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

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)

Key MIP Interventions
Intermittent preventive treatment in pregnancy (IPTp) with sulphadoxine-pyrimethamine
Insecticide treated bednets (ITNs)
Prompt and Appropriate malaria case management
Delivered on the platform of Antenatal Care

Akwa Ibom State, Nigeria: Year Round Malaria Risk CDI MP PILOT

Baseline in 2007 - MIP Indicators during Last Pregnancy 60% was RBM Target for 2005

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

Basic CDI Processes - Onchocerciasis
Community entry by Clinic Staff and meeting chiefs
Community orientation by Clinic Staff
Community selects community directed distributors (CDDs)
CDDs trained by Clinic Staff
Community conducts census
Community plans dates, approach
Community collects ivermectin from Clinic
Community distributes ivermectin
Monitor, treat and/or refer reactions
Clinic Supervises
Community submits treatment records to Clinic
Community evaluates its efforts and improves

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

CDDs equipped
Counseling Card
Medicines (SP)
Village Register
Monthly Tally Sheet
Referral Form

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

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

IPTp and ITN Delivery

Service Statistics: IPTp2 Distribution LLINs Q1 '09 Q2 '09 Q3 '09 Q4 '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%

Exit Interviews at Intervention Clinics

CDDs trained for ITN Distribution

Service Statistics: LLIN Distribution LLINs Q1 '09 Q2 '09 Q3 '09 Q4 '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%

Service Statistics: ANC Attendance 2009

Service Statistics: ANC Attendees Receiving Tetanus Toxoid in 2009

Improving Performance Quality

SBM-R Scores (%) for ANC Services

Follow-up Results

Malaria Transmission Knowledge: Mosquitoes

IPTp – Took SP Twice Last Pregnancy 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/CDD

Attended ANC at Local Government Clinic 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 ITN supplies were difficult to obtain. The World Bank Booster support for Akwa Ibom State was delayed and not available throughout the intervention period.

Achievements and Challenges
All 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

Advocacy: State Commissioner, LGA Chairs and Legislators

Success stories
ANC attendance improves at all facilities
CDDs remember to track net use
Improvement 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.

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

Next Steps
Refresher training of current CDDs
Continued advocacy for free services and commodity stocks
Training of health staff in additional facilities in both intervention and control local governments
Training of CDDs in Control Communities

Thank you

Community Directed Interventions to Improve Malaria in Pregnancy Control Services in Nigeria

by jehill3 on May 04, 2010

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Community Directed Interventions to Improve Malaria in Pregnancy Control Services in Nigeria — Presentation Transcript