7/29/2019 Adapting Community Interventions that Support Improved Outcomes for MIP
1/13
Adapting community interventions thatsupport improved outcomes for MIP !
while strengthening ANC services in Akwa Ibom State,Nigeria!
Bright C. Orji with!William Brieger, Joseph Okeibunor, Gbenga Ishola, !Emmanuel Otolorin, Barbara Rawlins, Eno Ndekhedehe!With support from the ExxonMobil Foundation!
7/29/2019 Adapting Community Interventions that Support Improved Outcomes for MIP
2/13
Basic Malaria in Pregnancy Interventionsand Indicators!
Malaria in pregnancy (MIP)causes anemia, miscarriage,still birth and low birth weight!
To control MIP we mustincrease ! Number of antenatal care
(ANC) visits (where MIPcontrol services provided)!
Use of insecticide-treated nets(ITNs) during pregnancy !
Taking the recommendeddoses of sulphadoxinepyrimethamine (SP) asintermittent preventivetreatment (IPTp)!
2!
7/29/2019 Adapting Community Interventions that Support Improved Outcomes for MIP
3/13
High Risk, Low Coverage!
3!
3
Study area has year-round
malaria transmission!
In Akwa Ibom atbaseline:!
Only 11.7% ofpregnant women hadslept under an ITN!
Only 5.8% of pregnantwomen had received
two doses IPTp!
7/29/2019 Adapting Community Interventions that Support Improved Outcomes for MIP
4/13
Basic Concepts!Malaria in Pregnancy! Coverage of interventions
remains low, despite massiveanti-malaria campaigns.!
Low uptake reflects! lack of knowledge,! poor access, and! limited support of programs by
local communities andauthorities!
To reduce MIP lessons wereadapted from communityservice delivery programs!
Community DirectedIntervention (CDI)! CDI happens when
communities plan andimplement health intervention
with minimal guidance fromthe health system!The Question we addressedwas ! Will CDI increase uptake of
the following malaria inpregnancy services:! ITN use during pregnancy?! number of ANC visits?! taking the recommended two
doses of SP for IPTp?!4!
7/29/2019 Adapting Community Interventions that Support Improved Outcomes for MIP
5/13
CDI works; so why not for MIP?!
5!
For the past 16 years, the African Program forOnchocerciasis Control has used CDI to provide ivermectinsuccessfully in over 100,000 African villages
WHO-supported research showed CDI could beadapted to deliver ITNs and malaria treatment!
7/29/2019 Adapting Community Interventions that Support Improved Outcomes for MIP
6/13
6!
Nigeria MIP Community-Clinic PartnershipIntervention!
CLINIC!MIP
performancestandards
developed and
implemented!
COMMUNITY!MIP skills and
responsibilitiesimplemented
through
community-
directedintervention!
Training,Supervision,
Mobilization,Commodities!
Referrals,
Records,Feedback!
7/29/2019 Adapting Community Interventions that Support Improved Outcomes for MIP
7/13
6 LGAs Selected for Intervention
A: Control Arm!Ikot Abasi, Mbo, MkpatEnin!
Train healthworkers on basic
malaria serviceprovision!
B: Treatment Arm!Eket, Esit-Eket,Onna!
Health workers train &equip CDDs with tools
and intervention drugs!
Supply ITN, SPand malaria casetracking forms tohealth facilities!
C C C C C C C
Two ClusterParallel Group
Design!Train healthworkers on basic
malaria serviceprovision!
Supply ITN, SPand malaria casetracking forms tohealth facilities!
C !Reduce Malaria in
pregnancy
Communi'esservedbyhealth
workersinhealthclinicorCDDs
athome
+
7!
7/29/2019 Adapting Community Interventions that Support Improved Outcomes for MIP
8/13
Intervention Timeline!Activity/Month! 0-6! 7-12! 13-18! 19-24!Baseline Survey!Cascade Training State, LGAStaff!Community Directed Distributor(CDD) Training, Equipping!Intervention Starts, Supervision!Supervision Continues, Supplies!Follow-up Survey!Training in Control Areas!
8!
7/29/2019 Adapting Community Interventions that Support Improved Outcomes for MIP
9/13
Performance Standards Scores (%) for ANCServices!
0!10!20!30!40!50!60!70!80!90!
Percentof16
Standards
Achie
ved
9!
Massivestafftransfer
Based on 16 Performance Standards!
7/29/2019 Adapting Community Interventions that Support Improved Outcomes for MIP
10/13
Key Findings! ANC visits rose in treatment and control groups
(estimated coefficient on group differences -0.016, 95%CI [-0.107, 0.074], p= 0.646).!
CDI led to substantial, additional increases in ITN useand in adherence to the prescribed IPTp protocol. ! Relative to women in the control area, an additional 7.4 % of
women slept under a net during pregnancy (95% CI [0.035,0.115], p
7/29/2019 Adapting Community Interventions that Support Improved Outcomes for MIP
11/13
Program Impact:!Improved IPTp Uptake! There was general
increase in uptake ofIPTp from baseline toendline assessment!
However, the interventionarm with CDI had greaterincrease of women takingany IPTp (p
7/29/2019 Adapting Community Interventions that Support Improved Outcomes for MIP
12/13
Improved Use of ITN and ANC Attendanceover Time!
28 3
1.
1
68.
9
52
20
49.8
50.
2
44.
2
40
10.
5
89.
5
76.
9
30
28.
1
71.
9
58.
3
0
10
20
30
40
50
60
70
80
90
100
SleptunderITNregularly NoANC AnyANC ANCinGovernmentClinic
ITNUse ANCAendance
BaselineInterven'on Basel ineControl EndlineInterven'on EndlineControl
12!
7/29/2019 Adapting Community Interventions that Support Improved Outcomes for MIP
13/13
Conclusions: CDDs Are on Hand to EncourageITN Use, IPTp Adherence and ANC Attendance!
The results suggest thatcommunity-basedprograms can substantiallyincrease effective accessto malaria prevention inhigh endemic, high burdenareas!
The participatory approachunderlying CDI programs
also promises tostrengthen ties betweenthe formal health sectorand local communities andimprove utilization of
services including ANC!
13!