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ORIGINAL ARTICLE
Year : 2017  |  Volume : 61  |  Issue : 4  |  Page : 267-273  

Assessment of the performance of community-directed treatment with ivermectin strategy for the control and elimination of onchocerciasis in Edo State, Nigeria


1 Lecturer, Department of Community Health, College of Medical Sciences, School of Medicine, University of Benin, Benin Edo State, Nigeria
2 Professor, Department of Community Health, College of Medical Sciences, School of Medicine, University of Benin, Benin Edo State, Nigeria

Date of Web Publication6-Dec-2017

Correspondence Address:
Amenze Oritsemofe Onowhakpor
Department of Community Health, College of Medical Sciences, School of Medicine, University of Benin, PMB 1154, Benin City, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_236_16

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   Abstract 


Background: Community-directed treatment with ivermectin (CDTI) was developed in the mid 1990's as a solution for the control and elimination of onchocerciasis. It requires that ivermectin be administered continuously over a period of at least 14 years with community involvement before elimination can be achieved. Objectives: The objective of this study is to assess the performance of CDTI strategy for control and elimination of onchocerciasis in endemic Local Government areas of Edo State. Methods: A descriptive evaluation in a cross-sectional, descriptive study design was conducted among 720 community members selected from six communities using multistage sampling technique, 11 Community directed distributors (CDDs), and 17 health workers involved in the implementation of the CDTI strategy in Edo State. Primary data were collected using an interviewer's administered questionnaire while secondary data were obtained from the State Ministry of Health. IBM SPSS version 21 software was used for data analysis. Results: The highest therapeutic coverage (95.5%) was observed in Aden II community while the least therapeutic coverage (56.6%) was observed in Imeke community. Regarding the performance indicators, ivermectin supply, work of CDDs, training, monitoring and supervision, finances by communities had scores ≥2.5 and were therefore considered as having satisfactory performance. However, community participation and ownership and health education and mobilization had scores <2.5 and as such considered as having unsatisfactory performance. Conclusion: Sustainability of the CDTI program in the study area is likely but not guaranteed as there is need for improvement in areas regarding community mobilization, participation, and ownership.

Keywords: Community-directed treatment with ivermectin strategy, control, elimination, onchocerciasis, performance


How to cite this article:
Onowhakpor AO, Okojie OH, Wagbatsoma VA. Assessment of the performance of community-directed treatment with ivermectin strategy for the control and elimination of onchocerciasis in Edo State, Nigeria. Indian J Public Health 2017;61:267-73

How to cite this URL:
Onowhakpor AO, Okojie OH, Wagbatsoma VA. Assessment of the performance of community-directed treatment with ivermectin strategy for the control and elimination of onchocerciasis in Edo State, Nigeria. Indian J Public Health [serial online] 2017 [cited 2019 Oct 19];61:267-73. Available from: http://www.ijph.in/text.asp?2017/61/4/267/220056




   Introduction Top


Community-directed treatment with ivermectin (CDTI) was developed in the mid 1990's as a solution for the control and elimination of onchocerciasis, which require that ivermectin be administered continuously over a period of at least 14 years before elimination can be achieved in hyper and mesoendemic communities.[1] Following its development, several multicountry studies were carried out to assess its feasibility and effectiveness. Reports from the studies revealed that high ivermectin coverage was achieved with community involvement in its distribution.[2],[3] Consequently leading to the adoption of the CDTI by African Program for Onchocerciasis Control (APOC) as the basis of its control strategy in 1997.[1]

The performance of the CDTI strategy under the onchocerciasis control program is assessed at the community level using 9 sustainability indicators.[4],[5],[6] The community-level instrument focuses on the attributes of community ownership and CDTI performance.[7] Five of the indicators address routine project activities and processes that support the CDTI strategy, they include planning, leadership, monitoring and supervision, ivermectin supply and distribution; and training/health education/sensitization/advocacy/mobilization (TRHSAM). Three of the indicators assess the resources available to project: financing, human resources, and transport and material resources. The last indicator assesses therapeutic coverage. Before the era of onchocerciasis elimination, therapeutic coverage of 65.0% was the threshold required to achieve onchocerciasis control within 15 years [5],[8] but emphasis is currently on 80.0% therapeutic coverage to achieve elimination. The success of the CDTI strategy is therefore vital for the elimination of onchocerciasis thus, the need to assess its performance. There is a paucity of comprehensive data on assessment of the performance of CDTI strategy in Edo State. This study will therefore be timely in filling the gaps in information regarding the CDTI strategy and also eliciting gaps in the program so as to enhance program effectiveness. This study therefore, assessed the performance of the CDTI strategy in onchocerciasis endemic Local Government Areas (LGAs) of Edo State under the following domains: planning, leadership, monitoring and evaluation, ivermectin supply and distribution, TRHSAM, human resource, material resource, financing, and coverage.


   Materials and Methods Top


Study area

The study was carried out in onchocerciasis endemic LGAs of Edo State, Nigeria, over a 14 months period using a descriptive evaluation in a cross-sectional study design. Edo State is divided into three senatorial zones, namely; Edo North, Edo Central, and Edo South senatorial zones. CDTI projects spans across the 3 senatorial districts.[9] The State has a total of 18 LGAs distributed across the senatorial districts, of which 12 LGAs are hyper and mesoendemic for onchocerciasis.[10] The distribution of the endemic LGAs across the three senatorial zones are as follows: Edo North-Akoko Edo, Etsako East, Etsako West, Owan East, Owan West; Edo Central-Esan South East, Esan North East, Esan West, Igueben; Edo South-Ovia North East, Ovia South West, Uhunwonde. CDTI projects are carried out in 824 communities in Edo State with a total number of 7070 Community directed distributors (CDDs) (Male-4841; Female-2229) and 1037 health staff involved in its implementation.[10] The population of Edo State as at 2006 census was 3,233,366.[11] However, the projected population for 2015 was 4,286,750.

Study population

The study population comprised all community members in endemic LGAs, CDDs, and health workers involved in the implementation of the CDTI strategy in Edo State.

Sample size determination

The minimum sample size for the community members was determined using the Cochran's formula for studying proportion.[12] The prevalence was taken as 30.5% which was the proportion of respondents knowledgeable about onchocerciasis in Okpuje community, Edo State, Nigeria.[13] Adjusting for 10% nonresponse and using a design effect of 2, the minimum calculated sample size was 720. In computing the sample size, a design effect of 2 was used to quantify for the reduction in design efficiency observed by the use of multistage sampling technique which is less than that of a simple random sample of the same size.

All CDDs and health workers involved in the CDTI strategy in the selected communities present as at the time of conduct of the study and who consented to partake in the study were also recruited for the study.

A total of 720 community members were selected from six communities (Aden I, Aden II, Eko Ibadin, Ubierumu Oke, Ayua and Imeke) in the endemic LGAs across the three senatorial districts using a multistage sampling method.

Stage 1: Selection of local government areas

Of the 12 LGAs endemic for onchocerciasis in Edo State, 3 were selected using simple random sampling technique (computer-generated table of random numbers) across the 3 senatorial districts (one from each senatorial district), namely: Ovia South West, Esan North-East, and EtsakoWest.

Stage 2: Selection of wards

Ovia South West, Esan North-East, and Etsako West consist of 10, 11, and 12 wards, respectively. Two wards were selected from each of the selected LGAs using simple random sampling technique (balloting). The selected wards are as follow: Ovia South West – Ward 7 and 8; Esan North-East – Ward 4 and 6; and Etsako West – Ward 4 and 6.

Stage 3: Selection of communities

One community from each of the 6 selected wards was selected using simple random sampling technique (computer-generated table of random numbers).

Stage 4: Selection of respondents

The population of individuals in each of the 6 selected communities was obtained from the Local Government Secretariat. Proportionate allocation was used to determine the number of respondents selected from each community. Thereafter, a systematic sampling technique was used to select respondents. The CDDs census register was used as the sampling frame in each selected community. Respondents in each community were selected using a sampling interval. Sampling interval was calculated using the formula:



Where,

K = sampling interval,

N = total number of individuals on the census register and

nc= desired sample size for each community based on proportional allocation.

The 1st respondent was selected by simple random sampling technique using balloting within the calculated sampling interval. Thereafter, every n th respondents who met the selection criteria was selected using the sampling interval until the calculated sample size for each community was obtained.

In addition, 11 CDDs and 17 health workers involved in the implementation of the CDTI strategy in the selected communities also participated in the study.

Methods and tools for data collection

Seven Community health extension workers were recruited as research assistants. Primary data were collected using a structured interview.er's administered questionnaire while secondary data were obtained from the State Ministry of Health. The questionnaire comprised questions addressing sociodemographic characteristics of respondents and the nine domains of community level indicators of performance as follows:[14]

  1. Planning: Were CDDs and community authorities planning and managing CDTI?
  2. Leadership: Were community leaders managing problems associated with distribution and was the larger community involved in key decisions?
  3. Monitoring and supervision: Were CDDs reporting complete and accurate distribution data?
  4. Ivermectin supply and distribution: Was the drug obtained and managed effectively by the community?
  5. Training/health education and mobilization: Were the CDDs trained? Were the community members educated on onchocerciasis and the CDTI strategy by the CDDs?
  6. Human resources: Were community members willing to help?
  7. Material resources: Did the community provide transport for ivermectin collection (at a point agreed upon with the health system)?
  8. Financing: Did the community support CDDs and CDTI? The Finance indicator will evaluate how communities dealt with the expenses of CDTI—transport, buying treatment record books and pencils, and how communities supported their CDDs (moral support, support in cash or in kind)
  9. Coverage: This assessed therapeutic coverage. It is the proportion of eligible community members who had received ivermectin in a given year.[14]


Secondary data consisted of CDDs treatment registers and health workers summary sheets in the last 1 year preceding the study were reviewed to obtain information on total population, number of people with height 90 cm and above treated (reason been that individuals with height 90 cm and below do not meet the eligibility criteria for ivermectin treatment), number of refusals, number of absentees and number of individuals not eligible for ivermectin in the communities studied.

Data analysis

Data was analyzed using IBM SPSS version 21 software (IBM Corp., Armonk, New York, United States). Each of the nine domains of the community level indicator for assessing performance was graded on a Likert scale of 0–4 as follows: If the findings around this indicator points to a situation which

  • Fully supports CDTI project sustainability – 4 (Fully)
  • Largely supports CDTI project sustainability, but there is some small room for improvement – 3 (Highly)
  • Only supports CDTI project sustainability about half as much as it could do. Two (Moderately)
  • Only supports CDTI project sustainability slightly – 1 (Slightly)
  • Does not support CDTI project sustainability at all – 0 (Not at all).


All the indicators within a group were graded using the Likert scale, following which an average score was worked out for each group of indicators. Based on this scoring system, scores of ≥2.5 on a 4-point scale was considered as a satisfactory performance and score of <2.5 was considered as an unsatisfactory performance.[5]

Ethical considerations

Ethical approval to conduct this research was sought and obtained from the University of Benin Teaching Hospital Ethics and Research Committee. Permission was sought from the Chairmen of the LGAs and the various Community Leaders. Informed written consent was obtained from respondents.


   Results Top


The mean age (standard deviation) of the respondents was 45.9 (15.2) years. Three hundred and eighty-five (53.5%) of the respondents were males while 335 (45.6%) were females.

Seven (63.6%) of the CDDs were aged 35 years and above while 4 (36.4%) were aged ≤34 years. Majority 9 (81.8%) of the CDDs were male while only 2 (18.2%) were females. Twelve (70.6%) of the health workers were aged 34 years and below while 5 (29.4%) were aged 35 years and above. The health workers were predominantly females constituting 11 (64.7%) while 6 (35.3%) were males.

Five (45.5%) of the CDDs said that the place of decision-making for distribution of ivermectin was at the community chief meeting, followed by 3 (27.3%) who said it was at the community health meeting. Five (45.4%) of the CDDs mentioned community elders' meeting as the place of selection of CDDs.

Six (54.5%) of the CDDs said that drugs were collected at a collection point. Ten (90.9%) and 11 (100.0%) of the CDDs had summary sheets and measuring tape, respectively. All CDDs said they never experienced drug shortage. Seven (63.6%) CDDs said they were not given incentives compared to 4 (36.4%) who said they were given incentives which was in the form of transportation allowance.

Majority 539 (94.1%) of the community members said decisions were made by community leaders at meeting this was followed by 23 (4.0%) who said decisions were by health workers. Five hundred and ninety six (82.8%) of the community members participated in meetings for CDD selection. Seven hundred and two (97.5%) said the CDDs in the community were indigenous volunteers. Majority 544 (75.6%) of the community members graded the CDDs in their communities as very good, only 8 (1.1%) graded their CDDs as poor [Table 1].
Table 1: Distribution of community members as per their participation in community-directed treatment with ivermectin and their awareness about community-directed distributors along with their performance (n=720)

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Among the health staffs studied 15 (88.2%) had received orientation on CDTI. All health staffs supervised their CDDs and had educated their communities and trained their CDDs on CDTI [Table 2].
Table 2: Distribution of health staffs as per their involvement in community-directed treatment with ivermectin implementation (n=17)

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The highest therapeutic coverage (95.5%) was observed in Aden II community while the least therapeutic coverage (56.6%) was observed in Imeke community. In Ayua community the proportion of CDDs to the population was 1: 1043. Aden II had the least (1:324) CDDs to population ratio. In comparism with the standard 1 CDD to 125 individuals none of the communities studied met this standard [Table 3].
Table 3: Therapeutic coverage and proportion of community-directed distributors to population in studied communities

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The indicator addressing ivermectin supply, work of CDDs, training, monitoring and supervision, finances by communities had scores ≥ 2.5 therefore they were considered as satisfactory performance while community participation and ownership and health education and mobilisation had scores < 2.5 thus are considered as having unsatisfactory performance [Table 4].
Table 4: Assessment of performance of community-directed treatment with ivermectin strategy in the study area

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   Discussion Top


Performance of the CDTI strategy in this study was assessed using the nine domains of community level indicators. In terms of planning of the CDTI program, based on reports by CDDs, it was observed that leadership and decision-making of the CDTI rested on the community leaders and not all the community members were involved in decision-making for distribution. Almost half of the CDDs studied said that CDDs were selected at the community elders meeting. This was in contrast to findings from a survey in 4 APOC countries where 72.1% of the communities selected their CDDs on the basis of a community decision at a village meeting.[4]

Above half of the CDDs said drugs were collected from the drug collection points. Contrasting finding were observed in studies in Cameroon and Nigeria in which 65.4% and 59.1% of the communities, respectively, did not collect ivermectin from a collection point.[4] In all surveyed communities, late supply or shortage of ivermectin was not experienced. However, less than one-fifth of the health workers reported delays resulting from transportation. In Edo State, The Carter Center is responsible for drug collection from the port to the State. In addition, they provide financial support for drug distribution. This could be responsible for the availability of ivermectin in adequate quantity when needed.

Ivermectin, when taken annually, has the ability to bring about sustained reduction in skin and eye microfilaria to very low levels with reduction in morbidity and transmission.[3] Eighty percent therapeutic coverage is necessary for significant and persistent reduction in morbidity.[13] Therapeutic coverage for the different communities studied ranged from 57.0% to 96.0%. This was similar to findings from a multicountry survey done in Tanzania, Nigeria, Uganda, and Cameroon where therapeutic coverage ranged from 41.0% to 85.0%.[4] In some of the studied communities, the therapeutic coverage was low. This may be attributed to the CDDs to population ratio. For the CDTI strategy, the standard is 1 CDDs to 125 persons,[15] none of the studied communities achieved this. This low therapeutic coverage could hinder the control and elimination of onchocerciasis, thereby leading to failure to interrupt transmission and further spread of the disease.

All CDDs in the studied communities had measuring device and completed treatment registers. This is commendable. This may have been the resultant effect of supervision of the CDDs by the health staff as observed in this study. Although the CDDs had completed records some irregularities were observed. This could be because they were probably filled in a hurry for the purpose of getting further supply of drugs. This was in concordance with a study in Anambra State, Nigeria.[16] Lack of accurate data could be detrimental to future planning for the programme needs and may hamper success of the program.

Furthermore, all communities had received education about the importance of ivermectin treatment and all the community leaders had been mobilized for CDTI activities. With respect to training, monitoring and supervision, all communities had trained CDDs and were supervised and monitored during the last distribution. This was contrary to finding in Anambra State, Nigeria, where monitoring and supervision was not commendable.[16] Increased and improved supervision, training, and communication activities and skills are all needed to allay the fears caused by actual side effects and rumors on the side effects.

For sustainability of the CDTI strategy, the community members must fully participate in these meetings. Over three-quarter of the community members attended community meetings for CDTI programs. This is in contrast to a study done in Ethiopia where only 46% of the respondents had attended at least one onchocerciasis meeting in the village.[17] In the flow of events for the CDTI strategy, the community members select their own CDDs; but from this study, it was observed that majority of the CDDs in the communities studied were mostly volunteers within the community. This may hinder the success of the program in the communities.[18]

In addition, evidence has shown that increased participation of women in all aspects of the CDTI strategy is associated with better performance. From this study, CDDs included females despite assumptions from the previous studies which stated that the women are already overburdened by their daily chores and so cannot be involved in such activities.[19] Another study also emphasized that women involvement could lead to improvement in coverage and sustainability of the programme.[20]

Less than half of the CDDs said they received support in the form cash for transport. Motivation of the CDDs in terms of financial incentives was observed to be poor. This is contrary to findings from a survey done in 10 countries including Nigeria where 62.9% of the communities made financial contributions to CDTI activities.[8] The work of the CDDs is to a large extent dependent on motivation by the community members. Incentives which can be either in the form of kind or cash for transportation could act as motivating factors for them to carry out the drug distribution.[21] When not available, the desired coverage could be impaired. This was supported by study findings which showed that motivation of CDDs was likely to increase when financial incentives were made available subsequently increasing coverage.[22] Aside from poor commitment on the side of the community members, the local and state governments which are primarily the sole owners of the program make minimal financial contribution which is usually delayed and grossly inadequate. The financial aspect of the program is mainly by nongovernmental organizations in the case of Edo State, The Carter Foundation. This lack of support from the government is a setback for the program as planning is defective, without funds a lot of the program needs are left unattended to. This may have a negative impact on the outcome of the program as donor funding can be withdrawn at any time hindering achievement of its set objective of eliminating onchocerciasis.

Coimplementation of onchocerciasis control with other health intervention has proven to be highly effective, leading to higher levels of therapeutic coverage for the control of onchocerciasis as well as improved delivery of other services.[17] Only about two-fifth of the community members said that the CDDs were involved in other health activities and no incentive was received for this purpose. This was in contrast to a study carried out in Uganda where 70% of the CDDs were involved in other health activities.[23] Noninvolvement of majority of the CDDs in other health activities could be the resultant effect of lack of incentives in the other health program as observed in this study. Other studies that have cited the involvement of CDDs in additional health activity (example, immunization programs), observed that it was mainly as a result of the incentives given. This infers that the issue of incentives has to be addressed critically so as to exceed the benchmark therapeutic coverage for onchocerciasis control and elimination. Furthermore, coimplementation of the program with other health services could also bring about improved health service delivery and health of the populace.

The performance of the CDDs was graded as very good by majority of the community members. This was similar to findings in other settings.[17],[24] This perceived good performance of the CDDs by the population may translate to increased coverage and compliance. However, demotivation of CDDs resulting from lack of incentives as elicited from this study could negatively affect coverage and compliance because it could lead to low performance of the CDDs, thereby reducing therapeutic coverage.


   Conclusion/recommendations Top


The overall performance of the CDTI program was satisfactory. Ivermectin supply, work of CDDs, training, monitoring and supervision, and finances by communities had satisfactory performance while community participation and health education and mobilization had unsatisfactory performance. The communities studied have performed well in the CDTI sustainability indicators in accordance with the CDTI system as proposed by APOC. However, gaps still exist in the provision of incentives to the CDDs. This could be a challenge to the overall performance of the program thus, the need to effectively address these gaps.

Limitations

  1. Recall bias since information obtained from respondents were mainly self-reported
  2. Quality of CDDs treatment register and health workers summary sheets affected the completeness of the secondary data review.


Financial support and sponsorship

University of Benin Tertiary Education Trust Fund.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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