Community Directed Interventions to Improve Malaria in Pregnancy Control Services in Nigeria
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Transcript of Community Directed Interventions to Improve Malaria in Pregnancy Control Services in Nigeria
COMMUNITY DIRECTED INTERVENTIONS TO IMPROVE MALARIA IN PREGNANCY CONTROL SERVICES IN NIGERIA
William R Brieger, Bright Orji, Joseph Okeibunor, Emmanuel Otolorin, Gbenga Ishola, Barbara Rawlins
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Background
Akwa Ibom State, Nigeria has high malaria transmission but is late in receiving malaria interventions
Jhpiego with support from ExxonMobil Foundation and the Akwa Ibom State Ministry of Health is working to reduce burden of malaria in pregnancy (MIP) using a two-ponged approach to reach pregnant women improving antenatal care (ANC) service quality
and community involvement through community-
directed intervention (CDI)
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Key MIP Interventions
Intermittent preventive treatment in pregnancy (IPTp) with sulphadoxine-pyrimethamine
Insecticide treated bednets (ITNs)Prompt and Appropriate malaria case
managementDelivered on the platform of
Antenatal Care
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4
Akwa Ibom State, Nigeria:Year Round Malaria Risk
CDI MP PILOT
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5
Baseline in 2007 - MIP Indicators during Last Pregnancy
11.65.8
23.3
11.7 13.8
0
10
20
30
40
50
60
Any IPTp IPT2 ormore
Slept underITN
sometime
Slept underITN every
night
Slept underITN Last
Night
Per
cen
t o
f 12
80 R
esp
on
den
ts
60% was RBM Target for 2005
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Nigeria MIP Partnership Concept and Project Design
CLINIC
MIP performance
standards developed
and implemented
COMMUNITY
MIP skills and responsibilities implemented
through community
directed intervention
Training, Supervision Mobilization,Commodities
Referrals, Records, Feedback
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Basic CDI Processes - Onchocerciasis1. Community entry by
Clinic Staff and meeting chiefs
2. Community orientation by Clinic Staff
3. Community selects community directed distributors (CDDs)
4. CDDs trained by Clinic Staff
5. Community conducts census
6. Community plans dates, approach
7. Community collects ivermectin from Clinic
8. Community distributes ivermectin
9. Monitor, treat and/or refer reactions
10. Clinic Supervises11. Community submits
treatment records to Clinic
12. Community evaluates its efforts and improves
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Community Organization for CDI in MIP Front line staff conducted community
outreach, meetings Kin groups formed basis of CDD selection Community members in 489 kin groups
(clans) chose 734 trained CDDs who were trained by front line staff
CDD kits provided – medicine, counseling cards, registers
Communities conducted mapping to identify socio-economic structures that will support MIP programming
Communities conducted census to estimate quantities of commodities required by each kindred
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CDDs equipped
•Counseling Card•Medicines (SP)•Village Register•Monthly Tally Sheet•Referral Form
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Capacity Building at State, District & Facility Levels Trained 18 State and
25 LGA core trainers on FANC, MIP, PMTCT, M&E, and CDI
Stepped down the training to 311 frontline health workers in 27 health facilities – intervention and control for basic MIP, intervention only for CDI and Performance Standards Improvement
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Quality Improvement Processes:Standards Based Management and Recognition SBM-R is a
collaborative process
Assessments are both external and self-assessments
Assessments lead to action plans
Plan implementation leads to measurable progress
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IPTp and ITN Delivery12
Service Statistics: IPTp2 Distribution
LLINsQ1 '09Q2 '09Q3 '09Q4 '09 Total
Coverage
Control Clinic 251 360 292 187 1090 18.7%
Intervention Clinic 395 384 409 385 1573 21.4%Community Distributors 2092 1246 1617 1823 6778 92.2%
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Exit Interviews at Intervention Clinics
0102030405060708090
100
Any IPTp IPTp Counsel
Round-1 (N=75)
Round-2 (N=70)
Round-3 (N=73)
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CDDs trained for ITN Distribution
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Service Statistics: LLIN Distribution
LLINsQ1 '09Q2 '09Q3 '09Q4 '09 Total
Coverage
Control Clinic 40 25 8 0 73 3.8%
Intervention Clinic 20 0 2 8 30 0.4%Community Distributors 1683 37 225 3699 5644 76.8%
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Service Statistics: ANC Attendance 2009
05
101520253035404550
At Least 1 4 or more
Prop
ortio
n of
Pre
gnan
t Wom
en
Times Attended ANC
Intervention (Pop~7349)
Control (Pop~5838)
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Service Statistics: ANC Attendees Receiving Tetanus Toxoid in 2009
0
20
40
60
80
100
120
TT1 TT2
Intervention
Control
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Improving Performance Quality
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SBM-R Scores (%) for ANC Services
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Follow-up Results21
Malaria Transmission Knowledge: Mosquitoes
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IPTp – Took SP Twice Last Pregnancy
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IPTp with SP was provided in the intervention arm at both ANC Clinics and through volunteer Community Directed Distributors. In the control area SP was made available at the clinics.
At Ikot Ebok TBA/CDD Brought Her Clients to Receive ANC Services
TBA/CDD24
Attended ANC at Local Government Clinic
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Community Directed Distributors were trained to refer pregnant women to the ANC clinic. One challenge was ANC card fee charges of N200-300.
Used ITN During Last Pregnancy
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ITN supplies were difficult to obtain. The World Bank Booster support for Akwa Ibom State was delayed and not available throughout the intervention period.
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Achievements and ChallengesAll pregnant women in intervention area
received at least I dose of IPTp and two-thirds received two doses
Quality improved but transfer of health staff trained by project slowed quality gains
Irregular stocks of commodities made ITN distribution difficult
Continued charging of user fees by local governments discourage ANC attendance
Continued motivation of health staff and CDDs was required
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Advocacy: State Commissioner, LGA Chairs and Legislators
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Success stories
ANC attendance improves at all facilities
CDDs remember to track net useImprovement on community linkages
with facilities (CDDs obtain MIP commodities and information and share with community members)
Community and opinion leaders happy with project, demand for inclusion of other members of the community.
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Key Lessons for CDI
CDI is a practical way to reach women who would not normally have attended ANC and be protected from malaria
Even if health services charge fees and discourage ANC attendance, health staff play a crucial role in community mobilization to guarantee malaria control services
Constant advocacy and encouragement are needed
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Next Steps
Refresher training of current CDDsContinued advocacy for free services
and commodity stocksTraining of health staff in additional
facilities in both intervention and control local governments
Training of CDDs in Control Communities
Thank you32