milaria prevention - concordia...

Running head: MALARIA PREVENTION 1

Community Health Promotion for Malaria Prevention in Uganda

Sandra Adrianne Pena

Concordia University – Nebraska

10 December 2013

MPH 585 / Health Education and Program Planning

Madeline Angela Meyer, PhD.

MILARIA PREVENTION 2

Malaria Prevention: Needs Assessment

Malaria is, “one of the most serious health threats to communities in developing

countries, and affects nearly half of the world's population” (The global poverty project, 2013).

Malaria is a merciless killer and “kills a child every 45 seconds” with over, “90% of malaria

deaths occurring in Africa” (The global poverty project, 2013). Malaria is a serious illness that,

“severely undermines individuals' ability to work and live a normal life” (The global poverty

project, 2013). Cases of malaria are known to drain the economies of countries that are most

severely affected. In 2009, “there were 81,735,305 probable and confirmed malaria cases in

2009, the vast majority of which 68,925,435 were recorded in Africa” (The Guardian, 2013).

Africa is irrefutably the country worst hit by this vector-borne disease. Within Africa, “Uganda

and Kenya were the countries with the highest numbers of probable and confirmed malaria cases

in 2009, with some 9.8 million and 8.1 million, respectively” (The Guardian, 2013). Of the

world's 117,704 inpatient malaria deaths in 2009, 111,885 occurred in Africa, but that number

merely reflects the individuals that are able to afford or have access to medical care and

treatment. Malaria is a problem that is destroying any chance of financial stability in these

countries that already face so many other problems such as hunger, poverty, and HIV/AIDS just

to name a few. Although, Africa is the country that is most ruthlessly affected by malaria other

countries on other continents are facing similar struggles and eradication should be the long-term

goal, but at the cost of more than five billion US dollars in 2009, and an estimated 6.2 billion in

2010, the cost is quickly growing and something that cannot be eradicated in one night (WHO,

2013). Since malaria cannot be addressed in one day it is critical that there are prevention

programs in place to address the needs that are occurring now until global eradication can occur

in the future.

MALARIA PREVENTION 3

Needs Assessment: Summary

A needs assessment is, “the process of identifying, analyzing, and prioritizing the needs

of a priority population” (McKenzie, Neiger, & Thackeray, 2013) in this case the priority

population will be children affected by or at risk for malaria within Africa. It is essential that a

comprehensive needs assessment is completed to ensure that time spent working within the

community is adequately utilized as sometimes time is usually a precious commodity. Needs

assessments are able to follow many different formats, but regardless of the form in which it

comes there are always similarities as needs assessments are commonly questions and answer or

come in interview formats.

What are the health problems within Uganda, Africa?

Uganda's infant mortality rate and life expectancy age are among the worst in the world.

More than 50 percent of Ugandans have no access to clean water, while malaria and respiratory

illnesses are widespread and are frequent causes of death. AIDS has claimed millions of

households throughout Uganda and has reduced the life expectancy (Foundation for Sustainable

Development [fsd], 2013)

Why do health issues exist within Uganda, Africa?

“Healthcare provision and overall infrastructure in Uganda are chronically underfunded

and highly variable in quality. The results are astounding. The scope of Uganda's success,

however, has come under increased scrutiny. The government repeatedly misused international

funds directed toward AIDS relief efforts, and in 2002, a medical journal The Lancet published


research that questioned the accuracy of previous reports in Uganda that indicated a dramatic

decline in HIV infections” (fsd, 2013).

What factors create or determine the health problems?

It has become clear that misreporting and governmental corruption have fueled some of the many

problems that are currently occurring in Africa

What resources are available to address the health problems.

There are numerous programs within Africa and specifically the Uganda area some of

those programs are UNICEF, Nets for Life, Peace Corps, Save the Children, Malaria

Consortium, and Doctors without Borders to name a few. Many of these programs are non-profit

or NGO that operate primarily from the services of volunteers.

What are the health needs of the community from a population-based perspective?

Contemporary public health emphasizes a community-based approach to health promotion and

disease prevention. The evidence from the past 20 years indicates, however, that many

community-based programs have had only modest impact (Merzel & D’Afflitti, 2003)

What statistical data is available to demonstrate the need?

“About 3.3 billion people – half of the world's population – are at risk of malaria. In 2010, there

were about 219 million malaria cases and an estimated 660 000 malaria deaths. Increased


prevention and control measures have led to a reduction in malaria mortality rates by more than

25% globally since 2000 and by 33% in the WHO African Region. People living in the poorest

countries are the most vulnerable to malaria. In 2010, 90% of all malaria deaths occurred in the

WHO African Region, mostly among children under five years of age (World Health

Organization [WHO], 2013)

Health Status

As discussed in the introduction the health issue is malaria and the problem is the fact that

malaria is causing crippling debilitations within these African communities as the disease causes

a major loss in workable hours leading to a weakened infrastructure that affects everyone in the

surrounding communities like an ill-fated succubus, leaching all the available viability from an

individual before moving on to the next victim. The Age range that this will be specifically

geared to is children age zero to five. To appropriately apply the PATCH model this preventative

endeavor needs to be specifically focused of certain communities. Within the introduction of this

paper I mentioned that Uganda is having particularly difficult time controlling malaria. With

assistance of, The Malaria Atlas Project I was able to determine that there are three regions

within Uganda that where most densely affected, of those the regions Jinja, Uganda, Africa was

most severely affected. Jinja is the second largest town in Uganda. Many rivers flow through

Jinja and it opens to a large body of water known as Lake Victoria. Smaller communities in the

area are Njeru, Buwenda, and Kimaka (Malaria Atlas Project [MAP], 2013).

It is imperative to remember and to consider that it is not the goal of this prevention

program to stampede the community and replace everything that has already been done to

educate the community on malaria prevention so this program will be complementary working

with the community health workers and the programs that are already in place. Should we


determine that there is a particularly rural community that has not been able to access any of

these already established prevention/education programs then our primary focus would be to

work with those communities as a newly established program.

The goal of this program is one of health promotion which involves the process of

enabling people to increase control over their health and to improve their health outcomes.

Health promotion endeavors to assist in planning effective strategies for each community and the

member within those communities to be able to develop and maintain positive and healthy

behaviors after the initial prevention program moves on to other areas that are in more need.

The PATCH model and malaria prevention

It is essential to adequately prepare when attempting to bring educational programs to

regions of the world that may not have experienced structured prevention programs in the past.

As the goal of this particular program is to instate a malaria education and awareness to rural

communities within Africa it is important to incorporate a logic model that breaks down the steps

of the program with short-term and long term goals and objectives that need to be met

successfully to move onto the next step of the logic model. In this instance the PATCH model

will be used. PATCH is a, “community health planning model that was developed in the mid-

1980s by the Centers for Disease Control and Prevention (CDC) in partnership with state and

local health departments and community groups.” (The Centers for Disease Control and

Prevention [CDC], 1996). Looking deeper into the PATCH model it is a, “process that many

communities use to plan, conduct, and evaluate health promotion and disease prevention

programs. The PATCH process helps a community establish a health promotion team, collect

and use local data, set health priorities, and design and evaluate interventions. It is adaptable and


it can be used when a community wants to identify and address priority health problems” (CDC,

1996).

Figure 1: PATCH Model

( Source: Institute of Medicine of the National Academies, 2003)

Step one of the PATCH model is mobilizing the community. This step is a critical

element to the success of this logic model and it requires that the community as a whole is

actively involved in the desired change. For the area of Jinja, Uganda it would be my desire to

meet the community and to determine if this community has any community health officials or

community leaders currently in place that can assist with the implementation of step one of this

health promotion program. This step would include holding a community meeting to discuss the

need(s) within the community. It might require ‘door-to-door’ notification to ensure the most

individuals possible are present. If there was a poor showing of community member’s alternative

methods would need to be utilized to ensure that we had the active participation of a majority of

the community to ensure the long term success of this malaria prevention program.


With step two the goal is to collecting and organizing data, this step may-well be the

most pivotal of the whole program because the data we collect within this step will affect all

future steps of this model therefore affecting the outcome. The data collected will be used to

“describe the overall community health status and the needs to help community members”

(CDC, 1996). This data will also affect possible future stakeholder’s interest because this data

will convey the severity of the need for monetary donations and volunteer support.

Moving to step three of this model it is important to identify and choose health priorities

and with statistics such as, 90% of all malaria deaths occurring in the WHO African Region, are

mostly among children under five years of age (World Health Organization [WHO], 2013). It is

essential that the behaviors of not only the children, but the parents, and other community

members/organizations that share the responsibility of raising such as schools and before and

after school programs are analyzed to determine where the shortcoming are as well as the areas

that need in utmost dire need of attention are addressed first.

Step four of the PATCH model is developing a comprehensive intervention plan. This is

where the information that is generated from steps II and III are utilized (CDC, 1996). During

step four strategies and time-tables are developed for use within the community. This is where

short-term and long-term goals are established, identifying realistic time frames in which goals

can be completed. This is also the step where we a prevention program will be able to begin

recruiting and training volunteers.

Step five of the PATCH model is possibly the most important as it determines the impact

that was made while my program is in place. This step is evaluation, and it continues long after I,

as a program manager leave the area. This is where program evaluations and/or short quiz that


can be either written or verbal depending on literacy rate of the area in which we are working

with these documents are designed to be completed by community health workers, teachers,

volunteers, and parents of children to determine effectiveness of the program, once that

information is done being collected the health promotion team members get together to analyze

the information contained within those evaluations.

Figure 2: Logic Model

Program Mission Statement

It is the mission of this program to educate and increase awareness; not only the children,

but whole families and communities to ensure that malaria is a smaller of of a problem for the

next generation than it is for this generation.

InputsMonatary for materials and travel, hours worked by staff and volunteers, preperation hours

OutputsTime spent in the community working with kids and families, education of staff and community workers, recrutment of future volunteers.

OutcomesDecreased incidence of malaria in Sub Sahran African regions, decrease in deaths, decrease in lost workable hours, decrease in medical cost


Program Vision Statement

Through this program we have confidence that we will be able to encourage and inspire

future generations to be aware of malaria and the benefits that can be reaped through simple

prevention habits which will result in a decrease in malaria related deaths and loss of workable

hours leading to a more sustainable society.

Figure 3: SWOT Analysis

StrengthsUse of an established evidence based program model (PATCH)Adressing a high visability/ known problem Dedicated team members Team members with international community health experience.

OpportunitiesCommunity members that are tired of seeing the devistation and are ready for a positive change

WeaknessesFirst attempt at implementing a program within an actual community - we could encounter problems I as a program manager may not know how to address

ThreatsMissuse of fundsdeviation from program designimpatience or lazynessoutlyiers that fight program rebels

S

O

W

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Short, Intermediate, Long Term Goals

It is assumed that all appointed community members will carry out their designated roles

as assigned and as designed. It is also assumed that government will assist not inhibit program

design. The impact outcomes are measurable on the short term, intermediate, and long term. The

short term goals are to utilize biostatistics to obtain the most accurate numbers possible for those

affected by malaria in the target age range zero to five in the given community Jinja, Uganda.

Intermediate goals are to initiate an effective program that can reach at least 30-40% of the

population of Jinja which is estimated at just over 500,000 within the first year. The long term

goals are to increase outreach within the outlying communities of Jinja by at least 5-9% a year

over the next five years and to increase that percentage every year thereafter.

As it has been made clear that there is a dire problem occurring in Africa as deaths of

children are on the rise. There have also been many programs introduced to address the problem

of the malaria incidence in children age zero to five within various African countries the problem

is still increasing in prevalence so in order to save the children it is essential that this program

create clear program goals that are set with the purpose to guide the program during on-site

implementation to ensure maximum effectiveness.

Goals and Objectives:

For this program to maximize its effectiveness within the community within a short

period of time it is essential that we travel with clear program goals and objectives.

Objective One: To find alternative ways in which to educate rural community members

within Jinja, Africa during June 2014, with a ultimate goal of decrease the incidence of malaria

related deaths in children age zero to five.


Short Term Indicator Goal One: By June 1, 2014, we will arrive within the community

of Jinja, Africa and I will endeavor to meet with 52-63% of the community members that define

themselves as either ‘community health worker’ or as a ‘community official’ to determine the

needs as seen by the locals. This will be completed semi-annually.

Short Term Indicator Goal Two: By June 3, 2014, I will have been able to deploy my

team of three individuals to begin a two-day, door-to-door family needs assessment, with a goal

of reaching 60-68% of families. This will be done at the beginning and at the end of the

community program intervention to assess change of behavior habits that directly relate to

malaria exposure. This will be completed semi-annually.

Objective Two: With the assistance of local community health workers and local

community leaders we will develop and implement an educational program(s) that will support

local residents in achieving a higher level of malaria awareness.

Goal One: By June 7, 2014 we will work with local community health workers and local

community leaders to implement the PATCH model in one community, community zero.

Goal two: By June 10, 2014 with this assistance of the local community health workers

of Jinja we will identify and work with three to four additional surrounding rural communities to

continue to implement the PATCH model.

With the assistance of these goals and objectives it is the sincere hope that we as a,

community health promotion program for malaria prevention in Uganda are able to make a

sustainable impact that will likely not be immediately measurable, but will be measurable over a

period of years. For the first two years we will do semi-annual on-site evaluations to assess

program adherence and assess progress, providing re-education when and where and if it is


necessary and to collect biostatical data. For the three years after that we will switch to annual

on-site evaluations that will hopefully serve merely as a time for observation of communities

being able to independently and effectively carry out the PATCH model and utilize the

biostatical data that the communities health workers collect that will likely show a slow, but

noticeable decreases in the incidence of malaria in in the priority population on children age zero

to five.

With the above listed and clearly stated program goals and objectives it is important that

we deploy and utilize pre- and post-tests and public surveys that will be used to gather bio

statistical information that can be used in the evaluation of this program for purposes of growth

and improvement of this health promotion program.

Budget

“Money is a constant topic of conversation among nonprofit leaders: How much do we

need? Where can we find it? Why isn’t there more of it? In tough economic times, these types of

questions become more frequent and pressing. Unfortunately, the answers are not readily

available. That’s because nonprofit leaders are much more sophisticated about creating programs

than they are about funding their organizations, and philanthropists often struggle to understand

the impact (and limitations) of their donations”(Landes-Foster, Kim, & Christiansen, 2009).

As a 501c3, (nonprofit program) it would be our programs goal and intention to be

primarily funded by contributions from sponsors, as funding from tax dollars and participant fees

will be virtually nonexistent as Uganda is a developing country and expecting funding from

those sources would almost guarantee failure in the long-run. The greatest costs are expected to

be incurred in expenditures for supplies and personnel.

http://www.ssireview.org/topics/category/nonprofits


Figure 4: Budget

With 2014 being our start-up year we expect to function on a minimal budget and with

scarce personnel resources we are even anticipating operating in the ‘red’ for the first three years

until we are able to establish ourselves as a sustainable, non-profit program that in making

progress in the community. Our major cost will be incurred with transportation of three people to

the country of Uganda, this would include housing, travel insurance, transportation within the

country, and all shots needed prior to departure. The second major cost would be supplies that

include malaria nets, teaching materials, and the items needed for the advertising our program.

We do not expect to be overwhelmingly successful when it comes to writing, preparing,

and receiving grants as our modest staff of three will all be novices in the grant proposal

preparation department. The three year budget model projection shows our program growing by

18% funding or about six percent a year. There is a five year projection of 29% growth,

primarily from grant dollars available within the United States and other international

organizations.

Revenue & Support

Sponsors ($3,000)Grants ($2,000)Gifts (fundraising)($950)

Expenditures

Personnel ($1500.00)Supplies ($3000.00)Advertising ($250.00)Indirect costs ($3000.00)


Marketing

“The health communications field has been rapidly changing over the past two decades. It

has evolved from a one-dimensional reliance on public service announcements to a more

sophisticated approach which draws from successful techniques used by commercial marketers,

termed "social marketing” (Weinreich, 2010). To ensure success and longevity of my prevention

program, that means that I have to take into consideration all of the various ways to successfully

market my program that includes taking into consideration the standard for “P’s” and the

additional social marketing “P’s”:

Product is essentially the physical product which in this case is a health promotion

program to prevent and reduce the incidence of malaria in African nations.

Price In this case this program would come to the consumer free of charge, but that is

only possible though grant dollars and private fundraising and/or donations made to this

nonprofit program.

Place ‘Community zero’ also known as the first community in which this program will

be brought too will be the community of Jinja which is located in Uganda, Africa.with a goal of

spreading to other African nations within the year.

Promotion Program promotion will be where a majority of early funds are spent because

the idea would be to create a fotonovela, pamphlets, and posters which will assist in the

education of literate community it will hopefully also aid in bridging the gap that is made by the

language barrier all while spreading the word on this much needed program that has an ultimate

goal of saving lives in developing nations.

Additional “P’s”


Publics Since we will be primarily funded by US and international donations and grants t

is essential that any program promotion be geared towards those individuals and communities as

well because without the donations our program would be dead in the water.

Partnership “Social and health issues are often so complex that one agency can't make a

dent by itself” (Weinreich, 2010). It would be my hope that my program would be able to work

with other programs in the area such as Nets for Life and UNICEF. As we all aim to accomplish

the same goal which is the loss of life due to preventable causes.

Policy “Is difficult to sustain unless the environment they're in supports that change for

the long run. Often, policy change is needed, and media advocacy programs can be an effective

complement to a social marketing program” (Weinreich, 2010).

Figure 5: Gantt Chart

Planning

Meeting community / Needs assesment

Working with community

Teach community leaders for sustainability

Evaluation of program / Idendification of next community

Training new staff / Volunteers

Release of program

16-May-

14

23-May-

14

30-May-

14

6-Jun-14

13-Jun-14

20-Jun-14


Process Evaluation

Process Evaluation is composed of six elements that contribute to, “any combination of

measurement obtained during the implementation of program activities to control, assure, or

improve the quality of performance of delivery” (McKenzie et al., 2013). Those elements

include: fidelity, dose, recruitment, reach, response, and context. Fidelity is the extent to which a

program was delivered as planned and a true measure of fidelity can only be obtained after the

program evaluation is complete, but a good program administrator will be able to indicate when

and where the plan is deviating as it is being administered and will be able to make a judgment

call as to allow it to happen or to correct it as it occurs. Dose is the number of presentations that

are intended on being delivered for my malaria health promotion program we intent to provide at

least two community presentations along with handing out bed nets when and where available.

Recruitment I believe is a critical step that takes place long before the finer details of a health

promotion program are ever created as this is where the priority population is selected, should

considerable thought not be given in the recruitment phase the affects will likely domino

affecting the final product for presentation. Reach as we as program creators are aware that it is

nearly impossible to obtain 100% reach in all areas of a health promotion program that is why an

entire field of biostatistics exists, but essential hoping to have a 68% participation rate takes into

account outliers that do not want to or do not participate for other personal reasons. Response is

the proportion of the priority population that actually participate (McKenzie et al., 2013) I have

hopes for a 68% participation rate which I believe to be reasonable as I know that I will

encounter cultural and language barriers that will affect my ability to work with the community.

Lastly, it is important to remember the last element of process evaluation which is context.

Context were briefly mentioned in the element of response, but other confounders could be


families that cannot or will not participate due to illness of a family member of work obligations

those who might be out of the area at the time of the program or communities that are already

working with other nonprofit groups in the area.

Figure 6: Process Evaluation

Formative Evaluation

Formative evaluation is much more complex than process evaluation as it has nearly

tripled the amount of elements to be considered. Formative evaluation is, “any combination of

measurements obtained and judgments made before or during the implementation of materials

methods, activities, or programs to control, assure or improve the quality performance or

delivery” (McKenzie et al., 2013). Those elements include: justification, evidence, capacity,

resources, consumer-orientation, multiplicity, support, inclusion, accountability, adjustment,

recruitment, reach, response, interaction, and satisfaction each one of the previously mentioned

PROCESS EVALUATION

FIDELITY RECRUITMENT RESPONSE

DOSE REACH CONTEXT


elements will be addressed below. Justification, reading about statistics like: “Malaria is a

merciless killer and “kills a child every 45 seconds” with over, “90% of malaria deaths occurring

in Africa” (The global poverty project, 2013). This information alone the justification needed to

support a malaria health promotion program in the country of Uganda, Africa. Evidence as we all

know not everything we find or read on the internet is true or can be described as ‘evidence-

based’ so we have to consider what information is credible such as the following: malaria is,

“one of the most serious health threats to communities in developing countries, and affects

nearly half of the world's population” (The global poverty project, 2013). I believe that

justification and evidence are pretty closely related when considering the elements of formative

evaluation. Capacity to be an effective program administration it is essential that I not only

become well versed in the health promotion aspects of malaria prevention, but I also have to be

competent in the cultural and language barriers that I will likely face during my time in Africa

and I have to find out how to teach so that they can learn the important lessons that I bring them.

Resources are essential to program success so it is essential that I form an accurate budget to

ensure program success I also need to know what other programs are in the area as we may be

able to help one another achieve program goals together as failure to recognize resources when

they present themselves can easily result in total program failure. Consumer-Orientation is

essential as my program is specifically designed for children in Sub-Saharan African nations so it

is very likely that if we were to take this exact program and deposit it in Steubenville, Ohio there

is no justification or evidence that warrants a program such as this in that region. Multiplicity

this malaria prevention program is one that primarily seeks to educate and to change

environment as we know the primary habitat of mosquitoes that carry malaria seek stagnate

water as there refuge we need to eliminate the number of these available to mosquitoes. Support


for this program will be primarily built around education posters that show the steps to reduce

the incidence and presence of disease causing mosquitoes.

Figure 7&8

(Minnesota Department of Health [MDH], 2013)

Inclusion is the extent to which an adequate range and number of appropriate partners or

organizations (McKenzie et al., 2013) and it is the goal of this health promotion program that we

integrate the needs of other nonprofits that are working with our promotion program to ensure

longevity and maximum productivity. Accountability is essential to a malaria health promotion

program abroad because we are constantly going to be working in a foreign region of the world

and we will only have a startup staff of three people so all persons involved in this project need

to be dedicated and accountable for the work assigned and that needs accomplished at all times.

Adjustment will be a constant as the program is released to the community taking constant

feedback from community leaders and participants to improve this malaria health promotion

program the best program possible. Recruitment will go hand-in-hand with reach and response as


one grows and improves it is expected that the other areas will improve as well striving to recruit

other dedicated like-minded public health professionals that will contribute to the overall

programs outreach. Reach although we know that we cannot reach 100% of the people 100% of

the time we will never turn away a dedicated and interested community member that seek

knowledge about how to improve their health and the health of their family. Response as

previously stated the program will be available to the entire community we are realistic in hoping

that we will have about a 68% enrollment/participation rate taking into account individuals who

are either unwilling or unable to attend. Interaction will be at the core of our program as all

employees of this health education program will be expected to be very hands-on working and

interacting with the community members daily during our time in Africa. Satisfaction will come

throughout the program where we will strive to meet the needs of the community which we serve

modifying our program as necessary to continue to meet the needs of the community we are

dedicated to serving.

Figure 9: Formative Evaluation


Summative Evaluation “is any combination of measurements and judgments that permit

conclusions to be drawn about impact, outcome, or benefits of a program method. It is done at

the conclusion of a program to provide a conclusive statement regarding program effects”

(McKenzie et al., 2013).

FORMATIVE EVALUATION

JUSTIFICATION

EVIDENCE

CAPACITY

RESOURCES

CONSUMER –ORIENTATION

MULTIPLICITY

SUPPORT

INCLUSION

ACCOUNTABILITY

ADJUSTMENT

RECRUITMENT

REACH

RESPONSE

INTERACTION

SATISFACTION


Table 10: Summative Evaluation Table

Program Objective

Data Indicators / Measures

Data Collection

Tool(s)

Data Analysis

Measurement Timelines

Alternative ways in which to educate rural community members within Jinja, Africa during June 2014

Literature review

Logic models

Record keeping of progress

Focus groups

Needs assessment

Statistical Starting four months prior to departure for Africa

With the assistance of local community health workers and local community leaders we will develop and implement an educational program(s) that will support local residents in achieving a higher level of malaria awareness.

Assessment and evaluation

Evaluation of outcomes

Public survey

Pre and post tests

Written evaluations/ tests

Lasting four months after program ends

Conclusion

Based on the statistical evidence that has been provided throughout this health promotion

initiative it is clear that malaria is a problem that needs more resources that are both financial and

physical. That confidently will make a difference in the lives of at first a select few, those

specifically located in Jinja, Uganda, but with time it is the on-going goal that this program will

spread additional communities in the surrounding areas that will consequently result in the

decrease of malaria related lost workable hours and malaria related deaths. This reduction in

deaths will result in improved quality of life and life expectancy in the region that will be


recognized by health care professionals, non-profits, and governmental agencies around the

world.


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