Home-based patient care in a

resource poor setting during an

influenza pandemic.

Field test of Key Messages.Sierra Leone Nov – Dec 2009 & March 2010

Dr Tim HealingDip.Clin.Micro, DMCC, CBIOL, FZS, FRSB

Course Director,

Course in Conflict and Catastrophe Medicine

Worshipful Society of Apothecaries of London

Faculty of Conflict and Catastrophe Medicine

The project

• This project was undertaken as a result of the

outbreak of the "Swine flu" pandemic 2009-10

– Virus identified in Mexico - April 2009.

– Spread rapidly - novel flu virus - few young people immune

– Not as serious as originally predicted - many older people were

already immune

– The relatively small number of serious/fatal cases mostly in

younger adults & children (particularly those with underlying

health problems) & pregnant women.

Concept• People in resource poor countries likely to be severely

affected by events such as an influenza pandemic

• Health care, especially in remote areas, likely to be very limited

• Very high levels of poverty - few can afford health care or drugs

To help address these problems WHO produced guidance on home-based patient care during a pandemic.

– This contained a number of Key Messages

– Had to be appropriate for the countries where they would be used

– WHO undertook field trials of the Key Messages in various parts of the world including Sierra Leone.

The key messages

Understanding the disease1. What is influenza A (H1N1)?

Preventing infection2) Cover your mouth and nose when you cough or

sneeze with a sleeve/scarf (respiratory etiquette)

3) Hand hygiene

4) Separate the sick from others

5) Ventilate the area where the patient is nursed

6) One care giver for each sick person

Nursing the sick7) Hydrate the patient

8) Antibiotic treatment for pneumonia

9) Assess if the patient needs to seek health care

The Sierra Leone programme team & MoHS & other

agencies working with the team

WHO Global Influenza Programme, Geneva

• Dr Tim Healing (Field Test Project Manager)

• Dr Julienne Ngoundoung Anoko (Social Anthropologist)

• Ms Anna Bowman (WHO Technical Officer)

• Mr Guilhem Alandry (Videographer)

WHO Office, Freetown

• Mrs Aminata Kobie (Health Promotion Information Adviser)

• Mrs Mary Massaquoi (Translator/Local adviser)

• Mr Lawrence Babawo (Translator/Local adviser)

MoHS National level

• Health and education team

• Disease prevention & control team

MoHS District level

• Health & education departments

• District medical authorities

• Lassa Fever outreach team (Kenema)

Sierra Leone

Slightly larger than the Republic of

Ireland, slightly smaller than

Austria

At the time of this study:

• Emerging from 11 years of

civil war

• Trying to reintegrate returning

refugees, relocated IDPs,

former combatants &

amputees

Sierra Leone 2009 Some basic facts

SL UK

5,485,998 61,708,895

UNDP HDI position 180/182 21/182

Annual income per capita $340 $28,350

Annual health expenditure per capita $43 $3,399

Annual health expenditure as % of GDP 3.5% 8.4%

%Popn below poverty line (<$1.25/day) 53% 0

Life expectancy at birth (m/f - years) 39/42 75/82

Healthy life expectancy (m/f - years) 27/30 69/72

Maternal mortality/100,000 live births 970 13.95

Infant mortality/1,000 live births 155 4.93

<5y mortality 26.9% 0.6%

Test Sites

Test sites

Two test sites were used

• George Brook (DwarzakFarm) - deprived community on the southern side of Freetown

• Blama town - main town of Small Bo Chiefdom, about 12 miles west of Kenema town

George Brook (Dwarzak

Farm) Community,

Freetown

• Urban site, edge of Freetown

• Population ca. 32,000

• Extends into the hills around the city

• Many houses hard to reach

• 16 ethnic groups

Official medical care

in George Brook• Government health centre

– Community Health Officer (CHO) with 25 staff

– Basic services

• ante- & post-natal care

• family planning

• treatment for infections including malaria &TB

• minor trauma

• HIV/AIDS tests (+ve cases referred to Freetown hospitals)

– 15 inpatient beds (mainly maternity)

– Labour room for deliveries

– Charge on cost recovery basis (some exemptions).

Other health care in George Brook

• Private clinics

• Self styled “doctors”

• Advice from pharmacies & unofficial drug

outlets

• Traditional Healers

(Many cheaper than the government clinic &

therefore used more).

Kenema

Small Bo chiefdom

• One of 16 chiefdoms

in Kenema District

• Population ca 34,550

• Ruled by a

Paramount Chief

Blama town, Small Bo Chiefdom

• Blama – country town, far from Freetown

• Ca. 9000 inhabitants

• 4 ethnic groups (Mende – largest)

• Formerly prosperous (rail centre)

• Rural economy with weekly market in central market place

Government and other health facilities

in Blama• Community Health Centre

– CHO, 5 staff + some volunteers

– Facilities include

• Ante- & post- natal clinics

• labour ward,

• TB, malaria & HIV/AIDS diagnosis

• minor trauma

• complicated cases referred to Kenema hospital

• Other health care similar to George Brook– Private clinics

– Self styled “doctors”

– Advice from pharmacies & unofficial drug outlets

– Traditional Healers

Main diseases affecting the

people of the two communities

George Brook Blama

Malaria Y Y

ARI Y Y

Watery & bloody diarrhoea Y Y

Malnutrition & dehydration in children Y Y

Worm infestations (GI tract) Y Y

(Typhoid fever) Y Y

Schistosomiasis Y

(Lassa fever) Y

Data for first 9 months of 2009 from Government Health Centres

The programme

Working with the communities

• Developed partnerships with the two communities

• Project aims presented to community leaders

• Anthropologist built relationship with the community

• This allowed the community to:

– take ownership of the programme

– select & develop the messages

– develop ways to deliver the messages

Gathering socio cultural information

• Qualitative

anthropological surveys

• As many community

groups as possible

interviewed

• Observation of day to

day life behaviours

Outcomes of the surveys

Local knowledge & explanations of

Influenza A (H1N1)

• “Doesn’t exist. The government is just creating

panic. Where are the sick people?”

• “A manipulation by the political authorities”

• “A disease created by the United States since the

terrorist attacks of 9/11”

• Some remembered that it affects Asian countries

and kills a lot of chickens

• A lot of pigs were killed in Egypt

• Not a Sierra Leonean concern

Why did radio messages about

H1N1 fail to reach the people?

• Broadcast at wrong times

• Market traders may have radios on but do not

listen carefully

• Radio batteries are expensive

Are colds and “flu-like illness” (“fresh cold”)

diseases?

Thinking about this was confused

• In general “Fresh Cold” not considered to be an infectious disease & not considered dangerous

• The result of unpleasant external conditions (e.g. the Harmattan)

• All are likely to get it so no attempts are made to avoid it “Better all have it at the same time than one after the other”

Therefore communities might not recognise H1N1 infection as a disease, or attempt to prevent its spread, at least initially, without extensive sensitisation

H1N1 became known locally as “New Fresh Cold”

Normal treatment for “fresh cold”

• Normally treated at home with:

– Hot pepper soup

– [But:

• No fluids (provokes vomiting)

• No hot drinks (due to sore throat)]

– Hot baths

– Warm clothes

– Mentholated rub

– Rest, paracetamol

– Nursed outside (sheltered part of

veranda) during day, go inside at

night to sleep

Attitudes to behaviours that could affect

transmission, prevention & mitigation of the

disease

• Washing hands

• Coughing and

sneezing

• Blowing the nose

• Spitting

Washing hands before eating

Don’t need to wash the hands before

eating because use a spoon to eat

But in fact

– handled meat, chicken or fish in their food

with their hands

– handled the dishes

Washing hands after cleaning the

baby’s bottom

• Mothers did not wash hands properly after

cleaning baby’s bottom

• “Children’s shit is not infectious, not dangerous”

Coughing and sneezing.

People tended to:

• Cover mouth and nose with both hands

• Rub the droplets into their hands and

clean their hands on their clothes

• Some used handkerchiefs - might be

kept in the pocket up to a week before

being washed

• Same handkerchief used on children

Blowing the nose

• Often blew the nose with fingers, threw the

mucus on the ground & cleaned their hands

on their clothes

• Children’s noses were cleaned with their

mother’s clothes/hands or the children’s

clothes

• Some mothers sucked their child’s nose with

their mouth to extract the mucus and then

spat it out.

Spitting

• Most people spat on the ground/floor in

the same place where they were

seated or were standing.

Understanding the disease

1. What is influenza A (H1N1)?

Preventing infection

2. Cover your mouth and nose when you cough or sneeze with a sleeve/scarf (respiratory etiquette)

3. Hand hygiene

4. Separate the sick from others

5. Ventilate the area where the patient is nursed

6. One care giver for each sick person

Nursing the sick

7. Hydrate the patient

8. Antibiotic treatment for pneumonia

9. Assess if the patient needs to seek health care

Understanding the disease

1. What is influenza A (H1N1)?

Preventing infection

2. Cover your mouth and nose when you cough or sneeze with a sleeve/scarf (respiratory etiquette)

3. Hand hygiene

4. Separate the sick from others

5. Use outside spaces

6. Eat from separate dishes and with separate utensils

Nursing the sick

7. Hydrate the patient

8. Antibiotic treatment for pneumonia

9. Assess if the patient needs to seek health care

The original Key Messages Messages assessed as

important at both sites

Developing the messages

• WHO team & MoHS

adapted key

messages to local

socio-cultural context

Coughing and sneezing

• Keep away from others & always cover your nose and mouth

• Always use a handkerchief or a clean piece of cloth

• Wash the handkerchief/cloth every day with soap & water & hang it out to dry

• Don’t suck the children’s noses with your mouth. Use a handkerchief or a clean piece of cloth

Wash your hands frequently with

water and soap

After coughing & sneezing

and

– When arriving at home

– Before eating

– Before touching or preparing

food

– Before feeding your baby

– After using the latrines

– After cleaning the baby’s

bottom

Reinforcing the hand

washing message

• Soap kills germs (washing

with water only doesn’t)

• Ask another person to

handle the kettle used for

washing

• (Use ash for mechanical

cleansing when soap/water

is short – ideally followed by

water rinse)

Hydration

• Drink a lot of fluids

(water/juice/lemon

grass/pepper soup)

• Eat fruit to help keep

the body strong and

prevent dehydration

• Continue breastfeeding

the baby

Use outside areas

• Reduces contact with infectious droplets

• Helps reduce infectious droplets inside.

Difficult to

1) Separate patient from others indoors due to large numbers of people in houses

2) Ventilate house at night –windows closed/covered to keep out mosquitoes

Eat from separate dishes, use

separate utensils

Helps prevent

transmission from

one person to

another

(Can be difficult to

follow due to

traditional food

sharing behaviours)

Using the health centre

• Go to the health

centre if you get

worse or do not get

better

Disseminating the messages

Selecting appropriate key

messages & adapting them for

local use

• The community selected:– the messages

– ways to disseminate them

– day(s) when this should be done

• Artist from MoHS drew drafts

• These were pre-tested at local market

• Comments used to select final versions of the drawings

Training sessionsHeld for medical staff and

community leaders to:

• Provide accurate information

• Inform them of the outcomes of the surveys

• Help plan the dissemination processes

• Give them printed copies of training material

They then disseminated information to their particular groups

Importance of women

• Women:

– the homecare givers

– as primary carers for the sick, are key to effective care of H1N1 patients in the community

– Women’s associations are more active than the men’s

• At the request of the communities, women were especially represented in the actions & training sessions

The Actions

Town criers• The town criers announced the actions in

advance

Processions• Held at both sites, moving through the

communities & the markets drawing attention to

the key messages

• Those in the processions wore T-shirts with the

messages & carried posters

Proceedings filmed and

photographed

Music, song and dance

• A brass band was

used at George

Brook to attract

attention to the

action

• Sierra Leonean

singer Amie Kallon

composed a song &

a dance for use at

the action in Blama

Drama groups

• Local drama groups produced short plays

& songs to highlight the different

messages

Reinforcing the

messagesLocal religious &

civic leaders:

• gave talks to

highlight the

importance of the

messages

• exhorted their

people to take

note & follow the

messages

Children were

very much

involved

Evaluation of the results19th – 29th March 2010

Objectives of the evaluationPrimary objectives

1. Evaluate whether the actions were implemented as planned

Were outputs delivered as planned (time and place?)

2. Evaluate the process

Did the message/activity reached the people for whom it was designed?

3. Assess the behavioural impact of the information package

As result of the communication activities, had people’s

behaviours changed?

Secondary objectives

• Assess:

– the community’s perception of the home-based care project

– the local authorities (Ministry of Health, WHO country office) perception of the home-based care project

– if there were any other consequences due to the project

Methods

Qualitative and quantitative evaluation methods used.

• Focus group discussions (FGD)

• Structured interviews (questionnaires)

• Unstructured observation/Behavioural observation

Results – Primary objectives

1. Were outputs being delivered as planned (time and place?)

2. Had message/activity reached the people for whom it was designed?

1. Yes

2. An increased understanding of:– influenza A H1N1

– importance of washing hands with water & soap

– importance of covering nose & mouth to avoid spreading the virus

Increased overall knowledge about the disease in both communities.

Varied substantially between the rural & the urban sites. (urban>rural)

Results – Primary objectives

3) As result of the

communication

activities, had people’s

behaviours changed?

3) Some schools were promoting hand washing & the use of handkerchiefs

But

Most people were not putting home care information into practice

Results – secondary objectives

1) A great acceptance of this project’s

approach both by the communities & by the

national authorities (Ministry of Health &

WHO)

2) An increased enthusiasm & a high level of

interest by the communities in health issues

Overall conclusions #1Difference between implementation & uptake of the messages between

the urban (GB) & rural (Blama) sites with more at the former.

• Possibly – people of GB received more health information than those of Blama via

the media.

– higher level of involvement by the community leaders in GB (urban site) than in Blama (rural site).

Community leaders are key stakeholders when implementing & following up on community level activities.

Overall conclusions #2The most efficient means of conveying

the messages:

• Via community channels at the grass roots level (more effective than mass media such as radio & TV)

• In GB, the town crier, & the drama group performances, enhanced interest & kept people informed

• In Blama, Amie Kallon’s original song on influenza was selected as the best information channel

• The impact of posters was very low

Any Questions?