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ORIGINAL ARTICLE
Year : 2018  |  Volume : 62  |  Issue : 1  |  Page : 10-14  

Perceived role and its enhancing factors among the village health volunteers regarding malaria control in rural myanmar


1 Dr and Deputy Project Manager, Medical Association - Malaria Project, Yangon, Myanmar
2 Assistant Professor and Dr, Departments of Community Health and Faculty of Public Health, Mahidol University, Bangkok, Thailand
3 Assistant Professor and Dr, Departments of Public Health Nursing, Faculty of Public Health, Mahidol University, Bangkok, Thailand
4 Dr and Programme Manager, Asia Pacific Malaria Elimination Network, Singapore

Date of Web Publication6-Mar-2018

Correspondence Address:
Tassanee Silawan
Department of Community Health, Faculty of Public Health, Mahidol University, 420/1 Ratchawithi Road, Ratchathewi 10400, Bangkok
Thailand
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_432_16

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   Abstract 


Background: Village health volunteers (VHVs) are key agents for malaria control in community. The Myanmar Medical Association-Malaria (MMA-Malaria) Project has promoted effective malaria control in endemic and high-risk townships by supporting roles of VHVs. Objectives: To assess the roles of VHVs on malaria control and factors enhancing their roles in rural Myanmar. Methods: A cross-sectional study was conducted in five townships where the MMA-Malaria Project has been implemented. One hundred and fifty VHVs were sampled from five townships by simple random sampling. Data were collected by trained interviewers using structured questionnaires, which covered sociodemographic, supportive, motivational factors, and roles of malaria control. Studied variables were described by proportions, means, and standard deviations and were analyzed for their association by odds ratio with 95% confidence interval and Chi-square tests. Results: Most of VHVs (96%) expected to demonstrate good roles on malaria control, but only 44.0% exhibited current roles at a good level. Factors enhancing their roles were female (P = 0.037), family income ≥50,001 kyat/month (P < 0.015), time serving as a volunteer 1–2 years (P = 0.006), good knowledge of malaria control (P < 0.001), good family support (P < 0.001), good community support (P < 0.001), and good motivational factors (P = 0.002). Conclusion: VHVs are key agents for malaria control in community. Most of VHVs expected to demonstrate good roles on malaria control, but less than half of them exhibited current roles at a good level. The systems and program for improving VHVs’ knowledge, encouraging family and community support, and promoting motivation are essential for their better roles.

Keywords: Malaria control, Myanmar, roles, village health volunteer


How to cite this article:
Aung P L, Silawan T, Rawiworrakul T, Min M. Perceived role and its enhancing factors among the village health volunteers regarding malaria control in rural myanmar. Indian J Public Health 2018;62:10-4

How to cite this URL:
Aung P L, Silawan T, Rawiworrakul T, Min M. Perceived role and its enhancing factors among the village health volunteers regarding malaria control in rural myanmar. Indian J Public Health [serial online] 2018 [cited 2018 Aug 15];62:10-4. Available from: http://www.ijph.in/text.asp?2018/62/1/10/226628




   Introduction Top


Malaria remains a health problem in WHO South-East Asia Region. More than three-fourths of total population are at risk to malaria in which most of a moderate- to high-risk people live in the six, out of eleven, countries which includes Myanmar.[1],[2] In 2012, 61.7% of population in Myanmar resided in endemic areas and the mass screening of cases with fever using the rapid diagnostic tests (RDTs) found approximately 40% confirmed Plasmodium falciparum and Plasmodium vivax cases.[3] Drug resistance, caused by many factors, is also a major barrier of malaria control in Myanmar.[4],[5] To tackle with the disease, the National Malaria Control Program declared to reduce malaria by 50% in 2016 and activities contributing to socioeconomic development and various control measures have been implemented, especially early diagnosis and effective treatment which are the key areas in malaria control.[3],[6] Community-based case management of malaria in Myanmar was established in 2001, of which a strategy called “home management of malaria” was implemented by community health volunteers or village health volunteers (VHVs).[7] The Myanmar Medical Association-Malaria (MMA-Malaria) Project has implemented such program in 2011, and thereafter, training courses have been provided for VHVs to raise their capability on diagnosis, early treatment for uncomplicated cases, and referral for severe or complicated cases.[1],[8],[9] The program covers 420 VHVs in remote areas of 14 townships under supervision of the MMA-Malaria Project.[8] The current research aimed to assess roles of VHVs and associated factors on malaria control in Myanmar where the MMA-Malaria Project has been implemented. The findings will guide for capability building and support VHVs to perform effective roles.


   Materials and Methods Top


A cross-sectional research was carried out in rural Myanmar where the MMA-Malaria Project has been implemented. Five, out of 14, townships were sampled and 150 VHVs who have worked for at least 1 year were sampled using simple random sampling. Sample size was calculated using a single proportion formula[10] as below and the sample size in each township was proportional to total VHVs.



Where n was minimum sample size; N was total VHVs in the MMA-Malaria Project in the year 2015, 420; was the standard value under the normal curve set at 1.96 (95% confidence interval [CI]);Pwas the proportion of volunteer who had a good performance (Thailand, 2006),[11] 76.3%; and d was the precise of the study, 5.5. Data were collected by trained interviewers using structured questionnaire in April 2015. The questionnaire comprised three parts. Part I, sociodemographic characteristics, consisted of age, gender, marital status, education, occupation, family income, and working experience. Part II, supportive factors, consisted of knowledge of malaria control, perception toward roles of malaria control, family support, and community support. Part III, motivational factors, consisted of incentive, reward, material, training, supervision, and relationship. Part IV, roles of malaria control, consisted of expected roles and current roles. Score 0 or 1 was given to “incorrect” and “correct” knowledge, respectively. Score 1–3 was, respectively, assigned to “disagree,” “uncertain,” and “agree” for perception and motivational factors. Score 0–2 was, respectively, given to “never,” “sometimes,” and “always” for family and community support. Score 0–2 was, respectively, given to “no,” “sometimes,” and “regular” for expected and current roles. Total score of each topic was classified into good (≥80% of total score) and poor (<80% of total score). The coefficient alpha for reliability ranged from 0.85 to 0.97. Data were processed and analyzed using SPSS version 18.0 (PASW Statistics 18) released by SPSS Inc., Chicago, USA. Studied variables were described by proportions, means, and standard deviations and were analyzed for their associations using odds ratio (OR) with 95% CI and Chi-square tests. P < 0.05 was considered as having statistical significance. The research project was approved by the Ethics Review Committee of Human Research, Faculty of Public Health, Mahidol University.


   Results Top


The average (mean ± standard deviation) age of the respondents was 29.7 ± 5.3 years, in which most of them were between 25 and 34 years (70.4%). Males (52.0%) were slightly more than females (48.0%). The majority were married (62.7%) and able to read and write (99.3%). Two-fifths of them graduated at the secondary school level (40.7%), followed by high school level (33.3%). Regarding VHVs’ major occupation, the majority were agriculturalists (47.3%) followed by small business owners (30.7%). The average monthly income was 268233.3 ± 184578.4 kyats and majority of VHVs had income more than 100,000) kyats (78.0%). Most of VHVs had no working experience concerning health before being a VHV (90.0%). The average time for being a volunteer was 2.02 ± 0.64 years, in which more than half of them had experiences <2 years (58.7%).

Overall, 48.7% of VHVs had good levels of knowledge on malaria control whereas 72.7% had good level of perception toward roles on malaria control. Most of VHVs (87%) always received support from family meanwhile 44% always received support from the community and 68.7% got good motivational factors.

Almost all VHVs (96.0%) expected to perform good roles on malaria control activities. Most of them (>90.0%), in overall, expected good roles in nearly all tasks, except for distributing of LLINs to the community (52.0%) and observing how people use LLINs (45.3%). Majority of the VHVs who had poor role level expected not to perform the activities of distributing LLINs to the community, observing how people use LLINs, and providing health education to community members with staff [Table 1].
Table 1: Distribution of study participants as per their expected and current roles on malaria control

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Concerning the current roles, only 44.0% of VHVs exhibited good roles on malaria control activities. Overall, less than half of them performed good roles in referral severe cases to the nearest hospitals, providing health education to community members with staff, distributing pamphlets and posters to the apid diagnostic tests (RDT) tested patients, distributing LLINs to the community, and observing how people use LLINs. Most of the VHVs who had poor role level could sometimes follow the procedures for RDT (92.3%), could sometimes provide health education to individual patient (94.2%), provide health education to community members with staff, and distribute pamphlets and posters to the RDT tested patients (93.3). Majority of the VHVs who had poor role level never distributed LLINs to the community (64.8%) and observed how people use LLINs (61.5%) [Table 1].

For the sociodemographic characteristics and few other attributes, it was found that sex, family income, time serving as a volunteer, knowledge on malaria control, family and community supports, and motivational factors were significantly associated with the current roles of VHVs (P < 0.05). Proportion of good roles performed was higher in VHVs who were females (OR = 1.99, 95% CI = 1.03–3.83), had family income ≥50,001 kyat/month (OR = 8.78, 95% CI = 1.09–70.48), served as a volunteer 1–2 years (OR = 2.59, 95% CI = 1.31–5.13), had good knowledge on malaria control (OR = 3.36, 95% CI = 1.71–6.60), had good family and community supports (OR = 6.95, 95% CI = 3.24–14.92), and had good motivational factors (OR = 9.77, 95% CI = 4.61–20.73) [Table 2] and [Table 3].
Table 2: Distribution of village health volunteers as per their current roles on malaria control and sociodemographic characteristics

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Table 3: Distribution of village health volunteers as per their current roles on malaria control and few other attributes

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   Discussion Top


Almost all VHVs expected to have a good roles on malaria control whereas less than half had good current roles, which is similar to the findings in Lao PDR and Myanmar.[8],[11] Expectation toward roles on malaria control of some VHVs was at a poor level; this might be due to the fact that some activities were rather difficult to perform, especially distributing of LLINs to the community and observing how people use LLINs; therefore, some VHVs might not expect that they could perform a good roles in all tasks. Moreover, the criteria used to indicate the good role in this research were quite high (≥80% of total score); some VHVs might expect to perform their roles in some tasks at a moderate level or rather high level but less than the criteria of a good role. The poor roles of VHVs in rural Myanmar are likely a result of the following factors: VHVs voluntarily and willingly perform malaria control activities, meanwhile the majority of them are employees who have to work for their families which still have low income, so they may not have enough time to perform their roles effectively. In addition, performing roles of malaria control comprises series of many activities which needs understanding and appropriate support, but many VHVs still lack knowledge as well as inadequate support to perform those roles. Moreover, only less than half of VHVs can perform their roles on LLINs usage and distribution, knowledge providing and dissemination and patient referral. The findings are concordant to the study of Ohnmar et al. in Myanmar which found that the use of RDT was still low, the tests were not performed in a timely manner, the number of patients tested declined over time, and the use of impregnated nets and the knowledge of malaria were low in all groups.[8] The campaigns and distributions on LLINs use among population at risk are accepted as an effective method for malaria control. Many studies and documents showed the low proportion of LLINs use and mentioned that the overall impact of LLINs depended not only on its insecticidal activity but also on various social and operational factors, which included cultural beliefs and practices, travel, gender roles, seasonality of mosquito nuisance, risk perception, affordability, acceptance, perceived effectiveness of available services, and faith in the service provider. The success of the interventions needed the effectiveness of volunteer actions provided with adequate training, supervision, and resources. Other groups which also played important roles of successful interventions were village chiefs, church leaders, community health promotion teams, and health-care workers.[12],[13],[14],[15],[16],[17] Prompt access to effective antimalarial treatment is also one of the major strategies for reducing the burden of malaria. The respondents in the study of Das et al. expressed lack of trust in the community health workers due to frequent drug stock-outs.[17] Performance of VHVs in Lao PDR was rated as poor results regarding artemisinin combination therapy (ACT) treatment, duration, and dosages. Prereferral treatment of severe malaria was also infrequent as well as often inadequate, and shortage of ACT was reported.[18] Thus, developing community ownership and sustainability of community volunteers through appropriate supports including incentives, equipment, and supplies are needed.[17],[18],[19],[20]

VHVs who had good knowledge had good roles on malaria control, but less than half had good knowledge on malaria control.[8],[21] This may due to the training system provided to them before started working might not practical or cannot build enough confidence for performing their roles in the community, especially about LLINs, RDT test, treatment, and patient referral. The refresher course or on the job training is also important for them to remind and keep pace with the changes, especially among those who have worked more than 2 years.

VHVs who received good family and community support as well as good motivational factors performed better roles than the rest. This may be due to the fact that the effective working depends entirely on the relationship with the community, and that effective programs to support and strengthen the interaction between VHVs and community members should be brought about such as raise public recognition and conducting appreciated dialogue. Since VHVs have to work for their daily lives, motivational factors which included multiple incentives, both monetary and nonmonetary, are required to support properly based on different duties and working environments by concerning the meaning of “volunteers.” In addition, monitoring and supervision system are also important support and strengthening of VHVs’ capability building.[17],[18],[19],[20],[21],[22]

This study can quantify the roles of VHVs on malaria control; however, qualitative method, as observation, should be conducted to confirm their actual roles. In addition, the opinion of malaria patients, community members, and community leaders toward the VHVs’ roles should also be taken into consideration in order to support VHVs to perform their roles which respond to the needs of community people.


   Conclusion Top


Most of VHVs expect to perform good roles on malaria control, but less than half of them exhibit good current roles. Factors associated with their roles are age, sex, family’s income, time serving as a volunteer, knowledge of malaria control, family support, community support, and motivational factors. To enhance VHV’s roles on malaria control in the community, systems and programs for knowledge improving, family and community support encouraging, and motivational promoting should be established and strengthened.

Acknowledgment

The study was partially supported for publication by the China Medical Board, Faculty of Public Health, Mahidol University, Bangkok, Thailand.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3]



 

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