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An oft-cited solution gets its value measured
In developing countries, TB and AIDS epidemics have outrun the capacities of existing health infrastructures. Programs often turn to outreach workers recruited from the community to plug the hole in the dike. It sounds good — community workers, after all, live close by, work for a pittance, and don’t need much training — but just how effective are they? In which kinds of situations do they work best?
To find some answers, the World Health Organization (WHO) launched a multinational study of "community involvement" sites scattered across the sub-Saharan region of Africa. The study is designed so that each intervention can be compared to a control project also under way.
The project is now in its third year. Soon, researchers will draw on their findings to develop training materials, says Mukadi Ya Diul, MD, project director and a member of the Operations and Epidemiological Research Unit of the Commun icable Disease Cluster at the WHO.
Although the project’s primary aim is to evaluate the usefulness of various community-based interventions, collaborators are hoping to find some community-based solutions to the problems that inspired the study.
"When we started this project, it was because we’d been having trouble as we began implementing directly observed therapy, short-course [DOTS]," says Mukadi. Despite TB program’s best efforts, DOTS programs often weren’t performing up to snuff. Cure rates stayed in the basement, and default rates were depressingly high in some places, he says.
Evidently, some patients default because they don’t like being forced to stay in the hospital for two months (customary for the initial phase of therapy in many parts of the region). In other instances, patients simply can’t travel long distances to inaccessible clinics. Still other reports cite complaints about overbearing DOT workers. At the same time, often there’s a disconnect between HIV and TB programs. This means that TB clinics often are filled with patients with AIDS who aren’t receiving treatment for it, and AIDS home care workers visit patients whose biggest problem is actually TB.
"The AIDS home health workers knew virtually nothing about TB, even though most of their patients had the disease," says Mukadi. Yet here was a good structure with strong patient linkages. Why not use it for TB?
Countries taking part in the study are all burdened with high rates of HIV, and each country was allowed to design its own intervention, accompanied by a control project, he adds. All told, there are eight projects.
One in a semi-urban region of Botswana uses HIV home care providers to observe TB therapy. A project in an urban area of Kenya piggybacks onto what’s called village development committees, a system that dates back to 1986, says Mukadi. Committee members’ jobs are to monitor various aspects of village health; for example, they keep track of how many children are born and who is sick with what illness. The committee members also are allowed to sell medications out of their houses, acting as a rural dispensary. "These people were given TB drugs to provide out of the homes — but for free," says Mukadi. District health officers check to make sure the drugs are being distributed properly and free of charge; and observation of treatment takes place.
A project in Malawi employs a hospital "guard ian," the person customarily assigned to care for a patient who is hospitalized, to monitor treatment for TB in the community. One project in rural Uganda takes advantage of village development committees by having a health officer notify them when a TB patient is about to be released to the community. The committee assigns someone to monitor that patient’s therapy. A second Uganda project, this one in an urban area, takes people from The AIDS Service Organization (TASO), which provides home care to AIDS patients. TASO workers are trained to care for TB victims as well. Here, trouble arose, notes Mukadi, because most TB patients dislike being associated with TASO, since AIDS bears such a strong stigma.
A project in South Africa solicits and trains traditional healers in the rudiments of TB and then uses them to provide direct observation. To find healers, directors used a doctoral candidate who was doing his thesis on the healers. In a Zambian project, volunteers trained by Catholic Church workers already provide AIDS care to the homebound. Now they are being trained to provide TB care as well.