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

1

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

4

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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8

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

9

10

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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11

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

19

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