk.” Jennifer Kates, of the Kaiser Family Foundation’s global health work, who has relied on past reports, told Political they are “the go-to place for the public health community to get information that’s scientifically vetted.” Alexander (a presidential appointee), in this missive, said any future reports related to the coronavirus “must be read by someone outside of CDC like myself.”

CHW Bill Brieger | 21 Nov 2019

Evaluation of the Contribution of Community Health Workers (CHWs) in improving Health Facility Attendance

The following colleagues addressed the role of Community Health Workers in promoting antenatal care in Chad: Naibei Mbaïbardoum, Ali Soumaine Baggar, Djimodoum Moyreou, Mamadjibeye Joseline, Noella Umulisa, Elana Dhuse, and Kodjo Morgah.  (Affiliation: Improving the Quality of Malaria Control Services in Chad and Cameroon program/Jhpiego, and the Provincial Health Delegation of the Logone Oriental Region, Chad). Their work entitled “Evaluation of the Contribution of Community Health Workers (CHWs) in improving Health Facility Attendance, particularly for timely ANC attendance and IPTp services, in six districts in the Provincial Health Delegation of the Logone Oriental Region in Chad” was a poster presentation at the 68th Annual meeting of the American Society of Tropical Medicine and Hygiene.

Malaria in Chad

Malaria in pregnancy causes up to 10,000 maternal deaths each year and contributes to high rates of maternal morbidity especially in first-time mothers Malaria is a leading cause of morbidity and mortality in Chad with ~2.2 million cases of malaria occur every year in Chad. In 2017, Chad national data revealed that malaria represented 36% of outpatient consultations and 30.8% hospitalization cases. Incidence of malaria in the Logone Oriental is 122/1000.

Malaria related death rate among pregnant women decreased from 11.1% in 2013 to 4.3% in 2017. In 2017, the coverage for the first dose of intermittent preventive treatment (IPTp1) was 81%, while IPTp3 and IPTp4 were only 29% and 9%, respectively .

Community Health Strategy in Chad

Chad introduced community health interventions in 2014. Malaria community interventions consist of promoting malaria prevention and raising awareness. Jhpiego introduced the CHW reference sheet as a tool that links the community with health facilities. Jhpiego trained CHWs and their supervisors on how to use the forms in referral and counter-referral within the community.

The “Improving the Quality of Malaria Control Services in Chad and Cameroon” project, implemented by Jhpiego, has trained, equipped and supported 109 community health workers in the Logone Oriental region To improve health facility attendance by the population, starting in April 2017, 77 of the 88 trained CHWs referred suspected cases of malaria and pregnant women for ANC/IPTp services using referral and counter-referral forms.

The objective of the evaluation is to assess the contribution of the CHWs in the improvement of health facility attendance particularly for timely ANC and IPTp services, using community-based referrals.

The Evaluation/Study question was “What is the contribution of CHWs in increasing community access to preventative care treatment for malaria, especially among pregnant women and children under five?” From Feb-Mar 2019, Jhpiego conducted a records review of the following  tools:

  • Facility Reporting forms
  • Referral forms and counter-referral forms
  • Registers of ANC and other consultation visits
  • CHW supervision reports conducted by supervisors in health centers

The referrals of 72 CHWs in six districts In Logone Oriental region were reviewed for the period of Jan-Dec 2018. There were 72 CHWs.

Cases referred to health centers. In total, 1153 persons were referred by the CHW. 59.9% (691/1153) of those referrals arrived at the health centers. Pregnant women referred for ANC/IPTp services were the group who reached health centers at the highest rate, followed by children under 5.

Conclusions and Recommendations

Findings of this evaluation show that CHWs could play a significant role in improving health facility attendance, increasing ANC/IPTp compliance at health centers in six districts in the Logone Oriental region. So far, this finding has made the following possible:

  • Review the mapping of CHWs to redefine the population to be covered
  • Update all CHW tools (registers, supervision grids, report cards)
  • Make orientation maps for the pregnant woman

One of the major challenges to scaling up the use of CHWs in strengthening linkages between community-level interventions and facility services is the size and geographical scope of the population covered by CHWs. CHW registers and reference sheets are not consistently completed as required, and supervisors do not always check on this

Re-mapping of CHWs is needed following national norms to include Number of villages, households, pregnant women to be covered by CHWs. An Increase the number of CHWs is also required with a focus on recruiting female CHWs to improve communication among women that encourages ANC attendance. The health services should strengthen existing supportive supervision system from health centers to CHWs to ensure that registers and reference sheets are consistently completed, leading to better delivery of services.

This work was supported by the had Ministry of Health, ExxonMobil Foundation, Esso and Jhpiego.

Case Management &CHW &Primary Health Care &Private Sector Bill Brieger | 04 Nov 2018

Experiences and Perceptions of Care Seeking for Febrile Illness among Caregivers and Health Providers in Eight Districts of Madagascar

Andrianandraina Ralaivaomisa, Eliane Razafimandimby, Jean Pierre Rakotovao, Lalanirina Ravony Harintsoa, Sedera Aurélien Mioramalala, Rachel Favero, Katherine Wolf, Patricia Gomez, Jocelyn Razafindrakoto, and Laurent Kapesa of MCSP/Jhpiego (Johns Hopkins University Affiliate), the Madagascar Ministry of Public Health and USAID presented their findings about febrile illness care seeking in Madagascar at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Details follow below.

Malaria Care and Treatment in Madagascar is hampered by low perception of malaria risk among caregivers. There is use of self-medication and a lack of health provider knowledge about malaria prevention and treatment in pregnant women. Low-quality care in primary health facilities is another concern (Source: WHO. 2015. Guidelines for the treatment of malaria, 3rd ed.).

As seen in the attached, Study Objectives focus on Caregivers and Pregnant Women as well as Health Providers to determine barriers to effective care seeking of febrile illnesses.

Both Qualitative and Quantitative Approaches were used. Among care seekers we conducted 16 focus group discussion sessions with 128 caregivers and pregnant women. There were also in-depth interviews with 32 pregnant women and 16 caregivers of children under 15. For Health Providers we conducted in-depth interview with 32 public and private health providers and administered 16 knowledge tests and case studies to health providers. We also reviewed logistic management information system records with 16 health

Barriers for Caregivers are seen in the attached table. Barriers were faced by both care seekers and those who did not seek care, but were more common among non-seekers.

Three tables follow that show perceptions of public sector providers, private providers and community health workers. There were positive and negative perceptions of each group of providers.

Health Provider Practices were also studied. They had low adherence to national guidelines for fever and malaria case management. Health workers reported high stock-outs rates of critical commodities (artemisinin-based combination therapy, artesunate). There was also lack of respectful care. Fortunately health provider diagnostic practices included 100% compliance with rapid diagnostic testing in cases of fever. They took temperatures and did physical exams appropriate to client’s symptoms and used microscopy at centers with local laboratory

General Bottlenecks to Timely Care Seeking still existed. There was insecurity due to political situation in some regions. Inability to pay for care or medications was common. Alternative health behaviors included seeking care with traditional healers, and self-medication. There was fear by clients of going to health facilities and inaccurate perceptions of care provided by formal health care system

Recommendations start with the need to train providers and CHWs on national treatment guidelines for managing fever in all age groups and in pregnant women. Efforts are needed to strengthen onsite provider mentoring and supportive supervision and improve respectful care of clients, especially in public sector. Since care seeking still based on cultural norms, there is need to strengthen community/family education about febrile illness dangers and advantages of timely care seeking. Communities can also consider forming “mutuelle” community insurance schemes to relieve cost of care burden.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

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