Home-based patient care during

an influenza pandemic.

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

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

Course Director,

Course in Conflict and Catastrophe Medicine

Worshipful Society of Apothecaries of London

Faculty of Conflict and Catastrophe Medicine

The Project• People living in resource-poor countries are likely to be

severely affected by events such as an influenza pandemic

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

• Very high levels of poverty mean that 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

• These 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 and other

agencies working with the team

WHO Global Influenza Programme, Geneva

• Dr Tim Healing (Field Test Project Manager)

• Dr Julienne N. 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 and control team

MoHS District level

• Health and education departments

• District medical authorities

• Lassa Fever outreach team (Kenema)

Sierra Leone

Slightly larger than the Republic of

Ireland, slightly smaller than

Austria

In 2009:

Still recovering from 11 years of

civil war

Trying to reintegrate returning

refugees, relocated IDPs,

disarmed combatants and

amputees

Sierra Leone

(2009) – some

basic factsSL UK

• Population 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

• Under 5y mortality 26.9% 0.6%

Test Sites

Test sites

Two test sites were used

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

• Blama town, the main town of the Small Bo Chiefdom, about 12 miles west of Kenematown

George Brook (Dwarzak

Farm) Community,

Freetown

• Urban site, edge of Freetown

• Population ca. 32,000

• Extends up a valley into the hills around the city

• Many houses hard to reach

• Home to 16 ethnic groups

Official medical care

in George Brook

• Government health centre– Community Health Officer (CHO)

with 25 staff.

– Basic services

• ante - and post-natal care,

• family planning

• treatment for infections including malaria and TB

• minor trauma.

– Tests for HIV/AIDS (+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 are cheaper than the government

clinic & therefore used more).

Kenema

Small Bo chiefdom

• One of 16 chiefdoms

in the 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 and post natal clinics

• labour ward,

• TB, malaria and HIV/AIDS diagnosis

• minor trauma

• complicated cases referred to Kenemahospital

• 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

• Malaria

• ARI

• Watery and bloody

diarrhoea

• Malnutrition and

dehydration in children

• Worm infestations (GI

tract)

• (Typhoid fever)

Blama

• Malaria,

• ARI

• Watery and bloody diarrhoea

• Malnutrition and dehydration in children

• Worm infestations (GI tract)

• Schistosomiasis

• (Typhoid fever)

• (Lassa fever also occurs)

Data for first 9 months of 2009 from Government Health Centre

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?”

• “Is 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 not reach the people?

• Broadcast at wrong times

• Market traders may have had radios on

but did 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 and not considered to be dangerous

• Colds and flu-like illness 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 an important disease, or attempt to prevent its spread, at least initially, without extensive sensitisation

H1N1 became known 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

– Wearing warm clothes

– Mentholated rub

– Rest, paracetamol

– Nursed outside (sheltered part of veranda) during

day, go inside at night to sleep

Attitudes to behaviours that can affect

transmission, prevention and 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

– handle meat, chicken or fish in their food

with their hands.

– handle the dishes

Washing hands after cleaning the

baby’s bottom

• Mothers don’t wash hands properly after cleaning

baby’s bottom

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

Coughing and sneezing.

People tend to:

• Cover mouth and nose with both hands

• Rub the droplets into their hands and

clean their hands on their clothes.

• Some use handkerchiefs which may be

kept in the pocket up to a week before

being washed

• Same handkerchief used on children

Blowing the nose

• Often blow the nose with fingers, throw the

mucus on the ground & clean their hands on

their clothes

• Children’s noses are cleaned with their

mother’s clothes/hands or the children’s

clothes

• Some mothers suck their child’s nose with

their mouth to extract the mucus and then

spit it out.

Spitting

• Most people spit on the ground/floor in

the same place where they are seated

or are standing.

The original Key

Messages

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

Messages assessed as

important (and “do-

able”) at both sites

1. Cover your nose and mouth

when you cough or sneeze &

use clean handkerchief

2. Hand washing with soap and

water

3. Use outside spaces

4. Eat from separate dishes and

with separate utensils

5. Hydration

6. Assess if the patient needs to

seek health care

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 and water and 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 and 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 sessions

Held for medical staff and community leaders to:

• Give them 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 are the homecare givers

• Women, as primary carers for the sick, are the 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 and training sessions

The Actions

Town criers• The town criers announced the actions in

advance

Processions• Processions were held at both sites, moving

through the communities and the markets

drawing attention to the key messages

• Those in the processions wore T-shirts with the

messages and carried posters

Music, song and dance

• A brass band was

used at George

Brook to attract

attention to the

action

• The Sierra Leonean

singer Amie Kallon

composed a song

and a dance for use

at the action in

Blama

Drama groups

• Local drama groups produced short plays

and songs to highlight the different

messages

Reinforcing the

messagesLocal religious and

civic leaders

gave talks to

highlight the

importance of the

messages and

exhort their

people to take

note and 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

Have outputs being delivered as planned (time and place?)

2. Evaluate the process

Has 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, what are people

doing now?

Secondary objectives

• Assess the community’s perception of the home-based care project

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

• Assess 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 objectives1. Have outputs being delivered as

planned (time and place?)

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

3. As result of the communication activities, what are people doing now?

1. Yes

2. An increased understanding of:– influenza AH1N1

– the importance of washing hands with water and soap

– the importance of covering their nose and mouth to avoid the spread of the virus

Increases in overall knowledge about the disease in both communities. But this varied substantially between the rural and the urban sites (better at the urban site).

3. Some schools are promoting hand washing and the use of handkerchiefs

But

Most people are not putting home care information into practice

Results – secondary objectives

1. A great acceptance of this project’s

approach both by the communities and by

the national authorities (Ministry of Health

and WHO)

2. An increased enthusiasm and a high level

of interest by the communities in health

issues

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

between the urban and rural sites (higher at the urban site)

• Possibly – because people of GB receive more health information than those of

Blama via the media.

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

Community leaders are very important stakeholders when implementing and following up on community level activities.

Overall conclusions #2

The most efficient means of conveying the messages:

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

• In GB, town crier and drama group performances enhanced interest and 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?