COHESION team meets in Nepal

Two members of the Swiss COHESION team (Sarah Lachat and Jorge Correia) traveled to Nepal
recently where they worked for 15 days with the local COHESION team (Nilambar Jha,
Suman Sing and Sanjib Sharma) at the B.P. Koirala Institute for Health Science.
The aim of the visit was to support the planning and implementation of the three
elements of the COHESION research project (policy analysis, health system assessment, community
perception study). In addition to working session at the BP Koirala, the selected sites of intervention
Itahari (urban) and Banyani (rural) were visited, including a visit of the two related Primary
Health Care centers and meetings with the local stakeholders (VCD committee members, staff from
the PHC centers, etc.). The current management of NCDs and leprosy was discussed, as well as perceptions regarding both types of diseases and related needs.
Another major aim of the visit was to perform a situational analysis of the management of patients affected by leprosy in Nepal, with a focus on therapeutic patient education, led by Dr.
Correia. This study was conducted in three sites, selected due to the number of leprosy patients that attend and the expertise of the institutions: B.P Koirala Institute of Health Sciences, Lalgadh Leprosy
Hospital and Services Center and the Anandaban Leprosy Hospital. More than 20 interviews were conducted with patients, caregivers, expert patients, health workers and program managers. Educational sessions were also observed.
Preliminary results show how stigma and social exclusion remain vivid, a source of distress for those who suffer from the disease. Many beliefs regarding the illness remain prevalent, still viewed by many patients as a curse or divine punishment despite the numerous education campaigns aimed at improving the understanding of the disease. Furthermore, treatment of leprosy and its reactions were discussed in-depth, and most importantly, the capital role of self-care to prevent disability. Different models of existing therapeutic education programs were analyzed. These were very well set up in the two specialized institutions visited, and limited in other health centers. Policy interviews with  program managers from three main NGOs involved in leprosy management were conducted jointly by the Swiss and Nepalese COHESION team members.
Before leaving the country, the joint team also paid a visit to the office of the Swiss Cooperation
Agency (SDC) and built a promising partnership with local officers. A brief policy interview on NCD
management was also performed with the WHO focal point of national Health Sector in Kathmandu.
A lot was done in little time. The main success was undeniably the opportunity to work together!

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.

r4d Mixed Methods Research Workshop

The Swiss Programme for Research on Global Issues for Development organized an r4d Skills Mixed Methods Research Workshop with Alicia O’Cathain, on integration and quality assessment. The full-day workshop took place in Bern on 28 October 2016 and congregated project leaders, project coordinators and Ph.D. students of r4d projects funded by the Programme, including COHESION.

Alicia O’Cathain is a Professor of Health Service Research, University of Sheffield, UK; and has published widely on mixed methods, mixed teams and randomized control trials. During the workshop, Dr. O’Cathain engaged participants in sessions covering definitions, rationales, designs, reporting, integration of qualitative and quantitative data, and assessing quality.

Four members of the COHESION team (Jorge Correia, Nathaly Aya Pastrana, Olivia Heller, Sarah Lachat) and one member of the project Advisory Board (Dr. Sigiriya Aebischer-Perone) participated in the workshop. Team members discussed and reflected on how to integrate and disseminate the findings of   data to be collected by the Project, balancing the insights obtained from qualitative methods with those from quantitative methods. Dr. Aebischer-Perone will share the reflections during the first Swiss COHESION Advisory Board meeting in Geneva on 21 November 2016.

To find more information about the workshop click here

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Selecting the NTD in Peru

“Selecting the NTD in Peru:
Engaging stakeholders in the difficult decision of selecting what underserved disease to prioritize”

The COHESION Project aims to address the double burden of disease that face health systems and communities by improving capacities at the national, local and community levels in three countries (Mozambique, Nepal and Peru). To assess the barriers that underserved communities face when accessing Primary Health Care (PHC) each country team selected a Neglected Tropical Disease (NTD) and two Non-communicable Diseases (NCDs) (diabetes and hypertension). These three diseases would be used as “tracer” conditions to understand the challenges of local health systems to effectively manage these diseases at the PHC level.

Why tracers? Because individuals with one or both, NTD or NCD, have the unique scenario of requiring chronic, engaging, meaningful, respectful and effective care. Both of these tracers, NTDs and NCDs, allow us a second chance to get it right, to redefine the user experience with our healthcare system.

In Mozambique, the selected NTD was Schistosomiasis, while the Nepalese team chose Leprosy. In Peru, we had initially selected Chagas but we felt we needed more information about the various NTDs with chronic sequels affecting people in Peru before making a final decision.

After several discussions with experts and internal conversations about the appropriateness of Chagas and other NTDs including Leprosy, Hydatidosis and Neurocysticercosis, we decided on Neurocysticercosis.

In this post, we share the reasons that lead us to this decision.

We first contacted an expert in Leprosy. We learned that it has not been fully eradicated in some regions in Peru, although the national prevalence rate is lower than 1 case x 10 000 inhabitants (Burstein, 2014). Leprosy still affects some small localities of the Amazon regions, where several geographical barriers and a dispersion settlement pattern predominate (Burstein, 2014). Addressing Leprosy is a challenge given the under diagnosis and other problems related with the epidemiological information systems for reporting of new cases.

Chagas disease affects over 8 million people in the Americas and about 190,000 persons with this disease live in Peru (Bayer et al., 2009). After different national and regional efforts in the nineties for the elimination of the Chagas vector (Triatoma infestans), the incidence of this disease was reduced. The main region affected in Peru is Arequipa, in the Southern Andes. As a result of efforts from different public and private institutions the vectorborne transmission of the disease has been significantly reduced and is now located in peri-urban shantytowns near the city of Arequipa as a response of urbanization processes and migration (Delgado et al., 2011). There is still work to do to eradicate Chagas, starting with the approval of a standardized protocol for the management of the disease and intensification of efforts in diagnosing people plus more thorough surveillance activities with special focus in shantytowns (Bayer et al., 2009). One reason that leads us to reconsider Chagas as the selected NTD is that symptoms may take about 20 years to develop and only few persons who have lesions show a recovery after pharmacological treatment. Additionally, the migration of the disease to peri-urban zone would leave us without the opportunity to explore the response of PHC for patients with NTD in rural area and to develop strategies to enhance the user experience with services provided by the PHC.

When exploring Hydatidosis and Cysticercosis, we learned that “controlling the parasitic infection in animals is crucial to reduce the incidence of human disease” (Otero-Abad & Torgerson, 2013). Both diseases are closely related with human behavior, for example with education about the transmission of the diseases and the prevention with hygiene actions. Currently, there is no vector control program for Hydatidosis in Peru. There was an effort for developing a program that included radio programs with educational messages and the empowerment of school teachers as providers of health and sanitary messages. However, control programs and educative activities were discontinued. Moreover, this disease is not notifiable in Peru, which makes it harder to know its current prevalence.

Finally, we looked into Neurocysticercosis (NCC), which is an “infection of the nervous system by the cystic larvae of Taenia solium” (Garcia, Nash, & Del Brutto, 2014) that frequently causes seizures and epilepsy. Worldwide, over 5 million cases of epilepsy are caused by Neurocysticercosis (Nash, Mahanty, & Garcia, 2013). Neurocysticercosis is especially endemic in areas characterized by poor water and sanitation systems and where pigs are not corralling with access to human feces (García, Gonzalez, Evans, & Gilman, 2003). In Peru, Neurocysticercosis affected approximately 35% of persons with active epilepsy, which is a very high rate comparable with Honduras and India. Only one out of every four patients with active epilepsy receive pharmacological treatment, but in sub-therapeutic doses (Moyano et al., 2014). It has been demonstrated that the transmission of Taenia solium was eliminated in 105 of 107 villages in Tumbes (region located in the north of the country) after an “attack phase” during one year that comprises people and pigs, and this result persisted over 1 year (Garcia et al., 2016; Maurice, 2014). However, there are still cases of NCC in the intervened region after several years of the implementation of the control program and there are other endemic regions affected by this disease in Peru.

The aforementioned efforts for the different NTDs and the pending actions for reaching the control of the diseases were the main topics discussed with different experts in the field. We were impressed with their high motivation, solidarity and expertise gained through the years. For example, there are strong research teams for the study of Chagas and Cysticercosis that have made relevant contributions like the risk mapping of the zones to inform surveillance system for Chagas or the massive intervention in persons and pigs from rural villages of northern Peru for blocking transmission of cysticercosis.

All experts agreed that whatever NTD we chose, we would be making a difference because they affect the most vulnerable.

Our decision about the selection of Neurocysticercosis for the purpose of the COHESION project was made considering to prioritize an NTD that generates a chronic condition that requires long-term treatment like epilepsy and affecting the poor of the poorest population in rural area, where PHC response is more relevant as the first point of entry for care. In so doing, by choosing NCC, together with an understanding of other major prevalent NCD conditions like diabetes and hypertension, will provide us with a second chance to get it right, to redefine the user experience within our healthcare system.

Acknowledgments: We thank César Náquira, Ricardo Castillo, Valerie Paz-Soldán, Aldo Lucchetti, Luz María Moyano, Ricardo Gamboa and H. Hugo García for their valuable time and insights about NTDs for the purpose of the COHESION project.

References:

Bayer, A. M., Hunter, G. C., Gilman, R. H., Carpio, J. G. C. del, Naquira, C., Bern, C., & Levy, M. Z. (2009). Chagas Disease, Migration and Community Settlement Patterns in Arequipa, Peru. PLOS Negl Trop Dis, 3(12), e567. http://doi.org/10.1371/journal.pntd.0000567

Burstein, Z. (2014). Critical appraisal about control programs and elimination of leprosy in Peru, and its consequences for Peru and America. Revista Peruana de Medicina Experimental Y Salud Pública, 31(2), 336–342.

Delgado, S., Neyra, R. C., Machaca, V. R. Q., Juárez, J. A., Chu, L. C., Verastegui, M. R., … Levy, M. Z. (2011). A History of Chagas Disease Transmission, Control, and Re-Emergence in Peri-Rural La Joya, Peru. PLOS Negl Trop Dis, 5(2), e970. http://doi.org/10.1371/journal.pntd.0000970

García, H. H., Gonzalez, A. E., Evans, C. A. W., & Gilman, R. H. (2003). Taenia solium cysticercosis. Lancet, 362(9383), 547–556. http://doi.org/10.1016/S0140-6736(03)14117-7

Garcia, H. H., Gonzalez, A. E., Tsang, V. C. W., O’Neal, S. E., Llanos-Zavalaga, F., Gonzalvez, G., … Gilman, R. H. (2016). Elimination of Taenia solium Transmission in Northern Peru. New England Journal of Medicine, 374(24), 2335–2344. http://doi.org/10.1056/NEJMoa1515520

Garcia, H. H., Nash, T. E., & Del Brutto, O. H. (2014). Clinical symptoms, diagnosis, and treatment of neurocysticercosis. The Lancet Neurology, 13(12), 1202–1215. http://doi.org/10.1016/S1474-4422(14)70094-8

Maurice, J. (2014). Of pigs and people—WHO prepares to battle cysticercosis. The Lancet, 384(9943), 571–572. http://doi.org/10.1016/S0140-6736(14)61353-2

Moyano, L. M., Saito, M., Montano, S. M., Gonzalvez, G., Olaya, S., Ayvar, V., … Peru, for T. C. W. G. in. (2014). Neurocysticercosis as a Cause of Epilepsy and Seizures in Two Community-Based Studies in a Cysticercosis-Endemic Region in Peru. PLOS Negl Trop Dis, 8(2), e2692. http://doi.org/10.1371/journal.pntd.0002692

Nash, T. E., Mahanty, S., & Garcia, H. H. (2013). Neurocysticercosis—More Than a Neglected Disease. PLOS Negl Trop Dis, 7(4), e1964. http://doi.org/10.1371/journal.pntd.0001964

Otero-Abad, B., & Torgerson, P. R. (2013). A Systematic Review of the Epidemiology of Echinococcosis in Domestic and Wild Animals. PLOS Negl Trop Dis, 7(6), e2249. http://doi.org/10.1371/journal.pntd.0002249