COHESION PI reflects on “Meu regresso a Moçambique”

Meu regresso a Moçambique – My return to Mozambique

Mozambique is a special place for me. It was the first country I visited in sub-Saharan Africa, my first project in looking at diabetes management in a low-income country and also a country where I was able to work for close to 7 years with the Ministry of Health and Diabetes Association. Besides the professional aspect, it was also a place where I made long lasting friendships with unique people who not only shared their passion for the work we were doing together, but also imparted me with the love of their beautiful country.

So the question I got from everyone after my recent trip to Mozambique for COHESION, how was it going back? AMAZING was my answer.

Going back to Mozambique was like seeing an old friend after a long time. The link, fondness and memories were there. Both Mozambique and I had moved on since my last visit. Economic development in Mozambique, but with current economic turmoil, more projects including the launch of COHESION and my move back to Geneva on my end.

My reunion with Mozambique was also positive in that the Mozambique COHESION Team had progressed with the research, been able to involve high-level individuals in the Advisory Boards as well as gain the support for our project in the two areas where our work will take place. I had a chance to visit Xipamanine and Moamba and speak to health professionals and local members of the community. In parallel Dr. Claire Somerville (Graduate Institute and COHESION Project Lead on the Policy Analysis component) and Sarah Lachat (University of Geneva, COHESION Project Manager) had the opportunity with our colleagues to work on and carry out some interviews regarding the Policy Analysis. We were also able to meet with the Swiss Cooperation Office in Maputo. The result of all of these discussions is that COHESION has a huge role to play in Mozambique to help improve the management of Noncommunicable (NCD) and Neglected Tropical Diseases (NTD).

Being back in Mozambique not only enabled me to see progress and continuing challenges based on my previous work, but mainly the importance of the current work of the COHESION Project. There are many challenges in Mozambique with a life expectancy of 53; high prevalence of HIV/AIDS and malaria; high maternal mortality, etc. NCDs and NTDs have been neglected by policy makers and donors. This results in a lack of capacity at the level of the health system to respond, leading to challenges for individuals and communities. The interventions that our project will develop will hopefully address these and help improve the conditions for people with NCDs and NTDs.

Até a proxima (until next time) Moçambique,

Dr. David H. Beran, Principal Investigator of COHESION

Swiss team goes to Mozambique

The COHESION team meets in Mozambique. Three members of the Swiss team (Dr. David Beran, Dr. Claire Somerville and Mrs. Sarah Lachat) join the Mozambique team this week at Eduardo Mondlane University.

Policy Analysis and gender are at the top of the agenda, but the team will not miss the opportunity to advance the community and health system assessments and reporting.

The team is grateful to be able to profit from face to face time in the country.

Community Health Perceptions Study in Peru

The Community Health Perceptions Study is one of the baseline studies of the COHESION project. It consists of a community mapping, focus groups and in-depth interviews with the aim to understand the community’s perceptions on healthcare services, health problems, (especially those related to diabetes, hypertension, and neurocysticercosis), as well as the implications of NCDs and NTDs at the individual, family and community level.

The community mapping in Peru was conducted in November 2016 in rural and peri-urban communities located in Northern Peru, namely: Ayabaca, Montero, Pingola and Sicacate. The fieldwork team was composed of one representative of CRONICAS Center of Excellence in Chronic Diseases (Silvana Pérez León) and a member of its local partner Centro de Salud Global of Universidad Peruana Cayetano Heredia (Fernando Urizar). They visited the selected communities and identified relevant actors to engage with in future COHESION activities.

This first visit helped to gain an overall understanding of the communities as well as to plan the data collection process, which took place earlier this year (February 1-21). Data were collected by two teams comprised of a man and  woman with social sciences degrees. They were joined by Nathaly Aya Pastrana, the COHESION PhD student from Università della Svizzera italiana in Lugano Switzerland. Nathaly participated in interviewing patients, caregivers and community leaders, as well as conducting focus groups with community members.

Data collection during the rainy season was challenging as the heavy rains made it difficult to access remote areas and to recruit participants for the focus groups. Intense rainfalls and floods continued until April 2017, creating public health concerns in the region, such as the spread of infectious diseases like dengue (Ministerio de Salud del Perú 2017). Fieldworkers (Gabriela Rengifo Briceño and Jorge Tuanama Álvarez) shared the following testimony of their fieldwork experience in the area:

“The dispersion of the population and the rains represented a challenge, but we learned that these are everyday conditions that people must solve when going to work, going to the health post for a checkup or for an emergency. Some are critical of the health service but it is the nearest alternative. Besides, going to other providers is expensive in time and money. Therefore, it was difficult to talk about health without offering in exchange attention, medicines or information.”

Ms. Aya Pastrana collected additional data through 1) interviews with representatives of communication channels, 2) recorded radio programs, 3) collected samples of printed communication material from local primary health care centers, and 4) documented observations of her field experience. The findings will provide additional insights to design interventions at the community level.

Preliminary analyses of the Community Health Perceptions Study show differences in the awareness about chronic conditions. People seem more aware of hypertension, with little knowledge of diabetes and neurocysticercosis. (see COHESION Newsletter Vol.1 Ed. 1)

References:

Ministerio de Salud del Perú (2017)  Aprueban “Lineamientos Para El Manejo Del Dengue En Zonas de Desastres Perú 2017.” http://www.minsa.gob.pe/?op=51&nota=22577, accessed July 20, 2017.

Interview with patient for the Community Health Perceptions Study, Sicacate, Northern Peru.

Focus groups with old women for the Community Health Perceptions Study. Pingola, Northern Peru.

 

Recruiting participants for the Community Health Perceptions Study. Montero, Northern Peru.

 

Recruiting participants for the Community Health Perceptions Study. Montero, Northern Peru.

 

Preliminary results from Household Survey in Nepal

Preliminary findings of the household survey in Nepal show that a total of 6245 people lived in 1209 households with an average family size of 5.17 ±2.02. Females were lesser in proportion (48.8%) than males and most of the people were living in nuclear families (64%). About one fourth of them were illiterate. The main source of drinking water was tube well among majority (97%) of the households and most of the households (68.2%) used firewood as a source of fuel for cooking. A quarter of households still practiced open field defecation. More than three fourth of them (78.1%) living below the poverty line.

About 66% of the households consulted a health care institution for health problems in the past one year. Among those who had visited PHC (41.4%) for consultation, 93.8% reported of having received information about their health problems; however 20.6% of them did not get sufficient time to ask for clarification. Although 47% of them were referred to other health institutions, almost half of them rated the service of PHC to be good. Most of them (70.5%) could reach the PHC by walking and about 29% of them were not accompanied by anybody during the visit to the PHC.

Among the health problems reported, there were two cases of leprosy, more than 8% were diabetes and about 9% were hypertension.

 

Apart from health workers such as doctors, nurses, health assistants and auxiliary health workers, and female community health volunteer, people also seek advice regarding health problems from their friends (10.6%), relatives (23%), neighbor (7.1%) and traditional healers (12%). None of the people had any form of health insurance.

 

 

Household Survey in Nepal

For the first time, in the rural area, Baniyani VDC, Jhapa district, South-western Nepal, a major household survey on several health issues was conducted by the Nepalese COHESION team during the last week of November 2016. The aim of the survey was to collect baseline information needed to assess the level of NCDs and NTD prevalence and related health care in one of the two selected site for COHESION intervention in Nepal.

The Household survey was conducted in the framework of the Interdisciplinary “Community Diagnosis Program” organized by School of Public Health and Community Medicine which comprises of two weeks of residential posting in rural setting for 1st Year MBBS, BDS and B.Sc. Nursing students. More than 200 students took part to the survey, supervised by 30 postgraduates and teachers, to collect data of more than 1200 households.

The questionnaires used are an innovative mixture of closed and open-ended questions concerning the socio-demographic profile of the community, reported health problems, health seeking behaviour and access to health facility and services at PHC level from a consumer perspective.

An orientation program was first organized at the B. P. Koirala Institute of Health Sciences (BPKIHS) to deliver lectures for the students on the different methods to be used. A meeting with local authorities including VDC heads, health worker, leaders, school teachers, Female Community Health Volunteers and others was also organized the week before field work, to inform the community of Baniyani VDC about the program and its aim.

The total of 201 medical graduate and nursing students under the supervision of 26 supervisors, including MD/MPH/MSc. nursing students were grouped in nine groups in accordance with the total number of wards of Baniyani VDC and performed house to house visits during 7 full days and collected more than 1200 households using semi-structured questionnaires regarding the above mentioned issues.

All households of the VDC were visited. The local communities were very cooperative in general. However, some resisted for the interview which could be due to mistrust towards health institutions or business. Others could not be assessed because of locked houses, probably due to the harvesting season or migration for work. Some members of household questioned about benefits of the survey: the fact that we were holding a health camp in parallel (day program of on the spot consultations offered by the MDs/faculties from B. P. Koirala Institute) helped a lot in this regard. At the end of the data collection exercise preliminary findings were shared with the community representatives, which also fostered mobilization of the villagers.

A challenge of the survey was to visit the place of study from the place of residence with such a huge group of students. We had to travel for more than an hour by bus. We all were very busy during the data collection with regard to visiting different households by walking. In every evening, attendance of students and briefing of status of data collection was organized.

In general, this survey was a success. Not only data were collected, but because all students had the opportunity to gain a lot of valuable experience.

The selected sites of Ayabaca and Montero in Piura – Peru

The COHESION project assesses the barriers that underserved communities face when accessing Primary Health Care (PHC) to treat chronic conditions in Peru, Mozambique, and Nepal. In Peru, the selected districts are Ayabaca and Montero in the Ayabaca province of Piura, North-Peru.

The northern region of Piura is well known for its tropical climate, white-sand beaches and surf. Far from the beaches on the coast, we find the province of Ayabaca in the highlands of Piura. Ayabaca is about six hours away from Piura city and it can only be accessed by road. Rural Ayabaca has often been neglected and forgotten by policy makers and private investors. Although blessed with rich flora and fauna, the Ayabaca province faces poverty and exclusion.

The Peruvian COHESION project team chose as its intervention sites two districts of the Ayabaca province: Montero and Ayabaca, where 6,683 and 38,339 people live respectively1. According to the National Institute of Statistic and Informatics, the poverty rate in Ayabaca is 69.4% and 55.9% in Montero1. One of the main problems in these districts is the lack of access to sanitation and clean water. Ayabaca province has one of the highest drinking water shortages and lack of basic sanitation, with wide differences between its urban (54%) and rural (99%) areas2. Lack of sanitation is one of the major risk factors3 for some Neglected Tropical Diseases like neurocysticercosis.

Access to health in places like Ayabaca is crucial and yet, scarce. Health facilities in both Ayabaca and Montero only provide very basic health services, focusing on maternal and child health. Out of the 31 health facilities in Ayabaca, 29 are basic primary health care posts. The other two are health centres. Montero, on the other hand, has only three basic primary health care posts and one health centre. The health centres have few health professionals and rudimentary hospitalization facilities. If there is an emergency in either of these districts that requires an urgent referral of the patient, the closest regional hospital is located in Sullana-Piura and it takes about four hours to get there by private vehicle. However, the ambulance in these health centres is not always operating. Addressing diseases like neurocysticercosis, hypertension, and diabetes in resource-limited districts like Ayabaca and Montero needs effective interventions that work at a community-based level and that are focused on the poorest of the poor.

Health Center – Ayabaca

 

Pingola Main Square

 

References:

  1. Instituto Nacional de Estadística e Informática (2016). “Peru en Cifras: Ayabaca, Piura” Retrieved November 04, 2016, from https://www.inei.gob.pe/.
  2. Instituto Nacional de Estadística e Informática  (2010). “Mapa del Déficit de Agua y Saneamiento Básico a Nivel Distrital, 2007”. Lima: Instituto Nacional de Estadística e Informática. Available at: https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib0867/libro.pdf
  3. Garcia HH et al. (2016). “Elimination of Taenia solium Transmission in Northern Peru”. The New England Journal of Medicine. 2016 Jun 16; 374(24): 2335-44. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27305193

Fieldworkers trained for Community Health Perceptions work in Peru

Fieldworkers received training in data collection tools and methods before heading to the selected sites: Ayabaca and Montero, located in the region of Piura in the north of Peru. They will be conducting interviews and focus group discussions, elements of the Community Health Perceptions research component of the project. Their work will be informed by the findings of a community mapping that took place in October 2016, and will be complemented by the insights of a Ph.D. student in Social Marketing from Lugano, Switzerland, who is joining them in the field.

The fieldwork takes place in February 2017, during the rainy season and some challenges lie ahead of the team. However, the team is excited to engage with the communities.

National Policy Analysis in Peru

One of the main research outputs of COHESION consists of an analysis of global and national policies related to non-communicable (NCDs) and neglected tropical diseases (NTDs). The partners in Switzerland conducted the global policy analysis, whereas national policy analyses are in progress in Mozambique, Nepal, and Peru.

The COHESION team in Peru met on January 23rd to review the preliminary findings of their national policy analysis. Interesting perspectives were raised in relation to the Peruvian policy agenda, methodological considerations were shared and lessons learned were expressed that will be shared with the partner countries. In addition, participants spoke about potential activities that will follow once the analysis is finalized, including publications and dissemination of findings to national stakeholders.

 

 

First Meeting of the Peruvian Advisory Board

The first Peru Advisory Board meeting was held on January 25, 2017. It was an important milestone for COHESION’s work in Peru. Advisors of diverse backgrounds and local team members participated in a cooperative session where the advisors repeatedly expressed their interest in contributing to the success of the project.

The members of the Advisory Board in Peru have expertise in preventive medicine, public health, epidemiology, health innovation, health communication, medical anthropology, research methods, non-communicable diseases, parasitology and tropical diseases.

During the meeting this group of experts contributed to the discussion on COHESION’s research components and methods, and provided suggestions for the upcoming activities. Furthermore, the advisors proposed a new meeting once data collection and analysis has been completed, to work together in the design of potential interventions.

 

 

The COHESION Project’s first Global Advisory Board Meeting

On the 21st of November 2016 at the Geneva University Hospitals (HUG) in a conference room overlooking the old town of Geneva, a significant event was held for the COHESION Project. This was the first Global Advisory Board Meeting. So why was this important?

First and foremost, it was the first time that the Global Advisory Board of the COHESION Project met. This meeting brought together 11 of the 12 Board members, providing a unique and diverse group of people from UNAIDS, WHO, London School of Hygiene and Tropical Medicine, the Permanent Missions of Mozambique and Peru, the State of Geneva and the HUG. This group of policy makers, clinicians and researchers all shared a common passion for global health.

COHESION presented its work and got feedback. Dr. Claire Somerville, COHESION Co-Investigator and lead on the Policy Analysis, presented the preliminary results of the Global Policy Analysis.

This meeting was a great opportunity to exchange and learn from the experience of our Advisors. Most importantly, this meeting was a chance for the COHESION Team to be challenged, in what we are doing and how we are doing it.

Our Advisors challenged COHESION with regards to the interventions and how to evaluate them. They argued that the development and evaluation should use both qualitative and quantitative methods and also use an iterative process. They all saw the value of what COHESION was trying to achieve and stressed that we have the potential to make a difference. P. Perel insisted that this impact needed to be measured and reported.

Discussions also focused on the wider determinants of Noncommunicable (NCD) and Neglected Tropical Diseases (NTD). P. Godfrey-Fausett recommended that COHESION look beyond health systems and look at “systems for health”. F. Romao and Y. Jackson added that the issue of vulnerability and gender needed to be examined in different ways, for example making services sensitive to men and women. S. Aebischer insisted on the necessity to adopt a non-vertical approach and to develop interventions at the community level as behaviour change is needed to reduce the risk of obtaining an NCD as well as for managing them.

So what are the lessons from our first meeting? COHESION needs to continue to think about the impact of our project and how to continuously measure this. As noted by A. Costello: “NCDs are the great big dark matter of health. They are invisible to most people, but are massive.” Through COHESION, we hope to ensure that NCDs and NTDs and the people who are faced with these health challenges become more visible and empowered to tackle these dark matter. We will strive to do this with the communities and systems we are working with. Together, we believe we can make a difference.

*From left to right

  • Dr. Anthony Costello, Head of the Department of Maternal, Newborn, Child and Adolescent Health at the WHO
  • Dr. Claire Somerville, CO-PI COHESION, Graduate Institute, Geneva
  • Dr. Sigiriya Aebischer, Senior Resident, Tropical and Humanitarian Medicine Division, Geneva University Hospitals (HUG)
  • Dr. Francelina Romao, Health Counselor, Embassy of Mozambique in Geneva
  • Prof. François Chappuis, Head of the Division of Tropical and Humanitarian Medicine, Geneva University Hospitals (HUG)
  • Dr. David Beran, Principal Investigator COHESION Project, Geneva University
  • Dr. Peter Godfrey-Faussett, Senior Science Adviser, Office of the UNAIDS Science Panel, UNAIDS
  • Ms. Maria Jesus Alonso Lormand, Director of the International Solidarity Service, State of Geneva
  • Dr. Yves Jackson, Senior Consultant, Division of Primary Care, Geneva University Hospitals (HUG)
  • Dr. Pablo Perel, Director of the Centre for Global NCDs at the London School of Hygiene & Tropical Medicine, Senior Science Advisor at the World Heart Federation
  • Dr. Gilles Eperon, Senior Resident, Tropical and Humanitarian Medicine Unit, Geneva University Hospitals (HUG)
  • Mr. Carlos Briceño, Ministro Consejero, Permanent Mission of Peru to the UN

 Not present: Ms. Lauranne Botti, Research Fairness Initiative (RFI) Manager at the Council on Research for Development (COHRED)