|ORIGINAL RESEARCH PAPER
|Year : 2011 | Volume
| Issue : 2 | Page : 474
A Community Health Worker Program for the Prevention of Malaria in Eastern Kenya
DG Stromberg1, J Frederiksen2, J Hruschka1, A Tomedi1, M Mwanthi3
1 University of New Mexico Albuquerque, New Mexico, USA
2 Via Christi Family Medicine, University of Kansas, Wichita, Kansas, USA
3 Department of Community Health, School of Medicine, College of Health Sciences, University of Nairobi, Nairobi, Kenya
|Date of Submission||20-Apr-2010|
|Date of Acceptance||14-Jul-2011|
|Date of Web Publication||10-Aug-2011|
D G Stromberg
409 Girard SZ Albuquerque, NM 87106
Source of Support: None, Conflict of Interest: None
Objective: To assess whether the development and implementation of a community health worker (CHW) project in rural Kenya was associated with an increase in knowledge about malaria and the use of insecticide-treated nets (ITNs) in children under five years of age.
Methods: A baseline knowledge and behavior questionnaire, adopted from the Kenyan Demographic Health Survey, was
conducted in August 2007 by Kenyan health officials in 75 villages. Two CHWs were chosen from each village and trained in appropriate use of ITNs. The CHWs provided educational sessions and ITNs to mothers in their respective villages. A follow-up survey was conducted in March 2008 of all families with children less than five years of age within randomly selected villages. The main questions addressed during the follow-up survey included knowledge about malaria and the practice of correctly using ITNs.
Findings: There were 267 surveys compiled for knowledge assessment before the intervention and 340 in the post-intervention analysis with an approximate 99% family participation rate. Of the families surveyed, 81% correctly knew the cause for malaria before the study and 93% after the CHW intervention (p < 0.01). Of those surveyed before the intervention, 70% owned and correctly used mosquito nets compared with 88% after the CHW intervention (p < 0.01).
Conclusions: There was a significant increase in knowledge about malaria and use of ITNs after the implementation of the CHW program.
Keywords: Community health aides, insecticide-treated bednets, malaria/diagnosis, malaria/prevention andcontrol, Kenya, rural health services, infant, child/preschool, questionnaires
|How to cite this article:|
Stromberg D G, Frederiksen J, Hruschka J, Tomedi A, Mwanthi M. A Community Health Worker Program for the Prevention of Malaria in Eastern Kenya. Educ Health 2011;24:474
Child mortality continues to be a major problem in Kenya. In 2007, the under-five child mortality rate was 121 per 1000 live births compared with 8 per 1000 in the United States1. Infant mortality rates (death before age one) in Kenya were similarly high, with 80 infant deaths per 1000 in Kenya compared to 7 per 1000 in the United States1. Unlike most developing countries, childhood mortality has worsened in Kenya over recent decades. The under-five and infant mortality rates have seen an increase of approximately 30% since 19892. In spite of advances in science and medicine, malaria continues to be one of Kenya's leading contributors to under-five mortality. It has been estimated that 26,000 children under the age of five die annually from malaria while 145,000 children under the age of four require hospitalization for this disease3.
One popular and very effective strategy for the prevention and control of malaria is the use of insecticide-treated nets (ITNs)4. These nets, often treated with either deltamethrin or permethrin, are draped over beds, effectively reducing physical contact to mosquitoes during sleep in the hours when mosquitoes are most active, while killing and repelling the insects that come in contact with the insecticide. The United Nations currently endorses the use of ITNs in its Millennium Development Goals, citing them as, 'one simple and cost-effective intervention against malaria'1. Several groups in Kenya, including the government, also support the use of ITNs3. However, reaching the widely-dispersed families in rural villages with any malaria prevention strategy can be challenging. One approach that offers potential for overcoming this challenge is to train local villagers as community health workers, who can be the ones to implement a malaria control program in their villages. Recently, there has been renewed interest in CHW programs designed to improve child survival, and there is a need to assess their ability to increase coverage of essential interventions, especially in communities with limited resources and high disease burden5.
While CHWs have been shown to be effective in delivering control, treatment and behavior measures, there are few studies that specifically assess the effectiveness if CHWs in promoting the use of ITNs and in malaria prevention in children6-8. The purpose of our study was to evaluate the relationship of the use of ITNs within a catchment area after implementation of a CHW program. Our study focused specifically on villagers’ knowledge about malaria and the use of ITNs before and after the CHW intervention. The study asked two questions: (1) After the implementation of this CHW program, was there an increase in the reported use of insecticide-treated nets (ITNs)? (2) Was the implementation of the CHW program associated with an increase in knowledge about malaria on the part of the caretakers of children less than five years of age?
One non-profit organization working in eastern Kenya, Global Health Partnership (GHP), has championed the cause of ITNs utilizing a CHW program. GHP provided assistance and support to local community leaders, in collaboration with the Kenya Ministry of Health, to complete the construction of a clinic and the development of a CHW project. The clinic and CHW project were designed by the community leaders and local chiefs to serve the 75 villages of two districts. The CHW program began when two CHWs for each village were recruited in a village meeting ('baraza') facilitated by the chief or assistant chief, who are appointed government officials. The selection of these individuals to train as CHWs was by consensus of the villagers in attendance at the meeting and typically based upon the motivation and ability of the recruited individuals to work as volunteers to provide health services to the community.
The training of CHWs consisted of a five-day course for individual teams of 35-40 CHWs, based on the 'Kenya Essential Package for Health: A Manual for Training Community Health Workers'. The topics covered during the initial training included methods of malaria control, childhood (under-five) respiratory tract infections and diarrheal disease, domestic and personal hygiene, child nutrition, reproductive health, HIV/AIDS including PMTCT and communication skills. The training methodologies consisted of introductory lectures, group discussions, audiovisuals, demonstrations and role playing.
After completing the training program, ITNs were purchased by GHP at a subsidized price from Population Services International (PSI), a non-governmental organization that promotes and distributes ITNs in Kenya and other countries. GHP purchased 4500 ITNs. This was a sufficient number to protect every child less than five years of age in the 75 villages. The ITNs were distributed through a local Ministry of Health dispensary. PSI staff provided additional training to the CHWs in the appropriate use of ITNs. The CHWs then arranged group sessions for the mothers of their villages to provide education about malaria and proper use of ITNs to effectively reduce malaria transmission.
A questionnaire, adopted from the Kenyan Demographic Health Survey2, was selected for this study. The pre-intervention survey was conducted in August 2007 by the Kenyan Machakos District Health Management Team. This survey was performed by a team of 16 Kenyan health officials working independent of this study, and it provided baseline data for our research. The baseline survey included questions on parents’ knowledge of the cause of malaria and the use of ITNs.
Using selected questions pertaining to malaria from this original survey instrument, three researchers and translators visited homes in the selected villages and questioned every family with children less than five years of age. The two principal questions addressed in our survey focused on the parents’ knowledge of malaria and the correct use of ITNs for children under five years of age (Appendix A). Questions regarding the reasons for not using an ITN were also asked for future improvement of ITN programs and education.
The target sample size was 500 children, or approximately 250 homes based on the region’s ratio of child ages 0 to 59 months per household. An 80% power to detect a difference of 4.7% between the null hypothesis (no behavioral/ educational changes post CHW intervention) and the alternative hypothesis (an evident change in behavior after CHW intervention) was calculated using a two-sided chi-square test with continuity correction and with a significance level of 0.05. In order to assure random sampling within sub-locations with sample sizes proportional to the number of children in each sub-location, several statistical analyses were completed. Within the 75 villages in which the CHWs were working, there was a population of 35,730, of whom 4462 or 12% are children under five years old. The villages were randomly selected for the sample with probability proportional to village size.
The data from the initial and follow-up survey were compiled using a standard database program, EpiInfo, and were entered by the three field researchers upon returning to the United States. Data analyses were completed using SAS and EpiInfo statistical software. Since villages were the primary sampling units, chi-square tests comparing knowledge about malaria and ITN use before and after intervention were adjusted for cluster level sampling9.
The study protocol was approved by the Human Research Protections Office of the University of New Mexico and the Kenya Ministry of Science and Technology review committee.
A total of 267 and 265 households with children under five years of age were enrolled in the baseline studies of knowledge of malaria and ITN use respectively. There were 340 households in the follow-up study. Upon comparing the pre-intervention versus the post-intervention data, it was observed that there was a significant increase in knowledge about malaria and ITN use after the implementation of the CHW program. Of the villages surveyed the mean percentage of families who correctly knew the cause for malaria was 81% before the study and 93% after the CHW intervention (p = 0.02) (Table 1). Of those surveyed before the intervention 70% had and reported that they correctly used mosquito nets compared with 88% after the CHW intervention (p = 0.04) (Table 2).
The causes of malaria reported by respondents are included in Table 3. Eighty-one percent of respondents answered, being 'bit by a mosquito' before and 93% after the intervention. Twenty percent of respondents answered, 'drinking dirty water' before and 8% after. Twenty-four percent of respondents had an 'other' answer before and 5% after.
Table 1: Knowledge of cause of malaria
Table 2: Reported use of a mosquito net (any type)
The household members who reported using an ITN after the intervention are shown in Table 4. The percentage of specific household members using an ITN included 64% of children, 61% of mothers/caretakers, 27% of spouses of mothers/caretakers, 21% of other family members and 1% were not used.
The reasons given for not using the mosquito nets were cost (44%), inaccessibility (7%), being uncomfortable (6%) and being unaware of their benefits (6%). Thirty-seven percent responded with 'other' reasons, which included family members being uncomfortable sleeping under the nets and the inconvenience of net installation.
Table 3: Responses to the question 'What causes malaria?'
Table 4: Person in household using a mosquito net, %
Based on the data, there was a significant increase in ITN use and knowledge about malaria after the implementation of the CHW program. While the data are consistent with a positive benefit, the study had several limitations including the fact that two different groups of surveyors were used for the pre- and post-intervention surveys. There were also cultural/linguistic barriers that could affect communications. A clear example of this surrounded the question that addressed the cause of malaria. The second most common reported cause of malaria cited was 'drinking dirty water' and the Kamba word for malaria can be directly translated to 'fever' as well as 'malaria.' From the standpoint of the study, the response 'drinking dirty water' was incorrect; however, from a Kamba perspective, certain water borne illnesses can cause a fever making it a correct response. There were likely other linguistic errors that were not identified.
The study also lacked a control group. During the design of the study, GHP members determined that it went against the organization’s humanitarian goals to provide a possibly beneficial intervention to one community while withholding it from others. As a last limitation, the communities studied were not isolated from other interventions by other organizations and governmental agencies. Paramount among these programs were the subsidies for ITNs given through the Kenyan government in cooperation with non-governmental organizations particularly the Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis. These subsidies were being expanded during the period of our study and it can be presumed that this other program was spreading into the region and population that were involved in our study. In spite of these limitations, it is reasonable to believe that the CHW program was effective in educating and changing behavior in the area studied. The documented change in ITN use and education was dramatic given the short interval of time (six months) between the two surveys and lends support to the suggestion that the CHW intervention was responsible for all or some of this change.
Because of their vulnerability to disease, it was encouraging to observe that the majority of nets were being used by children under five years old and females of child-bearing age. One reason why ITN use by spouses was low is likely due to the fact that many husbands in this area work in the cities of Nairobi and Machakos.
Cost was the more common identified reason given for not using nets (44%). During the time of the study, efforts were being made to remove this barrier. These included giving ITNs free of charge for pregnant women and neonates (less than one month of age) and subsides that have made ITNs available for all children under five years of age for 50 Kenyan shillings (approximately US$ 0.65, or € 0.49). Although this may not seem like a significant expense to the average Westerner, for the average Kenyan it is roughly equivalent to 19 US dollars, based on 2008 GDP per capita10. Nonetheless, this amount is less than the previous cost of 100 Kenyan shillings. Since ITNs last several years and can be used by multiple persons, their continued use can also help to minimize the cost to households. There are a variety of brands of ITN brands currently available. Previous basic ITNs lasted 6-12 months, or less if they were washed. Newer models, which constitute the bulk of the increase in nets being used, can last up to five years and can be washed up to twenty times while still retaining maximum insecticide protection11. These improvements in ITN manufacturing have made them a prevention strategy that more people can afford.
This study’s data add further support for the benefits of CHW programs. Robust previous studies have shown that ITNs effectively decrease childhood mortality from malaria. There remained the challenge of reaching the poorest and most underserved with this effective intervention. This study supports the implementation of CHW programs that target the use of ITNs in poor communities. Expanded use of CHW programs could help organizations and government agencies become more effective in reducing childhood morbidity and mortality from malaria. Future studies should address primary health outcomes such as morbidity and mortality rates beyond the surrogate outcomes used in this study. Other studies of CHWs as a means for disseminating other types of health information and health prevention tactics to difficult to reach populations should also be considered.
Betty Skipper was invaluable with her assistance with the statistical analysis and editing. Cheryl Schmitt was also very helpful as a statistical consultant. David Broudy was vital with data input and analysis. Peter Wahome provided key project assistance and support in Kenya. The authors have deeply felt gratitude for the whole community of Kisesini and surrounding area for their warm hospitality and generous spirits. Members of the community who were especially helpful were our dedicated and talented translators. Kisesini clinic nurse, Nicolas Mutuku, and community organizer, Mbeti Wambua, were also invaluable resources. Finally, we extend our sincerest appreciation to all the committed community health workers; it is their hard work that is truly changing the health of Kenyan communities.
1. United Nations. The Millennium Development Goals Report: United Nations Department of Public Information, New York; 2005.
2. Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], and ORC Macro. 2004. Kenya Demographic and Health Survey 2003. Calverton, Maryland: CBS, MOH, and ORC Macro. Available from http://www.measuredhs.com/pubs/pdf/FR151/FR151.pdf
3. World Health Organization, Roll Back Malaria. Kenya Country Profile World Malaria Report 2005. WHO: Geneva; 2005.
4. Lengeler C. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database of Systematic Reviews. 2004, Issue 2. Art. No.: CD000363.
5. 5. Haines A, Sanders D, Lehmann U, Rowe A, Lawn J, Jan S, Walker D, Bhutta Z. Achieving child survival goals: potential contribution of community health workers. Lancet. 2007; 369 (9579):2121-2131.
6. Kaseje DC, Sempebwa EK, Spencer HC. Malaria chemoprophylaxis to pregnant women provided by community health workers in Saradidi, Kenya. Reasons for non-acceptance. Annals Tropical Medical Parasitology. 1987;81 Suppl 1:77-82.
7. Ruebush TK, Zeissig R, Klein RE, Godoy HA. Community participation in malaria surveillance and treatment. II. Evaluation of the volunteer collaborator Network of Guatemala. American Journal of Tropical Medicine and Hygiene. 1992;46(3):261-271.
8. Pagnoni F, Convelbo N, Tiendrebeogo J, Cousens S, Esposito FA. Community-based programme to provide prompt and adequate treatment of presumptive malaria in children. Transactions from the Royal Society of Tropical Medicine and Hygiene. 1997;91(5):512-517.
9. Donner A, Klar N. Design and analysis of Cluster Randomization Trials in Health Research. New York: Oxford University; 2000.
10. Central Intelligence Agency. CIA World Factbook. (Online) Retrieved November 29, 2009. Available from: https://www.cia.gov/library/publications/the-world-factbook
11. Centers for Disease Control and Prevention. Malaria: Vector Control. (Online) Retrieved November 29, 2009. Available from: http://www.cdc.gov/malaria/malaria_worldwide/reduction/vector_control.html