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![Page 1: IMPROVING MANAGEMENT IN EPILEPSY Community based management program in Morang District, Nepal, involving Village Health Worker.](https://reader036.fdocuments.us/reader036/viewer/2022062718/56649e665503460f94b60b7c/html5/thumbnails/1.jpg)
IMPROVING MANAGEMENT IN EPILEPSY
Community based mana gement program
in Morang District, Nepal,
involving Village HealthWorker.
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Why is epilepsy a public health concern
in Nepal ?• Not much of hard data but reported prevalen -ce are:
– - 10 15 per thousand (Text books)– - 42 222. . per thousand in different India
n nnnnnnn– 7per thousand in Morang district (program
area)• Sociallydebi l i tati ngi l l ness wi thwhol e fami l y suff
.• nnnnnn nnnnnnnnnnn nnnnn nnnnnnn.• nn nnnnnnn nnnnn,3/ 4 .• nnnnn nn nnnnnnnn nnnnnnnnnn.
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Why did I choose it ?
•Low cost community based program is feasible
•My field of interest•Easy and effective entry
point for introduction of general mental health.
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Problem statement.
People suffering from e pilepsy in Morang distri
ct of Nepal are not utilizi ng the health services f
or treatment.
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Number of patients actuall y under treatment
(so 1998urce: Annual Report, Mental Health Project, )
0500
1000
1500
20002500
3000
3500
40004500
1995 1996 1997 1998
Cases under treatment
Developing country standard
Expected cases
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What is the root cause ? Causal web
Negativeadvoc ac y byT raditional
Healers
Negativepublic
attitude
G ovt. P o l ic y
Poverty
C aretak erunable to
bring
C aretak erunw il l ingto bring
C aretak erunaw arethat i t is
i l lnes s
M isc onc ept ion
L ac k of fa ithin
H ealthc aresys tem Number of
patients w ithepilepsy
attendinghealth post is
low
Ignoranc e aboutillness
P oorhealthservic e(misdiagnosis ,
treatment failure)
fi nanc ia l &manpow erc ons tra ints
P t tak en to T H
T H does notrefer
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What influences utilization ? Conceptual Framework
OC C U RANC E OFE PILE PSY
Nonbehavioural
c auses
Behaviouralc auses
Perc eived needfor c are
Non use ofhealth servic es
U se of health servic e
Predisposingfac tors
E nablingfac tors
FU LLRE C OVE RY
T reatmentfailure
Healthservic efac tor
Patientfac tor
C ONSE QU E NC E S
Reinforc ingfac tors
Adaptation of Determinants of health servic e utilization to explain the dynamic saff ec ting c are of epileptic s in the c ommunity (Anderson & New man 1973)
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What could be done to improve the situation ?• - Increase community awareness informati
on flooding• Desensitization of the community• Increment of social pressure• Involvement of the community• Involvement of other healing systems of th
e community• Strengthening the health delivery system :
Involvement of VHW.• Development of support system for the pati
ent and family
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What do I want to do ?
Empowerment and mobi lization of village health worker in the use of phe
nobarbitone to bring ab out better coverage and
quality care of epileptic s in Kerabari Health Pos
t of Morang District.
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Operational Definitions• Empowerment: ‘to give power to’. The
VHWs will be given some curative role und er supervision.
• Mobilization: ‘encouragement to take ac tion.’ VHWs will be more involved in active- case finding.
• Quality care: adherence to protocol leadi ng to better control of fits.
• Phenobarbitone: cheap, available at he alth post, present in essential drug list.
• Better coverage: increase in the % of ca ses under treatment out of total number of
cases identified.
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General objectives
• Improve health care in relati on to epilepsy.
• Increase community awareness.
• Reduce misconceptions.• Reduce taboo attached to th
e illness in the community.
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Health Postattendenc e
Progressnormally
Relapse
Periodic HPvis it
Rec overy
VHW attemptsto handle it
Suc c essful
U nsuc c essfulReferal bac k to
health post
Patientbec omes
sic k
H ow can V H W 's bring about change ?D iff er ent r oles of V H WNot brought
for treatment
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Specific Objectives
•To increase coverage.•To provide quality care.•To minimize defaulter rate.• Increase Quality of Life of
patients.
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Health post A(intervention)
B asel ineassessment
S ec ondassessment
F inalassessment
day1 12 month 18 month
Health post B(no intervention)
ST U D Y D E SI G N (Q uasi exper im ental)
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Study site• District : Morang (in eastern Nepal
)• Health post: Kerabari• Population coverage: 23,687• Manpower:
– -- Health Assistant 1– -- Community Medical Auxiliary 2– --1ANM– -- VHW 6
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How to implement it ? Strategy of implementation
•Horizontally integrated at the level of District Public Health Office.
•Ultimate service providers are DPHO staff.
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Components of training
•Methods of case finding•Screening criteria• Methods of treatment•When to refer•Counseling techniques•Communication skills
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Pre training preparations
• Curriculum design.• Formation of screening guidelines.• Formulation of diagnostic
guidelines and treatment protocol.• Development of T/L materials
– flip chart– brochure– reading material for trainer
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Human Resource & Technical Requirements•Trainer - Health assistant of the
health post and master trainer from DPHO.
•Supervisor / coordinator - to be borrowed from DPHO
•Data collectors (to be hired)•Audio visual equipment - (to be
hired)
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Information & Recording
• History sheet• Continuation
sheet• Referral slip• QOL
questionnaire• Monthly
reporting form
• Information from the health post collected at the DPHO.
• Local data-base maintained by supervisor.
• A copy of information from the DPHO sent to central data-base.
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Evaluation & Expected Outcome
• PROCESS– -- KAP of VHWs fluctuates with net rise
• OUTCOME– % of adherence to protocol– % of coverage– - Change in QOL of patients QOL score
gets better– - Seizure response about 1/3 of patients
6symptom free from months onwards
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Budget• VHW training 6,000• VHW refresher 7,000• Material development 25,000• Seed money for CDP 1,000• transportation 18,000• Salary 45,000• Contingency 8,000• TOTAL RS. 110,000
( $ 1692)
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Activity plan of proposed studyYear /Month (N- November,)
1999 2000 2001N D J F M A M J J A S O N D J F M A
Meeting withDPHOPreparationof materialTraining ofVHWRefreshertrainingEvaluationK AP & Pt.loadEvaluationQOL 1EvaluationQOL 2
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What is the motivation for VHW ?
Intrinsic factor
Change of role from health education to ‘medicine giving’ role which has higher status . in the community.
Extrinsic factorCarrying bagRepeated refresher
training
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Ethical issues
•Right of a person to choose –to be or not to be treated–choice of treatment
• If patient prefers other medication, he will be referred to district headquarters
•Poor patients -- DPHO rules prevails
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Sustainability
• DPHO manpower is trained• Technical support is
institutionalized with Dept of Psychiatry
• Practically no running cost
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Anticipated hurdles
• Working with Government System i s a slow process.
• Stigmatized illness: so the denial (n ormal) of the patient as to the exist
ence of the condition may be a problem.
• Traditional healer community may t urn against the program.
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Supportive Activities
• AIMS• increase
community awareness
• decrease misconceptions
• decrease taboo
• ACTIVITIES• training for communit
y leaders• training for other leve
ls i.e. FCHV’s, TBA’s.• training for traditiona
l healers• training for school tea
chers• felicitation of commu
nity meetings
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Data exercise
A cross sectional survey of
Quality of Life of patients with
epilepsy
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Objectives (data exercise)
• General Objective–Test the ‘DUKE Health Profile’ in patients and normal population
• Specific objectives–To access the QOL of epileptic patients
–To access the QOL of normal population.
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Duke Health Profile
• 17 point Questionnaire to be used i nnnnnnn nnnn nnnnnnnn.
• - nnnnnnn nnnnnnnn nnnnnnnnn nnnnnn n6 ,, , , nnnn nnnnnnn.
• - 5 ,dysfunction scores Anxiety Depre -nnnnnnnnnnn, , , .
• nnnnnnnnnnn & Validity tested in western population.
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Sample selection,size and technique
• 30Purposive sampling, in each group.• Patient population: ccccccccccc cccccccc cccccccc
ccccccccc c cc cc ccccc c cccccccc.– Inclusion:
๏ - onset of illness between 5 30 years.
• ๏ duration of illness more than 6 months
– exclusion: ๏ severely ill.
• ๏ Patients who did not give cons ent.
• Normal population: Staff of Adm. Section,CPH.
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Findings
• 13/ of sample in both groups were midliners.
• nnn n nnn n n n nnnnn n nn nnn nn nn nnnn nn population than optimum.
• The mean QOL score was lower in patien ts than in normal.
• n nn nnnn nn nnnnnnnn nnnnnnnnnnn n nnn nnn six domains of QOL.
• Anxiety and depression showed negativ e correlation with all domains.
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QOL score in different domains of health
0
20
40
60
80
100
Physica
l
Menta
l
Socia
l
General
Perceiv
ed
Self e
steem
Mean
score
NormalPatient
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Correlation between QOL scores in the different
domains among themselves in both groupsDomain A B C D E F G
Physical NP
1.0001.000
.263
.510**.395*.303**
.856**
.783**.543**.494**
.331
.467*-.465**-.449**
Mental NP
.263
.510**1.0001.000
.095
.439*.596**.851**
.303
.465*.558**.787**
-.212-.186
Soc ial NP
.395*
.303.095.439*
1.0001.000
.651**
.709**.118.259
.465**
.771**-.298-.221
General NP
.856**
.783**.596**.851**
.651**
.709**1.0001.000
.493**
.527**.598**.856**
-.477**-.363
Perceived NP
.543**
.494**.303.456*
.118
.259*.493**.527**
1.0001.000
.354
.352-.416*-.099
Self esteem NP
.331
.467*.558**.787**
.465**
.771**.598**.856**
.354
.3521.0001.000
-.451*-.267
AGE NP
-.465**-.449*
-.212-.186
-.298-.221
-.477**-.363
-.416*-.099
-.451*--.267
1.0001.000
** Correlation issignificant at ae 0.01level
* Correlation issignificant at the 0.05level
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Limitations & lessons learned
• Limitations• Sample size: small and
nonrandomized so cannot generalize findings.
• Two groups not identical: so cannot ‘compare’
• Lessons learned• Questions have to be reevaluated
in the cultural context.• Time management.