Harrison C. Spencer

Community-based malaria control in Saradidi, Kenya: description of the programme and impact on parasitaemia rates and antimalarial antibodies.

A community-based malaria control programme initiated in Saradidi, Kenya in 1982 is described. Antimalarial treatment provided by volunteer community health workers was made available in each village. Malaria was holoendemic. Parasitaemia rates by age were high and did not change after the control programme began. Plasmodium falciparum was the most common species and was present alone or mixed in 98.2% of 8105 infections. Virtually all (98.5%) of 2040 blood samples collected in May 1981 were positive (reciprocal titre greater than or equal to 80) to P. falciparum by the indirect fluorescent antibody (IFA) test. Seropositivity rates to P. falciparum in the IFA test or the enzyme-linked immunosorbent assay (ELISA) were high in all age groups and did not change significantly in longitudinal surveys or in a cohort of children zero to nine years old followed at intervals. While the malaria control programme was successful in bringing treatment to each village, malaria prevalence was not reduced. Parasitologic and serologic studies alone were not adequate to describe the impact of the community-based malaria control programme in Saradidi. Morbidity and mortality rates caused by malaria can decline, significantly improving the health of the population, in the absence of any decrease in parasitaemia rates.

Characteristics and functions of community health workers in: Saradidi, Kenya

A community-based health development programme in Saradidi, Kenya had 126 village health helpers (VHHs) for the 56 villages. These volunteer health workers lived in the community and served a total population of about 43,000 in an area of 225 km2. Each VHH served a maximum of 100 households averaging 4.0 persons. Conditions imposed by the community were that the VHH be perceived to be a mature person, to be compassionate and to have a desire to help people and to live in the village. Literacy or formal education were not requirements. VHHs were chosen and supported by the people who lived in their village. Characteristics of the 126 VHHs were that 96.8% were women, 99.2% were married, 75.4% were between 25 and 39 years of age, and 80.2% had at least five years of formal education (only 7.1% had none). The VHHs spent an average five to ten days each month on programme activities in addition to their other responsibilities which included preparing meals, cleaning their homes, carrying water and firewood from long distances, caring for their children and cultivating food for their family. Each VHH visited about 15 households per month, spending one to two hours on a visit. Problems experienced by a random sample of 36 VHHs included difficulties due to lack of transport, lack of medicines, slowness of the community to accept new ideas, distance from project clinic, lack of food in the village, weak village health committees, and no payment for services. The main support for the VHHs came from village women individually, womens groups, and the central programme committee. Village Health Committees did not provide effective support. Nevertheless, in four years only four of the 126 VHHs dropped out of the programme. The main reasons that 36 VHHs reported for continuing to volunteer were as follows: the continuous training they were given was beneficial (mentioned by all); they agreed to serve the villages and did not want to go back on their word (36.1%); they liked the work (19.4%); they felt they have an impact on the health of people in the village (16.7%); the allowances they sometimes receive (22.2%); and personal development (13.9%). The characteristics and responsibilities of community health workers in Saradidi were similar to those elsewhere. The ingredients for a successful volunteer programme such as this one are present in many areas.(ABSTRACT TRUNCATED AT 400 WORDS)

Malaria chemoprophylaxis to pregnant women provided by community health workers in Saradidi, Kenya. II. Effect on parasitaemia and haemoglobin levels

To determine the effects of chloroquine phosphate (300 mg base weekly) chemoprophylaxis for malaria provided by volunteer village health helpers (VHHs), pregnant women attending antenatal clinics in Saradidi, Kenya, were examined each month. Parasitaemia, haemoglobin level, and the presence of urinary 4-aminoquinolines were determined at each visit. The age composition and parity of women taking chemoprophylaxis were not statistically significantly different from those of the other women. A total of 104 (29.1%) of 357 pregnant women from 23 villages where chemprophylaxis was provided by VHHs said they were taking it. Women 30 to 44 years of age (43.9%) of 82) were more often taking prophylaxis than those younger (25.1% of 271) (P less than 0.0005). An additional 573 pregnant women to whom regular chemoprophylaxis was not provided from 33 control villages were also examined at least once. When compared with those from women not taking prophylaxis, blood samples from pregnant women on antimalarial prophylaxis had lower parasite rates (17.7% of 265 compared with 26.2% of 1700, P less than 0.005), higher haemoglobin levels (59.1% of 127 were greater than or equal to 10.0 g l-1 compared with 49.7% of 1111, P less than 0.05), and a higher mean haemoglobin level (9.95 g dl-1 compared with 9.62, P = 0.019) and urine samples were more often positive for 4-aminoquinolines (15.7% of 255 compared with 8.3% of 1656, P less than 0.0005). For women with two or more parasitologic samples, 69.6% of 79 pregnant women on prophylaxis had no parasites found on any visit compared with 51.6% of 516 women not on chemoprophylaxis (P less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Malaria chemoprophylaxis to pregnant women provided by community health workers in Saradidi, Kenya. III. Serologic studies.

Parasitaemia and antimalarial antibodies were examined from May 1983 to March 1984 in monthly samples taken from 930 pregnant women attending antenatal clinics in Saradidi, Kenya, and 317 of their infants; 104 women were taking chloroquine phosphate 300 mg base weekly for chemoprophylaxis. Seropositivity rates in pregnant women were uniformly high, and mean enzyme-linked immunosorbent assay (ELISA) absorbance values were not related to presence of parasitaemia or history of chemoprophylaxis. Parasitaemia was present in 26.5% of 1677 slides from pregnant women and there was little variation by month of sample. Mean ELISA absorbance values varied by month of sample. Seropositivity rates in infants were high as measured in both the indirect fluorescent antibody (IFA) test (81.6% of 938) and ELISA at 1:100 (83.8% of 1025) and 1:1000 (34.8% of 1025) serum dilutions. Seropositivity rates decreased slightly after birth but by four months of age rates were again high. Parasitaemia was present in 26.5% of 1677 slides from pregnant women. Paired comparisons were made on maternal samples collected less than two months before parturition and samples from the infants collected within two months after birth. The paired antibody response by IFA or ELISA was not dependent on the presence of detectable parasitaemia in the mother. Infants from mothers with a history of antimalarial chemoprophylaxis had significantly (P = 0.04) lower IFA titres than other infants. Measuring the absorbance of a 1:100 serum dilution by ELISA appeared to be an excellent method with which to measure longitudinal serologic changes in a population.

Community leadership and participation in the Saradidi, Kenya, rural health development programme.

Community participation and leadership in initiating and implementing a health development programme in Saradidi, Kenya were examined. Organization of the area into villages had to be sensitive to existing community organizational structures such as geography, religion, kinship and administrative boundaries. The lowest level government leaders did not always have the support of the community. Some groups such as women and those who were not wealthy were not always included in leadership positions; these people, however, were often most aware of certain village problems. In Saradidi, womens groups were important for community development; they supported the volunteer community health workers and carried out many village health activities. Many village health committees did not function effectively. Village health workers were supported principally by the programme centre. Village income-generating activities were not very successful. Group involvement in income raising ventures proved to be inefficient; many ended up as income draining activities. Village group income projects must be well selected relative to the skills and resources available and the ability of the product to be marketed; only exceptional ones should be encouraged. Those based at the programmes centre were more successful perhaps because of a greater investment in skills, money and marketing. Age was an important factor in accepted leadership roles in Saradidi; most effective leaders were more than 45 years of age. Village health helpers volunteered a significant proportion of their time despite poor support by village health committees and no financial remuneration. The central project structure and the training they received compensated for the lack of guidance by village health committees.

Changes in sources of treatment occurring after inception of a community-based malaria control programme in Saradidi, Kenya.

To determine the changes in source of antimalarial treatment and perceptions about malaria after the initiation of a community-based malaria control programme in Saradidi, Kenya, two identical surveys were carried out; one in March 1982 (before the programme began in May 1982) and the other in December 1984. Three areas were involved: areas A and B had antimalarial treatment provided by village health helpers (VHHs) and area C had VHHs who did not provide treatment. Two groups of randomly selected women age 15 to 59 years were interviewed: 45 in survey 1 and 92 in survey 2. A decided change in the source of malaria treatment was observed. In the first survey, 52.9% of the respondents from areas A and B combined purchased antimalarial medicine from shops; other sources were government health facilities, mission clinics, and the Saradidi community clinic. By the second survey, 85.2% of the respondents in areas A and B obtained treatment from the VHHs; no significant change occurred in area C. In both surveys the leading reasons given for people purchasing drugs from shops was that the distance to health facilities was great, that no transport was available and that shops were open when emergencies occurred. The shopkeeper frequently advised which drug to take and the dosage as well as selling the drugs. For family illnesses of unknown aetiology most people (82.2% in survey 1 and 97.8%, in survey 2) went to a hospital or clinic. These results demonstrate that the malaria control programme in Saradidi has influenced both the source of antimalarials and the attitudes people have about malaria. In Saradidi, Kenya people chose to obtain antimalarial treatment and advice from community health workers.

Epidemiology of chloroquine-associated pruritus in Saradidi, Kenya.

The association of pruritus and ingestion of chloroquine phosphate in Saradidi, Kenya, was determined by randomly giving 437 children (less than 18 years) and 182 adults either 10 mg base kg-1 of regular chloroquine, 10 mg base kg-1 of enteric-coated chloroquine, 10 mg base kg-1 of amodiaquine, or one 300 mg tablet of enteric-coated ferrous sulphate. Before treatment, a blood smear was taken. Paired urine samples were tested for 4-aminoquinolines to exclude prior drug ingestion, to document drug absorption, and to exclude chloroquine or amodiaquine intake in persons who received iron. The following day, the incidence of itching was ascertained. More adults (20.3%) reported itching than did children (12.8%) (P less than 0.05); no significant difference between males and females was noted. A history of itching 24 hours after treatment was not significantly more common in persons with malaria parasitaemia. Pruritus was more frequent in those receiving regular chloroquine (21.5% of 186) and enteric-coated chloroquine (17.8% of 118) than after amodiaquine (11.6% of 173) or iron (8.5% of 142) (P less than 0.005). Amodiaquine which is a 4-aminoquinoline like chloroquine did not appear to cause significant pruritus in this population. These results demonstrate that chloroquine-associated pruritus is experienced frequently in Saradidi. This side effect of malaria treatment could influence usage of chloroquine phosphate provided by village health workers.

The Saradidi, Kenya, rural health development programme.

A primary health care community development programme was initiated in 1979 by people living in Saradidi, Kenya. The community was involved in planning, organization, setting of priorities and objectives, implementation, evaluation and benefits. This paper describes the developmental process that occurred including how the programme began, how it was organized and what it attempted to accomplish.

Consumption of chloroquine phosphate provided for treatment of malaria by volunteer village health workers in Saradidi, Kenya.

A community-based malaria control programme in Saradidi, Kenya provided chloroquine treatment for malaria in each village beginning in May 1982. Malaria was holoendemic in Saradidi. Treatment was provided by volunteer community health workers chosen and supported by the village. Consumption of the drug and characteristics of persons treated were recorded. Between 1 September 1982 to 31 August 1983, 40,649 treatments with chloroquine were given to village residents. The treatment rate per person in the mid-year population was 1.24. However, at least 41.8% of the mid-year population of 32,650 did not receive a single treatment. Multiple treatments were given to 50.5% of persons treated at least once and 13.4% of 13,879 persons treated at least once received five or more treatments during the year. Consumption patterns were not random: they were higher in females, in persons above 30 years of age and in the area with greater community organization and community participation. There is need to ascertain the reasons why so large a proportion of the population never received a single treatment in this highly malarious area and why adults who should not have had a high frequency of clinical malaria were treated so often. Nonetheless, the results demonstrate that volunteer community health workers can effectively provide treatment for malaria.

Community-based distribution of family planning services in Saradidi, Kenya.

Community-based distribution (CBD) of family planning services was initiated in 1980 in Saradidi, Kenya, as part of a community development effort. Family planning information and services in each village were provided by volunteer health helpers (VHHs) chosen and supported by the people in each village. The initial examination and supply of commodities was provided at a community clinic. Less than 1% of women 15 to 49 years of age used a family planning method before CBD was initiated. In 1983, 31 (17.3%) of 179 randomly selected currently married women and 26 (52.0%) of 50 currently married VHHs reported having used a family planning method; 38 (66.7%) were still using a method at the time of the survey. Family planning use increased with age and education. Women who used family planning had higher parity, were less likely to want more children and had had a longer time since the last delivery. From 1980 to 1983, 732 persons (including 121 men) were seen at the Saradidi clinic requesting family planning services; 17.2% were referred from the VHHs. About one-third of clients referred from VHHs to the clinic for examination and commodities actually came. Allowing VHHs to carry out the initial examination and provide the first supply of commodities to the acceptors might have significantly increased the rate of family planning use. The findings demonstrate an increased use of family planning services in Saradidi following the inception of CBD.