Development of an integrated, holistic care package for people with lymphoedema for use at the level of the Primary Health Care Unit in Ethiopia.

BACKGROUND: Neglected Tropical Diseases (NTDs) are a group of several communicable and non-communicable diseases prevalent in tropical and subtropical areas. The co-endemicity of these diseases, the similarity of their clinical signs, and the need to maximize limited financial and human resources suggest the importance of adoptingan integratedapproach to their prevention and treatment. AIMS: This study describes the development of a comprehensive package of physical, mental health and psychosocial care for people with lower-limb lymphoedema caused bypodoconiosis, lymphatic filariasis (LF)or leprosy as part of the EnDPoINT program in Ethiopia. METHOD: The care package was developed using a mixed-methods approach, consisting of a literature review, situational analysis, Theory of Change (ToC) workshops, qualitative research, and additional workshops to fine-tune the draft care package. The care package was developed between March 2018 and January 2020 in Addis Ababa and the implementation research site, Awi zone in the North-West of Ethiopia. RESULTS: The holistic care package includes components implemented at three levels of the health care system:health organization, facility, and community. Sections of the care package are directed at strengthening capacity building, program management, community engagement, awareness-raising, stigma-reduction, morbidity management, disability prevention, follow-up visits, referral linkage, community-based rehabilitation, and monitoring and evaluation. CONCLUSIONS: The study developed a holistic integrated care package for lower limb disorder and co-morbid mental health problems caused by podoconiosis, LF or leprosy. The approach has the potential to significantly reduce lower limb disorder-associated morbidity, disability, and psychosocial problems. It also standardizes a scalable approach appropriate for the Ethiopian setting and, most likely, other countries where these NTDs are present.

Sustainability of integrated leprosy services in rural India: perceptions of community leaders in Uttar Pradesh.

As part of a community-based action research to reduce leprosy stigma, village committees were formed in 3 hyper endemic states of India. From a total of 10 village committees with nearly 200 members from Uttar Pradesh, a systematic random sample of 69 men and 23 women were interviewed in-depth regarding their views on sustainability of integrated leprosy services, as currently adopted. Their recommendations were also sought for further enhancement. Percentages were computed and compared for statistical significance using the z-normal test. The findings show that less than 50% of the respondents were confident that the present trend in voluntary early reporting for MDT and management of complications was adequate to sustain the integrated leprosy services. There were no differences by men or women members and they felt that lack of proper facilities, training and orientation of staff are most influencing factors. Many suggestions were given for improving the sustainability.

Public awareness on integration of leprosy services at primary health centres in Uttar Pradesh, India.

Leprosy services were integrated into the general health a decade ago but it seems that a majority of public are still ignorant of this development. Hence, a study was done in Uttar Pradesh, India to determine the awareness about integration and its relationships to various socio-demographic factors. A multistage representative random sample of 3000 persons was chosen in Faizabad district, selecting a sample of 3 villages each situated within 1 km, 1-3 km and beyond 3 km of a PHC. A systematic random sample of 10% of households was chosen from selected villages and an adult male and an adult female from each household interviewed by a qualified investigator. Data were computerized and cross- tabulated against distance from the PHC, sex, age, education and occupational status. Only 45.7% in Uttar Pradesh are aware of the availability of leprosy treatment facilities at PHC but most knew that MDT was free. A smaller proportion was also aware of other facilities such as ulcer dressing and treatment of complications. Family members and health workers and PHC were the main source of information. It is concluded that massive efforts are urgently needed to educate the rural public on integration.

Integration of leprosy in general health system vis-à-vis leprosy endemicity, health situation and socioeconomic development: observations from Chhattisgarh & Kerala.

This study looked at the integration of leprosy services in the GHS in context of health and socioeconomic situations using predefined indicators. It also looked at clients' perception of MDT services. The Indian states of Chhattisgarh and Kerala, which are at two extremes in leprosy endemicity, health situation and socioeconomic development, have been compared using predefined integration indicators related to the training of health workers, availability of MDT services, maintenance of MDT stock and involvement of Sub-centres in leprosy care. Data was collected by surveys of health facilities, sub-centres and communities in the two states, during 2006-2007. Information was collected by interviewing health personnel and clients, checking of records and on the spot observations using specifically designed formats. Results showed that integration is more inclusive in Chhattisgarh and has reached up to Sub-centre level. Both the community and health systems are sensitive and responsive to leprosy as it is perceived to be a major public health threat. But in Kerala, despite integration, it continues as a vertical programme with dependence on specialists and districts hospitals for diagnosis and treatment. MDT stock management is even poorer. Clients' perception towards MDT services are similar in both states.

Integration of leprosy into GHS in India: a follow up study (2006-2007).

In India leprosy services, were integrated into the General Health Services (GHS), in a phased manner, in different provinces, from 2001 to 2004. This study reports the findings from a follow-up operational research undertaken in 2006-2007, to assess the level of integration, on predetermined indicators related to: referral services, training of health functionaries, availability of diagnosis, treatment, MDT dispersal and counselling guidelines in health facilities, recording and reporting by GHS staff, MDT stock management and involvement of health sub-centres in different Indian provinces. Nine provinces, 18 districts, 88 health facilities and 108 sub-centres were selected, by using multistage stratified random sampling techniques. Reverse integration, as reflected by the training and deployment of vertical staff in GHS, was also assessed. Data was collected by medical officers experienced in leprosy, with the assistance of state health functionaries, and recorded on separate schedules for health facility and sub-centre levels. The study also touched on the issue of client perception towards MDT services by interviewing 149 under treatment/cured leprosy cases (who had completed treatment within the last year), in the community with the help of local interpreters. Results showed wide variations across the selected provinces in various parameters. District leprosy nuclei were understaffed in 12(66.7%) districts, and district hospitals were not working as referral institutions anywhere. The training status of medical officers and multi-purpose workers in leprosy was low in Andhra Pradesh (6.9 and 22.4%), Madhya Pradesh (26.3 and 14.5%), Rajasthan (19.7 and 40.9%) and Kerala (25.5 and 65.7%). MDT stock availability as per the National Leprosy Eradication Programme (NLEP) guidelines was not adequate in all provinces. Availability of patient counseling guidelines was nil/low in Kerala, Karnataka, West Bengal, Orissa, Rajasthan and Andhra Pradesh. The involvement of sub-centres, in case referral, recording and dispensing MDT was nil Kerala and Rajasthan and poor in Andhra Pradesh. Ninety percent of clients in Kerala and 38.0% in Andhra Pradesh and Madhya Pradesh did not get MDT in the nearest health facilities or sub-centres.

Integration of leprosy elimination into primary health care in orissa, India.

BACKGROUND: Leprosy was eliminated as a public health problem (<1 case per 10,000) in India by December 2005. With this target in sight the need for a separate vertical programme was diminished. The second phase of the National Leprosy Eradication Programme was therefore initiated: decentralisation of the vertical programme, integration of leprosy services into the primary health care (PHC) system and development of a surveillance system to monitor programme performance. METHODOLOGY/PRINCIPAL FINDINGS: To study the process of integration a qualitative analysis of issues and perceptions of patients and providers, and a review of leprosy records and registers to evaluate programme performance was carried out in the state of Orissa, India. Program performance indicators such as a low mean defaulter rate of 3.83% and a low-misdiagnosis rate of 4.45% demonstrated no detrimental effect of integration on program success. PHC staff were generally found to be highly knowledgeable of diagnosis and management of leprosy cases due to frequent training and a support network of leprosy experts. However in urban hospitals district-level leprosy experts had assumed leprosy activities. The aim was to aid busy PHC staff but it also compromised their leprosy knowledge and management capacity. Inadequate monitoring of a policy of 'new case validation,' in which MDT was not initiated until primary diagnosis had been verified by a leprosy expert, may have led to approximately 26% of suspect cases awaiting confirmation of diagnosis 1-8 months after their initial PHC visit. CONCLUSIONS/SIGNIFICANCE: This study highlights the need for effective monitoring and evaluation of the integration process. Inadequate monitoring could lead to a reduction in early diagnosis, a delay in initiation of MDT and an increase in disability rates. This in turn could reverse some of the programme's achievements. These findings may help Andhra Pradesh and other states in India to improve their integration process and may also have implications for other disease elimination programmes such as polio and guinea worm (dracunculiasis) as they move closer to their elimination goals.

Impact of integration on the profile of newly diagnosed leprosy patients attending a referral hospital in South India.

This article compares the clinical profile of new untreated leprosy patients attending a referral hospital (The Schieffelin Institute for Health Research & Leprosy Centre, formerly known as SLR&TC, Karigiri, South India, in post-integration period (2005-2007) with that during the pre-integration period (1995-1996). A total of 529 patients--259 in pre-integration and 270 in post-integration period--were seen at this hospital. The clinical data culled from records for the earlier period were compared with data gathered prospectively for the latter period and was analyzed using SPSS software. The results showed a significant increase in the mean age of registration, percent multibacillary (clinical criteria) and grade 2 diabilities in post-integration period. Increase in proportion of cases with grade 2 deformities is a matter of concern and suggests continued need for referral hospitals for their management and also population based overall assessment whether actual numbers with deformities have increased or it is peculiar to a tertiary care hospital where the cases with problems may be coming. As the proportion of bacteriological positive cases was not found to change, it is a positive sign of effective coverage in the post-integration scenario in this population.

A descriptive study of MDT services in Chhattisgarh.

INTRODUCTION: The study was conducted to ascertain the registration status, time lag and reasons for non/delayed registration, pattern and sources of MDT, among new cases of leprosy, initially reporting to a tertiary level institution and subsequently referred after diagnosis, to Primary Care institutions. METHODOLOGY: All new cases referred from RLTRI, Raipur to three adjoining blocks between Nov. 2005 and Oct. 2006 were listed and followed at monthly interval at the PHC/CHC, Sub center and household levels, from 2 to 6 months after RLTRI visit. RESULTS: A total of 371 cases were referred, of which 326 (87.9%) could be traced. The level of PHC/ CHC registration of cases, which was 58.0% after 2 months, rose to 80.4% after 6 months of follow up. 82.9% of the registered cases collected subsequent doses of MDT from the nearest Sub center or PHC. Main reason for non/ delayed registration were delay in reporting from patient side (30.7%), non availability of MDT at PHC (24.1%), non-availability of concerned staff (7.3%) and other operational problems (38.0%). CONCLUSION: The study highlights the need to strengthen the "MDT Services" through monitoring and supervision of leprosy activities delivered by General Health Services in post integration phase.

Leprosy control activities in India: integration into general health system.

Integration of leprosy control into the general health system is an essential element of a leprosy elimination strategy. In India, the process has been undertaken with the assistance of World Bank in a phased manner. In the first phase (2001-2002), 24 low/moderately endemic provinces for leprosy were targeted. Operational research was undertaken in these low/moderate endemic provinces to assess the progress of integration of leprosy control in general health system using defined categories, viz. structural integration, training status, availability of MDT and recording/reporting of cases. Selection of nine provinces, 18 districts, 86 health facilities and 108 sub-centres was performed using multistage stratified random sampling technique. Data were collected by interviewing GHS/vertical staff, scrutiny of records and spot checking of MDT stock by Health officers of three leprosy institutions of the Government of India. The result showed that district leprosy nuclei had formed in 16 of 18 districts. In 56% of health facilities vertical staff were redeployed for delivering general health care. Forty-five percent of medical officers, 71% of health supervisors and 75% of multipurpose workers were trained in leprosy. MDT treatment was available in >80% of health facilities. In only 2% of health facilities 3 months MDT stock of all types was present. Forty-four percent of sub-centres were delivering subsequent doses (second dose onward) of MDT. Reporting through a simplified information system was universal. This study emphasizes the need for reorientation training of Medical Officers, better MDT stock management and decentralized management of cases up to sub-centre level.

Inter-state variations in integration of leprosy services into general health system in low/ moderately endemic states of India.

The objective of the study was to analyse inter-state variations in integration of leprosy services into the general health system, covering broad categories of structure integration, training of health functionaries, availability of MDT services and record maintenance, in 24 low/moderately endemic states. Multi-stage random sampling technique was used to select 9 states, 86 health facilities (including district hospitals, community health centres, primary health centres) and 108 sub-centres. Information from each level was collected on a pre-tested form by officers of three leprosy institutions of the Government of India. The results showed wide inter-state variations on each aspect. Redeployment of vertical staff was complete (100%) in Tamil Nadu and Tripura. Assam reported a higher level of training (97%) of medical officers in leprosy. Training of health supervisors and multipurpose workers was better than that of medical officers in most of the states. Tripura reported negligible training of all the health functionaries because of specific local problems. In Assam, Maharashtra and Sikkim, all the urban and rural health facilities were providing MDT. Three months' stock of all types of MDT blister packs was available only in one health facility in Andhra Pradesh and in Goa. Assam and Haryana had lower availability of MDT stocks. In Assam and Maharashtra, medical officers in all health facilities were diagnosing and treating leprosy cases, as compared with Himachal Pradesh where the value was 30%. Involvement of sub-centres in MDT delivery was more at 92% and 100% in Tamil Nadu and Maharashtra respectively in comparison to none in Himachal Pradesh and Tripura. Use of the Simplified Information System (SIS) 2002 guidelines and formats was universal. However, lower involvement of GHS staff in recording and reporting was noted in Assam (0%), Andhra Pradesh (10% and 30%). The study emphasized the need for further tailor-made follow-up studies to suit local problems.

Leprosy Referral Centre: an intervention critical to sustain elimination and support integration.

LRC (Leprosy Referral Centre) centered activities are aimed to augment the services for leprosy affected persons by involving the GHC system to sustain leprosy elimination activities during integration phase. The LRC activities are focused to promote the integration of MDT services within the general health services, strengthening surveillance and monitoring at the local level, supporting special surveys among specific groups of population, enhancing community participation and social communication to increase awareness, entwined with capacity building of the GHC personnel, promotion of prevention of disabilities and rehabilitation activities.

Integration of leprosy control into general health care system: observations from a state with low endemicity.

The study was undertaken as part of operational research to assess the level of integration of leprosy services into general health care system in 24 low or moderately endemic states/union territories by the Ministry of Health and Family Welfare, Government of India. Himachal Pradesh was one of the nine randomly selected states for the study. Out of the 12 districts in the State, 2 were selected randomly for the study. In each of the selected districts, 8 health facilities (that included a district hospital, an urban hospital/urban health centre, an Employees' State Insurance Hospital, a community health centre and a primary health centre) and 9 sub-centres were surveyed. Selection was done randomly at each stage. Data were collected on training in leprosy of general health care staff, availability of drugs for MDT in the system and maintenance of leprosy records by the staff of the system. The study showed mixed results. About half (53.2%) of the existing medical officers, 83.9% of health supervisors and 96.8% of multi-purpose workers were trained in leprosy. But only 31.3% of medical officers were able to diagnose leprosy and most of them were relying on vertical staff and skin specialists for confirmation. MDT services were provided by 20% of rural and 66.7% of urban health facilities that were acting as treatment centres. None of the health facilities had 3 months' stock of all types of blister packs, as per the guidelines of the Government of India. None of the sub-centres was involved in MDT delivery. However, reporting as per SIS formats was universal. The study emphasized the need for training and better management of MDT drug stock.