Sudan Medical Specializations Board

Community Medicine Council

Effect of training of health cadres on National malaria protocol knowledge& practice in Khartoum North locality (Bahry), Khartoum state-Sudan-2014

Proposal submitted in partial fulfillment of the Requirements for Medical Doctorate in Community Medicine
BY

Nazik Ahmed Babiker Ahmed MMBS, Kordofan University

Supervisor: Dr . Mona Hasan Mostafa MMBS, MD

Nazik Research proposal 1

List of content
1- Introduction 1.2 Problem statement 1.3 Justification 1.4 Research question 2- Objectives: 2.1 general objectives 2.2specific objectives 3- Methodology: 3.1Study design 3.2Study area 3.3Study population 3.4Inclusion &exclusion criteria 3.5Sampling 3.6Sample size 3.7Sample size technique 3.8Method of data collection 3.9Tolls of data collection 3.10Variables 3.11Data management 4-Ethical consideration 5 -Budget 6- Work plan 7- Reference

8- Annex
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Introduction
Malaria is one of the most severe public health problems worldwide. It is a leading cause of death and disease in many developing countries; an estimated 3.4 billion people are at risk of malaria, of which 1.2 billion are at high risk. In high-risk areas, more than one malaria case occurs per 1000 population. There were an estimated 207 million cases of malaria in 2012 and an estimated 627 000 deaths, 90% of all malaria deaths occur in subSaharan Africa, in 2012, malaria killed an estimated 482 000 children under five years of age. That is 1300 children every day or one child almost every minute. (1)

Malaria is still a big challenge for the Eastern Mediterranean Region, as more than 50% of the regional population lives in areas in which there is a risk of contracting malaria. Based on 2010 estimates, about 10.4 million people were affected by malaria and 15 000 people die of malaria in the Region every year. (2). In Sudan, it is estimated that 75% of the population (24 millions) are at risk of malaria, while 25% are at risk of malaria epidemics Seasonal transmission and malaria epidemics related to meteorological factors, irrigation schemes and river flooding occur in the hypo and meso-endemic areas of Sudan. In addition, epidemics related to large influx of vulnerable populations can occur in areas of hyper endemic malaria, leading to overload of health services and high mortality. (3)
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Indeed, being one of the MDGs, the country continues to prioritise efforts for malaria control as reflected in the key goals of the National Health Sector Strategic Plan (NHSSP). The country vision in that respect is to have halted by 2015, and begun to reverse, the incidence of malaria and other major diseases and the spread of HIV/AIDS (MDG6).(3)

Sudan has contributed to and endorsed the World Health Organization (WHO) global strategy for malaria control and Roll back malaria. It has been observed that ,unless diagnosis and treated promptly , patient with malaria deteriorate rabidly and the outcome is grave; hence plans to formulate a national malaria protocol for control of malaria were apriority in Sudan.(4) The national protocol is aset of recommendation and regulations concerning diagnosis of malaria and ant malarial drugs and their utilization in a country formulated in 2004 the main components are:

1- Ensuring early diagnosis and prompt treatment. 2- Multiple prevention such as vector control ,insecticide
treated nets and intermittent preventive treatment for pregnant mother; 3- Forecasting ,early detection and containment of the epidemics; 4- Strengthening of the malaria control activities through improvement of the information system and implementation of operational research results.(5)

1.2 - Problem statement An estimated 3.4 billion people are at risk of malaria, of which 1.2 billion are at high risk. In high-risk areas, more than one malaria case occurs per 1000 population. There were an estimated 207 million cases of malaria in 2012 and an estimated 627 000 deaths, 90% of all malaria deaths occur in sub-Saharan Africa. In 2012, malaria killed an estimated 482 000 children under five years of age. That is 1300 children every day or one child almost every minute. (1) A national, cross-sectional, complex-sample, health facility survey was conducted in Malawi to assess patient-, health worker-, and health facility-level factors associated with malaria case management quality using multivariate Poisson regression models found that: Among the 2,019 patients surveyed, 34% had confirmed malaria, 67% of which correctly prescribed the first-line anti-malarial, 31% of patients without confirmed malaria were over treated with an anti-malarial, The most important determinants of correct malaria case management were patient-level clinical symptoms, such as spontaneous complaint of fever to health workers, which increased both correct treatment and overtreatment by 72 and 210%, respectively, this reflect that health workers must systematically assess all patients for fever, and then test and treat accordingly, otherwise, malaria control programmes might miss an opportunity to dramatically improve malaria case management, despite better diagnostic tools.(6)
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More than 50% of the Mediterranean region population lives in areas in which there is a risk of contracting malaria. Based on 2010 estimates, about 10.4 million people were affected by malaria and 15 000 people die of malaria in the Region every year. (2) Based on the reported data in 2011, Malaria remains problematic in Pakistan, Sudan, South Sudan, Somalia and Yemen; where large numbers of cases were reported between 2000 and 2010 with no discernable downward trend noted. Malaria is a leading cause of morbidity and mortality in Sudan, Symptomatic malaria accounted for 9.3% of outpatients clinic visits and 8.7% of hospital admissions in 2011. Case fatality rate among admitted patients is 2.6%, while overall country reported case fatality rate of 0.05% of all reported malaria cases, and an annual reported malaria incidence of 357/10,000 population attending outpatient clinics .(3) .

Cross sectional study done on 2011 about Self-reported fever, treatment actions and malaria infection prevalence in the northern states of Sudan reflect that, parasitological diagnosis of all fevers before treatment is an appropriate strategy for malaria casemanagement. Improved regulation and supervision of health workers is required to increase the use of diagnostics and remove the practice of prescribing artemisinin monotherapy. (7). In Khartoum state from routine data (weekly report from epidemiology department) from sentinel sites first quarter of 2014 reported about 12418 cases of malaria, 12376 of which diagnose on clinical bases only. In Khartoum North locality about.. this may be due to many factors that related to malaria control. Adherence to national malaria protocol is one of the important
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components in malaria control, it is questioned weather there is adherence to a good level or not? (8). 1.2 Justification

Malaria is the silent emergency that kills 1300 children every day or one child almost every minute Over one million people die from malaria each year, mostly children under five years of age, with 90 per cent of malaria cases occurring in Africa, south of the Sahara. Malaria hampers children's schooling and social development. Many children who survive a serious attack of malaria develop physical and mental impairment. Pregnant women and their unborn children are also particularly vulnerable to malaria, as a result of low birth weight and maternal anaemia. Infants born to mothers with malaria are more likely to have low birth weight the single greatest risk factor for death during the first months of life. Almost An estimated 3.4 billion people are at risk of malaria, of which 1.2 billion are at high risk Prompt and effective case management is needed to reduce malaria morbidity and mortality. However, malaria diagnosis and treatment is a multistep process that remains problematic in many settings, resulting in missed opportunities for effective treatment as well as overtreatment of patients without malaria.(9). The outcome of my study will hopefully improve knowledge & practice about national malaria protocol in Khartoum North locality, so as to participate effectively in malaria cases management and control of malaria.

1.3- Research questions What is the level of knowledge & practice about national malaria protocol? What the effect of training on knowledge & practice about national malaria protocol?

2- Objectives
2.1-General objectives To assess the role of training on knowledge and practice about national malaria protocol in Khartoum North locality, Khartoum stat- 2013.

2.2- Specific objectives 2.2.1- To assess knowledge, and practice about national malaria protocol in North Khartoum locality before and after training, Khartoum state-2014.

2.2.2-To compare between knowledge, and practice about national malaria protocol in Khartoum North locality before and after training, Khartoum state-2014. .

3- Materials and methods 3.1- Study design An interventional study (pre post)facility based study. The study will be conducted in three phases: First phase: It is a baseline assessment phase, during this phase data will be collected using of questionnaire filled by medical doctors collected by data collector which will receive training on the questionnaire before data collection. Second phase: it is interventional phase and it contains the package of training (annex). Third phase: it is the evaluation phase. Used same baseline questioners.

3.2 - Study setting (Area)

Khartoum North (Bahry) locality is one of 7 localities in Khartoum state, it about 455907.7 Kilometers square, it situated between Longitudinal lines 24-25 &16-31, and latitudinal lines 8-15 & 1645, population about 704617, it border from South by Blue Nile, from North by Gary, from East By Gandra & ALselate agriculture project, from west by naher Anile it consist of three sectors Bahry locality health team have 6 sentinel site(Ahmed gasim hospital ,haj alsafi hospital , elshaabia
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health center ,shampat health center , elkhatmeia health center ,elsababy health center . , North bahry health team it have 10 sentinel site ( alhalfaya health center ,aldroshab health center ,alkadro health center ,taybat alahamda ,ashad government ,om algura government ,alsham charity hospital ,ali abd alfatah hospital ,om dryoa health center ,alsamrab health center) , Rural bahry health team it have 10 sentinel site ( alkhojalab health center ,alfaki hashem health center ,galat wad malek health center ,alkabashi hospital ,gare hospital ,aljaeli health center ,wad ramly health center ,alzakyab health center ,alkomor health center ,alsagay health center ) .

3.3 - Study population Medical doctors in 25 sentential site 78 doctors have permanent jobs they work in out pt & in medicine & pediatrics unit& one medical assistant.

3.4 - Inclusion criteria: Medical Doctors.

3.4 -Exclusion criteria: House officer, registrar.

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3.5 -Sampling 3.6-Sample size:

Where = (P1 - P2) We want to have a power of at least 80%. So we have = 0.05 1- = 0.80 P1=0.44 z1-/2 = 1.96 z1- = 0.84 P2=0.65

P1 I got from a previous study in 2011, p2 expected result after training. (5) =45

3.7. - Sample technique Sample was collected from tow hospital as convenient sample for training.

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3.8- Methods of data collection

Structured questionnaire for health cadres in sentinel site will be filled by trained personnel.

Training program:
Training start on January three weeks for one month for about 20 medical doctors in each week for first 2 weeks then 14 +one medical assistant for the last week about national malaria protocol I will do it in the hospitals after permission from hospital or health center directorate I consider number of basic facilities and equipment
must be organized before training can begin. Ideally, one large room should be available for presentations and group discussions; pictures projected by the overhead and/or slide projectors will be seen more easily if the level of lighting can be controlled. Chairs and small tables or desks will be needed for this room. Whatever the conditions, I do my best to ensure that the learners are as comfortable as possible in the circumstances available. Teaching equipment For teaching sessions and group discussions: Multimedia & computer or overhead projector Slide projector Screen Flip chart's papers, stand and markers Blackboard and chalks For health facilities work:
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 Sphygmomanometer Stethoscope Thermometer Weighing scale Learner's equipment Copies of the national protocol for treatment of malaria Learner's guides Notebooks Pens I will evaluate the training through pre and post course questionnaires, consisting of multiple choice and open-ended question ,Each multiple-choice question is provided with a list of possible answers from which the doctors select the one they think it is correct. At the end I will analyze the results to identify topics that were not clearly understood.

I depend on standard malaria treatment training guide (schedules of training annex).

3.9- Tools of data collection

Structured questionnaire for the medical doctor before and after training.

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3.10-Study Variables Independent variables: age, gender, job, sex.ect Dependant variables knowledge and practice about national malaria protocol: 1- Knowing case definition suspected, probable, confirmed. 2- Diagnosis of malaria. 3- Treatment of simple malaria first, second, third line of treatment. 4- Feature of sever malaria. 5- Complication of sever malaria. 6- Treatment of severe malaria. 7- Feature of malaria in pregnancy. 8- Treatment of malaria in pregnancy. 9- Malaria in children. 10-Treatment of vivax malaria. 11-Malaria prophylaxis and prevention. 12-Practices with malaria cases.

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3.11- Data management Data will be collected and cleared in the field for the consistency and completeness. Data will be entered in the soft ware program. Descriptive statistics; Mean, Stander deviation, Frequencies and percentages. Inferential statistics; Confidence interval, multiple logistic regression and chi-square tests will be used for testing the significance. P Values less than 0.05 will be considered statistically significant.

4-Ethical consideration The proposal will be submitted to ethical review committee (SMSB) Participants: confidentiality & informed consent will be insured before any subject will be enrolled in the study

Quality assurance: Quality control will be one of the major activities to be carried out during the course of the study. This will be granted by regular and frequent supervision to the data collection sites by the principal investigator to ensure quality of collected data. Regular checks at the field level will be done to ensure the completeness, consistency and correctness of filled questionnaires. Quality of data entry will
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be assured by a double entry method. In addition, entered data will be cleaned and checked for completeness, consistency and correctness. Challenge: Are the continuous turn over for the staff. I will minimize the effect of that by doing on job training for the new cadre continuously

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5-Work plan Activities Month 4 5 6 7 8 9

Submission of the Final Proposal ,pretesting, training ,ethical Approval and finalized the tool Data collection(Pre)

Data entry

Data analysis & Training

Data collection(post) Data entry Data analysis & submission of the progress report

Submission of the final report and dissemination of the final result

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6-Budget Activity
Materials& supplies Transportation Questionnaire& stationary Training Data collection Data analysis Report writing Unseen Total

cost
2000 2000 1000 10000 6000

5000 2000 2000 30000

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7-References:
1- WHO, factsheet on the world malaria, report 2013. 2- Malaria Fact Sheet, World Malaria Day 2013. 3- National Statistical Report, 2011. 4- Impact of the national protocol for malaria treatment on prescribing pattern in Gezira state, Sudan 2004. 5- National protocol for treatment of malaria, June 2004. 6-Patient, health worker and health facility level determent of correct malaria case management at publicly funded health facility in Malawi, 2-2004. 7-Elmardi, K. A., A. M. Noor, et al. (2011). "Self-reported fever, treatment actions and malaria infection prevalence in the northern states of Sudan." Malar J10: 128 8 - Routine data (weekly epidemic report) in epidemiology department, KH-MOH 9-Gomal journal of medical Sciences ,December 2010 10-WHO.2012.world malaria report 2012.Geneva: WHO. 11-kokwawo G2009, ongoing challenges in the management of malaria. 12-Roll back malaria. Key malaria facts. http://www.roll back malaria.org /key facts.html. 13-Bates1, Bekoe v, asamoa-aduA.impoving the accuracy of malaria laboratory test in Ghana. (PMID 15516269). 14-vander Hoke w, premasiri DA, wickremasinghe Ar. Clinical diagnosis of un complicated malaria in Sirlanka.south east Asian J Trop Med public health (PMID 9886105). 12-prevention of malaria. Med let.2005:47(1223) .
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Schedules of training
Day
Lecture 9-11pm facilitator

activities
Break fast Lecture 1-3am Current situation of malaria diagnosis and treatment What to do when you suspect malaria + Diagnosis and management of uncomplicated malaria Follow-up of patients and assessing recovery Managing malaria at home and at PHC units Post-test and course evaluation Pre-test + Malaria in Sudan Anti-malarial drugs and its use + Definition and classification of malaria cases Assessment and management of severe malaria Malaria in pregnancy + Malaria in children Malaria prevention and chemoprophylaxis facilitato r Nazik Nazik

5-5-2014 6-5-2014

Nazik

Nazik +lab technicia n Nazik

7-5-2014 8-5-2014 9-5-2014

Nazik

Nazik

Nazik

Nazik

Nazik

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Questionnaire
1- Date of interview 2- Name of health facility General information 3- Age 4- Sex 1-Male 2- Female 5- Occupation 1-Doctor 2-Medical assistant 3-lab technician 6- Are you hear about national malaria protocol 1 Yes 2- No 7- If yes You have a copy of national malaria protocol 1- Observe it 2- not observe it 8 You have training on national malaria protocol 1-yes 2- no 9-when you training 1- 1 year ago 2- 2 years ago 3-3years ago 4other 10-When you suspected cases of malaria if pt has 1-fever 2- Fever +headache 3-fever +headache + vomiting
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4- fever +headache +vomiting +sweating 5- other 11- What is the confirmed case of malaria? 1- Demonstration of asexual form in the thick or thin peripheral blood film 2- Rapid diagnostic test 3-ICT 4- other

12-What is first line treatment of simple malaria 1 - AS +SP 2 AS only 3- SP only 4- other 13-What is second line treatment of malaria 1 -AS +SP 2 Artemetherlumefantrine 3- both 4-other

14-What is third line treatment of simple malaria 1 -quinine 2 quinine +AS+SP 3-quinine +AS 4 -other 15-what is feature of sever malaria 1 -impaired level of consciousness 2 respiratory distress 3repetitive convulsion 4-circulatory collapse
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5pulmonary oedema 6- Abnormal bleeding 7jaundice 8 haemoglobinurea 9 prostration 10-other 16-what is suitable drug for treatment of severe malaria 1 quinine 2-artesunate 3-artemether 4-other 17-How you treat pregnant women with malaria 1- According to pregnancy trimester 2regardless trimester 18 if according trimester-what the treatment of malaria in pregnancy in first trimester 1 Oral quinine 2- AS+SP 3combination 4- other 19- What the treatment of malaria in pregnancy in second &third trimester 1 Oral quinine 2- AS+SP 3combination 4- other 20- I4- fever +headache +vomiting +sweating 5- other 11- What is the confirmed case of malaria?
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1- Demonstration of asexual form in the thick or thin peripheral blood film 2- Rapid diagnostic test 3-ICT 4- other

12-What is first line treatment of simple malaria 1 - AS +SP 2 AS only 3- SP only 4- other 13-What is second line treatment of malaria 1 -AS +SP 2 Artemetherlumefantrine 3- both 4-other

14-What is third line treatment of simple malaria 1 -quinine 2 quinine +AS+SP 3-quinine +AS 4 -other 15-what is feature of sever malaria 1 -impaired level of consciousness 2 respiratory distress 3repetitive convulsion 4-circulatory collapse 5pulmonary oedema 6- Abnormal bleeding 7jaundice 8 haemoglobinurea 9 prostration
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10-other 16-what is suitable drug for treatment of severe malaria 1 quinine 2-artesunate 3-artemether 4-other 17-How you treat pregnant women with malaria 2- According to pregnancy trimester 2regardless trimester 18 if according trimester-what the treatment of malaria in pregnancy in first trimester 1 Oral quinine 2- AS+SP 3combination 4- other 19- What the treatment of malaria in pregnancy in second &third trimester 1 Oral quinine 2- AS+SP 3combination 4- other 20-is the drug of choice for prophylaxis and prevention of malaria mefloquine 1 yes 2- no 21- You treat pt according to 1-your own way 2-protcol 3-other 21-pt with fever or history of fever with headach,vomiting,sweating what do you do a-request BF for malaria b- treated as malaria
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22- If request BF the result negative 1-Treated as malaria 2- repeat BF for malaria 3- request another investigation 4- other 4- fever +headache +vomiting +sweating 5- other 11- What is the confirmed case of malaria? 1- Demonstration of asexual form in the thick or thin peripheral blood film 2- Rapid diagnostic test 3-ICT 4- other

12-What is first line treatment of simple malaria 1 - AS +SP 2 AS only 3- SP only 4- other 13-What is second line treatment of malaria 1 -AS +SP 2 Artemetherlumefantrine 3- both 4-other

14-What is third line treatment of simple malaria 1 -quinine 2 quinine +AS+SP 3-quinine +AS 4 -other 15-what is feature of sever malaria 1 -impaired level of consciousness
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2 respiratory distress 3repetitive convulsion 4-circulatory collapse 5pulmonary oedema 6- Abnormal bleeding 7jaundice 8 haemoglobinurea 9 prostration 10-other 16-what is suitable drug for treatment of severe malaria 1 quinine 2-artesunate 3-artemether 4-other 17-How you treat pregnant women with malaria 3- According to pregnancy trimester 2regardless trimester 18 if according trimester-what the treatment of malaria in pregnancy in first trimester 1 Oral quinine 2- AS+SP 3combination 4- other 19- What the treatment of malaria in pregnancy in second &third trimester 1 Oral quinine 2- AS+SP 3combination 4- other 20-is the drug of choice for prophylaxis and prevention of malaria mefloquine
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1 yes 2- no 21- You treat pt according to 1-your own way 2-protcol 3-other 21-pt with fever or history of fever with headach,vomiting,sweating what do you do a-request BF for malaria b- treated as malaria 22- If request BF the result negative 1-Treated as malaria 2- repeat BF for malaria 3- request another investigation 4- other s the drug of choice for prophylaxis and prevention of malaria mefloquine 1 yes 2- no 21- You treat pt according to 1-your own way 2-protcol 3-other 21-pt with fever or history of fever with headach,vomiting,sweating what do you do a-request BF for malaria b- treated as malaria 22- If request BF the result negative 1-Treated as malaria 2- repeat BF for malaria 3- request another investigation 4- other

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