Characteristics of effective village treatment assistants: the Kongwa Trachoma Project

Optimizing Trichiasis Case Finding to Attain the Elimination of Trachoma as a Public Health Problem

BACKGROUND

As national trachoma programmes increase efforts to reduce the burden of trachomatous trichiasis (TT), TT case finding and referral are critical public health programme components. Our research aimed to explore the most effective and efficient approaches to finding, referring, and managing TT cases.

METHODS

This was a prospective descriptive study, utilizing both routine programme data and primary data collection. This study compared four different approaches to finding TT cases across three different local government areas (LGAs) in Kano State, Nigeria. Each of the study LGAs was divided into four sub-units to accommodate the four different approaches.

RESULTS

The number of outreach attendees was 4795 across the four case finding approaches, and this varied hugely, with the smallest number and proportion (403, 0.26%) in settings only employing house-to-house case finding and the largest number and proportion (1901, 0.99%) when town criers were used. That said, the proportion of TT cases among people presenting at outreach was highest (32.5%) when house-to-house case finding was used and lowest (10.3%) when town criers were used. More female TT patients were found (53-70%) and had surgery (79-85%) compared to male cases, across all approaches. The average project expenditure for finding one TT case was similar for approaches that included house-to-house case finding (USD 5.4-6.3), while it was 3.5 times higher (USD 21.5 per TT case found) when town criers were used.

DISCUSSION

This study found that the house-to-house TT case finding approaches were the most efficient method with the highest yield of TT cases. Including other eye condition and/or vision testing yielded similar results but required more personnel and cost.

Gender-related factors affecting health seeking for neglected tropical diseases: findings from a qualitative study in Ethiopia

BACKGROUND

Despite known gender-specific differences in terms of prevalence, transmission and exposure to neglected tropical diseases (NTDs), there is limited discussion of the influence of gender in NTD programmes and interventions. There is a paucity of research on how gender interacts with NTD service provision and uptake. This study, part of broader implementation research in Ethiopia, applied a gender lens to health seeking for five NTDs: lymphatic filariasis, podoconiosis, schistosomiasis, soil-transmitted helminth infection and trachoma.

METHODOLOGY/PRINCIPAL FINDINGS

The study was conducted in a district of the Southern Nations, Nationalities, and Peoples' Region of Ethiopia where the five NTDs are prevalent. A qualitative methodology was adopted to explore participants' perspectives and experiences. Data generation methods included 20 interviews and four focus group discussions. Community members, volunteer Health Development Army leaders, Health Extension Workers and a range of health workers at the health post, health centre and hospital level (n = 59) were purposively sampled. Interviews and focus group discussions were audio recorded, transcribed verbatim into English then analysed through open coding, drawing on constant comparative methods. Gender related factors affected care seeking for NTDs and were described as reasons for not seeking care, delayed care seeking and treating NTDs with natural remedies. Women faced additional challenges in seeking health care due to gender inequalities and power dynamics in their domestic partnerships. Participants recommended raising community awareness about NTDs, however this remains problematic due to gender and social norms around appropriate discourse with members of the opposite gender.

CONCLUSIONS/SIGNIFICANCE

The findings from this study provide crucial insights into how gender interacts with accessing health services, at different levels of the health system. If we are committed to leaving no one behind and achieving universal health coverage, it is essential to address gender disparities to access and utilisation of interventions delivered by national NTD programmes.

Review of the factors influencing the motivation of community drug distributors towards the control and elimination of neglected tropical diseases (NTDs)

BACKGROUND

Community drug distributors or neglected tropical disease (NTD) volunteers have played a crucial role in ensuring the success of mass drug administration (MDA) programs using preventive chemotherapy (PC) for lymphatic filariasis, onchocerciasis, schistosomiasis, trachoma and soil transmitted helminths. In recent years however, a noticeable decline in motivation of some of these volunteers has been perceived, potentially negatively impacting the success of these programs. Potential hypotheses for this change in motivation include the long duration of many MDA programs, the change in sociocultural environments as well as the changes to the programs over time. This literature review identifies factors that affect NTD volunteer performance and motivation, which may be used to influence and improve future programming.

METHODOLOGY/PRINCIPAL FINDINGS

A systematic search was conducted to identify studies published between January 1995 and September 2016 that investigate factors pertaining to volunteer motivation and performance in NTD drug distribution programs. Searches from several databases and grey literature yielded 400 records, of which 28 articles from 10 countries met the inclusion criteria. Quality assessment of studies was performed using the Critical Appraisal Skills Programme(CASP) checklist. Data pertaining to motivation, performance, retention and satisfaction was extracted and examined for themes. Recurring themes in the literature included monetary and material incentives, intrinsic motivation, gender, cost to participate, and health systems and community support. Of these, community support and the health system were found to be particularly impactful. Very few studies were found to explicitly look at novel incentives for volunteers and very few studies have considered the out of pocket and opportunity costs that NTD volunteers bear carrying out their tasks.

CONCLUSIONS/SIGNIFICANCE

There is currently great interest in incorporating more attractive incentive schemes for NTD volunteers. However, our results show that the important challenges that volunteers face (cultural, health systems, financial and community related) may have less to do with financial incentives and may actually have a larger impact on their motivation than has previously been understood. Further integration of NTD programs into existing health systems is expected to improve the NTD volunteer working environment. Relevant community engagement related to the MDA program should also provide the supportive environment needed in the community to support NTD volunteers. Programs need to consider these issues to improve working conditions for NTD volunteers.

Assessment of a Novel Approach to Identify Trichiasis Cases Using Community Treatment Assistants in Tanzania

Background

Simple surgical intervention advocated by the World Health Organization can alleviate trachomatous trichiasis (TT) and prevent subsequent blindness. A large backlog of TT cases remain unidentified and untreated. To increase identification and referral of TT cases, a novel approach using standard screening questions, a card, and simple training for Community Treatment Assistants (CTAs) to use during Mass Drug Administration (MDA) was developed and evaluated in Kongwa District, a trachoma-endemic area of central Tanzania.

Methodology/Principal Findings

A community randomized trial was conducted in 36 communities during MDA. CTAs in intervention villages received an additional half-day of training and a TT screening card in addition to the training received by CTAs in villages assigned to usual care. All MDA participants 15 years and older were screened for TT, and senior TT graders confirmed case status by evaluating all screened-positive cases. A random sample of those screened negative for TT and those who did not present at MDA were also evaluated by the master graders. Intervention CTAs identified 5.6 times as many cases (n = 50) as those assigned to usual care (n = 9, p < 0.05). While specificity was above 90% for both groups, the sensitivity for the novel screening tool was 31.2% compared to 5.6% for the usual care group (p < 0.05).

Conclusions/Significance

CTAs appear to be viable resources for the identification of TT cases. Additional training and use of a TT screening card significantly increased the ability of CTAs to recognize and refer TT cases during MDA; however, further efforts are needed to improve case detection and reduce the number of false positive cases.

Surgical management of trachomatous trichiasis (TT) is recommended by the WHO as a cost-effective strategy to mitigate blinding trachoma. However, a large surgical backlog exists and many individuals suffering with TT remain unknown to the health system. To identify TT cases, we designed a standard set of screening questions, a card, and simple training for Community Treatment Assistants (CTAs) to identify trichiasis during community-wide Mass Drug Administrations (MDA). To evaluate the sensitivity, specificity, and positive predictive value of this approach, we conducted a community randomized trial in 36 communities in trachoma-endemic Kongwa District, Tanzania. Additional training and the use of a TT screening card increased the sensitivity of TT identification and resulted in more cases identified compared to the usual training of CTAs. The positive predictive value was low, indicating a need for further verification of TT cases identified by the enhanced screening. MDA appears to be a good opportunity for TT screening by CTAs, but further training to improve screening sensitivity is suggested.

Gender and performance of community treatment assistants in Tanzania

OBJECTIVE

To examine the effects of gender and demographics of community treatment assistants (CTAs) on their performance of assigned tasks and quantity of speech during mass drug administration of azithromycin for trachoma in rural Tanzania.

DESIGN

Surveys of CTAs and audio recordings of interactions between CTAs and villagers during drug distribution.

SETTING

Mass drug administration program in rural Kongwa district.

PARTICIPANTS

Fifty-seven randomly selected CTAs, and 3122 residents of villages receiving azithromycin as part of the Kongwa Trachoma Project.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Speech quantity graded by Roter interaction analysis system, presence of culturally appropriate greeting and education on facial hygiene for trachoma prevention from coded analysis of audio-recorded interactions.

RESULTS

At sites with all female CTAs, each CTA spent more time and spoke more in each interaction in comparison with CTAs at sites with only male CTAs and CTAs at 'mixed gender' sites (sites with both male and female CTAs). At 'mixed gender' sites, males spoke significantly more than females. Female CTAs mentioned trachoma prevention with facial cleanliness more than twice as often as male CTAs; however, both genders mentioned hygiene in <10% of interactions. Both genders had culturally appropriate greetings in <25% of interactions.

CONCLUSIONS

Gender dynamics affect the amount of time that CTAs spend with villagers during drug distribution, and the relative amount of speech when both genders work together. Both genders are not meeting expectations for trachoma prevention education and greeting villagers, and novel training methods are necessary.

Prevalence of non-vision-impairing conditions in a village in Chakwal district, Punjab, Pakistan

PURPOSE

To determine the prevalence of non-vision-impairing ocular conditions (NVIC) and estimate the number of primary eye care treatments per 1000 population per month.

METHODS

A cross-sectional study in a random sample of 1670 people was done to determine the load of NVIC in a village in Chakwal district.

RESULTS

The prevalence of NVIC was 30.6% (306 per 1000 population). NVIC with the exclusion of presbyopia accounted for 14.6%. The main NVIC were allergic conjunctivitis (3.7%), bacterial conjunctivitis (3.5%), pterygium/pinguicula (2.6%) and acute/chronic dacryocystitis (1%). The average Complaint Frequency (CF) per month/1000 population was 55, excluding complaints of near vision and watery eyes.

CONCLUSIONS

The foundation of a comprehensive district eye care strategy in the light of VISION 2020 - the Right to Sight - remains an effective primary eye care service whose elements are treatment of NVIC, detection and referral of cataracts and refractive errors, and promotion of eye health.