Community-directed Intervention Research Articles

Mass drug administration campaigns: comparing two approaches for schistosomiasis and soil-transmitted helminths prevention and control in selected Southern Malawi districts

BackgroundMass drug administration is one of the key interventions recommended by WHO to control certain NTDs. With most support from donors, health workers distribute antihelminthic drugs annually in Malawi. Mean community coverage of MDA from 2018 to 2020 was high at 87% for praziquantel and 82% for albendazole. However, once donor support diminishes sustaining these levels will be challenging. This study intended to compare the use of the community-directed intervention approach with the standard practice of using health workers in delivery of MDA campaigns.MethodsThis was a controlled implementation study carried out in three districts, where four health centres and 16 villages in each district were selected and randomly assigned to intervention and control arms which implemented MDA campaigns using the CDI approach and the standard practice, respectively. Cross-sectional and mixed methods approach to data collection was used focusing on quantitative data for coverage and knowledge levels and qualitative data to assess perceptions of health providers and beneficiaries at baseline and follow-up assessments. Quantitative and qualitative data were analyzed using IBM SPSS software version 26 and NVivo 12 for Windows, respectively.ResultsAt follow-up, knowledge levels increased, majority of the respondents were more knowledgeable about what schistosomiasis was (41%-44%), its causes (41%-44%) and what STH were (48%-64%), while knowledge on intermediate host for schistosomiasis (19%-22%), its types (9%-13%) and what causes STH (15%-16%) were less known both in intervention and control arm communities. High coverage rates for praziquantel were registered in intervention (83%-89%) and control (86%-89%) communities, intervention (59%-79) and control (53%-86%) schools. Costs for implementation of the study indicated that the intervention arm used more resources than the control arm. Health workers and community members perceived the use of the CDI approach as a good initiative and more favorable over the standard practice.ConclusionsThe use of the CDI in delivery of MDA campaigns against schistosomiasis and STH appears feasible, retains high coverages and is acceptable in intervention communities. Despite the initial high costs incurred, embedding into community delivery platforms could be considered as a possible way forward addressing the sustainability concern when current donor support wanes.Trial registrationPan-African Clinical Trials Registry PACTR202102477794401, date: 25/02/2021.

Community-Directed Educational Intervention for Lassa Fever Prevention Practices Among Nursing Mothers Attending Primary Health Care Centres in Akinyele, Ibadan, Oyo State, Nigeria: A Quasi-Experimental Study

Community-Directed Educational Intervention for Lassa Fever Prevention Practices Among Nursing Mothers Attending Primary Health Care Centres in Akinyele, Ibadan, Oyo State, Nigeria: A Quasi-Experimental Study

Reach and uptake of mass drug administration for worm infections through health facility, school, and community-based approaches in two districts of Zambia: a call for scale-up.

Helminthiases cause significant health deficiencies among children. Mass administration of anthelminthic drugs has had significant results to counter these effects. We assessed the effects on and determinants of treatment coverage of community-directed treatment among children in Zambia, using cross-sectional survey data, and using chi-square test and multilevel mixed-effects model. Of 1,416 children, 51.5% were males and 48.5% were females, while 52.7%, were school-age, and 47.3% were preschool-age. Overall treatment coverage was 53.7% (95% confidence interval (CI) 51.1, 56.4). More preschool-age children were treated compared to school-age ones, 65.2% versus 43.4%, P < 0.001. Similarly, more children under community-directed intervention were treated compared to regular mass drug administration (65.2% versus 51.1 %, P < 0.001). Treatment among school-age participants was associated with being male (Adjusted Odds Ratio (AOR 1.83, 95%CI 1.23-2.72), receiving community-directed treatment (AOR 5.53; 95%CI 3.41-8.97), and shorter distance to health facility (AOR 2.20; 95%CI 1.36-3.56). Among preschool-aged participants, treatment was associated with being residents of Siavonga district (AOR 0.03; 95%CI 0.01-0.04) and shorter distance to health facility (AOR 0.35; 95%CI 0.21-0.59). Community-directed treatment can be used to increase treatment coverage, thereby contribute to 2030 vision of ending epidemics of neglected tropical diseases.

Contrasting epidemiology of urogenital schistosomiasis among pastoral communities surrounding three Ramsar wetland in Nigeria.

Suspected changes in the epidemiology of schistosomiasis due to several hybridization reports between human and livestock Schistosoma speciesin Africa calls for epidemiological investigations among potential high-risk groups and sites. Althoughthe use of wetlands for pastoralism has been linked to schistosomiasis, there is limited information on the epidemiology of the disease among pastoralists in Nigeria. In this study, urine samples from 355 participants from pastoral communities settled around three Ramsar wetlands (Wetlands of International Importance) in Nigeria, (Dagona Sanctuary, Maladumba, and Pandam-Wase) were screened for the eggs of Schistosoma haematobium. Only participants in the Dagona Sanctuary were infected with 34.2% prevalence. Macrohematuria was however observed in some individuals at the Dagona Sanctuary wetland (2.5%) and Maladumba (2.8%). Regular praziquantel administration, functional health care facilities and awareness about schistosomiasis were contributory factors to the contrasting epidemiology of the disease among the study population. Schistosomiasis control requires the inclusion of pastoral and nomadic communities in mass drug administration of praziquantel based on a community-directed intervention strategy.

Caregiver´s perception of the home-based management of childhood malaria in Baneghang and Fombap health areas in the West Region of Cameroon.

Introductionadequate community perception of malaria is crucial to improving prevention, diagnosis, and treatment. This study aimed to determine the caregiver´s perception of the home-based management of childhood malaria in Baneghang and Fombap health areas, Cameroon.Methodsa cross-sectional study was carried out to assess the knowledge, attitudes, and practices of home caregivers (HCGs) in Baneghang, a health area under Community Directed Intervention (CDI), and Fombap, a CDI-free health area. Community health workers (CHWs) conducted a census to identify households with under-five children that constituted a sample frame, and then a systematic random sampling was used to select HCGs. Analysis of variance was used to compare the mean score perceptions of HCGs in the management of childhood malaria at the two sites.Resultsout of 420 HCGs interviewed, 161 (38.3%), 226 (53.8%), and 271 (64.5%) displayed correct knowledge, positive attitude, and good practice, respectively, towards childhood malaria prevention, diagnosis, and treatment in both study sites. The mean score knowledge of HCGs in Baneghang was significantly higher than that of those in Fombap (7.33 versus 6.94, p < 0.001). The mean score of attitudes of HCGs towards childhood malaria was also higher in Baneghang than in Fombap (6.59 versus 6.29, p=0.013). However, the mean scores of good practices of HCGs on childhood malaria in both health areas were similar (5.94 versus 5.92, p=0.921).Conclusionhome-based management of childhood malaria seems to have contributed to good knowledge and positive attitudes of HCGs on malaria prevention, diagnosis, and treatment.

Assessing the Efficacy of a Tobacco Prevention and Control Intervention in a Rural Area of India: A Quasi-Experimental Study.

Background:Tobacco use, disproportionately higher in rural areas, is a major cause of morbidity and mortality in India. Interventions to reduce tobacco use in rural areas are scarce.Objectives:The objective of this study was to assess the efficacy of a community-directed tobacco prevention intervention in reducing tobacco use in rural areas.Materials and Methods:A single-group pre-/postquasi-experimental study was conducted in Lakhmapur village, Maharashtra. Data were collected from one adult each in 296 and 307 randomly selected village households before and at the end of intervention, respectively.Results:Between pretest and posttest, reported tobacco use reduced from 56.4% to 23.5%; average daily expenditure on tobacco from INR 16.07 to INR 9.47, respectively. A logistic model, controlling for sociodemographic variables, showed that the postintervention group had a significantly lower likelihood of using tobacco; however, males and lower education subgroups were more likely to use.Conclusions:Multipronged community-based interventions involving schools, students, teachers, frontline workers, elected leaders, and community influencers hold promise in reducing tobacco use in rural India.

Home-Based Intervention for the Prevention and Treatment of Malaria Among Children Younger Than 5 Years in the West Region of Cameroon: Protocol for a Randomized Controlled Trial

BackgroundAlthough malaria is preventable and curable, 1 child dies of this disease every 2 minutes in Africa. Home-based management of malaria reduces the progression of severe malaria by more than 50%. Scalable, efficacious, and cost-effective strategies are needed to empower the capacities of home caregivers of children younger than 5 years of age in health education, diagnosis, and treatment of malaria at home.ObjectiveThe main objective of this trial is to assess the impact of the management provided by home caregivers on the prevention, diagnosis, and treatment of malaria in children younger than 5 years as compared to the home-based malaria management component of the integrated community-directed intervention (CDI) strategy of community health workers (CHWs).MethodsA randomized controlled trial will be conducted. CHWs have conducted a census of all households where there is at least one child younger than 5 years with their home caregivers. These children and their home caregivers have been randomly placed into the intervention or control groups among the households identified. The trial will allow malaria home-based prevention, diagnosis, and treatment of 350 children younger than 5 years old by home caregivers in the Fombap area (intervention group) where the integrated CDI strategy will not implemented. This group will be compared to the home-based malaria management component of the integrated CDI strategy in which 350 children in the same age group will be followed up by CHWs in the Baneghang area (control group). The primary outcomes will be the prevention, diagnosis, and treatment of malaria in children younger than 5 years of age by home caregivers at home. The secondary outcomes comprise the malaria follow-up indicators produced by home caregivers in the intervention group and those produced by CHWs in the control group. Both descriptive and one-way analysis of variance estimation techniques will be used to compare the mean difference in the 2 strategies.ResultsFrom September 2019 to October 2019, all home caregivers with children younger than 5 years of age were identified in the intervention and control group by CHWs. Following this, 203 home caregivers with their 350 children younger than 5 years were randomly selected and enrolled in the intervention group, while 225 home caregivers with their 350 children younger than 5 years were enrolled in the control group. In the intervention group, 203 home caregivers were trained in November 2019. This home treatment effectively started in December 2019 and will continue until May 2020.ConclusionsFindings from this randomized controlled trial will contribute to resolving the challenges of severe malaria and to limiting the death due to malaria of children younger than 5 years. This will bring benefits to home caregivers who will know how to promptly diagnose and properly treat malaria in their children at home.Trial RegistrationPan African Clinical Trial Registry (PACTR) 202003487018009; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9788International Registered Report Identifier (IRRID)DERR1-10.2196/19633

Mass administration of medicines in changing contexts: Acceptability, adaptability and community directed approaches in Kaduna and Ogun States, Nigeria.

Nigeria has the highest burden of NTDs in sub-Saharan Africa. Commitments to reach the control and elimination of many Neglected Tropical Diseases (NTDs), particularly those amenable to preventive chemotherapy (onchocerciasis, schistosomiasis, soil transmitted helminths, lymphatic filariasis and trachoma) by 2020 are detailed in the London declaration. Strategies to reach targets build on existing approaches, one of which is the use of community directed intervention (CDI) methods to deliver the mass administration of medicines (MAM). However, treatment using this approach has been inconsistent and there are questions about the acceptability and adaptability of these interventions during periods of programmatic, social, and political change. This paper explores the current strengths and weaknesses of CDI approaches in MAM delivery. We consider the acceptability and adaptability of existing MAM approaches to ensure equity in access to essential treatments. Using qualitative methods, we explore implementer perspectives of MAM delivery. We purposively selected programme implementers to ensure good programmatic knowledge and representation from the different levels of health governance in Nigeria. Data collection took place across two States (Kaduna and Ogun). Our results indicate that CDI approaches have underpinned many historic successes in NTD programme acceptance in Nigeria, specifically in Kaduna and Ogun State. However, our results also show that in some contexts, factors that underpin the success of CDI have become disrupted presenting new challenges for programme implementers. Capturing the tacit knowledge of health implementers at varying levels of the health system, we present the current and changing context of MAM delivery in Kaduna and Ogun States and consolidate a platform of evidence to guide future programme delivery and research studies. We situate our findings within the broader NTD literature, specifically, in identifying how our findings align to existing reviews focused on factors that shape individual acceptance of MAM.

Towards eradication: adopting a community-directed intervention strategy in the prevention and management of malaria in Zimbabwe

Zimbabwe continues to struggle to eliminate malaria despite the availability of several global health initiatives to manage the disease There is little empirical evidence on how to achieve the integration of community level interventions in the context of malaria prevention and management and public health in general This monograph traverses the dangers posed by malaria as a disease within the Zimbabwean context It proposes and encourages the conducting of theory based research to generate appropriate data that can be used in the implementation of strategies aimed at eventual eradication of malaria and management and control of other diseases

A Community-Directed Integrated Strongyloides Control Program in Queensland, Australia.

This paper describes two phases of a community-directed intervention to address strongyloidiasis in the remote Aboriginal community of Woorabinda in central Queensland, Australia. The first phase provides the narrative of a community-driven ‘treat-and-test’ mass drug administration (MDA) intervention that was co-designed by the Community Health Service and the community. The second phase is a description of the re-engagement of the community in order to disseminate the key factors for success in the previous MDA for Strongyloides stercoralis, as this information was not shared or captured in the first phase. During the first phase in 2004, there was a high prevalence of strongyloidiasis (12% faecal examination, 30% serology; n = 944 community members tested) that resulted in increased morbidity and at least one death in the community. Between 2004–2005, the community worked in partnership with the Community Health Service to implement a S. stercoralis control program, where all of the residents were treated with oral ivermectin, and repeat doses were given for those with positive S. stercoralis serology. The community also developed their own health promotion campaign using locally-made resources targeting relevant environmental health problems and concerns. Ninety-two percent of the community residents participated in the program, and the prevalence of strongyloidiasis at the time of the ‘treat-and-test’ intervention was 16.6% [95% confidence interval 14.2–19.3]. The cure rate after two doses of ivermectin was 79.8%, based on pre-serology and post-serology tests. The purpose of this paper is to highlight the importance of local Aboriginal leadership and governance and a high level of community involvement in this successful mass drug administration program to address S. stercoralis. The commitment required of these leaders was demanding, and involved intense work over a period of several months. Apart from controlling strongyloidiasis, the community also takes pride in having developed and implemented this program. This appears to be the first community-directed S. stercoralis control program in Australia, and is an important part of the national story of controlling infectious diseases in Indigenous communities.

Comparing reliability of skin microfilarial load with first internal transcribed spacer primers DNA amplification in monitoring onchocerciasis treatment control

Treatment compliance is a serious challenge to community-directed treatment intervention (CDTI) targeting onchocerciasis eradication. Isolated cases of active infections could jeopardise decision to stop mass drug distribution. Onchocerciasis co-endemicity with lymphatic filariasis in the study-area informed the use of primers capable of differentiating sympatric infections in a single assay. The study-population was hitherto found to be negative for presence of skin microfilaria. DNA extracted from skin snips of patients (n=63) comprised of males, n=21 and females, n=42 were analysed using 18S first internal transcribed spacer (ITS1) in polymerase chain reaction (PCR) assay. Amplified DNA sequences were subjected to basic local alignment search tool. Spectrophotometric analysis of DNA concentrations ranged between 1.5- and 24.5 Nano gram (ng) and the two positive controls (adult worm DNA extract) were 10.5 and 105 ng at 260 nanometer (nm) wave length. The 260/ 280 nm ratios were between 1.44 and 1.68. Four samples (6.35%), two males and two females, and the two positive controls showed PCR amplification products. Two of the positive samples indicated double bands in an agarose gel electrophoregram with molecular weight of 350 and 500 base pairs (bp), while two had single band of 350bp, which is within the expected Mw range of 344 bp for Onchocerca volvulus. The double bands may not be due to unspecific amplification. Moreover, the DNA sequence of a sample had 69.1% homology with control sequence but not with O. volvulus sequences available in the GenBank database. This study underscored the need to assess effectiveness of CDTI with highly sensitive test and not depend on microscopy of emerged microfilaria from skin snips. Whether the DNA was from dead or living microfilaria remained a conjecture. Keywords : Skin microfilaria; DNA sequences.

Experiences and perspectives of community health workers from implementing treatment for schistosomiasis using the community directed intervention strategy in an informal settlement in Kisumu City, western Kenya

BackgroundThe Community Directed Intervention (CDI) strategy has been used to conduct various health interventions in Africa, including control of Neglected Tropical Diseases (NTDs). Although the CDI approach has shown good results in the control of onchocerciasis and lymphatic filariasis with respect to treatment coverage using community drug distributors, its utility in the control of schistosomiasis among urban poor is yet to be established. Using a longitudinal qualitative study, we explored the experiences, opportunities, challenges as well as recommendations of Community Health Workers (CHWs) after participation in annual mass drug administration (MDA) activities for schistosomiasis using the CDI approach in an urban setting.MethodsUnstructured open-ended group discussions were conducted with CHWs after completion of annual MDA activities. Narratives were obtained from CHWs using a digital audio recorder during the group discussions, transcribed verbatim and translated into English where applicable. Thematic decomposition of data was done using ATLAS.ti. software, and themes explored using the principle of interpretative phenomenological analysis (IPA).ResultsFrom the perspective of the CHWs, opportunities for implementing CDI in urban settings, included the presence of CHWs, their supervisory structures and their knowledge of intervention areas, and opportunity to integrate MDA with other health interventions. Several challenges were mentioned with regards to implementing MDA using the CDI strategy among them lack of incentives, fear of side effects, misconceptions regarding treatment and mistrust, difficulties working in unsanitary environmental conditions, insecurity, and insufficient time. A key recommendation in promoting more effective MDA using the CDI approach was allocation of more time to the exercise.ConclusionFindings from this study support the feasibility of using CDI for implementing MDA for schistosomiasis in informal settlements of urban areas. Extensive community sensitization and provision of incentives may help address the aforementioned challenges associated with implementing MDA using the CDI strategy. Opportunities highlighted in this study may be of value to other programmes that may be considering the adoption of the CDI strategy for rolling out interventions in the urban setting.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3662-0) contains supplementary material, which is available to authorized users.

Rethinking corporate‐community engagement in the petro‐economy of the Niger Delta

This study applies the political ecology perspective in reframing corporate‐community engagement and adapts the community‐directed intervention (CDI) strategy using Global Memorandum of Understanding (GMoU) framework in relation to 30 rural communities that are likely to be affected by gas exploration and production activities in the Niger Delta region. The study draws attention to the indigenous structures and capacities of communities to implement CDI initiatives for possible replication in areas facing similar development challenges. Adopting the CDI framework as represented by the GMoU model could reconfigure social relations of power between companies and communities and fast‐track development and prevent or, at least, reduce corporate‐community tensions and conflicts in the petro‐economy of the Niger Delta.

Community-directed interventions are practical and effective in low-resource communities: experience of ivermectin treatment for onchocerciasis control in Cameroon and Uganda, 2004-2010.

The community-directed intervention (CDI) approach has improved treatment coverage in onchocerciasis-affected communities. However, there is still a lot to learn. This study assessed its performance and highlighted the lessons learnt so far. Representative samples of households were selected from Cameroon and Uganda program areas through multi-stage random sampling. An adult male and female from every selected household were interviewed separately on their involvement in CDI activities every year between 2004 and 2010. Community health workers (CHWs) were interviewed and treatment records reviewed to determine whether 90% treatment coverage was attained within 2 weeks. Records related to training of CHWs and their supervisors were analyzed. Decision making decreased for community leaders and health workers, while it increased for community members. The proportion of CHWs attaining 90% treatment coverage within 2 weeks improved as their demand for monetary incentives, and number of persons they served, reduced. The number of CHWs supervised by a community supervisor remained low, but increased for the health workers. The cost of training a CHW and a community supervisor reduced to about US$1 and US$4.8, respectively. The CDI approach was effective, culturally appropriate and probably less costly in delivering health services in low-resource communities.

Contribution and performance of female Community-Directed Distributors in the treatment of onchocerciasis with Ivermectin in Sub-Saharan Africa: a systematic review.

The African Program for Onchocerciasis Control (APOC) was launched in 1995 with the main goal being to boost the fight against onchocerciasis in Africa. In 2011, over 80 million people benefited from this intervention thanks to the contribution of 268.718 Community-Directed Distributors (CDD). These significant results obscure the role of women CDD in this fight. Indeed, the insufficient involvement of female CDD has been identified as a concern by the APOC partners early in the program. The present study aims to assess the contribution and performance of women involved in a strategy to control onchocerciasis by community-directed treatment with ivermectin in sub Saharan Africa. We searched the following electronic databases from January 1995 to July 2013: Medline, Embase (Excerpta Medica Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), LILAS (Latin American and Caribbean Literature on Health Sciences), International Bibliography of Social Sciences, Social Services s, and Sociological s. Two research team members independently conducted data extraction from the final sample of articles by using a pre-established data extraction sheet. The primary outcome was the contribution of female CDD in the control of onchocerciasis by community-directed treatment with Ivermectin. Of 25 hits, 7 papers met the inclusion criteria. For the management of onchocerciasis, female CDDs are elected by the health committee from the communities they will serve. The significant proportion of those treated (about 61%) were women, although only 24% of CDDs were women. Many community members reported that women were more committed, persuasive and more patient than men in the distribution of ivermectin. Some studies have identified underutilization of female CDD as one reason for the limited effectiveness or, in some cases, pure failure related to the distribution of Ivermectin interventions in the fight against onchocerciasis in sub-Saharan Africa. Evidence from this review suggests that female CDD contribute to the treatment of onchocerciasis with Ivermectine in sub-Saharan Africa. Large-scale rigorous studies including Randomized controlled trials (RCTs) are needed to compare Community-Directed intervention involving men and women CDDs.

Assessing resources for implementing a community directed intervention (CDI) strategy in delivering multiple health interventions in urban poor communities in Southwestern Nigeria: a qualitative study

BackgroundMany simple, affordable and effective disease control measures have had limited impact due to poor access especially by the poorer populations (urban and rural) and inadequate community participation. A proven strategy to address the problem of access to health interventions is the Community Directed Interventions (CDI) approach, which has been used successfully in rural areas. This study was carried out to assess resources for the use of a CDI strategy in delivering health interventions in poorly-served urban communities in Ibadan, Nigeria.MethodsA formative study was carried out in eight urban poor communities in the Ibadan metropolis in the Oyo State. Qualitative methods comprising 12 focus group discussions (FGDs) with community members and 73 key informant interviews (KIIs) with community leaders, programme managers, community-based organisations (CBOs), non-government organisations (NGOs) and other stakeholders at federal, state and local government levels were used to collect data to determine prevalent diseases and healthcare delivery services, as well as to explore the potential resources for a CDI strategy. All interviews were audio recorded. Content analysis was used to analyse the data.ResultsMalaria, upper respiratory tract infection, diarrhoea and measles were found to be prevalent in children, while hypertension and diabetes topped the list of diseases among adults. Healthcare was financed mainly by out-of-pocket expenses. Cost and location were identified as hindrances to utilisation of health facilities; informal cooperatives (esusu) were available to support those who could not pay for care. Immunisation, nutrition, reproductive health, tuberculosis (TB) and leprosy, environmental health, malaria and HIV/AIDs control programmes were the ongoing interventions. Delivery strategies included house-to-house, home-based treatment, health education and campaigns. Community participation in the planning, implementation and monitoring of development projects was reported as common practice. The resources available for these activities and which constitute potential resources for the CDI process include community volunteers, CBOs and NGOs. Others are landlords; professional, women and youth associations; social clubs, religious organisations and the available health facilities.ConclusionThis study’s findings support the feasibility of using the CDI process in delivering health interventions in urban poor communities and show that potential resources for the strategy abound in the communities.

Factors associated with coverage of praziquantel for schistosomiasis control in the community-direct intervention (CDI) approach in Mali (West Africa).

BackgroundDespite the progress made in the control of Neglected Tropical Diseases (NTD), schistosome and soil-transmitted helminth infections are far from being effectively managed in many parts of the world. Chemotherapy, the key element of all control strategies, is faced with some difficulties in terms of access to treatment. Our study aims to describe the factors involved in the success or failure of the community-directed intervention (CDI) approach through control programmes, which aims to achieve consistent high coverage at affordable and sustainable costs in endemic areas.MethodsThe CDI approach was carried out from December 2007 to October 2008 in ten villages of the district of Diéma, Mali. At inclusion, each child part of the study’s sample was interviewed and submitted for a physical examination. The study focused on: data collection, treatment of the eligible population, evaluation of the treatment coverage, performance of community drug distributors (CDDs), and the involvement and perception of populations.ResultsA total of 8,022 eligible people were studied with a mean coverage rate of 76.7%. Using multiple regression, it was determined that receiving praziquantel as treatment was associated with five factors: belonging to the Fulani or Moorish ethnic minority versus the Bambara/Soninke, use of the central versus the house-to-house drug distribution mode, the ratio of the population to the number of CDDs, the lack of supervision and belonging to the age group of 15 years or above (p<0.05). As well as that, it was found that the presence of parallel community-based programmes (HIV, tuberculosis) that provide financial incentives for community members discouraged many CDDs (who in most cases are volunteers) to participate in the CDI approach due to a lack of incentives.ConclusionsThe findings indicate that the success of the CDI approach depends on, amongst other things, the personal characteristics of the respondents, as well as on community factors.

Community-directed educational intervention for malaria elimination in Bhutan: quasi-experimental study in malaria endemic areas of Sarpang district

BackgroundAs per the World Malaria Report 2011, there was a 17% reduction in morbidity and 26% reduction in mortality in 2010, compared to 2000. In Bhutan, there were only 194 malaria cases in 2011 as compared to 5,935 cases in 2000. As the country moves towards an elimination phase, educating the community and empowering them on malaria prevention and control is imperative. Hence, this study was conducted to elucidate the effectiveness of the community-directed educational intervention on malaria prevention and control in malaria-endemic areas of Sarpang district, Bhutan.MethodsThis quasi-experimental study design was conducted using both qualitative and quantitative data collection methods. In-depth interviews and focus group discussions were carried out in addition to household survey using a structured questionnaire conducted before and after the intervention. Intervention was conducted using community action groups, who were provided with training and which then developed action plans for implementation of interventions within their communities.ResultsThe study resulted in a significant improvement in knowledge and attitude in intervention as compared to control during the post-intervention survey (p < 0.001). The practice score was higher in the control group both during pre- and post-intervention, however, the mean ( ±sd) score of practice in intervention group increased from 6.84 ± 1.26 in pre-intervention to 8.35 ± 1.14 in post-intervention (p < 0.001), where as it decreased from 9.19 ± 1.78 to 9.10 ± 1.98 in the control group (p = 0. 68). When comparing pre- and post- in the intervention group, there was significant improvement during post-intervention in knowledge, attitude and practice (p < 0.001).ConclusionsThe findings from this study corroborate that community-directed interventions can be utilized as an effective means for improving knowledge, attitude and practice in the malaria-endemic areas of Bhutan. Further studies are needed to see the long-term effect and sustainability of such interventions.

Prospects of using community directed intervention strategy in delivering health services among Fulani Nomads in Enugu State, Nigeria

BackgroundThe Community Directed Interventions (CDI) strategy has proven effective in increasing access to health services in sedentary populations. It remains to be seen if CDI strategy is feasible among nomads given the dearth of demographic and medical data on the nomads. This study thus characterized the nomadic populations in Enugu State, Nigeria and outlined the potentials of implementing CDI among nomads.Study design and methodsThis exploratory study adopted qualitative methods. Forty focus group discussions (FGD) were held with members of 10 nomadic camps in 2 LGAs in Enugu State, as well as their host communities. Thirty in-depth interviews (IDIs) were held with leaders of nomadic camps and sedentary populations. Ten IDIs with traditional healers in the nomadic camps and 14 key informant interviews with health workers and programme officers were also conducted. Documents and maps were reviewed to ascertain the grazing routes of the nomads as well as existing health interventions in the area.ResultsLike sedentary populations, nomads have definable community structures with leaders and followers, which is amenable to implementation of CDI. Nomads move their cattle, in a definite pattern, in search of grass and water. In this movement, the old and vulnerable are left in the camps. The nomads suffer from immunization preventable health problems as their host communities. The priority health problems in relation to CDI include malaria, measles, anemia, and other vaccine preventable infections. However, unlike the sedentary populations, the nomads lack access to health interventions, due to the mutual avoidance between the nomads and the sedentary populations in terms of health services. The later consider the services as mainly theirs. The nomads, however, are desirous of the modern health services and often task themselves to access these modern health services in private for profit health facilities when the need arises.ConclusionGiven the definable organizational structure of the nomads in Enugu State and their desire for modern health intervention, it is feasible to test the CDI strategy for equitable healthcare delivery among nomads. They are willing and capable to participate actively in their own health programmes with minimal support from professional health workers.

Integrated community-directed intervention for schistosomiasis and soil transmitted helminths in western Kenya – a pilot study

BackgroundSchistosome and soil-transmitted helminth (STH) infections are recognized as major global public health problems, causing severe and subtle morbidity, including significant educational and nutritional effects in children. Although effective and safe drugs are available, ensuring access to these drugs by all those at risk of schistosomiasis and STHs is still a challenge. Community-directed intervention (CDI) has been used successfully for mass distribution of drugs for other diseases such as onchocerciasis and lymphatic filariasis. A national control programme is yet to be instituted in Kenya and evidence for cost-effective strategies for reaching most affected communities is needed. This study evaluated the effectiveness and feasibility of the CDI strategy in the control of schistosomiasis and STHs, in East Uyoma location, Rarieda district, a community of western Kenya that is highly endemic for both infections.ResultsPre-treatment prevalence of S. mansoni averaged 17.4% (range 5-43%) in the entire location. Treatment coverage in different villages ranged from 54.19 to 96.6% by community drug distributor (CDD) records. Assessment from a household survey showed coverage of 52.3 -91.9% while the proportion of homesteads (home compounds) covered ranged from 54.9-98.5%. Six months after one round of drug distribution, the prevalence levels of S. mansoni, hookworm and Trichuris trichura infections were reduced by 33.2%, 69.4% and 42.6% respectively.ConclusionsThis study shows that CDI is an accepted and effective strategy in the mass treatment of schistosomiasis and STH infections in resource constrained communities in Kenya and may be useful in similar communities elsewhere. A controlled trial comparing CDI and school based mass drug administration to demonstarte their relative advantages is ongoing.