Social Mobilization for enhanced Microplanning and Deworming Programs

 

The African Institute for Health and Development (AIHD) and the END Fund partnered with the governments of Kenya and Rwanda alongside numerous technical experts to design, operationalize and evaluate a comprehensive microplanning approach specifically tailored to community-based mass drug administration for Soil Transmitted Helminthiasis and Schistosomiasis. In Kenya, the project was implemented in the five Sub Counties of Vihiga County: Emuhaya, Luanda, Vihiga, Hamisi and Sabatia. From the study, Vihiga county showed a high prevalent rate of Soil Transmitted Helminthiasis (round worms and hookworms). The parasites are found in contaminated water bodies and penetrate through the skin into the body causing infections.

 

In 2019, the END Fund’s Dew Innovation Fund (DIF) was launched to harness creative solutions to accelerate progress towards the interruption of parasite transmission in four countries: Ethiopia, Kenya, Rwanda, and Zimbabwe. One of its key objectives was to identify and leverage innovations from other sectors of health and development, which could improve the efficiency and effectiveness of deworming. High-quality microplanning is an innovation that can directly impact DIF’s overall goal, by improving the performance and reach of community-level mass drug administration.

Social mobilization is an essential tool for development. It is a process that engages and motivates a wide range of partners and allies at national and local levels to raise awareness of and demand for a particular development objective in this case, to increase the geographical coverage and uptake of deworming medicines in Kenya and Rwanda through dialogues.

It helps individuals, population segments and entire communities to understand the benefits and importance of participating in health interventions. By doing so, it generates demand for treatment in endemic areas and supports program goals of disease control and elimination. Neglected tropical diseases (NTDs) are a diverse group of communicable diseases that occur under tropical and sub-tropical climate conditions and are intimately linked to poverty (WHO, 2010). These include but are not limited to; schistosomiasis (SCH), soil transmitted helminthiasis (STH), lymphatic filariasis (LF), trachoma, dengue, leprosy, among others. More than 25 million of Kenyans are affected by NTDs with most at risk being poor communities. To address the burden of these diseases, the Government of Kenya (GoK) established the Breaking Transmission Strategy (BTS) 2019-2023 as part of its commitment to achieving the global control and elimination targets for 4 preventive chemotherapy (PC) NTDs endemic in the country.

AIHD recommended the need for long-term interventions targeting community members for example, conducting health talks at health facilities level and public education of communities. Also barriers of communication from the community needed to be addressed by developing targeted messages for different cohorts in the communities. “In our public health programs, we should take the health messages to the people. That is why we have Community Health Volunteers (CHVs) to create health awareness education to the community in terms of hygiene and nutrition.”( Dr. Wilbur Ottichilo, Governor, Vihiga County).

There was the need to engage families e.g. Muslim families in STH community-based interventions related to WASH. This is regarding hygiene after toilet use since some of them use only water (without soap) to clean. This behavior may put them at risk of STH and other diseases. There is therefore a felt need to develop a message encouraging people to wash their hands with clean water and soap after toilet use.

The project aimed to achieve the following outcomes:

  • Improved coverage and reach of MDAs through better understanding of the size and distribution of the target population and its burden of disease.
  • Improved allocation of resources for the MDA, through more efficient drug and human resource allocation and improved social mobilization; and
  • Better assessment of program performance, through improved supervision and accountability and faster and more accurate reporting.

The World Health Organization (WHO) recommends five public-health strategies for the prevention and control of these diseases: preventive chemotherapy; intensified disease management; integrated vector management; management of neglected zoonotic diseases; and provision of safe water, sanitation, and hygiene (WHO, 2012).  Currently, there are global efforts to control and eliminate neglected tropical diseases (NTDs) through partnerships between communities, governments, United Nations (UN) agencies, development partners and pharmaceutical companies (MoH Strategic plan 2019-2023)

Feasibility, Acceptability, and Usability of Peer-To-Peer Motivational Interviewing tool to Improve Vaccine Conversations among Somali communities in Kenya (2022).

The African Institute for Health and Development (AIHD), Centers for Disease Control and Prevention (CDC), the Task Force for Global Health (TFGH) and in collaboration with Nairobi County conducted a field test of a peer-to-peer (P2P) Motivational Interviewing (MI) tool aimed at increasing vaccine confidence and uptake among the Somali community in Kenya. MI is a collaborative communication style used to strengthen a persons’ own motivation and commitment to change. It is based on three key components: cultivating a culture of partnership and empathy, fostering engagement in the relationship, and targeting the goal of the intervention; and understanding the patient/caregiver and adapting to their specific needs. The project is cognizant of the fact that vaccine confidence is increasingly globalized as national and diaspora communities are better connected through mobile phone technology and social media. Evidence through the use of the technology and social media shows that the Somali community has been affected by low confidence in Mumps Measles and Rubella (MMR) vaccines in recent years. Therefore, the use of MI was assumed to being particularly a successful tool in the Somali community because it rests on oral forms of communication that are highly valued in the community.

This project applied the examination of training modules to support P2P vaccine conversations in promoting vaccine confidence with a focus on routine childhood vaccinations and coronavirus disease (Covid-19) on the Somalis living in Kenya. It was conducted in Nairobi County within areas with a high Somali population; (Kamukunji, Langata, and Starehe Sub-Counties). The findings from this study are meant to inform future adaptations and implementation of the P2P mobile training tool to the unique needs of Somali diaspora communities in Kenya and worldwide.

Covid 19 is the new viral pathogen, discovered in late year 2019 and early year 2020, that is highly contagious, caused enormous health issues, economical downfall, and social problems. It has adversely affected the entire functioning system of the world, making it difficult for the human species to recover both mentally, socially, psychologically, and financially. Covid 19 spreads faster through undetected viruses from person to person, therefore there is a need for educating the public on the seriousness of Covid-19 and their role in preventing its spread. The disease spreads inequitably and the vulnerable tend to suffer higher rates of infection and complications.

The International Union for Health Promotion and Education (IUHPE) was invited by the World Health Organization (WHO) and Vital Strategies to develop health promotion and education actions, to support ongoing response to the Covid-19 pandemic in the African continent. The African Institute for Health and Development in Kenya, together with Nairobi Metropolitan Services and Kisii County developed health promotion and education strategies, to support ongoing response to the COVID-19 pandemic. The project was implemented in Ruai and Njiru wards, Nairobi, and Kitutu central ward in Kitutu Chache south Sub-County in Kisii County.

The response was advocated by influencers, community engagement with the risk groups, social mobilization, community media and social media activities were carried out through Community Own Resource Persons (CORPs) and gatekeepers, including the ward administrators, Nyumba Kumi elders, religious leaders, chiefs, women and youth leaders and persons with disabilities. To avert possible risk of escalating new infections or further Community transmission of COVID19, the community engagement activities promoted positive behavior change thus enabling people initiate, sustain and maintain desirable behavior outcomes, an interactive process of Social Behavior Change Communication (SBCC).

The weak health systems which face a huge burden of the virus, had to be addressed through health promotion which aids to increase people’s control over their health. This required enabling individuals and communities to acquire the knowledge, skills, and efficacy to take preventive behavioural actions and access support and services that would protect and promote their health in the face of the pandemic.

Social Science Research to assess the Adoption of a Child-friendly Paediatric Formulation of Praziquantel for the Treatment of Schistosomiasis among Pre-school aged Children in Endemic Counties in Kenya – (ADOPT)

There is paucity of a suitable praziquantel formulation for over fifty million preschool age children that need treatment for chronic schistosomiasis in most African countries. This explains why they are excluded from preventive chemotherapy. Schistosomiasis also known as bilharzia, is a waterborne parasitic disease found in sub-Saharan Africa, the Middle East, Southeast Asia, and the Caribbean. The fresh water becomes contaminated from infected animal or human urine or faeces. The parasites penetrate human skin, enter the bloodstream, and migrate to the liver, intestines, and other organs. A rash, itchy skin, fever, chills, cough, headache, stomach pain, joint pain and muscle aches are symptoms.

The European & Developing Countries Clinical Trials Partnership (EDCTP) together with the Global Health Innovative Technology Fund (GHIT), provided funding to conduct a transdisciplinary multi-stakeholder implementation. This is already effective in Kenya through The African Institute for Health and Development, with support from Technical University of Munich (TUM) and in partnership with the Ministry of Health, Division of Vector Borne & Neglected Tropical Diseases (DVBNTDs) and Kenya Medical Research Institute (KEMRI), by research to prepare the introduction of Levo-Praziquantel in selected schistosomiasis-endemic counties.

It occurs mostly in Western, Coastal, and Eastern parts of the country and caused by Schistosomiasis mansoni. Over the years, children in primary schools have been targeted for treatment for Bilharzia. Nevertheless, there has been a challenge for treating the young children (1-4 years) with the current drug treatment for Bilharzia. The African Institute for Health and Development is researching and advocating through health promotion activities, formulas for proper treatment for bilharzia for preschool age going children. Currently, various organizations including World Health Organization (WHO) have produced a new drug- L-PZQ 150mg for this age group. This drug is due for implementation in Kenya for the first time in counties where Bilharzia is found hence the need to determine the obstacles and factors that may compel community’s willingness to take the new drug.

The target counties are Homabay and Kwale involving local members of the community who are parents/caregivers of young children (1-4 years), community leaders, local administration, religious leaders, healthcare authorities and healthcare workers. The aim is to assess knowledge and perception of (paediatric) schistosomiasis and acceptability of its treatment in PSAC among parents/guardians, primary healthcare personnel and key community stakeholders at diverse levels. This research project is on-going effectively between the year 2022 to 2025.

The African Institute for Health and Development actively worked with the CDC – Atlanta team, WHOAFRO and the Baringo County department of health in implementing an immunization project on vaccine hesitancy towards tetanus toxoid among women of childbearing age in Tiaty Sub County, Baringo County in phases. The phase 1 of the study was done in 2016 in two study sites Eldama Ravine town and Torongo in Koibatek Sub County: Chemolingot and Nakoko in Tiaty Sub County. The two sub counties were control and test sites respectively. Study findings from phase 1 indicated that confusion, inadequate communication, inadequate health education, opportunity cost and inaccessibility to immunizing health facilities are the contributing factors to lower uptake of TT vaccine in Tiaty Sub County in comparison to Koibatek Sub County. It is against these findings that the phase 2 of the project was commissioned in 2020.

The overall goal of the phase 2 project was to the strengthen confidence in TT-containing vaccine among male head of households and influential community leaders in Baringo County, Kenya. The project aimed to achieve the following objectives:

  • Address any lingering community misconceptions about TT-containing vaccine.
  • Gain the support and commitment of influential leaders and male heads of households for TT-containing vaccine and routine immunization.
  • Increase faith-based support for TT-containing vaccine and routine immunization; and
  • Boost or restore confidence of the community on the community health care workers participating in campaigns and health care workers in general.

The phase 2 project utilized a participatory approach and adapted from the Community Action Model (CAM model); methodology designed to build communities’ capacity to address their public health concerns through active engagement with community members. The AIHD, in collaboration with the Baringo County, implemented phase 2 of the project in Baringo County, Tiaty Sub County, Silale and Ribkwo wards.

Lymphatic filariasis is a neglected tropical parasitic disease caused by microscopic, thread-like worms. The adult worms only live in the human lymph system. The lymph system maintains the body’s fluid balance and fights infections and spread from person to person by mosquitoes. It is the leading cause of disability morbidity globally causing serious psychosocial, sexual, and social disfunction. In Kenya, lymphatic filariasis is found in the coastal areas where the predominant vectors are anopheline and culicine mosquitoes in the rural and urban settings, respectively. As a result, the Neglected Tropical Diseases (NTD) program was re-launched in 2013 to oversee the re-establishment of the National Program to Eliminate Lymphatic Filariasis (NPELF) initiated in 2001 for LF control.

The African Institute for Health and Development did formative research for Task Force for Global Health and The End Fund. The results indicated that LF was of public health importance only in the coastal region. Out of the twenty-six sub-counties in this region, twenty-three qualified for mass drug administration (MDA). As a result, the recommended WHO regimen of diethylcarbamazine (DEC) and albendazole (DA) was adopted for the control of LF and the soil transmitted helminthiasis (STH), a process that was initiated in 2002. Several countries have found that, the response to the present Mass Drug Administration regimen has been sub-optimal in some IUs necessitating additional rounds. The gaps in implementation and the sub-optimal achievements of the elimination agenda have led to the need for complementary or alternative strategies to accelerate global elimination.

The Government implemented IDA in the whole of Lamu County and in Jomvu sub-County. These are high microfilariae rate locations and are like other endemic sub-Counties in the coastal region on a programmatic scale. The primary objective of the study was to strengthen community and health system participation to reach more than 80% coverage with MDA using triple-drug therapy IDA. Lamu residents confirmed that they had knowledge of Lymphatic Filariasis, and they had a local name for the disease – “Matende,” “mahende,” “Madende” which is mostly used in Lamu east. Lamu residents noted that it was not main health problem in their regions, but men were at higher risk of getting infected. “I have seen mostly men being affected by the disease” (FGD-Men-Lamu). “Men and elderly people are more affected, but men normally hide in those lessos... they are afraid to come out” (FGD-Women-Jomvu).

In conclusion, for the community to receive and swallow the drugs, they must be informed on why they must take the drugs, how, and where to receive treatment. In addition, having a strong social mobilization and communication component was critical for any mass drug administration program to succeed. Social mobilization and community awareness go a long way in addressing issues related to fears of adverse effects and severe adverse events and reaching special populations such as migrants fisher folks, mangrove harvesters, nomadic pastoralist, urban dwellers, employees, systematic compliance, among others.

In current national studies, 80% of Kenyans are unknowingly affected by non-communicable diseases, with similar projections for both urban and rural areas where majority of Kenyans reside. In Kenya, non-communicable diseases contribute to one in every death and account for half of all hospital admissions. Non-communicable diseases are the leading causes of morbidity and mortality globally. Notably, deaths due to non-communicable diseases are projected to rise to 55% by the year 2030 unless appropriate interventions for sustained attention prevention and care are put in place. The four major non-communicable diseases: Cancer, Diabetes and Chronic Respiratory Diseases that comprise 57% of all the NCD deaths. The other less prevalent are, epilepsy, sickle cell disease and other haematological disorders, Alzheimer’s disease, Lupus, Psoriasis, genetic conditions, and congenital anomalies which account for the rest of the deaths (43%).

The Government of Kenya through the Ministry of Health has been working closely with likeminded civil society organizations, development partners and the private sector in addressing the burden of non-communicable diseases. The African Institute for Health and Development has partnered with the MoH since 2004. Some of the achievements of this partnership are the establishment of the Non-Communicable Diseases Alliance in Kenya (NCDAK); the establishment of the Consortium for NCD prevention and Control in Sub-Saharan Africa (CNCD-Africa), implementation of the STEPS survey (2015) and the development of the Kenya National NCD strategy 2015-2020. 

In addition, AIHD has further worked with the Nairobi County Government - Department of Non-Communicable Diseases, in implementing a project titled, ‘NCD quality Management’ since 2016 with the aim to improve the quality of NCDs data collected in health facilities within Nairobi County. In line with this, the Institute proposed to partner with the government and NCDAK in implementing the activity, “Accelerating the achievement of Sustainable Development Goals (SDGs) through the management of Non-Communicable Diseases (NCDs) in Nairobi County.’

AIHD aimed to increase the priority, attention, and budget allocation to non-communicable diseases, pursuing the increased awareness on non-communicable diseases especially on major diseases in the county namely, diabetes 1 and 2, hypertension, asthma, and sickle cell anaemia. Also, we sought to establish or strengthen existing follow-up mechanisms for persons living with non-communicable diseases and enhance frequent community screening for NCDS for early identification of non-communicable diseases. It was also important to strengthen the protection of persons living with NCDs during the COVID-19 pandemic and evidence building on the burden of non-communicable diseases at the county level.

Hypertension has been a killer disease in Kenya and sub-Saharan Africa as a whole. Diabetes is a rising epidemic within the country. In Kenya, the prevalence of diabetes in adults is estimated to be 4.56% amounting to almost 750,000 persons and 20,000 annual deaths. This rise in the burden of diabetes is associated with demographic and social changes such as globalization, urbanization, aging population, and adoption of unhealthy lifestyles such as excessive alcohol consumption.

The institute and NCDAK created awareness on non-communicable diseases by educating the community on several aspects of NCDs such as prevention, control, and management. Education can take place at various levels in the community with healthcare workers, community leaders, persons living with NCDs and their caregivers and the community at large. Persons living with NCDs are likely to encounter a lot of challenges in managing their conditions apart from attending their usual clinics at healthcare centres. The institute conducted home visits to persons living with NCDs, availed drugs and screening equipment to the nearest health facility by mass drug administration and strengthened existing groups for persons living with NCDs, by community accountability. The target locations were Nyeri, Isiolo, Taita Taveta, Makueni, Vihiga, and Kisii.

The 58th World Health Assembly urged member states to ensure that “health-financing systems introduce prepayment mechanisms for the health sector, with a view to sharing risk, avoid catastrophic health-care expenditure and impoverishment of individuals as a result of seeking care” (WHO). The 2010 World Health Report identified the vital role of health financing in achieving universal health coverage (UHC). Health care financing has three interrelated functions namely: (i)revenue collection- process by which health systems receive money from households and organizations; (ii) pooling- accumulation and management of revenues to ensure that the risk of paying for health care is borne by all the members of the pool; and (iii) purchasing- pooled funds are paid to providers in order to deliver a set of health interventions on behalf of the population for which the funds are pooled.

The WHO identified four key elements necessary towards the realization of universal coverage:

  • A strong, efficient, well-run health system.
  • A system for financing health services.
  • Access to essential medicines and technologies; and
  • A sufficient capacity of well-trained, motivated health workers.

The Government of Kenya (GoK), with support of various stakeholders, has over the years, initiated policy reforms and strategies earmarked towards improving the health of its citizens. Its commitment is outlined in policy documents such as Kenya Health Policy Framework (KHPF 1994–2010), Health Sector Strategic Plans, Vision 2030, Constitution 2010, and the Health Act No.21 of 2017. The Government further provided a legal framework for ensuring a health care delivery system that is driven by the people while bridging the gap on geographical access by providing for a devolved system of governance. These efforts can be seen to contribute towards universal health coverage for the populace in the country.

The Government has also made strides in promoting access to comprehensive health care services to its people. Kenya adopted UHC as one of the big four priority agenda by His Excellency the President, with an aspiration that by 2022, all persons in Kenya will be able to use the essential services they need for their health and wellbeing through a single unified benefit package, without the risk of financial catastrophe. The UHC program was piloted in four (4) counties: Machakos, Nyeri, Isiolo and Kisumu, and has provided the Ministry of Health (MoH) and County Governments key lessons to roll it out to the rest of the country.

Despite efforts made by the Government, the country grapples with a high disease burden. Although communicable diseases, maternal, neonatal, and nutritional conditions have been leading causes of Disability Adjusted Life Years (DALYs) in Kenya in the past, non-communicable diseases (NCDs) and injuries are increasingly becoming an important contributor to the disease burden and represent the leading DALYs among adults. For example, while HIV contribution to the burden of disease has decreased by 61% in the period 2005-2016, the combined contribution of ischaemic heart disease and cerebrovascular disease has increased by 57% in the same period (MOH, 2018). Generally, NCDs account for 50% of hospital admissions, 55% of hospital deaths and 33% of total deaths in the country.

The proposed assignment is part of Non-Communicable Diseases Alliance of Kenya’s (NCDAK) effort to comprehensively address NCDs in the country by analysing the status of UHC and inclusion of NCDs in UHC in Kenya. The NCDAK is working towards developing a policy brief that will steer its participation in the development of the UHC framework in Kenya. The development of the policy brief will be achieved by undertaking thorough review of the UHC performance reports in the four pilot counties; MoH policy framework around UHC; global best practices on UHC and experiences of people living with NCDs (PLWNCDs) relating to access to health care, essential drugs and commodities.

This assignment aimed to develop a UHC policy brief that will provide strong recommendations towards the development of the Kenya UHC framework.

Eliminating trachoma by 2020 required the effective implementation of the SAFE strategy. For the “A” component of the strategy, a key objective was to achieve sufficiently high population coverage (at least 80%) through equitable Mass Drug Administration (MDA) campaigns with Zithromax in all trachoma-endemic areas.

The objectives were:

  • To identify the factors associated with low and inequitable coverage and compliance in trachoma endemic areas in Tanzania and Kenya with nomadic populations.
  • To prioritize factors in terms of amenability to intervention, and then
  • To use the evidence generated to design specific interventions that could improve the reach and impact of campaigns of Zithromax MDA in both countries.

Data was collected through direct observation of mass drug administration campaigns, focus group discussions and semi-structured interviews. The study areas were Narok and Kajiado in Kenya and Ngorongoro and Longido in Tanzania. Community members, community drug distributors and MoH staff involved in MDA campaigns participated in the study.

Preliminary results showed that community rumours about the antibiotic is a significant factor behind refusals e.g., beliefs that the drug is a contraceptive. Maasai communities associate not taking western medicine with heroism and see that as a source of pride. Political issues also play a role in the success of MDA campaigns. Government interventions, including health-related campaigns, are viewed with suspicion by some community members. Geographical barriers affected programmatic implementation in different ways in the study communities.

The AIHD recommended that:

  • MDA campaigns need to be regular and predictable, yet also take into consideration temporary migration patterns.
  • Existing structures should be used to distribute drugs and create awareness e.g., village elders, chiefs, youth groups, the Morans.
  • There is need for multifaceted social mobilization efforts to create a high level of awareness.
  • There is need for adequate time allocation for the training of CDDs to equip them with sufficient knowledge about trachoma, the antibiotic, and the MDA campaign.
  • Trachoma champions should be used to advocate on the importance of taking the antibiotic during trachoma MDAs.
  • There is need to diversify further the mechanisms for community mobilization, as well as increasing the number of CDDs.