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Community participation in the eradication of guinea worm disease
Acta Tropica, 61 (1996) 121-136 © 1996 Elsevier Science B.V. All rights reserved 0001-706X/96/$15.00
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ACTROP 00489
Community participation in the eradication of guinea worm disease S a n d y C a i r n c r o s s a,,, E k a I. B r a i d e b, S a m Z. B u g r i c a Dept. ofEpidemiology & Population Sciences, London School of Hygiene & Tropical Medicine, Keppel Street, London WCI E 7HT, UK b Nigeria Guinea Worm Eradication Programme, Southeast Zone, 16 Ibom Layout, Calabar, Nigeria c Ghana Guinea Worm Eradication Programme, Ministry of Health, Private Mail Bag, International Airport, Accra, Ghana (Accepted 25 April 1995)
As Guinea worm eradication programmes have got under way in endemic countries over the last decade, there has been a shift towards more participatory methods. The approach to surveillance has changed from periodic cross-sectional surveys to monthly village-based reporting of cases by a volunteer village health worker. At the same time, the emphasis regarding control interventions has moved from the provision of safe water supplies to health education. The new approach has proved very effective. The village health volunteers who carry out both surveillance and health education seem to be motivated largely by the social status of their role; still more commitment will be required of them in the final stages of eradication. It is to be hoped that the networks of village health workers established for Guinea worm eradication will find a useful role in health promotion after the worms have gone. Key words: Guinea worm; Dracunculiasis; Eradication; Surveillance; Health education; Community participation
I. Introduction Guinea worm disease (dracunculiasis) currently affects twenty countries, all but three of which are in Africa (Fig. 1, Map). It kills few people but causes debilitating pain, usually in the planting or weeding season, and so can have far-reaching economic effects by reducing the ability to work of most of the population. It is the only disease which is exclusively transmitted in drinking water. The mature female worm, about 0.5 m long, lies under the skin and creates a painful or irritating blister, usually on the leg. When this blister is immersed in water or when water is splashed onto it, as is often done to soothe the irritation, the worm releases thousands of microscopic larvae. If the larvae are washed into a pond or shallow well, they are eaten by tiny crustaceans, known as cyclopoids, and develop inside these new hosts. The cyclopoids are only 0.8 mm long, and so are easily consumed inadvertently in water from a contaminated pond or well. Although the cyclopoids themselves are not dangerous to drink, any Dracunculus larvae they contain will develop further in the human host and any fertilised female worm will *Corresponding author. Tel.: (+44) 71 636-8636. fax: (+44) 71 636-7843. SSDI 0 0 0 1 - 7 0 6 X ( 9 5 ) 0 0 1 0 6 - 9
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Fig. 1. Geographical distribution of Guinea worm, Dracunculus medinensis. The shaded areas are those in which the disease was reported or probably existed in 1991. Since then, it has been eliminated from Pakistan, and a few cases found in Northern Yemen. (WHO Collaborating Center for Research, Training, and Eradication of Dracunculiasis, Atlanta).
make her way to the legs and form a new blister a year later, ready to start a new cycle. Several aspects of Guinea worm disease make it a suitable candidate for eradication. The disease only affects man, so that there is no reservoir in animals. The parasite does not live beyond its one-year transmission cycle, so that there are no long-term carriers. The disease is readily diagnosed, and cases can easily be prevented from passing the disease on to others. Moreover, it does not have a vector which can fly about, transmitting infection over long distances. Interest in the eradication of Guinea worm disease increased during the International Water Decade, and in 1991, the World Health Assembly declared its resolve to eradicate the disease by 1995. One by one, the endemic countries have mounted national searches for cases in recent years, and these have been followed by the establishment in each country of a national eradication programme. A number of international agencies, including UNICEF, W H O and the Carter Center, have supported this activity. The main preventive interventions are: - provision of safe water supply, health education to individuals and to the community at large, distribution of cloth filters, organisation of support (and possibly sanctions) to ensure that cases avoid contact with ponds, -
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123 simple treatment of cases by immersion of lesions in water and application of bandages, and - treatment of ponds with an insecticide non-toxic to man, to kill the intermediate host. All but the first and last of these interventions can be implemented at village level; indeed they are probably best done by villagers within their own village, and particularly by a trained village health worker (VHW). The surveillance which is an essential part of any eradication campaign is also a task for which the VHW is well suited. While Guinea worm eradication has paid lip service to community participation from the start, there has been an increasing awareness of the greater effectiveness of surveillance and prevention when performed by members of the community, and a gradual shift towards more participatory approaches to both surveillance and intervention for Guinea worm eradication. The role of the VHW is crucial to both of these activities.
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2. T h e role o f the village h e a l t h w o r k e r
In some countries, such as Burkina Faso, an existing network of VHWs was mobilised, and the village volunteers brought together for training by local health staff in the additional tasks of Guinea worm surveillance and prevention. In other cases, as in those villages in Uganda where village health workers did not previously exist, the Guinea worm workers have been selected with a view to subsequently re-training them in other aspects of health care so that the Guinea worm eradication programme can open the way to a strengthened primary health care system. In almost every endemic country, the VHWs who form the backbone of the eradication programme have been chosen by their communities, though the criteria of choice may vary. In Nigeria, they are required to be literate, in order to be able to complete their surveillance returns; this has sometimes led to the appointment of "village-based health workers" who are not in fact resident in the village but in a nearby town, and who write down information received from an illiterate villager, often a relative. In other countries, such as Niger and Mauritania, most of the VHWs are illiterate; they manage with special surveillance forms, on which cases can be recorded as tally marks in spaces denoted by illustrations. Other information, such as the names of cases, can be added in writing either by a friend or by the VHW's supervisor during monthly visits. In Ghana, it was found that illiterate VHWs were as reliable as literate ones (Bugri et al., 1992). Relaxing the literacy requirement makes it possible to recruit women as VHWs. While many programme administrators do not think it possible to do this in a traditional, often islamic community, experience suggests otherwise. For example in Mauritania, where 80% of the VHWs are women, it was found that women, particularly married women, performed more reliably in this role than men. They were less likely to be motivated by ambition or the hope of material rewards, and less likely to leave their village. In some countries, such as Burkina Faso, both a man and a woman have been trained in each village. Gender is not the only important factor in the selection of a VHW; in Ghana's Northern Region, Bugri et al., (1992) found that a second VHW was needed in villages inhabited by more than one ethnic group. The ethnic unrest which flared
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up in that region in early 1994, and similar tensions found in some parts of other countries, have underlined the need for sensitivity to ethnic differences. In Mauritania, dracunculiasis is more prevalent among the so-called "Maures noirs", who are less likely to have access to safe water than the rest of the population. In other parts of the Sahel, cases are often to be found in temporary settlements of the Fulani or Bella people on the periphery of the main village (and therefore far from the village borehole), and these may be missed if the only VHW is from another group. Where specialised Guinea worm volunteers have been selected and trained, attempts are often made to integrate their activity with existing initiatives at village level; for example, the village workers in Crte d'Ivoire are ex officio members of their village's water supply maintenance committee, and in Mali they participate in the village hygiene and sanitation committee. They can then count on the assistance of the other committee members in the early detection of cases, the dissemination of health education messages, and so on. It has also been found that VHWs can be more effective when they are organised in an association (Brieger et al., 1989). In one area in Togo, the village health workers formed an association on their own initiative (Sylla Awani, 1994). This enabled them to strengthen their activities in a number of ways: organising a theatre group to tour the area, giving mutual support at the public health education meetings they organise in their respective villages, - detecting those VHWs whose performance is poor, offering assistance by the literate members to their illiterate colleagues in completing their surveillance returns, and promoting exchange of information and ideas between villages, and between the VHWs and the management of the programme. While the details of their rrle vary from one country to another, the principal tasks of a VHW in Guinea worm eradication have been surveillance and prevention, the latter chiefly through health education. These are now discussed in turn. -
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S u r v e i l l a n c e
Any eradication programme depends essentially on efficient surveillance; one cannot be sure that all cases have been eliminated unless one is also sure that all cases can be detected (Richards and Hopkins, 1989). However, cases of Guinea worm disease are rarely presented at health centres, for three main reasons; there is little which can be offered by way of treatment, the disease makes walking difficult and painful, and it tends to be found in villages which are far from the nearest health facility. Surveillance must therefore be based in the community, and this requires the community's participation. Fortunately, the disease tends to remain mostly concentrated in the same minority of villages in successive years, so that most of the effort of surveillance and prevention can be focused on those endemic communities. The first programmes to start, such as those in India, Cameroon, Nigeria and Ghana which began in the 1980s, used annual case searches for surveillance. These were expensive to carry out, and subject to a number of sources of error, not least because they were carried out by staff external to the endemic communities. Outsiders
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may miss cases, and may also fail to translate the official case definition accurately in terms of local concepts of disease (Brieger and Kendall, 1992). Another problem is the bias involved in the one-year recall period of the annual case searches (Huttly et al., 1990). Most of the national eradication programmes have shifted to surveillance based on monthly home visits by a VHW, who reports cases to a supervisor, typically the nurse at the nearest health centre. The programmes which began in recent years have adopted this approach from the start. Fig. 2 shows how the number of endemic villages covered by such a community-based surveillance system has increased in recent years as a result. By the end of 1994, almost all of the 17 000 known endemic villages in Africa were covered. The sensitivity of these village-based surveillance systems is quite striking, considering that the main work is done by volunteers, and the logistical difficulty of carrying out a regular visit to every endemic village for supervision of the VHW and collection of surveillance data. The system in Ghana, from which over 90% of the villages send a monthly report within a specified number of days, has been shown to detect 87% of cases within the known endemic villages (Hours and Cairncross, 1994); the corresponding figure for Burkina Faso was found by Ourdraogo and Hutin (1993) to be 73%. For operational purposes, it is more important for the system to detect endemic villages than individual cases, and by this measure, performance is better. A recent evaluation of the programme in Burkina Faso showed that in those communities where community-based surveillance had been established, it successfully detected 95% of endemic villages. Equally remarkable, 58% of previously unknown endemic villages occurring within the year were also detected, although most of them had only a couple of cases. VHWs also played a key role in this broader, country-wide surveillance. On the other hand, community-based surveillance is not inexpensive. The experience of a number of Guinea worm programmes in Africa suggests that they cost between $100 and $200 per village per year to run, although the cost of the surveillance system (mainly training and supervision of the VHWs) can also cover the delivery of a number of simple interventions, particularly health education. Community-based surveillance systems established in Africa, Asia and Latin America for other purposes, such as nutrition monitoring and education, have similar costs (O'Neill, 1993). Other methods have been tried in a few cases; for example, in non-endemic cantons near endemic areas in Cameroon, the canton chief keeps a case register, and is supposed to report cases during regular supervisory visits. However, it seems that this arrangement has not been entirely satisfactory, as some chiefs have failed to declare cases occurring in their areas (Sam-Abbenyi, 1993). A more promising approach is to use local markets as a means to collect information. An experimental Guinea worm surveillance system based on farm markets in Oyo State, Nigeria, successfully detected 79% of endemic villages. It also produced significantly less false positive reports than a case search conducted by the national eradication programme (Brieger, 1991 ). In neighbouring Niger, VHWs have spontaneously taken to using weekly village markets to find out about cases in outlying hamlets, although this cannot be as effective as household visits.
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Thousands 20
15
10
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0 1989
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1991
~
1992
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Other countries
Fig. 2. Progressiveextensionof village-basedsurveillancefor Guinea worm in Africa, showingthe number of villages with monthly reporting of cases at the end of each year. The total number of villages to be covered is approximately 20 000, although only about 17 000 villages are still endemic.
4. Preventive interventions Initially, it was held that the most effective means of preventing the disease was the provision of a safe water supply (National Research Council, 1983), and the first discussion of its eradication was in the context of the International Water Decade (Hopkins, 1983). A n u m b e r of the early efforts at eradication, for instance in Kwara, Oyo and I m o States, Nigeria (Edungbola et al., 1988; Edungbola and Watts, 1990;
127 Huttly et al., 1990), and in Zou Province, Benin (Sebastian et al., 1991), depended largely on this intervention and water supply construction absorbed the lion's share of their budgets. However, the provision of a safe water supply in a village only prevents transmission of the disease due to the water used at home, and does not necessarily guarantee its elimination, because it does not prevent transmission due to casual use of other water sources, for instance when working in the fields (Cairncross and Tayeh, 1988). Moreover, in the relatively arid areas where Guinea worm tends to be found, it is not always feasible to provide a water supply to every village and hamlet. In the project in Zou Province, Benin, the endemic villages with less than 150 inhabitants had a prevalence of Guinea worm four times higher than the largest villages, but they were specifically excluded from the borehole programme as they were considered too small to justify the cost of drilling and to afford to maintain a hand pump (Yellott, 1990). Thus, it has become increasingly clear that the main preventive intervention is health education, to encourage villagers to avoid drinking surface water, or else to filter it with a cloth (Gbary et al., 1987). The filtering of water builds on existing practices in most of the endemic regions, where cloth or sieves are widely used to filter various liquids, but the type of filter cloth was also important. An important key to success in inducing behaviour change was the introduction of an appropriate technological input; the tight type of filter cloth. Early eradication programmes distributed cotton cloth, sometimes with the programme's logo printed on it. In Benin the attractive design on the cloth led many villagers to w e a r the cloth or to hang it on the wall, rather than to use it to filter water. In other cases, as in parts of Ghana, housewives complained at the time it took to do the family's filtering, as the cloth tended to clog with the heavy load of sediment in the water. In recent years, the cotton cloth has been replaced by a monofilament nylon cloth donated by Dupont Precision Fabrics through the Carter Center, which is less susceptible to clogging (Duke, 1984). This has proved so popular that it has been difficult to prevent it from being diverted and sold in village markets, even in non-endemic districts. Households use it to filter water whether or not they have been told that it can prevent Guinea worm disease. The advantages of health education over water supply are illustrated by surveillance data from Enugu State, Nigeria (Braide et al., 1994). Between November 1989 and April 1990, with assistance from the Japanese International Cooperation Agency (JICA), 150 functioning boreholes were provided in 132 endemic villages in Ezza, Ikwo and Awgu districts. Complete surveillance data are available for 77 of these villages, and for 30 comparable villages in nearby Abakaliki District which were not covered by the project. All four districts were covered by a vigorous health education campaign, costing about $110 per endemic village per year, which advocated the following measures: filtering or boiling of unsafe drinking water; protection of water sources from contamination, particularly by preventing persons with Guinea worm ulcers from wading into water sources; cleaning and coveting Guinea worm ulcers with a clean cloth or bandage. Fig. 3 compares the geometric mean annual number of cases per village in the villages with and without boreholes. The significant effect of the boreholes in reducing the number of cases one year after their installation is clearly visible (Guinea worm -
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128 Geom. mean c a s e s / v i l l a g e 200
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Fig. 3. Comparativeimpact of safe water supply and health education in Enugu State, Nigeria. Seventyseven villages received boreholes and health education, and 30 received health education only. There was a significant difference in the geometric mean number of cases only in 1989/90 and 1990/91. (Braide et al., 1994).
has an incubation period of one year), but is dwarfed by the greater and more sustained impact of the health education which covered both sets of villages. As Guiguemd6 et al. (1991) first pointed out, health education is cheaper than some other interventions for Guinea worm prevention. In the relatively short time perspective of an eradication programme, and ignoring the many other benefits of water supply (Briscoe, 1984), health education and surveillance through a network of VHWs, at $100-200 per village per year, is far less costly than boreholes at $10 000 or more per village. In practice, of course, health education and water supplies are complementary interventions, rather than alternatives. Villagers are often unwilling to discuss health education unless the possibility of a water supply is also included in the agenda. Health education also increases the effectiveness of other interventions (Nwaorgu, 1991). There are good reasons for combining health education activities with surveillance. The monthly household visits by the VHW, required for the detection of cases, provide an excellent opportunity for discussion of preventive measures, especially when a case is detected. Current cases are the ideal targets for preventive health education, for two reasons. First, they are the source of infection for the next year's cases; second, they are also five times more likely than others to have the disease again a year later, as there is a marked predisposition to reinfection year after year (Tayeh et al., 1993). Moreover, patients incapacitated and in pain due to Guinea
129 worm are a relatively captive and receptive audience for advice on how to prevent the disease. In addition, most VHWs are encouraged to offer health education at public meetings. In Burkina Faso, they organise these village meetings twice a year on average, usually on the occasion of a visit from their supervisor. However, when the VHWs have a visual aid, such as a set of posters, they also organise meetings on their own initiative. Guinea worm eradication programmes in a number of countries have organised supplementary activities for social mobilization in support of village-based health education. Some of these have produced a substantial response. In Dassa, Benin, for example, at the final session of a regional competition to find the best song in traditional style about Guinea worm, local officials commented that it had drawn the biggest crowd they had seen there for thirty years. Very little rigorous literature exists on the effectiveness of health education in developing countries (Loevinsohn, 1990), and there is a need for more research regarding the relative efficacy of participatory health education activities and more passive approaches such as the use of mass media. For instance, the knowledge of how Guinea worm is transmitted is now fairly widespread in the endemic areas, but it would be of interest to know whether this is due mainly to radio broadcasts on the subject, to the talks given to patients awaiting treatment at health centres, or to the passing on of information from person to person. Some indication of the contribution of VHWs can be had, however, from the recent field evaluations of the eradication programmes of Burkina Faso and Niger. As part of these surveys, ten households in each of a sample of endemic villages were asked to explain how one could catch the disease, whether they had attended a health education meeting about Guinea worm, and whether they had been visited by their VHW during the last month or so. In both countries (64 villages in Burkina Faso, 108 in Niger) there were significant correlations between the proportion of households in a village giving the correct explanation, and the proportions which had attended a health education session and which had been visited.
5. Motivating the VHW Guinea worm eradication activities, if carried out conscientiously, can impose a substantial workload on a volunteer VHW. For example, according to a Ghanaian volunteer in a village of 1,000 people, it took him one to two days a month to visit every household to look for cases. In the Sahel, most cases occur during the 3-month rainy season when most of the year's agricultural work has to be concentrated. In this period of hectic activity in the fields, many families move out of the main village into a number of small hamlets which may be several kilometres apart. For a volunteer to leave his own fields and visit each of these every month during the rains requires dedication indeed. In the circumstances, it is not surprising that many VHWs do not in fact visit every household routinely. Rather, they rely on word of mouth to inform them of cases in their village. In practice, experience has shown that villagers are usually aware of all cases of Guinea worm disease occurring within a radius of about 2 km of their homes.
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The need to motivate VHWs applies to Guinea worm just as much as to other aspects of primary health care, where a number of mechanisms for material reward have been suggested (De Zoysa and Cole-King, 1983). In Pakistan's eradication programme, one of the first programmes to start, village workers were paid a salary, but this would be too expensive in most endemic countries, and could make the VHW reluctant to work himself out of a job - a dangerous conflict of interest in an eradication programme! A material reward linked to the tasks performed by the VHW may be more promising. In some endemic countries, such as Togo, the cloth filters are sold by the VHW, who is encouraged by being allowed to keep some of the revenue. In Togo, the income from the sale of filters also helped to maintain the commitment of local health staff for many months in 1993 during which government salaries were not paid due to a general strike. In Ghana and in parts of Nigeria, the VHWs are re-trained once or twice a year; the training, together with a generous transport and subsistence allowance for those attending the course, is an important motivating factor. Most countries, however, have preferred to give the VHWs presents such as hats, wrappers and tee-shirts rather than cash. Printed with the logo of the eradication programme or with a suitable slogan, these items are worth far more to the VHW than the cost of producing them. Because they are not available on the market, they become status symbols. They can also serve as "mobile posters" for health education. Nevertheless, a survey among 37 village volunteers in Northern Ghana found that material rewards were not the primary factor motivating them to work for Guinea worm eradication. Their most important incentives, they said, were their improved social status and the progressive decline in the number of cases in their villages. Clearly, to be credited with the elimination of a hated scourge can only increase one's prestige in the community. One young village volunteer in C6te d'Ivoire, asked whether his fellow-villagers did not owe him something for his efforts, replied, "My fellow-villagers are my fathers and mothers: they brought me into the world. If anyone owes something, I owe it to them, not they to me." He added that a young man like him would never normally be allowed to speak to the village chief, but that now the chief presented him to the people and allowed him to address public meetings. Since he had become the VHW, some neighbours had even offered him their daughters in marriage... Building on the importance of social status in the motivation of the VHW, other programmes have offered certificates of diligence, or awards for the best worker. As Walt (1988) pointed out, one of the most important motivational factors, not to be underestimated, is regular supervision. Most of the national Guinea worm eradication programmes aim to ensure that the VHW is visited each month by a supervisor, such as the nurse from the local health centre or a technician from district level, who can collect surveillance data, replenish the stock of cloth filters as required, provide moral and technical support for health education activities, and monitor the VHW's performance. However, the supervisors do not always manage to make a monthly visit. Another approach is to call the VHWs to a regular meeting. This can be the excuse for paying them a generous "travel allowance", and has the advantage of enabling them to exchange ideas, feel part of a team, and measure up their performance against that of their neighbours. All of these can help to maintain the VHWs' enthusiasm for their work.
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6. Village institutions A variety of groups and community institutions have been mobilised to spread the word about how to prevent Guinea worm disease, including women's groups, religious and traditional leaders, pump repair artisans, and schoolteachers. Schools have great potential for this purpose, even in areas of instability and conflict. For example, in the war-torn areas of Southern Sudan, where the eradication campaign has yet to have a significant impact, some 9,000 schools continue to function. Though the children are forced to move when they flee from the areas of fighting, their teachers also move with them. The health education message has often spurred villagers to take collective decisions to combat Guinea worm. In the Bondoukou region of C6te d'Ivoire, many villages have changed the method of payment for water by which the residents contribute to the hand pump maintenance fund. Instead of a payment per bucket collected, which led many women to prefer the free (but contaminated) surface water, they have changed to a monthly subscription, payable by every household, under sanction from the chief, whether or not the pump has been used. Chiefly sanctions have other uses, too. In one village in Ghana's Volta Region, the women's group spontaneously decided to impose a fine on anyone entering the village pond with an open lesion on their leg; they have to pay two bottles of Schnapps to the chief! On the Mossi Plateau of Burkina Faso, a traditional village institution has been harnessed to provide reinforcement to the programme's health education message. In those villages where an artificial rainwater catchment pond, or boulli, is used for drinking water, a boulli naba, or "chief of the pond" is appointed, whose duty it is to watch over the pond and ensure that local rules are adhered to. These duties may include: - prohibiting the use of soap at the boulli; - requiring those who collect water to help deepen and enlarge the boulli by digging from time to time. Sometimes there are several boulli nabas, who take turns to watch the pond. Encouraged by local health staff and given a stock of extra cloth filters, the boulli nabas in some villages now require women to use them when they collect water, and have also placed cement blocks at the edge of their boulli, to make it easier to collect water without stepping into the pond.
7. The final phase of eradication Judging by the progressive reduction in cases now evident in most endemic countries, the current participatory approaches to Guinea worm eradication are proving remarkably successful (Fig. 4). It is perhaps too early as yet to draw detailed lessons from the experience, except to say that the VHWs have played an major role in this success, and that their full potential has yet to be fully exploited. Now that the numbers of cases and endemic villages have been substantially reduced, most of the endemic countries are currently moving into a new phase; case containment. The case containment strategy implies an intensified level of activity, in which the focus shifts from the measures healthy individuals can take to protect
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themselves, to the detection and containment of individual cases to protect the community (Greer et al., 1994). For case containment, monthly surveillance reports are no longer sufficient; each case of Guinea worm must be detected within 24 hours of first emergence of the worm for steps to be taken in time to prevent transmission. This requires a higher degree of awareness and participation on the part of the community. Patients with Guinea worm, or their relatives or neighbours, have to take the initiative and inform the VHW. More is also expected of the VHW in this phase; he/she must bandage each lesion immediately, persuade patients and their families to ensure that no emerging worm is immersed in a source of drinking water, and report cases quickly to his/her supervisor in time for confirmation of the diagnosis and further containment measures. This strategy is more costly in terms of effort, and additional funds are also needed, particularly for training and for the medical supplies. Results from Cameroon (Greer 1994) and from Niger suggest that it costs some $250 per endemic village, or $100 per village more than the cost of the basic eradication activities. The initial indications are that communities and VHWs are rising to the challenge. In Ghana, the first African country to implement the new strategy on a wide scale, it is estimated that over half of all cases were successfully contained during the first nine months of 1994. Most of the endemic countries are now moving towards some degree of case containment. However, it is still too early to judge whether it will have the desired effect of accelerating the final reduction of the number of cases to zero.
8. Integration and the future As more and more villages cease to be endemic, the commitment of the VHWs to surveillance will be hard to maintain; few people will want to continue making monthly visits to every household in search of Guinea worm cases, when the chance of finding one becomes vanishingly small. At the same time, it would be a great pity to waste the expense and effort which has gone into setting up community-based surveillance systems, and the credibility which the VHWs have gained as health educators by eliminating Guinea worm from their villages. A solution to both problems lies in the integration of Guinea worm surveillance with the monitoring of other health conditions and interventions ( W H O / U N I C E F / CDC/Global 2000, 1993), and extension of health education to include other messages. For example, a VHW who makes monthly visits to record cases of Guinea worm can also record births and keep a register of the immunizations given to the children born in each month. This can be used to direct visiting immunization teams to those children who are due to receive each antigen, and can also remind the VHW which mothers to mobilize to take their children for immunization. Incidentally, the register of births will also help those who will later require identity documents. This makes the health worker's monthly surveillance visits more interesting, more positive, and less morbidly focused on a single disease which, even in highly endemic villages, is almost absent for much of the year. The monitoring of children's immunization status helps volunteers' motivation, as can be seen from the fact that VHWs in Burkina Faso have spontaneously started
134 helping immunization teams to identify children to vaccinate. The teams seek the VHW out when they come to the village, and then follow his guidance, all of which adds to his status in the community. Guinea worm volunteers in Crte d'Ivoire are already monitoring children's vaccine status in this way, and it is planned to give them this task in other countries, including Ghana and Senegal. In Mali and Ethiopia, they also conduct surveillance for other diseases such as measles. One disease for which such community-based surveillance is likely to be particularly useful is neonatal tetanus. Improved methods for surveillance of neonatal tetanus and for monitoring the coverage of tetanus immunization are badly needed (Nokes and Cutts, 1993). We have no reliable way of detecting cases of neonatal tetanus unless the surveillance is active, and carried out by a person who knows the family and thus knows when a baby has been born. For this purpose, then, community-based surveillance is essential. Of course, the existing Guinea worm surveillance systems cover only the endemic villages, but those would make excellent sentinel villages for a number of other purposes, such as monitoring immunization coverage or measuring tetanus toxoid vaccine efficacy. In the more endemic countries and regions, about one village in three was affected by Guinea worm when the eradication programme was established, and VHWs selected and trained. In the longer term, it should be possible to extend the community-based surveillance to all villages, as is already planned in Ghana. While the system is expensive if considered on its own, most of the cost represents the logistical expense of the monthly supervisory visits, which are needed for many other health activities. In particular, it includes not only the surveillance activities, but also the delivery of the health education interventions which usually accompany them. As implementation of the Bamako Initiative is extended to include outreach activities, community-based surveillance and health education can become a part of the package. If the existing networks of VHWs are abandoned as the Guinea worm retreats, an unparallelled opportunity for better public health in Africa will have been lost. Not much time remains to grasp this opportunity and incorporate the Guinea worm VHWs into broader surveillance and prevention activities before the national eradication programmes begin to wind down. The eradication of Guinea worm can then not only free tens of thousands of communities from a centuries-old scourge, but also develop the means for them to participate more fully in the monitoring and promotion of their own health.
Acknowledgements The eradication of Guinea worm disease is a collaborative endeavour towards which many people have contributed their efforts and ideas, in addition to those cited above. Much of the unpublished information presented in this paper is from reports presented by the National Programme Coordinators at annual Programme Review Meetings which are sponsored by the CDC, Global 2000, UNDP, UNICEF and WHO.
135
References Braide E.I., Ibanga N., Johnson M., Bassey A.E., Igbon O., Nweke L., Alo E.T., Martin O., Martin O., Inyang A. and Ekpo U. (1994) Impact of JICA boreholes on the incidence of Guinea worm disease and school attendance in Enugu State. Calabar, Nigeria: Nigeria Guinea Worm Eradication Programme. Brieger, W.R. (1991) A farm market based system for detecting Guinea worm endemic villages in Southwestern Nigeria. DPH thesis, Johns Hopkins University. Brieger, W.R. and Kendall C. (1992) Learning from local knowledge to improve disease surveillance: perceptions of the Guinea worm illness experience. Health Education Research 7, 471-485. Brieger, W.R., Ramakrishna, J. and Adeniyi, J.D. (1989) Community response to social marketing: filters for Guinea worm control. Int. Quarterly of Community Health Education 10, 3-17. Briscoe, J. (1984) Water supply and health in developing countries: selective primary health care revisited. Am. J. Public Health 74, 1009-1013. Bugri S.Z., Asigri V.L.L., Marfo W.A., Dason B. and Tinorgah A.I. (1992) Guinea worm volunteers in Northern Region, Ghana: present performance and future role. Tamale, Ghana: Ghana Guinea Worm Eradication Programme. Cairncross S. and Tayeh A. (1990) Guinea worm and water supply in Kordofan, Sudan. J. Inst. Water and Environmental Management 2, 3, 268-274. De Zoysa I. and Cole-King S. (1983) Remuneration of community health workers: what are the options? World Health Forum 4, 125-130. Duke, B.O.L. (1984) Filtering out the Guinea worm. World Health, March 1984, 29. Edungbola L.D. and Watts S.J. (1990) The elimination of dracunculiasis in Igbon, Oyo State, Nigeria: the success of self-help activities. Jour. Trop. Med. Hyg. 93, 1-6. Edungbola L.D., Watts S.J., Alabi T.O. and Bello A.B. (1988) The impact of a UNICEF-assisted rural water project on the prevalence of Guinea worm in Asa, Kwara State, Nigeria. Am. J. Trop. Med. Hyg. 39, 1, 79-85. Gbary A.R., Guiguemd~ T.R. and Ourdraogo J.B. (1987) La dracunculose, un flrau eradiqu6 dans trois villages du Burkina Faso par l'rducation sanitaire. Bull. Soc. Path. Ex. 80, 390-395. Greer G., Dama M., Graham S., Migliani R., Alami M. and Sam-Abbenyi A. (1994) Cameroon: an African model for final stages of Guinea worm eradication. Am. J. Trop. Med. Hyg. 50, 4, 393-400. Guiguemd6 T.R., Gbary A.R. and Ourdraogo J.B. ( 1991 ) Contrrle de la dracunculose par trois techniques au sud-ouest du Burkina Faso: efficacit6 comparre des techniques. Mrdecine Tropicale 51, 4, 445-450. Hopkins D.R. (1983) Dracunculiasis, an eradicable scourge. Epidemiologic Reviews, 5, 208-219. Hours, M. and Cairncross S. (1994) Long-term disability due to Guinea worm. Trans. Roy. Soc. Trop. Med. Hyg., 88, 559-560. Huttly S.R.A., Blum D., Kirkwood B.R., Emeh R.N., Okeke N., Ajala M., Smith G.S., Carson C.D., Dosunmu-Ogunbi O., and Feachem R.G. (1990) The Imo State (Nigeria) drinking water supply and sanitation project, 2. Impact on dracunculiasis, diarrhoea and nutritional status. Trans. Roy. Soc. Trop. Med. Hyg. 84, 316-321. Loevinsohn B.P. (1990) Health education interventions in developing countries; a methodological review of published articles. Int. J. Epidemiol. 19, 4, 788-94. Nokes D.J. and Cutts F.T. (1993) Immunization in the developing world: strategic challenges. Transactions of the Royal Society of Tropical Medicine & Hygiene, 87, 353-354. National Research Council (1983) Opportunities for Control of Dracunculiasis; Report of a Workshop. Washington DC: National Academy Press. Nwaorgu O.C. (1991 ) The effectiveness of combined control measures on the prevalence of Guinea worm disease in Anambra State, Nigeria. J. Helminthol. 65, 3, 226-231. O'Neill, K. (1993) Community-based surveillance; a critical examination of nine case-studies. MSc dissertation, London School of Hygiene & Tropical Medicine. Ourdraogo J.B. and Hutin Y.J.F. (1993) Eradication de la Dracunculose au Burkina Faso: Evaluation Intermrdiaire du Projet Pilote dans les Provinces du Barn et de l'Oubritenga. Bobo-Dioulasso: Organisation de Coordination et de Cooprration pour la Lutte contre les Grandes Endrmies, for UNICEF. Richards F. and Hopkins D.R. (1989) Surveillance, the foundation for control and elimination of dracunculiasis in Africa. Int. J. Epidemiol. 18, 4, 934-943. Sam-Abbenyi, A. (1994) Cameroon Guinea worm eradication program. In: Summary Proceedings, 1993
136 Program Review of the Guinea Worm Eradication Programs of Benin, Burkina Faso, Cameroon, Crte d'Ivoire and Togo. Centers for Disease Control and Prevention, Atlanta. Sebastian H., Collbran J. and Saint-Lot M. (1991) Assessment of Interagency Collaboration in the Benin Rural Water and Sanitation Project and its Guinea Worm Reduction Component. VBC Report No. 81152. Arlington, Virginia: Vector Biology and Control Project, USAID. Sylla Awani, A. (1994) Evaluation de la mobilisation sociale du Programme National d'Eradication de la Dracunculose. Unicef, Lomr. Tayeh, A., Cairncross, S. and Maude, G.H. (1993) Water sources and other determinants of dracunculiasis in the Northern Region of Ghana. Journal of Helminthology, 67, 213-225. Walt G. (1988) Community health workers; are national programmes in crisis? Health Policy & Planning 3,1. WHO/UNICEF/CDC/Global 2000 (1993) Integrated Surveillance in Dracunculiasis Eradication Programmes: Joint Statement by WHO, UNICEF, Global 2000 and the WHO Collaborating Centre at CDC. Geneva, New York and Atlanta. Yellott H.L. (1990) Enqurte sur l'Incidence de la Dracunculose dans six districts du Zou Nord de la Rrpublique du Brnin. Cotonou: the Pragma Corporation for USAID.
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ACTROP 00489
Community participation in the eradication of guinea worm disease S a n d y C a i r n c r o s s a,,, E k a I. B r a i d e b, S a m Z. B u g r i c a Dept. ofEpidemiology & Population Sciences, London School of Hygiene & Tropical Medicine, Keppel Street, London WCI E 7HT, UK b Nigeria Guinea Worm Eradication Programme, Southeast Zone, 16 Ibom Layout, Calabar, Nigeria c Ghana Guinea Worm Eradication Programme, Ministry of Health, Private Mail Bag, International Airport, Accra, Ghana (Accepted 25 April 1995)
As Guinea worm eradication programmes have got under way in endemic countries over the last decade, there has been a shift towards more participatory methods. The approach to surveillance has changed from periodic cross-sectional surveys to monthly village-based reporting of cases by a volunteer village health worker. At the same time, the emphasis regarding control interventions has moved from the provision of safe water supplies to health education. The new approach has proved very effective. The village health volunteers who carry out both surveillance and health education seem to be motivated largely by the social status of their role; still more commitment will be required of them in the final stages of eradication. It is to be hoped that the networks of village health workers established for Guinea worm eradication will find a useful role in health promotion after the worms have gone. Key words: Guinea worm; Dracunculiasis; Eradication; Surveillance; Health education; Community participation
I. Introduction Guinea worm disease (dracunculiasis) currently affects twenty countries, all but three of which are in Africa (Fig. 1, Map). It kills few people but causes debilitating pain, usually in the planting or weeding season, and so can have far-reaching economic effects by reducing the ability to work of most of the population. It is the only disease which is exclusively transmitted in drinking water. The mature female worm, about 0.5 m long, lies under the skin and creates a painful or irritating blister, usually on the leg. When this blister is immersed in water or when water is splashed onto it, as is often done to soothe the irritation, the worm releases thousands of microscopic larvae. If the larvae are washed into a pond or shallow well, they are eaten by tiny crustaceans, known as cyclopoids, and develop inside these new hosts. The cyclopoids are only 0.8 mm long, and so are easily consumed inadvertently in water from a contaminated pond or well. Although the cyclopoids themselves are not dangerous to drink, any Dracunculus larvae they contain will develop further in the human host and any fertilised female worm will *Corresponding author. Tel.: (+44) 71 636-8636. fax: (+44) 71 636-7843. SSDI 0 0 0 1 - 7 0 6 X ( 9 5 ) 0 0 1 0 6 - 9
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Fig. 1. Geographical distribution of Guinea worm, Dracunculus medinensis. The shaded areas are those in which the disease was reported or probably existed in 1991. Since then, it has been eliminated from Pakistan, and a few cases found in Northern Yemen. (WHO Collaborating Center for Research, Training, and Eradication of Dracunculiasis, Atlanta).
make her way to the legs and form a new blister a year later, ready to start a new cycle. Several aspects of Guinea worm disease make it a suitable candidate for eradication. The disease only affects man, so that there is no reservoir in animals. The parasite does not live beyond its one-year transmission cycle, so that there are no long-term carriers. The disease is readily diagnosed, and cases can easily be prevented from passing the disease on to others. Moreover, it does not have a vector which can fly about, transmitting infection over long distances. Interest in the eradication of Guinea worm disease increased during the International Water Decade, and in 1991, the World Health Assembly declared its resolve to eradicate the disease by 1995. One by one, the endemic countries have mounted national searches for cases in recent years, and these have been followed by the establishment in each country of a national eradication programme. A number of international agencies, including UNICEF, W H O and the Carter Center, have supported this activity. The main preventive interventions are: - provision of safe water supply, health education to individuals and to the community at large, distribution of cloth filters, organisation of support (and possibly sanctions) to ensure that cases avoid contact with ponds, -
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123 simple treatment of cases by immersion of lesions in water and application of bandages, and - treatment of ponds with an insecticide non-toxic to man, to kill the intermediate host. All but the first and last of these interventions can be implemented at village level; indeed they are probably best done by villagers within their own village, and particularly by a trained village health worker (VHW). The surveillance which is an essential part of any eradication campaign is also a task for which the VHW is well suited. While Guinea worm eradication has paid lip service to community participation from the start, there has been an increasing awareness of the greater effectiveness of surveillance and prevention when performed by members of the community, and a gradual shift towards more participatory approaches to both surveillance and intervention for Guinea worm eradication. The role of the VHW is crucial to both of these activities.
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2. T h e role o f the village h e a l t h w o r k e r
In some countries, such as Burkina Faso, an existing network of VHWs was mobilised, and the village volunteers brought together for training by local health staff in the additional tasks of Guinea worm surveillance and prevention. In other cases, as in those villages in Uganda where village health workers did not previously exist, the Guinea worm workers have been selected with a view to subsequently re-training them in other aspects of health care so that the Guinea worm eradication programme can open the way to a strengthened primary health care system. In almost every endemic country, the VHWs who form the backbone of the eradication programme have been chosen by their communities, though the criteria of choice may vary. In Nigeria, they are required to be literate, in order to be able to complete their surveillance returns; this has sometimes led to the appointment of "village-based health workers" who are not in fact resident in the village but in a nearby town, and who write down information received from an illiterate villager, often a relative. In other countries, such as Niger and Mauritania, most of the VHWs are illiterate; they manage with special surveillance forms, on which cases can be recorded as tally marks in spaces denoted by illustrations. Other information, such as the names of cases, can be added in writing either by a friend or by the VHW's supervisor during monthly visits. In Ghana, it was found that illiterate VHWs were as reliable as literate ones (Bugri et al., 1992). Relaxing the literacy requirement makes it possible to recruit women as VHWs. While many programme administrators do not think it possible to do this in a traditional, often islamic community, experience suggests otherwise. For example in Mauritania, where 80% of the VHWs are women, it was found that women, particularly married women, performed more reliably in this role than men. They were less likely to be motivated by ambition or the hope of material rewards, and less likely to leave their village. In some countries, such as Burkina Faso, both a man and a woman have been trained in each village. Gender is not the only important factor in the selection of a VHW; in Ghana's Northern Region, Bugri et al., (1992) found that a second VHW was needed in villages inhabited by more than one ethnic group. The ethnic unrest which flared
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up in that region in early 1994, and similar tensions found in some parts of other countries, have underlined the need for sensitivity to ethnic differences. In Mauritania, dracunculiasis is more prevalent among the so-called "Maures noirs", who are less likely to have access to safe water than the rest of the population. In other parts of the Sahel, cases are often to be found in temporary settlements of the Fulani or Bella people on the periphery of the main village (and therefore far from the village borehole), and these may be missed if the only VHW is from another group. Where specialised Guinea worm volunteers have been selected and trained, attempts are often made to integrate their activity with existing initiatives at village level; for example, the village workers in Crte d'Ivoire are ex officio members of their village's water supply maintenance committee, and in Mali they participate in the village hygiene and sanitation committee. They can then count on the assistance of the other committee members in the early detection of cases, the dissemination of health education messages, and so on. It has also been found that VHWs can be more effective when they are organised in an association (Brieger et al., 1989). In one area in Togo, the village health workers formed an association on their own initiative (Sylla Awani, 1994). This enabled them to strengthen their activities in a number of ways: organising a theatre group to tour the area, giving mutual support at the public health education meetings they organise in their respective villages, - detecting those VHWs whose performance is poor, offering assistance by the literate members to their illiterate colleagues in completing their surveillance returns, and promoting exchange of information and ideas between villages, and between the VHWs and the management of the programme. While the details of their rrle vary from one country to another, the principal tasks of a VHW in Guinea worm eradication have been surveillance and prevention, the latter chiefly through health education. These are now discussed in turn. -
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S u r v e i l l a n c e
Any eradication programme depends essentially on efficient surveillance; one cannot be sure that all cases have been eliminated unless one is also sure that all cases can be detected (Richards and Hopkins, 1989). However, cases of Guinea worm disease are rarely presented at health centres, for three main reasons; there is little which can be offered by way of treatment, the disease makes walking difficult and painful, and it tends to be found in villages which are far from the nearest health facility. Surveillance must therefore be based in the community, and this requires the community's participation. Fortunately, the disease tends to remain mostly concentrated in the same minority of villages in successive years, so that most of the effort of surveillance and prevention can be focused on those endemic communities. The first programmes to start, such as those in India, Cameroon, Nigeria and Ghana which began in the 1980s, used annual case searches for surveillance. These were expensive to carry out, and subject to a number of sources of error, not least because they were carried out by staff external to the endemic communities. Outsiders
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may miss cases, and may also fail to translate the official case definition accurately in terms of local concepts of disease (Brieger and Kendall, 1992). Another problem is the bias involved in the one-year recall period of the annual case searches (Huttly et al., 1990). Most of the national eradication programmes have shifted to surveillance based on monthly home visits by a VHW, who reports cases to a supervisor, typically the nurse at the nearest health centre. The programmes which began in recent years have adopted this approach from the start. Fig. 2 shows how the number of endemic villages covered by such a community-based surveillance system has increased in recent years as a result. By the end of 1994, almost all of the 17 000 known endemic villages in Africa were covered. The sensitivity of these village-based surveillance systems is quite striking, considering that the main work is done by volunteers, and the logistical difficulty of carrying out a regular visit to every endemic village for supervision of the VHW and collection of surveillance data. The system in Ghana, from which over 90% of the villages send a monthly report within a specified number of days, has been shown to detect 87% of cases within the known endemic villages (Hours and Cairncross, 1994); the corresponding figure for Burkina Faso was found by Ourdraogo and Hutin (1993) to be 73%. For operational purposes, it is more important for the system to detect endemic villages than individual cases, and by this measure, performance is better. A recent evaluation of the programme in Burkina Faso showed that in those communities where community-based surveillance had been established, it successfully detected 95% of endemic villages. Equally remarkable, 58% of previously unknown endemic villages occurring within the year were also detected, although most of them had only a couple of cases. VHWs also played a key role in this broader, country-wide surveillance. On the other hand, community-based surveillance is not inexpensive. The experience of a number of Guinea worm programmes in Africa suggests that they cost between $100 and $200 per village per year to run, although the cost of the surveillance system (mainly training and supervision of the VHWs) can also cover the delivery of a number of simple interventions, particularly health education. Community-based surveillance systems established in Africa, Asia and Latin America for other purposes, such as nutrition monitoring and education, have similar costs (O'Neill, 1993). Other methods have been tried in a few cases; for example, in non-endemic cantons near endemic areas in Cameroon, the canton chief keeps a case register, and is supposed to report cases during regular supervisory visits. However, it seems that this arrangement has not been entirely satisfactory, as some chiefs have failed to declare cases occurring in their areas (Sam-Abbenyi, 1993). A more promising approach is to use local markets as a means to collect information. An experimental Guinea worm surveillance system based on farm markets in Oyo State, Nigeria, successfully detected 79% of endemic villages. It also produced significantly less false positive reports than a case search conducted by the national eradication programme (Brieger, 1991 ). In neighbouring Niger, VHWs have spontaneously taken to using weekly village markets to find out about cases in outlying hamlets, although this cannot be as effective as household visits.
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Thousands 20
15
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0 1989
1990
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1991
~
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Fig. 2. Progressiveextensionof village-basedsurveillancefor Guinea worm in Africa, showingthe number of villages with monthly reporting of cases at the end of each year. The total number of villages to be covered is approximately 20 000, although only about 17 000 villages are still endemic.
4. Preventive interventions Initially, it was held that the most effective means of preventing the disease was the provision of a safe water supply (National Research Council, 1983), and the first discussion of its eradication was in the context of the International Water Decade (Hopkins, 1983). A n u m b e r of the early efforts at eradication, for instance in Kwara, Oyo and I m o States, Nigeria (Edungbola et al., 1988; Edungbola and Watts, 1990;
127 Huttly et al., 1990), and in Zou Province, Benin (Sebastian et al., 1991), depended largely on this intervention and water supply construction absorbed the lion's share of their budgets. However, the provision of a safe water supply in a village only prevents transmission of the disease due to the water used at home, and does not necessarily guarantee its elimination, because it does not prevent transmission due to casual use of other water sources, for instance when working in the fields (Cairncross and Tayeh, 1988). Moreover, in the relatively arid areas where Guinea worm tends to be found, it is not always feasible to provide a water supply to every village and hamlet. In the project in Zou Province, Benin, the endemic villages with less than 150 inhabitants had a prevalence of Guinea worm four times higher than the largest villages, but they were specifically excluded from the borehole programme as they were considered too small to justify the cost of drilling and to afford to maintain a hand pump (Yellott, 1990). Thus, it has become increasingly clear that the main preventive intervention is health education, to encourage villagers to avoid drinking surface water, or else to filter it with a cloth (Gbary et al., 1987). The filtering of water builds on existing practices in most of the endemic regions, where cloth or sieves are widely used to filter various liquids, but the type of filter cloth was also important. An important key to success in inducing behaviour change was the introduction of an appropriate technological input; the tight type of filter cloth. Early eradication programmes distributed cotton cloth, sometimes with the programme's logo printed on it. In Benin the attractive design on the cloth led many villagers to w e a r the cloth or to hang it on the wall, rather than to use it to filter water. In other cases, as in parts of Ghana, housewives complained at the time it took to do the family's filtering, as the cloth tended to clog with the heavy load of sediment in the water. In recent years, the cotton cloth has been replaced by a monofilament nylon cloth donated by Dupont Precision Fabrics through the Carter Center, which is less susceptible to clogging (Duke, 1984). This has proved so popular that it has been difficult to prevent it from being diverted and sold in village markets, even in non-endemic districts. Households use it to filter water whether or not they have been told that it can prevent Guinea worm disease. The advantages of health education over water supply are illustrated by surveillance data from Enugu State, Nigeria (Braide et al., 1994). Between November 1989 and April 1990, with assistance from the Japanese International Cooperation Agency (JICA), 150 functioning boreholes were provided in 132 endemic villages in Ezza, Ikwo and Awgu districts. Complete surveillance data are available for 77 of these villages, and for 30 comparable villages in nearby Abakaliki District which were not covered by the project. All four districts were covered by a vigorous health education campaign, costing about $110 per endemic village per year, which advocated the following measures: filtering or boiling of unsafe drinking water; protection of water sources from contamination, particularly by preventing persons with Guinea worm ulcers from wading into water sources; cleaning and coveting Guinea worm ulcers with a clean cloth or bandage. Fig. 3 compares the geometric mean annual number of cases per village in the villages with and without boreholes. The significant effect of the boreholes in reducing the number of cases one year after their installation is clearly visible (Guinea worm -
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128 Geom. mean c a s e s / v i l l a g e 200
\
\
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~
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-t-
I
I
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Fig. 3. Comparativeimpact of safe water supply and health education in Enugu State, Nigeria. Seventyseven villages received boreholes and health education, and 30 received health education only. There was a significant difference in the geometric mean number of cases only in 1989/90 and 1990/91. (Braide et al., 1994).
has an incubation period of one year), but is dwarfed by the greater and more sustained impact of the health education which covered both sets of villages. As Guiguemd6 et al. (1991) first pointed out, health education is cheaper than some other interventions for Guinea worm prevention. In the relatively short time perspective of an eradication programme, and ignoring the many other benefits of water supply (Briscoe, 1984), health education and surveillance through a network of VHWs, at $100-200 per village per year, is far less costly than boreholes at $10 000 or more per village. In practice, of course, health education and water supplies are complementary interventions, rather than alternatives. Villagers are often unwilling to discuss health education unless the possibility of a water supply is also included in the agenda. Health education also increases the effectiveness of other interventions (Nwaorgu, 1991). There are good reasons for combining health education activities with surveillance. The monthly household visits by the VHW, required for the detection of cases, provide an excellent opportunity for discussion of preventive measures, especially when a case is detected. Current cases are the ideal targets for preventive health education, for two reasons. First, they are the source of infection for the next year's cases; second, they are also five times more likely than others to have the disease again a year later, as there is a marked predisposition to reinfection year after year (Tayeh et al., 1993). Moreover, patients incapacitated and in pain due to Guinea
129 worm are a relatively captive and receptive audience for advice on how to prevent the disease. In addition, most VHWs are encouraged to offer health education at public meetings. In Burkina Faso, they organise these village meetings twice a year on average, usually on the occasion of a visit from their supervisor. However, when the VHWs have a visual aid, such as a set of posters, they also organise meetings on their own initiative. Guinea worm eradication programmes in a number of countries have organised supplementary activities for social mobilization in support of village-based health education. Some of these have produced a substantial response. In Dassa, Benin, for example, at the final session of a regional competition to find the best song in traditional style about Guinea worm, local officials commented that it had drawn the biggest crowd they had seen there for thirty years. Very little rigorous literature exists on the effectiveness of health education in developing countries (Loevinsohn, 1990), and there is a need for more research regarding the relative efficacy of participatory health education activities and more passive approaches such as the use of mass media. For instance, the knowledge of how Guinea worm is transmitted is now fairly widespread in the endemic areas, but it would be of interest to know whether this is due mainly to radio broadcasts on the subject, to the talks given to patients awaiting treatment at health centres, or to the passing on of information from person to person. Some indication of the contribution of VHWs can be had, however, from the recent field evaluations of the eradication programmes of Burkina Faso and Niger. As part of these surveys, ten households in each of a sample of endemic villages were asked to explain how one could catch the disease, whether they had attended a health education meeting about Guinea worm, and whether they had been visited by their VHW during the last month or so. In both countries (64 villages in Burkina Faso, 108 in Niger) there were significant correlations between the proportion of households in a village giving the correct explanation, and the proportions which had attended a health education session and which had been visited.
5. Motivating the VHW Guinea worm eradication activities, if carried out conscientiously, can impose a substantial workload on a volunteer VHW. For example, according to a Ghanaian volunteer in a village of 1,000 people, it took him one to two days a month to visit every household to look for cases. In the Sahel, most cases occur during the 3-month rainy season when most of the year's agricultural work has to be concentrated. In this period of hectic activity in the fields, many families move out of the main village into a number of small hamlets which may be several kilometres apart. For a volunteer to leave his own fields and visit each of these every month during the rains requires dedication indeed. In the circumstances, it is not surprising that many VHWs do not in fact visit every household routinely. Rather, they rely on word of mouth to inform them of cases in their village. In practice, experience has shown that villagers are usually aware of all cases of Guinea worm disease occurring within a radius of about 2 km of their homes.
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The need to motivate VHWs applies to Guinea worm just as much as to other aspects of primary health care, where a number of mechanisms for material reward have been suggested (De Zoysa and Cole-King, 1983). In Pakistan's eradication programme, one of the first programmes to start, village workers were paid a salary, but this would be too expensive in most endemic countries, and could make the VHW reluctant to work himself out of a job - a dangerous conflict of interest in an eradication programme! A material reward linked to the tasks performed by the VHW may be more promising. In some endemic countries, such as Togo, the cloth filters are sold by the VHW, who is encouraged by being allowed to keep some of the revenue. In Togo, the income from the sale of filters also helped to maintain the commitment of local health staff for many months in 1993 during which government salaries were not paid due to a general strike. In Ghana and in parts of Nigeria, the VHWs are re-trained once or twice a year; the training, together with a generous transport and subsistence allowance for those attending the course, is an important motivating factor. Most countries, however, have preferred to give the VHWs presents such as hats, wrappers and tee-shirts rather than cash. Printed with the logo of the eradication programme or with a suitable slogan, these items are worth far more to the VHW than the cost of producing them. Because they are not available on the market, they become status symbols. They can also serve as "mobile posters" for health education. Nevertheless, a survey among 37 village volunteers in Northern Ghana found that material rewards were not the primary factor motivating them to work for Guinea worm eradication. Their most important incentives, they said, were their improved social status and the progressive decline in the number of cases in their villages. Clearly, to be credited with the elimination of a hated scourge can only increase one's prestige in the community. One young village volunteer in C6te d'Ivoire, asked whether his fellow-villagers did not owe him something for his efforts, replied, "My fellow-villagers are my fathers and mothers: they brought me into the world. If anyone owes something, I owe it to them, not they to me." He added that a young man like him would never normally be allowed to speak to the village chief, but that now the chief presented him to the people and allowed him to address public meetings. Since he had become the VHW, some neighbours had even offered him their daughters in marriage... Building on the importance of social status in the motivation of the VHW, other programmes have offered certificates of diligence, or awards for the best worker. As Walt (1988) pointed out, one of the most important motivational factors, not to be underestimated, is regular supervision. Most of the national Guinea worm eradication programmes aim to ensure that the VHW is visited each month by a supervisor, such as the nurse from the local health centre or a technician from district level, who can collect surveillance data, replenish the stock of cloth filters as required, provide moral and technical support for health education activities, and monitor the VHW's performance. However, the supervisors do not always manage to make a monthly visit. Another approach is to call the VHWs to a regular meeting. This can be the excuse for paying them a generous "travel allowance", and has the advantage of enabling them to exchange ideas, feel part of a team, and measure up their performance against that of their neighbours. All of these can help to maintain the VHWs' enthusiasm for their work.
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6. Village institutions A variety of groups and community institutions have been mobilised to spread the word about how to prevent Guinea worm disease, including women's groups, religious and traditional leaders, pump repair artisans, and schoolteachers. Schools have great potential for this purpose, even in areas of instability and conflict. For example, in the war-torn areas of Southern Sudan, where the eradication campaign has yet to have a significant impact, some 9,000 schools continue to function. Though the children are forced to move when they flee from the areas of fighting, their teachers also move with them. The health education message has often spurred villagers to take collective decisions to combat Guinea worm. In the Bondoukou region of C6te d'Ivoire, many villages have changed the method of payment for water by which the residents contribute to the hand pump maintenance fund. Instead of a payment per bucket collected, which led many women to prefer the free (but contaminated) surface water, they have changed to a monthly subscription, payable by every household, under sanction from the chief, whether or not the pump has been used. Chiefly sanctions have other uses, too. In one village in Ghana's Volta Region, the women's group spontaneously decided to impose a fine on anyone entering the village pond with an open lesion on their leg; they have to pay two bottles of Schnapps to the chief! On the Mossi Plateau of Burkina Faso, a traditional village institution has been harnessed to provide reinforcement to the programme's health education message. In those villages where an artificial rainwater catchment pond, or boulli, is used for drinking water, a boulli naba, or "chief of the pond" is appointed, whose duty it is to watch over the pond and ensure that local rules are adhered to. These duties may include: - prohibiting the use of soap at the boulli; - requiring those who collect water to help deepen and enlarge the boulli by digging from time to time. Sometimes there are several boulli nabas, who take turns to watch the pond. Encouraged by local health staff and given a stock of extra cloth filters, the boulli nabas in some villages now require women to use them when they collect water, and have also placed cement blocks at the edge of their boulli, to make it easier to collect water without stepping into the pond.
7. The final phase of eradication Judging by the progressive reduction in cases now evident in most endemic countries, the current participatory approaches to Guinea worm eradication are proving remarkably successful (Fig. 4). It is perhaps too early as yet to draw detailed lessons from the experience, except to say that the VHWs have played an major role in this success, and that their full potential has yet to be fully exploited. Now that the numbers of cases and endemic villages have been substantially reduced, most of the endemic countries are currently moving into a new phase; case containment. The case containment strategy implies an intensified level of activity, in which the focus shifts from the measures healthy individuals can take to protect
132
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themselves, to the detection and containment of individual cases to protect the community (Greer et al., 1994). For case containment, monthly surveillance reports are no longer sufficient; each case of Guinea worm must be detected within 24 hours of first emergence of the worm for steps to be taken in time to prevent transmission. This requires a higher degree of awareness and participation on the part of the community. Patients with Guinea worm, or their relatives or neighbours, have to take the initiative and inform the VHW. More is also expected of the VHW in this phase; he/she must bandage each lesion immediately, persuade patients and their families to ensure that no emerging worm is immersed in a source of drinking water, and report cases quickly to his/her supervisor in time for confirmation of the diagnosis and further containment measures. This strategy is more costly in terms of effort, and additional funds are also needed, particularly for training and for the medical supplies. Results from Cameroon (Greer 1994) and from Niger suggest that it costs some $250 per endemic village, or $100 per village more than the cost of the basic eradication activities. The initial indications are that communities and VHWs are rising to the challenge. In Ghana, the first African country to implement the new strategy on a wide scale, it is estimated that over half of all cases were successfully contained during the first nine months of 1994. Most of the endemic countries are now moving towards some degree of case containment. However, it is still too early to judge whether it will have the desired effect of accelerating the final reduction of the number of cases to zero.
8. Integration and the future As more and more villages cease to be endemic, the commitment of the VHWs to surveillance will be hard to maintain; few people will want to continue making monthly visits to every household in search of Guinea worm cases, when the chance of finding one becomes vanishingly small. At the same time, it would be a great pity to waste the expense and effort which has gone into setting up community-based surveillance systems, and the credibility which the VHWs have gained as health educators by eliminating Guinea worm from their villages. A solution to both problems lies in the integration of Guinea worm surveillance with the monitoring of other health conditions and interventions ( W H O / U N I C E F / CDC/Global 2000, 1993), and extension of health education to include other messages. For example, a VHW who makes monthly visits to record cases of Guinea worm can also record births and keep a register of the immunizations given to the children born in each month. This can be used to direct visiting immunization teams to those children who are due to receive each antigen, and can also remind the VHW which mothers to mobilize to take their children for immunization. Incidentally, the register of births will also help those who will later require identity documents. This makes the health worker's monthly surveillance visits more interesting, more positive, and less morbidly focused on a single disease which, even in highly endemic villages, is almost absent for much of the year. The monitoring of children's immunization status helps volunteers' motivation, as can be seen from the fact that VHWs in Burkina Faso have spontaneously started
134 helping immunization teams to identify children to vaccinate. The teams seek the VHW out when they come to the village, and then follow his guidance, all of which adds to his status in the community. Guinea worm volunteers in Crte d'Ivoire are already monitoring children's vaccine status in this way, and it is planned to give them this task in other countries, including Ghana and Senegal. In Mali and Ethiopia, they also conduct surveillance for other diseases such as measles. One disease for which such community-based surveillance is likely to be particularly useful is neonatal tetanus. Improved methods for surveillance of neonatal tetanus and for monitoring the coverage of tetanus immunization are badly needed (Nokes and Cutts, 1993). We have no reliable way of detecting cases of neonatal tetanus unless the surveillance is active, and carried out by a person who knows the family and thus knows when a baby has been born. For this purpose, then, community-based surveillance is essential. Of course, the existing Guinea worm surveillance systems cover only the endemic villages, but those would make excellent sentinel villages for a number of other purposes, such as monitoring immunization coverage or measuring tetanus toxoid vaccine efficacy. In the more endemic countries and regions, about one village in three was affected by Guinea worm when the eradication programme was established, and VHWs selected and trained. In the longer term, it should be possible to extend the community-based surveillance to all villages, as is already planned in Ghana. While the system is expensive if considered on its own, most of the cost represents the logistical expense of the monthly supervisory visits, which are needed for many other health activities. In particular, it includes not only the surveillance activities, but also the delivery of the health education interventions which usually accompany them. As implementation of the Bamako Initiative is extended to include outreach activities, community-based surveillance and health education can become a part of the package. If the existing networks of VHWs are abandoned as the Guinea worm retreats, an unparallelled opportunity for better public health in Africa will have been lost. Not much time remains to grasp this opportunity and incorporate the Guinea worm VHWs into broader surveillance and prevention activities before the national eradication programmes begin to wind down. The eradication of Guinea worm can then not only free tens of thousands of communities from a centuries-old scourge, but also develop the means for them to participate more fully in the monitoring and promotion of their own health.
Acknowledgements The eradication of Guinea worm disease is a collaborative endeavour towards which many people have contributed their efforts and ideas, in addition to those cited above. Much of the unpublished information presented in this paper is from reports presented by the National Programme Coordinators at annual Programme Review Meetings which are sponsored by the CDC, Global 2000, UNDP, UNICEF and WHO.
135
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