Village Volunteers Research Articles

Persistent rheumatic musculoskeletal pain and disorders at one year post-chikungunya epidemic in south Maharashtra—a rural community based observational study with special focus on naïve persistent rheumatic musculoskeletal cases and selected cytokine expression

The recent Chikungunya (CHIKV) epidemic (2006) unleashed an unrecognized spectrum of rheumatic musculoskeletal (RMSK) pain and disorders. The data on persistent RMSK is lacking. About 10% clinical acute cases are considered to suffer from chronic arthritis. We used an arthritis camp approach in a 9000 populated village Modnimb (district Sholapur) in December 2007 to identify naive cases of RMSK following symptomatic CHIKV outbreak in December 2006. A 10-day intensive publicity through public announcement and media pamphlet distribution program was carried out to attract villagers with persistent aches and pains and a past history of acute CHIKV illness to attend a 3 day free of cost evaluation arthritis camps. Blood samples were collected from consenting patients. Village volunteers and health workers participated in it. 1.4 percent (95% confidence interval 1.13, 1.60) village population was found to suffer from naive persistent RMSK pain and disorders at 1 year following acute CHIKV infection. Patients were generally >45 years age and females were predominant. Knee was the predominant pain site in 79% cases. Though 27% cases suffered from non-specific arthralgias (NSA), the diagnosis in 48% and 15% cases respectively was consistent with OA (often knee and spine) and undifferentiated inflammatory arthritis (0.2% crude prevalence). Overall, the clinical RMSK profile was benign and none reported any significant functional disability or mobility impairment. Seventy-three percent patients tested seropositive for anti-CHIKV IgG antibody; none for IgM antibody. None showed any abnormality on routine laboratory haematology and biochemistry testing; seropositive RF, ANA and anti-CCP was infrequent. Though CRP values were low, IL-6 was elevated and was not associated with any clinical phenotype. As compared to normal healthy population values assayed a year prior to the epidemic in a neighboring village, cases with persistent RMSK showed elevated IFN-γ, TNF-α and IL-13. Also, the clinical phenotype and cytokine expression did not seem to differ between the seropositive and seronegative groups for anti-CIKV IgG antibody. Conclusion In this rural community study, at least 1.4% population continued to suffer from some form of RMSK at 1 year following acute CHIKV epidemic. Though clinically unimpressive, a large number showed elevated pro-inflammatory cytokine expression. A longer follow-up may explain this disconnect.

Enhanced case detection and improved diagnosis of PKDL in a Kala-azar-endemic area of Bangladesh.

ObjectivesTo support the Bangladesh National Kala-azar Elimination Programme (NKEP), we investigated the feasibility of using trained village volunteers for detecting post-kala-azar dermal leishmaniasis (PKDL) cases, using polymerase chain reaction (PCR) for confirmation of diagnosis and treatment compliance by PKDL patients in Kanthal union of Trishal sub-district, Mymensingh, Bangladesh.MethodsIn this cross-sectional study, Field Research Assistants (FRAs) conducted census in the study area, and the research team trained village volunteers on how to look for PKDL suspects. The trained village volunteers (TVVs) visited each household in the study area for PKDL suspects and referred the suspected PKDL cases to the study clinic. The suspected cases underwent physical examinations by a qualified doctor and rK39 strip testing by the FRAs and, if positive, slit skin examination (SSE), culture, and PCR of skin specimens and peripheral buffy coat were done. Those with evidence of Leishmania donovani (LD) were referred for treatment. All the cases were followed for one year.ResultsThe total population of the study area was 29,226 from 6,566 households. The TVVs referred 52 PKDL suspects. Probable PKDL was diagnosed in 18 of the 52 PKDL suspect cases, and PKDL was confirmed in 9 of the 18 probable PKDL cases. The prevalence of probable PKDL was 6.2 per 10,000 people in the study area. Thirteen PKDL suspects self-reported from outside the study area, and probable and confirmed PKDL was diagnosed in 10 of the 13 suspects and in 5 of 10 probable PKDL cases respectively. All probable PKDL cases had hypopigmented macules. The median time for PKDL development was 36 months (IQR, 24–48). Evidence of the LD parasite was documented by SSE and PCR in 3.6% and 64.3% of the cases, respectively. PCR positivity was associated with gender and severity of disease. Those who were untreated had an increased risk (odds ratio = 3.33, 95%CI 1.29–8.59) of having persistent skin lesions compared to those who were treated. Patients' treatment-seeking behavior and treatment compliance were poor.ConclusionImproved detection of PKDL cases by TVVs is feasible and useful. The NKEP should promote PCR for the diagnosis of PKDL and should find ways for improving treatment compliance by patients.

Dracunculiasis in South Sudan

A Dinka-tribesman came to Marial Lou Hospital, South Sudan, in 2005. He experienced severe discomfort from a Dracunculus Medinensis (Guinea worm) emerging from his perineum (see Figures 1 and ​and2).2). The 80-cm-long parasite was successfully extracted. Figure 1. Dracunculus Medinensis emerging from patient's perineum. This figure appears in color at www.ajtmh.org. Figure 2. Dracunculus Medinensis emerging from patient's perineum. This figure appears in color at www.ajtmh.org. Persons get Dracunculiasis by drinking water containing water fleas harboring the larvae of the worm. The larvae are released into the water by the adult worm that emerges through the skin of infected people. Eighty percent of cases today exist in South Sudan. Sudan's civil war officially ended in 2005 after decades of fighting. Following the peace agreement the Southern Sudan Guinea Worm Eradication Program was created in 2006, counting thousands of village volunteers and health staff. The same year an increase of 270% (> 20,000 cases) occurred because of prior underreporting.1 In the first 6 months of 2009 only 1,188 cases were reported. New episodes of violence in South Sudan pose the greatest challenge for again giving Dracunculiasis the upper hand. In the first half of 2009, 23 incidents of insecurity were reported to disrupt program operations.2 Widespread violence will make coherent surveillance and provision of safe drinking water impossible leaving sporadic treatment to medical humanitarian organizations. Keeping peace contains the hope not only of preventing cases but altogether eradicating Dracunculiasis.

Jerome Kabakyenga: prioritising rural health research in Uganda

Jerome Kabakyenga: prioritising rural health research in Uganda

Community health insurance in Gudalur, India, increases access to hospital care

To reduce the burden of out-of-pocket payments on households in India, the government has introduced community health insurance (CHI) as part of its National Rural Health Mission. Indian CHI schemes have been shown to provide financial protection and have the potential to improve quality of care, but do not seem to improve access. This study examines this dimension of CHI performance and explores conditions under which a CHI scheme can improve access to hospital care for the poor. We conducted a panel survey at the ACCORD-AMS-ASHWINI (AAA) CHI scheme in India. The AAA CHI scheme protects the poorest sections of society against hospitalization expenses. 297 insured and 248 matched uninsured households were observed by village volunteers on a weekly basis for 12 months. Any patient presenting with a 'major ailment' in these households was interviewed using a structured questionnaire. Outcomes measured were utilization of hospital services, cost of treatment and quality of treatment received. The two cohorts were similar regarding demographic, social and economic parameters. More insured than uninsured households expressed trust in the CHI scheme organizers. Both groups had similar levels of minor ailments, but the insured had higher incidence of chronic and major ailments. Insured patients had a hospital admission rate 2.2 times higher than uninsured patients, independent of confounding factors. This higher rate among the insured was also found in children and those with pre-existing conditions. Vulnerable sections of the insured population-children, pregnant women, the poorest-had the highest admission rates. Most admissions, in both cohorts, took place in the ASHWINI hospital. Credible and trustworthy organizers, effective providers, low co-payments, and low indirect costs contributed to this result. A well-designed CHI scheme has the potential to improve access to hospital care, even for vulnerable sections of the community-the poorest, individuals with pre-existing conditions like diabetes and hypertension, and pregnant women.

Impact of community-based presumptive chloroquine treatment of fever cases on malaria morbidity and mortality in a tribal area in Orissa State, India

BackgroundIn the Global Strategy for Malaria Control, one of the basic elements is early detection and prompt treatment of malaria cases, especially in areas where health care facilities are inadequate. Establishing or reviving the existing drug distribution centers (DDC) at the peripheral levels of health care can achieve this. The DDCs should be operationally feasible, acceptable by community and technical efficient, particularly in remote hard-core malaria endemic areas.MethodsVolunteers from villages were selected for distribution of chloroquine and the selection was made either by villagers or head of the village. The services of the volunteers were absolutely free and voluntary in nature. Chloroquine was provided free of charge to all fever cases. The impact was evaluated based on the changes observed in fever days, fever incidence, parasite incidence and parasite prevalence (proportion of persons harbouring malaria parasite) in the community. Comparisons were made between 1st, 2nd and 3rd year of operation in the experimental villages and between the experimental and check areas.ResultsA total of 411 village volunteers in 378 villages in the experimental community health center with a population of 125,439 treated 88,575 fever cases with a mean annual incidence of 331.8 cases per 1,000 population during the three-year study period. The average morbid days due to fever (AFD) was reduced to 1.6 ± 0.1 from 5.9 ± 2.1 in the experimental villages while it remained at 5.0 ± 1.0 in the check villages. There was a significant reduction, (p < 0.05) in Annual Fever Incidence (AFI) in the experimental hilltop and foothill villages in comparison to check villages. The change in Annual Parasite Incidence (API) was, however, not statistically significant (p > 0.05). In plain villages that were low endemic, the reductions in AFI and API in experimental villages were statistically significant (p < 0.05). There was significant reduction in the parasite prevalence in high endemic villages of the experimental area both during 2nd and 3rd year when compared with the check area (p < 0.05) but no such reduction was observed in low endemic areas (p > 0.0.5). Mortality due to malaria declined by 75% in the experimental villages in the adult age group whereas there was an increasing trend in check villages.ConclusionThe study demonstrated that a passive chloroquine distribution system operated by village volunteers in tribal areas is feasible and effective in reducing malaria-related morbidity and mortality.

Design and evaluation of a community participatory, birth preparedness project in Cambodia

Objective to evaluate a pilot project, which used a community participatory approach to introduce birth preparedness in rural Cambodia. Design a feasibility and outcome evaluation. This included observation, interview, document analysis and costing. Setting the project was undertaken in 15 villages linked to five health centres in Kampong Chhnang, Cambodia. Participants key management personnel, local midwives, village leaders, village volunteers and village members who had participated in the programme. Findings community engagement was not only feasible but was also a successful and cost-effective way to introduce birth preparedness. A high degree of satisfaction was reported by the health staff and the community. Over the year in which the project was undertaken, there was a 22% increase in antenatal care, a 32% increase in the number of women delivered by a midwife, and a 281% increase in referrals to hospital. Implications for practice discussion about birth preparedness should occur not only with pregnant women but also with the communities that support them. Communities that are poor and isolated are responsive to the health needs of their women as they give birth, and articulate their needs when given the opportunity. Interacting with health staff in a way in which there is shared information can lead to greater utilisation of the health services that they provide.

Socio-economic and Socioecological Study of Sambalpur Forest Division, Orissa

The present study on socio-economic and socio-ecological aspects of Sambalpur Forest Division of Orissa reveals that forests play an important role in the economy of the State in terms of contribution to state revenue, State Domestic Product as well as dependence of people for livelihood. The people living adjacent to the reserved forests of Sambalpur Forest Division (pre-reorganised) are heavily dependent on these forests. Although the nominal forest cover of the state continues to remain unchanged one notices a gradual decline in the effective forest cover of the state. In terms of socio-economic profile ,it was found that majority of the sample respondents (71.83) lived in kacha houses with only 4.83% having own toilet facilities,92.7% depending on outside dug well and tube well for drinking water and 90.5% depending on wood litter collected from forest for fuel requirement. Cultivation is the primary occupation among Other Backward Class (OBC) group where as daily wage labours largely belong to Scheduled Caste and Scheduled Tribe population. Per capita annual income stands at Rs.3684/- which is significantly low and indicates the degree of deprivation of the people.The study on extent and nature of dependence on forest and people's perceptions about the causes of degradation and methods of conservation reveals that the people living adjacent to the reserved forest areas are highly dependent on the forest for medicinal plants(about 51 species).Regarding cultural practices of the people in the sacrifice of trees and animals, only 2.3% of respondents indicated sacrifice of trees and majority of respondents resorting to sacrifice of domestic animals but not wild life. Regarding loss of forest species 92.35% of the respondents stated about 28 different species lost from the forests. Most important causes of degradation as perceived by the respondents are domestic use by villagers, business/trading, fuel wood crisis in the region, illegal forest produce sale etc. Important methods of forest conservation are Village committee, VSS, Vana Mahostava, Social forestry etc. A very high proportion of the respondents suggested that there should be more forest personnel, formation and effective role of village committees and recruitment of more village volunteers. Regarding the magnitude of exploitation, about 29% visualized that there is frequent exploitation by outsiders.

Building capacity and community resilience to HIV: A project designed, implemented, and evaluated by young Lao people

A partnership was formed between a mass youth organization, a national HIV coordinating committee, and an international agency, to implement an HIV capacity building project in the youth sector of Lao PDR. Involving the local community in situation analysis, planning and skills-building was a key focus of the project. District project working teams were trained in situation analysis, strategic planning, proposal development, and the implementation of HIV prevention activities. Young village volunteers were trained in participatory research, analysis, and behaviour change communication to promote HIV prevention. After 6 years, the partnership used qualitative methods to evaluate the local outcomes of the project. We found that district project working teams and young volunteers had improved skills in the areas in which they had been trained. Communities and local government workers had developed greater understanding of the HIV situation in their districts, and expressed a strong sense of ownership over their activity plans. Young people more readily acknowledged personal risk of HIV infection and were more comfortable talking about sexually transmitted infections. Although there were challenges to sustaining project activities in some areas, we found that our approach helped to engage youth and build their resilience to HIV in this country of low prevalence.

Insecticide‐treated bednets for the prevention of Plasmodium falciparum malaria in Cambodia: a cluster‐randomized trial

To validate and quantify the impact of insecticide-treated bednets (ITN) on malaria morbidity and mortality in Cambodia. A paired, cluster-randomized trial of ITN was conducted in Rattanakiri, North East Cambodia. Thirty-four villages with a total population of 10,726 were randomized to receive deltamethrin-impregnated bednets or to control (no net provision). Cross-sectional surveys measured Plasmodium falciparum prevalence at baseline and 10 months after ITN distribution. Village malaria volunteers in control and intervention villages treated dipstick-positive P. falciparum cases with artesunate and mefloquine. The resulting passive surveillance data were used as an estimate of the incidence of clinical P. falciparum infections. There was a protective efficacy of 28% in P. falciparum incidence (adjusted rate ratio 0.72, 95% CI 0.47-1.08) and 9% in P. falciparum prevalence (adjusted prevalence ratio 0.91, 95% CI 0.65-1.28) in ITN relative to control villages; however, neither of these estimates reached statistical significance. Individual-level analysis indicated a greater reduction in P. falciparum prevalence among under 5-year-olds (adjusted OR = 0.63, 95% CI 0.26-1.53) compared to older individuals (interaction P = 0.042). The protective efficacy of 35% (95% CI -28, 67%) with respect to clinical P. falciparum incidence in under 5-year-olds was more pronounced than the corresponding estimates for prevalence but was again not significant. Lack of statistical significance in the results is likely to be due to a lack of power. The analysis provides further evidence for ITN effectiveness in South East Asia, particularly among individuals under 5 years of age.

SLAYING LITTLE DRAGONS: LESSONS FROM THE DRACUNCULIASIS ERADICATION PROGRAM

The word dracunculiasis comes from the Latin phrase “afflicted with little dragons.” The global Dracunculiasis Eradication Program (DEP) spearheaded by President Jimmy Carter and The Carter Center has quietly “inched” towards world eradication with stunning success, as shown in Figure 1. In the midst of huge publicity and monies going into such global health campaigns as polio eradication, malaria, tuberculosis, and human immunodeficiency virus control, global guinea worm eradication is occurring without vaccine or curative therapy. As illustrated in this issue of the American Journal of Tropical Medicine and Hygiene, the DEP has implemented grass-root innovative public health initiatives in Uganda with the help of multiple external donors. Despite civil strife, arguments about vertical or horizontal implementation strategies, migrating infected refugees, and egregious safety insecurities, the Uganda eradication effort succeeded and thus has much to teach us about tenacity, flexibility, and cooperative innovative strategies within infected communities. Dracunculiasis or guinea worm disease is transmitted to humans in contaminated drinking water containing copepods (water fleas) that are infected with the larvae of the worm. The larvae are expelled into the water by adult worms that emerge through the skin of infected people approximately one year after infection. Emergence of the adult worm is painful, disabling, and incapacitates individuals often during prime working periods for 2–3 months. Humans are the only reservoir and there is no effective treatment or vaccine. Infection is prevented by educating people to filter their drinking water through finely woven cloth to remove copepods by using temephos (Abate ; American Cyanamid, Wayne, NJ) larvicide in water supplies to kill copepods and larva or by providing clean drinking water from safe sources such as hand dug wells or borehole wells. As described by Rivakimari and others, women are often the predominant victims presumably (although not studied well) as a consequence of their role as the main gatherers of household water supplies where opportunities for drinking from contaminated sites is enhanced. In Uganda, a unique coalition of public and private sectors spearheaded by The Carter Center came together to provide ongoing operational support, filtering cloths, larvicides, and borehole wells. A national task force met monthly and cadres from ministries, non-government organizations, political leaders, religious and traditional leaders, and village volunteers all worked on empowering individual and community participation in the eradication campaign. When the usual measures of containment hit an impasse, unusual measures were taken such as employing elderly men “Pond Care Takers” to guard ponds against contamination by people with emerging worms. Water sources (to control access) were then watched over and * Address correspondence to Michele Barry, Department of Medicine, Yale University School of Medicine, 333 Cedar Street, PO Box 208025, New Haven, CT, E-mail: michele.barry@yale.edu

Deployment of Early Diagnosis and Mefloquine- Artesunate Treatment of Falciparum Malaria in Thailand: The Tak Malaria Initiative

BackgroundEarly diagnosis and treatment with artesunate-mefloquine combination therapy (MAS) have reduced the transmission of falciparum malaria dramatically and halted the progression of mefloquine resistance in camps for displaced persons along the Thai-Burmese border, an area of low and seasonal transmission of multidrug-resistant Plasmodium falciparum. We extended the same combination drug strategy to all other communities (estimated population 450,000) living in five border districts of Tak province in northwestern Thailand.Methods and FindingsExisting health structures were reinforced. Village volunteers were trained to use rapid diagnostic tests and to treat positive cases with MAS. Cases of malaria, hospitalizations, and malaria-related deaths were recorded in the 6 y before, during, and after the Tak Malaria Initiative (TMI) intervention. Cross-sectional surveys were conducted before and during the TMI period. P. falciparum malaria cases fell by 34% (95% confidence interval [CI], 33.5–34.4) and hospitalisations for falciparum malaria fell by 39% (95% CI, 37.0–39.9) during the TMI period, while hospitalisations for P. vivax malaria remained constant. There were 32 deaths attributed to malaria during, and 22 after the TMI, a 51.5% (95% CI, 39.0–63.9) reduction compared to the average of the previous 3 y. Cross-sectional surveys indicated that P. vivax had become the predominant species in Thai villages, but not in populations living on the Myanmar side of the border. In the displaced persons population, where the original deployment took place 7 y before the TMI, the transmission of P. falciparum continued to be suppressed, the incidence of falciparum malaria remained low, and the in vivo efficacy of the 3-d MAS remained high.ConclusionsIn the remote malarious north western border area of Thailand, the early detection of malaria by trained village volunteers, using rapid diagnostic tests and treatment with mefloquine-artesunate was feasible and reduced the morbidity and mortality of multidrug-resistant P. falciparum.

Local fever illness classifications: implications for home management of malaria strategies

The Ugandan Ministry of Health has adopted the WHO Home Based Fever Management strategy (HBM) to improve access to antimalarial drugs for prompt (<24 h) presumptive treatment of all fevers in children under 5 years. Village volunteers will distribute pre-packed antimalarials free of charge to caretakers of febrile children 2 months to 5 years ('Homapaks'). To explore the local understanding and treatment practices for childhood fever illnesses and discuss implications for the HBM strategy. Focus Group Discussions were held with child caretakers in three rural communities in Kasese district, West Uganda, and analysed for content in respect to local illness classifications and associated treatments for childhood fevers. Local understanding of fever illnesses and associated treatments was complex. Some fever illness classifications were more commonly mentioned, including 'Fever of Mosquito', 'Chest Problem', 'the Disease', 'Stomach Wounds' and 'Jerks', all of which could be biomedical malaria. Although caretakers refer to all these classifications as 'fever' treatment differed; some were seen as requiring urgent professional western treatment and others were considered severe but 'non-western' and would preferentially be treated with traditional remedies. The HBM strategy does not address local community understanding of 'fever' and its influence on treatment. While HBM improves drug access, Homapaks are likely to be used for only those fevers where 'western' treatment is perceived appropriate, implying continued delayed and under-treatment of potential malaria. Hence, HBM strategies also need to address local perceptions of febrile illness and adapt information and training material accordingly.

Rural perspectives on HIV/AIDS prevention: a comparative study of Thailand and Ghana

The paper compares rural perspectives in Thailand and Ghana on the level of condom acceptance in sexual relations, willingness to test oneself for HIV before and in marriage and sources of information on HIV/AIDS. We also compared the policy approaches to combating HIV/AIDS in both countries. The results indicates that in the villages studied in Thailand, all single men and the majority of the single women were in favour of using condoms in sexual relations. This group also showed a positive attitude to HIV/AIDS test before and in marriage. However, married men in rural Thailand disapproved of the use of condoms with their wives but married women in the sample population were open to the possibility of using condoms. Both married men and women were strongly against HIV/AIDS test in marriage. In contrast to Thailand, most single men in the communities studied in Ghana showed a disapproval to the use of condoms in sexual relations. However, they condoned HIV test before marriage. Married men and women in rural Ghana were against the use of condoms in sexual relations as well as HIV/AIDS test in marriage. In order to mitigate mother-to-child transmission, the Thais applied anti-retroviral drug care for HIV positive pregnant women during pregnancy and after delivery. In Ghana on the other hand, pregnant women were subject to HIV test and counselling. The mode of information acquisition on HIV/AIDS in both countries were through the media, campaigns and village volunteers. Finally, we observed that fighting poverty is a sine qua non for the success of any HIV/AIDS eradication programme.

Trapping the vector: community action to curb sleeping sickness in southern Sudan.

South Sudan experienced a resurgence of trypanosomiasis (sleeping sickness) in the 1990s. In 1997 in Tambura County, public health officials combined standard mass screening and treatment techniques for infected persons with an additional component-trapping the vectors of the disease. The intent of this integrated approach was to lower the number and concentration of the tsetse flies that spread the disease while reducing the level of infection in the human population to make the likelihood of transmission extremely low. Because the trapping project depends on village participation (making, setting, and maintaining the traps), village volunteers and their neighbors learned more about the causes and prevention of sleeping sickness and became much more willing to participate in serosurveys and to seek treatment.

Urinary schistosomiasis: options for control within endemic ruralcommunities: a case study in south-west Nigeria

A preliminary investigation was conducted into factors that may bring about control of morbidity due to endemic urinary schistosomiasis in rural communities. A Knowledge, Attitudes, Practices and Beliefs (KAPB) study was conducted among primary schoolchildren (those with more than four years elementary education) in Ogbagba village, Osun State, Nigeria, from October 1990 to December 1993, to ascertain their understanding of urinary schistosomiasis. The study further assessed the potential of subjective haematuria, i.e. asking children with haematuria in the recent past to so indicate, in detecting urinary schistosomiasis. It was established that subjective haematuria is both sensitive and specific for detecting urinary schistosomiasis in endemic communities. The study also established that subjective haematuria offers a valid, easy to recognize target for morbidity control in endemic situation. It is proposed that with appropriate health education; availability of safe, effective, easy-to-administer drugs, such as praziquantel, morbidity control of urinary schistosomiasis is feasible within the primary health care system with the lower cadre health worker or even a volunteer village health worker (VVHW) at the centre of the control effort.

Health education to promote community involvement in the control of tropical diseases

Health Education is any combination of learning activities that promote voluntary adaptations in health-related behaviour. In pursuing this definition, health workers generally work in two main directions, a community development approach and a behavioristic, communications approach. While Health Education in tropical, developing countries often takes the developmental approach with full community involvement, including the setting of programme priorities, Health Education for disease control has more often been characterized as the behavioristic mode utilizing simplistic, professionally determined messages and short-term campaigns to attempt to influence health behaviours related to disease transmission. Efforts in Idere, Nigeria, have tried to merge the two approaches building on community concern about one endemic tropical disease, Guinea worm. From this base, volunteer village health worker (VHW) training was developed. VHWs, once trained, developed their own association, which served as an organizational base for further health development programming, directed by the VHWs themselves.

Community participation in the eradication of guinea worm disease

As Guinea worm eradication programmess have got under way in endemic countries over the last decade, there has been shift toward more participatory methods. The approach to surveillance has changed from periodic cross-sectional surveys to monthly village-based reporting of cases by a volunteer village health worker. At the same time, the emphasis regarding control interventions has moved from the provision of safe water supplied to health educatioon. The new approach has proved very effective. The village health volunteers who carry out both surveillance and health seem to be motivated largerly by the the social status of their role; still more commitment will the required of them in the final stages of eradication. It is be hoped that the networks of village health workers established for Guinea worm eradication will find a useful role in health promotion after the worms have gone.

Village Health Worker Attrition and Function Levels in the ILE-IFE Area of Nigeria

Volunteer village health workers (VHWs) form the backbone of primary health care (PHC) from both philosophical and logistical perspectives. They represent an underlying PHC ethic of community involvement as well as a practical means for delivering health care at the grassroots. Although VHW recruitment and training does not rival the cost of training formal medical and health workers, the investment in not insubstantial. Thus when VHW dropout rates approach 50 percent in many countries, there is cause for alarm and for investigation into the possible causes of attrition. Nigeria embarked on a national PHC program in 1986, supported by national PHC policy in 1987. Nearly 1500 VHWs have been trained in model local government areas (LGAs) during the intervening years. Although there have been anecdotal reports of VHW attrition, little study into the reasons for drop-out from this large scale and expensive operation have been undertaken. This study looked at the former Oranmiyan LGA (now divided into three) where 115 VHWs had been trained. Only 79 percent of trainees took up PHC tasks, and another 7 percent left their villages shortly thereafter due to school admission or job opportunities. Two to three years after the initial training, 58 percent of the original trainees self-reported that they were still functioning as VHWs. A PHC function test, based on VHW job descriptions, was developed and administered within a questionnaire among the VHWs still living in their villages. Three factors were associated with function score: farming as an occupation, reported recent supervision and reported attendance at a continuing education activity. The results indicate two main points of intervention for preventing VHW attrition. During recruitment, effort should be made to explain the voluntary nature of the work and to encourage villagers to select people (like farmers) who will reside permanently in the village. After training, supervision and continuing education must be planned to maintain a high level of VHW functioning.

Working with Communities to Increase the Use of Health Services: An Experience from Togo, West Africa

A project in Togo, West Africa, demonstrated that motivated and skilled district health teams can increase community involvement in promoting positive health behavior. Village health committees, village volunteers, health workers, itinerant health agents, and school teachers collaborated with district health personnel in village-wide efforts to increase the use of health services targeted to children under five years of age. The project also demonstrated that in areas where health services are accessible, high levels of service utilization can be achieved by villages through a combination of strategies that rely on person-to-person and group methods of communication. Village-level educational programs, which included theater, storytelling, patient education at health facilities, and child-to-child activities in schools contributed to improvements in immunization coverage levels in children twelve to twenty-three months of age after less than one year following the educational intervention. The major factors responsible for the success of the project are summarized, and issues related to project replication and diffusion are discussed.