WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE
ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA PROGRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFRIQUE DE L'OUEST
EXPERT ADVISORY COMMITTEE Ad hoc Session Ouaeadougou. ll - 15 March 2002
I EAC.AD.9 Original : French August-September 2001
SOCIO.DEMOG HIC STUDY IN THE OTI BASIN ITS TRIBUTARIES (K6ran, Kara;
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CHAPTER I _ BACKGROUND
1. Background to onchocerciasi s control in the Kara reqton.
OCP started its activities in Togo in 1977, by treating the Oti basin and its tributaries (Kara, Keran, Mo). This area is called the "initial zote". The activities were mainly vector control (insecticide spraying).
In 1986, another zone was demarcated and named the "southern extension zone". This is found in the southern part of the country, in two groups of basins: the Mono basin (with its tributaries: Anie, Amou, Amoutchou, Ogou, Chra), and the YotolZio and Haho basin, to which the great rivers of Gban-Houo, Wawa and Asukawkaw are added.
In 1988, ivermectin distribution started in some areas of the Kara region. This second/new method of treatment was conducted by an OCP team, including some national health workers (health assistants, nurses) and doctors.
In 1989, the National team was put in place to assist members of OCP. This collaboration was to enable mass treatment in the villages to be carried out. But this phase ended in 1996, after the training of nurses involved in implementing CDTI in the region of Kara. These nurses, in tum, were to train community treatment agents, selected by the communities themselves. After this, the CDTI implementation process was to be extended to the entire national territory, with a rapid training of health workers of the four other regions of the country in 1997.
Observation: It might be necessary to recall here, in passing, that the training for CDTI implementation in Togo dates back to 1996197, and that since then no other training nor re- training was given to the agents in charge of implementing this strategy. To make matters worse, a lot of new health workers are recruited and posted to health facilities, beginning 1998. Most of these workers, out of necessity, are involved in Oncho control, without any prior training. Could CDTI implementation be effective in such conditions?
2. The entomo-epidemioloeical situation in the Oti basin (and its tributaries)
2.1. The epidemiological situation in the Oti basin (and its tributaries)
Prior to the inception of the Onchocerciasis Control Programme in West Africa in 1974, this disease was a critical public health problem in Togo. The disease was hyper-endemic in the affected areas, especially in the Oti basin and its tributaries: Kara-Keran-Mo, where prevalence rates were between 70 and 80%o, and blindness rates reached between I and 3oh. Dw to the collaborative efforts of vector control, which have gradually been made in these basins since 1977 by the Programme, and the use of ivermectin since 1988, onchocercal disease is no more a public health problem in Togo. The epidemiological surveys undertaken in the endemic follow-up villages showed that prevalence rates of between 70 and 80oZ recorded at the beginning of the programme, have dropped and are considerably low. The rates could currently be around l|Yo on the basins (in Togo), except in the Kara-Keran area, where they are still 60%t. It is worth noting
I Data from the National Team report J
that onchocerciasis in the Kara-Keran region is blinding, and it is transmitted by the savanna species.
2.2. The entomological situation in the Oti basin (and its tributaries)
Prospecting surveys showed that since the Kompienga dam was filled with water in 1988/89, the Oti has become a perennial river. Certainly black flies might be crossing from the Oti to its tributaries (Keran, Kara, Mo), and despite the intensification of larviciding, there was, in this endemic zone, an increase in black fly numbers (captured and infecting) in 1997.
According to two recent reports2, the entomological situation of the zone is as follows: - the measures taken in 1977, namely, the intensification of prospecting and ground larviciding, the extension of larviciding to lower Keran and lower Kara, the experimental treatment of the Oti, the enhancement of distribution of ivermectin to populations; - in 1999, Annual Transmission Potential figures (O. volvulus) were higher than 100 at only one point of Tchitchira (Keran), and the ATP, which was equal to-l54 in 1988 fell to 135 in 1999; in Tapounte, on the upper Keran, the ATP was 91 in 19983. All the other points on Keran Kara, Mo had corrected O.volvulus ATPs that are lower than 100 in 1999.
The analysis of results show that the rates of reduction in gross ATP figures in 1999, as compared to pre- control data, or before the South-East Extensions, were between 78 and 94o/o on the Keran, 93 and 99o/o on the Kara, and99o/o and 100% on the Mo.
The persistence of transmission on the upper Keran in Tchitchira needs to be given special attention.
Considering the data on the entomo-epidemiological situation, it appears that the elimination of onchocerciasis in the endemic areas (Kara-Keran-Mo) is below expectation, hence the entomo- epidemiological problem in this endemic zone.
3. Issue of the entomo-epidemioloeical situation in the Oti basin (and its tributaries)
After several years of combined control of onchocerciasis (in this zone), i.e.
vector control, with the intensification of prospecting, extensive larviciding, and the experimental treatment of the Oti at particular periods of the year; distribution of ivermectin to populations of the zone; the conclusion that could be drawn, to date, is that the entomo-epidemiological profile of the disease is still not satisfactory in this endemic zone.
This situation is of concern and raises some questions: why this situation? What could be the underlying causes? In other words, to what could causes of this partial failure be attributed?
' & 3 - Meetrng report on entomological research (Ouagadougou24-25 March 2000) - Meeting report on strategies and operational research (Ouagadougou2T-29 March 2000) 4
Let us start with the assumption that vector control (with all measures intact) is successful, and that it is well conducted and efficacious. Or, that it is a failure, insufficient or badly carried out? We leave the task to the specialists to find responses to this.
If, therefore, the problem and the hypothesis of vector control are not taken into consideration, one may ask if the causes are not social and demographic-related? As a matter of fact, the mode of population settlement, the migration pattern, the organization of treatment, the degree of involvement of actors in the CDTI strategy etc... could not be said to be favourable or unfavourable factors. What about other potential factors such as the disturbing ancestral practices, the levels of patronage and appreciation of ivermectin by the beneficiary population, their level of ignorance etc..
If all this is verifiable, then there is reason to question the coherence of the onchocerciasis control programme in this endemic zone.
4. Objectives and expected outcomes of the study
For a better appreciation of the objectives pursued in this study, as well as the expected results, we deem it necessary to recall its goal and content, as contained in the terms of reference.
4.1. Goal and content of study
To better clariff the situation that obtains in the Oti basin, (and its tributaries: Kara, Keran, Mo), and to improve same before the end of the Programme, a socio-demographic study is necessary in order to f,rnd the linkage between, on the one hand:
- the mode of settlement of populations, the spatial distribution and accessibility of agglomerations in the zone; - potential migration inflow, periods of great population movements, their causes and influence on the efficacy of Oncho control actions; - treatment organization: those in charge, their incentives (motivation), and their numbers in each agglomeration, the mode of distribution, (door to door, meeting places) etc.., period of distribution, the number of annual treatment conducted by distributors; - any other factor that could explain the present situation in the zone, or which could influence it (attitudes and behaviour of populations, health personnel incentives, and their involvement in control activities...
And on the other hand:
the entomo-epidemiological situation, as obtain to date in the zone.
4.2. Objectives of the study and expected results
On the basis of the goals and content of the study (which in some respects, is a kind of guiding evaluation) it will try and take stock of the situation.
The study must throw light on the modes of population settlement and their projection on the sites: space distribution and territorial partitioning. From here, it should be possible to arrive at how this 5 form of agglomeration leads to social logics, as for example: the ethnic factor in land issues, identity competitions (rivalry, quarrels), the setting of boundaries and modalities of inter-clan linkages, and other forms of articulation and disarticulation of the social fabric, and of the social experience that go through the length and breadth of the sites. At this point of the demonstration, it would be helpful to also show whether there are constraints or not, and the scope of action of community distributors, who are called (or obliged) to work in these surrounding environments. ln other words, the study must allow for the appreciation of the link befween the dispersed nature of habitats and the geographical inaccessibility or land-locked nature of some sites, by explaining the relationship between the organization of CDTI and these different variables. [n a word, there is need to bring to the fore the existence of potential difficulties that this form of agglomeration, and the natural character of sites may create and show how this may compromise the CDTI strategy.
In addition, this study must give exact information on population movements: the extent of migration swings, the period/periods of year when these movements are on the high side, their causes i.e. the reasons behind the movement of these men and women/children, why they leave their villages, and their destinations. Or why do some come from other places to live in the zone in question, and where do they come from? It is important to evaluate, if possible, the duration of their stay (both for the migrants and immigrants). In short, there is need to identiff the leading principle of individual and collective existence in order to arrive at temporal causality, determine predictability and viability and understand with these social protagonists, what anthropologists call "popledonlimeg", the periodical nature of the phenomenon (with cross-section situations, i.e. those that are observable during a given period), or its generative nature (with longitudinal situations, those that could be perceived, according to the destiny of generations).
In short, it would be educative to establish, short of a causal relationship, the potential existence of close linkages between the various population dynamics (caused or favoured by migration), and the insufficiency or inefficacy of CDTI.
On the other hand, this study, must give reliable information for evaluating the organisation of population treatment with ivermectin. How is treatment organized on the sites: the frequency of distribution and the adequacy of these periods, the number of distributions per year and their regularity. At the same time there is need to know the attitudes and social./behavioural inflexions of the beneficiary population in relation with CDTI, what they know and how they appreciate it, their expectations and grievances. The study will also appraise the mode of distribution used: is it door-to-door or group distribution; is it agreed on or accepted by the population? What are the advantages and disadvantages of each mode of distribution? There is also need to evaluate the extent and quality of involvement of health workers: the training received for this work, the experience gained, the mastery of knowledge, the number and regularity of supervisions. There is also need to appraise evaluations of distributors, the results obtained and lessons learnt. The work of community treatment agents will also be evaluated: their knowledge and mastery of CDTI, the potential inherent difficulties relating to their work, grievances and their self-evaluation etc...
Finally, it would be exciting and instructive to show the influence of other factors, such as: the effect of some ancestral practices, the ownership of onchocerciasis by some mythical/religious movements, the ignorance of populations and their rejection of modern health services, the lack of incentives for distributors, the refusal of populations to collaborate etc... 6
The impact of CDTI on beneficiaries will also be addressed: the extent of their involvement in the various stages of the programme, and the level of Oncho CAPs/CDTI. There is also the need to discover the changes in behaviour, the favourable factors, the impeding factors (problems and obstacles) and what their extents are.
CHAPTER II : PHYSICAL ASPECTS
l. Presentation of the Site
l.l. Some geographical characteristics
The Kpaha sectors (made up of the Andjide, Hounde, Kpaha, Animade and Tchitehide villages), and the Massedena sector (with settlements such as Massedena, Tchitchira, Doufelgou and Tchatounoh) have a rugged relief (which are sometimes very rugged), especially in Hounde, which is entirely surrounded by mountains, and which has only one access: the sky. It is not easily accessible, either geographically or environmentally, given its rocky and sloppy routes. On the contrary, the Tapouke sectors (made up of Tapounte, Koutantagou, Koutamagou, Koutougou, Solla and the Tchitchira sector (Tchitchira-Maison, Nyande, Goulbi, Wartema, Kotandiegou, Animate-Kouniti and Tchitchira Ferme l) are on plains, and are very herbaceous during the rainy season. The problem is that the roads (or rather access paths) are muddy and clayey and are almost impassable, especially during the rainy season.
1.2. Tlpe and mode of settlement
It might be appropriate to recall here that these populations have a deep love for round huts, which are chain-like and circular to form compounds. Each compound houses a nuclear family (or sometimes an extended family)a
The compounds are dispersed, separated by lands that are generally cultivated with millet, beans, maize, yam and cotton.
NB: It is worth noting here that in all cases, the principle of radio centricity is observed, in that descendants (of a head of family), who are adult (with their nuclear families) build their compounds, not far from that of the parent, in order to respect the circular form.
Most of the time, the compounds indicate a kind of clan propensity, which requires all members of a family to be together on one land belonging to them, and to which they have an inalienable right. This, maybe, is the quest for identity competition or a survival reflex. In the event of an attack, or danger, they will be able to defend themselves.
a An extended family is made up of several nuclear families, when, for instance, the head of family shares the same compound with his adult children, each of who has their nuclear families. l
2. Some social/cultural data
2.1. aspects
Three major linguistic groups overlap the sectors: the Tambermas, Lambas and Sollas. Thus, in the Tchitchira sector, the Lambas and Tambermas live separately in interfaced villages. The Kpaha sector is inhabited by the Lambas only, as well as Massedena, where we find Kabyes and Hausas. Finally, the Tapounte sector, where the Tamberrnas are in majority, there are Lambas and Sollas. The population is relatively young, with the majority being females.
N.B.: The presence of Fulanis is observed almost everywhere. They are nomads, who go from village to another, from sector to sector in transhumance, and they are hardly stable.
2.2. The polygyny phenomenon
All interviewed (men and women) practise or belong to polygynouss homes. The heads of family, who were interviewed, have on the average, three wives. The problem is that sometimes, they do not know the number of their children. This is a question, which embarrassed a number of them, who had to call in a third person to help answer this question. (Most of them also did not know their age).
2.3. Religious and mythico-religious aspects
Any visitor is struck by the presence of several enclosures and alters of respected divinities and spirits. This is a vivid indication of the depth of belief in supernatural forces. All compounds, without exception, have one in front of them.
N.B. Churches and places of worship of imported religions (catholic, protestant, moslem), but they give the impression of not being regularly attended.
Churches and mosques on one side, enclosures, alters for ritual, and sacred forests on the other. This shows that Jesus and Mohammed on one hand, are in competition with the ancestral spirits, divinities and fetishes, which are ostentatiously displayed.
This is a capsule presentation of some physical and socio-cultural traits of the sectors that were visited.
5 Commonly called polygamy (which rs *'rong). anti which means that one has one or more successive marriages after several divorces 8
CHAPTER ITI _ METHODOLOGY
1. Exploratory and pre-survey stages
First stage:
Prior to starting the actual survey, we spent four (4) days at the OCP headquarters in Ouagadougou, for a preliminary briefing and mission preparation. This period was used to draw up the survey questionnaire (meant for the beneficiary population), two interview guides for health workers (involved in CDTI) and community distributors. These three tools were discussed at length with the technical advisor of OCP and the computer expert in charge of research and socio-demographic surveys. Finally, after several amendments, reviews and corrections, the terms were adopted. This critical stage lasted four days instead of three (as previously planned). There was therefore a one-day delay.
Second staqe
In Kara, we necessarily had to meet members of the National Team, including the Coordinator and his immediate collaborators) for a second briefing and practical modalities for this mission. The Sector team, in a way, initiated us before the National team, which gave us a second briefing, which met with most of our expectations. This enables us to finally write up the questionnaire and interview guides. Then appointments were made, thanks to the National Coordinator and the officer in charge of National Onchocerciasis Control Programme - Togo activities.
2. Actual Survey
Given the objectives pursued, and to ensure the reliability of the results of this study, the following method was applied:
The qualitative approach, which is essentially based on focus group techniques, in-depth interviews and direct and participatory observation. These techniques made it possible for base data to be collected on the socio-ethnological profile of the area, by identiffing the social logics that cut across these communities, the ancestral practices (beliefs, mentalities, ideologies), the reasons underlying attitudes and behaviours in the face of diseases in general, and onchocerciasis in particular etc...
The quantitative approach (questionnaires with closed/open questions) is used to quantifo data (and some critical points of the qualitative phase) in order to draw trends from palpable figures. This technique made it possible to appraise the adequacy and relevance of health services that are generally offered by health workers, and the perception beneficiaries have of the former. In addition, this approach helped us to evaluate, with beneficiaries, their knowledge, artitudes and practices under CDTI, the way they perceive the work of community treatment agents, the mode of selection of the latter, the quality of work and type of collaboration or assistance they give. It is also at this level that information is collected on migration etc. . . Lastly, intervierv guides in the form of open and closed questions, administered to health workers and distributors, helped in evaluating the organization of 9
CDTI, the difficulties encountered, their self-evaluation, the strong and weak points, the issue of migratory swings in relation with geographical and therapeutic coverage of CDTI.
It could be concluded that the two approaches used eased the conduct of the survey, and helped in arriving at the objectives set.
3. Scope of survey
The study was conducted over ten (10) days, from 26 August through 4 September 2001, in the Upper Keran basin.
The team, made up of the consultant, the National coordinator and the officer in charge of NPOC- Togo activities, visited and interviewed:
trvo (2) prefecture directors of health (Keran and Doufelgou) from the two zones concerned; two (2) people in charge of CDTI from the two prefectures mentioned above; six (6) primary health workers;
twenty-two (22) community distributors ; hundred and fifty-one (151) persons from the beneficiary target population.
On the whole, 183 people were interviewed. It is worth underscoring that four sectors were mainly concerned:
the Massedena sector the Tapounte-Koutougou (Keran) sector; the Tchitchira (Keran) sector; the sector Kpaha (Doufelgou) sector.
These include 57 villages.
4. Target groups and sampling
On the advice of members of the National team, which have in-depth knowledge of the endemic zone, a spatial sample of twenty (20) villages was taken. Note that this choice was carefully studied, taking into account the distances that separate villages, the specificity of the situation in the various sectors, entomo-epidemiological data, and the evolvement of the situation. An analytical choice of villages was made, according to their geographical distribution, their size, age, as well as their migration status. Following is the breakdown of the sample, by sector:
in the Tapounte-Koutougou sector, five (5) villages were selected: Tapounte, Koutantagou, Solla Koutougou (formerly Solla Keran), Koutamagou, Koutougou; in the Massedena sector, Massedena, Tichtchira, Doufelgou and Tchatounoh, were selected; in all 3 villages were selected; in the Kpaha sector, five were selected, namely, Kpaha, Andjide, Hounde, Animade and Tichtchide; l0
And lastly, seven villages in the Tchitchira sector: Tchitchira-Maison, Nyande, Goulbi, Wartema, Koutandiegou, Aminate (Kounitui) and Tichtchira-Ferme 1.
The team visited a total of 20 villages, i.e. 35% of the total
5. Conduct ofsurvey
The National team did their best to provide us with the needed input: the Coordinator was able to contact by telephone, (fixed/mobile) the provincial directorates of health, who in turn sent messengers to the provincial health centers, which carried out the necessary duties prior to our arrival. These channels of communication proved very useful. This meant that our arrival at any site was planned, at Ieast} hours in advance.
The actual survey lasted for ten days, including two days of meeting with the National team to carry out the last arrangements for an effective and efficient deployment in the field. It was at this stage that the pre-testing of the questionnaire was conducted in a neutral follow-up village, i.e. Welou, in the Kara basin (on the Bassar road), far from the study area.
We noticed the cumbersome nature of the questionnaire, which took two hours to be administered to only one interviewee, whereas the interview guides took a relatively short time to be administered (hardly 15 to 18 minutes). The questionnaire had to be reviewed, corrected and adapted to the survey, with the help of the National coordinator and the officer in charge of the NPOC-Togo. The interview guides also had to be completed to integrate other aspects, which we missed out earlier on. And it is only after these last corrections/changes that the actual survey started.
In the field, it was difficult for us to communicate with the village chiefs, and through them, with the population, except for a few missed opportunities. Often after the introductions, and after presenting the aim of the survey, and after preliminary discussions for opening the floor and preparing people's minds, we went right to the essential thing.
The qualitative part was carried out on the basis of individuaUcollective in-depth discussions. Women were interviewed separately, as well as men, taking into account the age and social status. For example: the village chiefs were interviewed, far from any inquisitive ears.
We were able to have the confidence of these men, women and youth for spontaneous information and confessions. It was a real psycho-sociological investigation, in which we tried to help the interviewees to control their sentiments, due to the difficulties brought about by the disease, and to overcome the ethnic concerns (mainly the principle of reserve and secrecy). We believe we succeeded in doing this. It is not easy in a focus group session, where often a leader emerges and talks on behalf of others. We, however, were able to get information on some social logics, which cut across these villages. This approach helped us to go much deeper into some aspects, to try and understand the socio-ethnological profile of the environment (and its inhabitants). After that we addressed the interviews, one after the another, while making sure other interviewees were not close; and this is the time we administered the survey questionnaire, reserved for CDTI beneficiaries. 11
Besides, we had discussions with the health workers involved in CDTI (who could be somewhat considered as patrons in the area), and with community distribution agents (CTAs) or CDs), who are, in fact the key men in the field.
Observation:
We, individually and collectively, Iistened to people who gave their impressions about CDTI and the activities that had been conducted to date; they also voiced their concerns, grievances and difficulties met with in the organization (especially with the persistence of migration, the attitude of those who categorically refuse treatment with ivermectin etc. ..
6. Some of the difficulties encountered
The first problem has to do with the inaccessibility of some sites during the rainy season. The paths become muddy and almost impassable. For example, we got stuck in the mud in two places (at Solla and Tapounte). We were saved by the spontaneous mobilization of nearby inhabitants from other villages. The bridges were broken at this time (especially in the Tapounte sector), which forced the team to, literally, go on the river bed, or sometimes the vehicle on slippery stones, under the effect of seaweeds.
The village of Hounde, for instance, which is in the heart of the mountains that surround it at all sides, has only one outlet: the sky. To get there, we walked over two kilometers before climbing down the sharp slope. One could therefore imagine the tediousness of the return trip.
We regret we could not get to another village (in the heart of the mountain as Hounde, because only a helicopter could get there).
The second difficulty had to do with the unavailability of the inhabitants. This was due to the fact that the study period coincided, unfortunately, with the rainy season, when inhabitants were busy with farm work. Thus, a lot of Community treatment agents and beneficiaries were absent.
The third difficulty pertains to administration: despite the fact that the Coordinator informed the Provincial health director on time, and that the latter was, in turn, supposed to do same at the health centre level etc... this couldn't happen. Some CDTI officers in the zone were not informed on time. And this made the team lose precious time.
7. Limits or shortcomings of the study
As we indicated earlier on, the period chosen for the study was not ideal. This is what had Iimitative consequences on the study and did not guarantee optimal conditions for a research of such magnitude. Additionally, the time allocated *,as short or insufficient, especially as an in- depth study was required.
During the survey, especially with the Tambermas and Sollas, there was a problem of contact/communication with the inhabitants. For example, in the Tamberma custom, a woman is t2 not allowed to answer questions put by any man, let alone a visitor, in the absence of her husband. Thus, to administer the questionnaire to a woman, the husband comes in. This means that during the interview, he talks to the woman from time to time, and this causes interferences, which may compromise the information given. But we found a way round this (buying a drink for the husband so as to get him farther away from the interview spot).
With the Sollas, the issue was quite different: the refusal of some inhabitants to submit to the interview. When a question was asked and interpreted, the interviewee would take a questionable look at you and murrnur what, obviously expressed refusal. The interview in this case is simply a failure. We were informed that these were those who refused CDTI, and who threw tablets given them into the river.
Our language handicap forced us to use the Community Treatment Agents (CTAs) or local health workers as interpreters. And the inhabitants were being asked to give their impressions about the work of these CTAs, who were present. Could the information collected here be said to be reliable in such circumstances? (If we had the means, we would have hired the services of neutral interpreters, as in the case of some villages, where CTAs were absent).
Despite all these handicaps, the survey was carried out to the end. The exploitation of the data obtained, their analysis and interpretation produced outcomes that are presented in the second part as follows. l3
RESULTS OF THE STTJDY t4
I. SOCIAL AND ETHICAL PROFILE
1. The conception of disease
It is obvious that for these people, disease hardly has a natural cause. This is what explains their behaviour when they generally face disease. Almost all the people interviewed confessed that in the event of disease, they consult traditional healers, or they try to find the causes, with the help of a diviner before going to the dispensary. Sometimes if the treatment given at the dispensary does not heal, they go back to ancestral practices. This was confirmed by the quantitative survey (this will be seen later). Some people, however, believe that a disease may have a natural cause, such as onchocerciasis.
2. The burden of belonging to a clan
These communities are divided both vertically and horizontally
There is rivalry among the various clans, which claim supremacy, one over another. For instance, the descendant of an eponymous ancestor (founder of the village; the first to arrive there) considers himself superior to the other, by virtue of this, and claims the entire landed property, at the expense of the others. This may create interface situations: rivalry, quarrels, suspicion and hatred. These cases are rampant in the areas where the survey was conducted, especially in the Tchitchira and Tapounte sectors.
There is, for example, secular antagonism between the villages of Wartema and Tchitchira-Ferme 1. The interviewees here (including the chief) bitterly stated that their neighbours claimed to be owners of the land they occupy, and so they have no right to touch any fruit tree on the land. They may farm on the land, but they could not lay claim to it6.
Irony of the situation: the distributors of Wartema abandoned the work for lack of incentives. The chief of the said village randomly and authoritatively chose two of his nephews to do the work, in replacement of those who absconded, and it appears the latter had no knowledge of CDTI, except for some hours of briefing given by the nurse of Warango.
Could distributors of Tchitchira Ferme I be solicited, since the two villages are in conflict? It is not certain. (We did not deem it proper to ask this question, given the atmosphere that prevailed).
In the Tapounte sector, the mother-village, Tapounte, is in a bi-ethnic situation: the division is physically clear, because there are two distant residential areas occupied by only the Tambermas on one side, and the Lambas on another.
In Kpaha, a big village with several residential areas, 12 distributors may have the same problem, if the antagonism is deep. (Of course, of the l2 community distributors, we only met two).
6 According to the information obtained, Tchichira Ferme was artificially created by immigrants from Tchichira maison l5
3. The pre-eminence of men
With the Tambermas, respect is given first to age, but respect is also the privilege of men, to the detriment of women.
The proof of this is the difficulties we had in interviewing a woman, without the consent of her husband. It was made clear that a woman found alone with a visitor/stranger (as custom demands), has to put a ring on her lips (perforated), and her mouth is sewn up so she can no longer talk. This is a very sacred act, from which one may not go scot-free, without a "cosmic" punishment.
In addition, the supremacy of men over women is such that it is always the man, i.e. the head of family, who has the right to decide on the therapeutic itinerary, in case of disease. Could it be said, in these conditions, that the knowledge (or ignorance) of the head of family may positively/negatively impact the attitudes and behaviour of members of his family, in relation to onchocerciasis?
During the survey, we, mistakenly, embarrassed a farmer by insisting to know why the women do not have this righUprivilege? He obviously got enraged, and pronounced two words, which the interpreter said meant, "...the knee does not wear a hat when the head is alive".
On the contrary, an educated woman is highly considered, and has her "image capital" raised, in that she will have acquired social value, which at worst, will put her on the vertical hierarchy above man (here age is not considered). Could this not be a variable (or criterion) to be taken into account, if the social persuaders in the area are to be identified?
4. Territorial oartitioning of space and potential consequences
Village space is divided according to one's ethnic belonging (cases of Tapounte, Wartema and Tchitchira Ferme I for example). But within an ethnic group, there is rivalry among clans; this is the case of Tapounte and Tapounte-Koubougou: the former is the home-village, while the latter, due to hegemony struggles, is claiming its autonomy, and wants to change its name to Koubougou. This is to express its secession, but also, and above all, its clan propensity.
This clan propensity, in the same village, may be so pronounced that people spy on one another, are mistrustful etc.., and so there may be a relationship of avoidance'. In such event, it would be difficult or even impossible for the distributor to normally do his/trer work. As a matter of fact, according to certain bold and open revelations, one could suspect some distributors of using or having identity reflexes, which are the direct consequences of clan or ethnic propensity. This is the case of distributors who work at Tchitchira-maison (according to the nurse). Ethnic propensity may cause one to recoil into one's shell or become defensive, and only "those from one's home" would be regarded.
In addition to this, the dispersed nature of habitats makes the movement of distributors difficult, especially if the door-to-door system is practiced. This was the case almost everywhere in the Solla
'This is when social protagonists cannot share the same corrrmon space. For instance in some societies, the mother-in-lau' and the son-in-law must avoid each other; same goes for father-in-law and son-in-law. l6
region, where several people are found absent during distribution. This forces the distributors to go back to them for another round of distribution.
In the same woy, the dispersed nature of habitats compromises the traditional social communication channels, which work so well in communities with clustered habitats, and where community reality is palpable and lively.
Several village chiefs (in the Tamberma and Tapounte areas) complained of the lack of respect (or sometimes outright disobedience) of subjects, and especially of the youth. The chief of Koutoukou village (Alpha) the role he had to play as "a flaming stone in the hand". The roofs of the schools in the village have been ripped off for the past several years (due to a stormy weather), and so the pupils and teachers are making do with sheds for classrooms. The bridge on the path, which links his village to others, is still not repaired, and so the youth and village inhabitants of his village do not respond to meetings. The task of the chief in this situation is not easy. This creates social disorder, and the loss in social stature of the chief.
Anthropologists studied the dispersed nature of habitats, and the following was what they came up with:
Sometimes in these cases, there is lack of socialization, and all that characteizes good collective life, since social "short-circuits", linkages and the interwoven nafure of society are absent. And suddenly, the protective nature of collective life is destabilized, and this makes social mobilization difficult, and even impossible.
This is why, according to the anthropologists, this type of populations have a strong love for lively markets, which constitute one of the rare occasions for them to meet and feel some human warmth.
These are the social logics and the living characteristics of the communities living in the sectors of the endemic area.
It is in these environments, with the concourse of people of this social fabric, that CDTI is introduced. In addition to these social concourses, there are, above all the tributaries of the Keran, which waters them, not forgetting the savanna black flies that come with it. Apart from all this, CDTI is initiated here without any prior study or sensitization.
But there are other factors, which are linked to the entomo-epidemiological situation of the zone.
We will try and go into the details of these factors.
II. MIGRATION
Migratory movements are observable and observed at various degrees in the region. Generally speaking, these movements are periodical in character, in that they are observed at specific periods of the year. They are, therefore, rarely generative (or longitudinal), with permanent and continuous residence, over one or more generations. In other words, the migrants go and come. There are no cases where immigrants settle definitely lor very long periods. t7
NB: We do not take into consideration the cases of villagers (of the zone), who went and settled elsewhere in Togo, or in a foreign country, and who live there for good.
Apart from the social, economic, ethnic, environmental and legal implications, could not this phenomenon impact the epidemiological and entomological situation of the zone in question? The following figures might throw some light on this.
EMIGRATION
Table l: Survey on the question: "Do people often leave this village to go and settle in farm hamlets?
Value Absolute Relative Opinion frequency Frequency Yes 100 68% No 47 32% Total r47 r00%
Regarding the above data, it is obvious that the immigration phenomenon is real - 68% of respondents affirm this, as against 32Yo. Some villages (like Tchitchira) are much more affected, while others (like Goulbi) rather experience heavy influx of strangers.
The same question was put to health workers in the zone. The following was the trend:
Table 2: Breakdown of interviewees, according to the following question: "Do people leave this village to go and settle in farm hamlets?"
Value Absolute Relative Opinion frequency frequency Yes 8 88.9%
No 1 tt.t% Total 9 100%
To this question, 8 health workers out of 9 (88.9%) gave an affirmative response. Only 1 out of 9 ( I l. I %) said the contrary.
Comparing the data, it appears that6Soh of the inhabitants and 88.9% of the health workers recognize (or affirm) the existence of migration to farm hamlets.
These are people who move into the endemic zone. It is to be known whether they are treated before they leave, or they get treatment on arrival. Here, only knowledge about the departure and distribution periods may help. a
One has to know, therefore, the period of the year when departures are observable and observed. l8
Table 3: Survey breakdown on the response to the following question: What period of year?
Value Absolute Relative opinion frequency Frequency Dry season 47 56 Rainy season 62 74.6 Others I t.2
To this question, the responses sound somehow like a paradox, since some interviewees think it is both in the dry and rainy seasons; others, however, think it only in the rainy season, and some think it only in the dry season that there is migration.
Thus, for 560/o of the respondents, departures are observed during the dry season, and74.60/o think that these departures..... This is somewhat paradoxical, since we have more responses than responders.
We went further in this investigation to have some more details from the interviewees, who gave double-sided responses: they justifo their answers by saying that sometimes some inhabitants leave a little bit earlier, toward the end of the dry season, to go prepare the land (clearing, weeding, burning) before the rains set in. This way, they are ready and can start planting just after the first rains. This information needs to be verified for confirmation.
Table 4: Breakdown of health workers, according to the response to the same question (period of emigration)
Value Absolute Relative Opinion value Value Rainy season 4 44.4% Dry season 5 5s.6% Total 9 t00%
The health workers had different views: 4 out of 9 (i.e. 44.4%) mention the rainy season as the period of migration, whereas 5 of them (55.6%) think it is rather in the dry season.
When compared to the responses of the inhabitants themselves, it could finally be concluded that these population movements take place all year round (in all seasons)
What are the causes of these movements?
Table 5: Breakdown of population interviewed, according to responses to the question: "what are the causes of emigration?"
Value Absolute Relative opinion frequency Frequency Agriculture 28.6 28.6% Sharecropping 14.3 14.3% Search for fertile land 14.3 14.304 19
Harvest 14.3 14.3% Land preparation 14.3 14.3% Total 85.80 8s.80%
Here too the choice of responses is not exclusive.
It could be concluded that the main reason (the only one) is agriculture, because be it agriculture, search for fertile land, harvest or land preparation, everything points to farming. And even the person going in for sharecropping, undertakes planting or harvesting.
IMMIGRATION
We will now try and understand the phenomenon of immigration.
Table 6: Breakdown of interviewees according to the response to the question: "To the best of your knowledge, do people come from other places to live in this village (or in the endemic area?)"
Opinion Absolute Relative Value frequency Frequency Yes 4l 2935% Non 97 70.6s% Total r32 r00%
According to these figures,29.35% of the inhabitants affirm that immigrants come to settle in their sectors, while 70.65% declare the contrary.
It is true that no immigrants settle in this zone. These movements are rather specific. For example: Tchitchira experiences migration, whereas Goulbi complains of too much of immigration.
Table 7: Breakdown of health workers with regard to responses to the question: "Are there any immigrants?"
Opinion Absolute Relative Value frequency Frequency Yes 7 71.8% No 2 22.2% Total 9 100%
The figures obtained for this question are as follows: 77.8% of health workers asserted that the endemic zone actually experiences the presence of immigrants. 22.2o/o of them do not recognize this phenomenon.
t This confirms the responses to the same question put to the inhabitants. [t could be concluded that immigrants invade the endemic area.
But why, when and where do they come flrom? That is what we are going to find out in the following tables: 20
Table 8: Breakdown of poputation according to the response to the question: "*hy do the people immigrate?
Opinion Absolute Relative value Frequency Frequency Agriculture + fertile land 53 53% Economic problems 84 84% (survival) Health problems 5 5% Other factors 4 4%
Since the responses to this question were inclusive, the figures are consistent with them. But these are the general trends: 53%, of the respondents think that the immigrants come in to look for fertile lands for farming. The economic problems and those of survival (search for gold, animal raising, sharecropping etc...) are alleged to be to the reason for the movement of immigrants, and account for 84o% of respondents. 5o/o of the populations assert that there could be health reasons, whereas 4% thir/r. that there could be other reasons.
NB: It is worth underscoring that the health problems mentioned here must not be confused with onchocerciasis/CDTl, but rather therapeutic motives relating to consultation with haditional healers and others.
Table 9: Breakdown of health workers, according to responses to the same question:
Opinion Absolute Relative Value value Value Animal raising farmer 83.3 83.3% Traditional ceremonies t6.7 16.7% Total 100 r00%
According to the health personnel, the main reason underlying immigration is agriculture (83.3%), with the second reason being traditional ceremonies (which could be likened to health factors stated by the populations). Where, then, do the immigrants come from?
Table 10: Breakdown of respondents, according to the origin of immigrants.
Opinion Absolute Relative Value frequency Frequency Strangers 113 99% Togo & prefectures 6 s.0%
It appears the majority of immigrants are expatriates (from Benin, Niger and Burkina Faso). This is the view of 95oh of respondents. Only an insignificant proportion of these immigrants come from Togo (Keran and other prefectures) 2t
Table I I : Breakdown of health workers pertaining to the same question: place of origin of immigrants
Opinion Absolute Relative Value Frequency Frequency Prefecture I t2.s%
Other prefectures 1 12.5% Foreign countries 6 7s% Total 8 r00%
Seventy-five percent of health workers think that the immigrants are expatriates, and that only l2.5Yo come from the prefecture, and 12.5% come from other prefectures. This corroborates the projected figures express by the inhabitants, who think (95% of them) the immigrants are expatriates.
We tried to understand the reality of this phenomenon; thus, we asked the health workers this question: "are there hamlets and farms in your health zone?" And the following are the responses:
Table 12: Breakdown of health workers, according to their responses
Value Absolute Relative Opinion frequency Frequency Yes 6 66.7% No 3 333% Total 9 r00%
Sixty-seven percent of the health workers assert that there are farms and hamlets in their health zone. This could also mean that at the time of ivermectin distribution, isolated populations are not fteated.
Migratory movements are observed in the area, and automatically impact demographic data and projections. They also impact the social fabric and life of inhabitants. For example:
Socially, there are problems of neighbourhood, sociability and ethnic interface. Hosts and immigrants do not always agree. They spy on, avoid each other, accuse and suspect one another. The proof of this is that the host claimed that the immigrants (especially gold winners are expatriates: Ghanaians, Benin and Burkina nationals) are strangers, who have bad behaviours. They sometimes even go to the extent of "diverting" their wives. They succeed in doing this by exhibiting gold nuggets and money. The Fulani are reputed for being mistrustful, and do well not to be "assimilated". This simply stems from ethnic propensity, and is even a reflex of identity.
Economically, the presence of immigrants (with a purchasing power far and above that of the hosts) more or less influences prices of goods. The herds of Fulani, for example, destroy crops, and the inhabitants complain about this. How could these losses be reckoned? Maybe the economists/development experts could help solve this.
On the environmental level, there are activities are not adapted to the zone. The Fulani, with their cattle, devastate the vegetation. This, somehow, changes the vegetation cover of 22
the surrounding environment. On the part of the "gold winners", large trenches are dug in riverbeds (and do not fill them up). The physical and technical aspects of the land are in danger, with geographical discontinuity, which could affect the natural and human environment. Only soil scientists (and others) may be best placed to assess the consequences.
- Legally speaking, there are automatically issues pertaining to heritage (property). The immigrants are accused of occupying the sites in an inordinate and arbitrary manner. They settle in places of their choice, as if they are in conquered territory, without prior authorization. They sometimes occupy the place first before negotiating for an authorization, thus obliging the landowners into acceptance.
NB: In short, given the foregoing, it may appear, with the migratory movements, that there is a kind of transformational dynamics of sites, with respect to several aspects of their nomenclature.
And yet, beyond all these factors (social, economic, inter-ethnic, environmental and legal), there are serious disparities in the status of populations under CDTI.
As a matter of fact, demographic perspective and the mobility of populations for sure, have repercussions on the effrcacy of treatment with ivermectin. Let us see what the figures say in this direction:
Table 13: Breakdown of health workers, according to the response to the question: "Do you think these movements negatively impact CDTI activities?"
Value Absolute Relative Opinion frequency Frequency Yes 8 88.9% Non I tt.r% Total 9 rco%
Eighty-eight point nine percent of health workers establish a link between the migration and the poor performance of CDTI in this zone, while ll.I % think otherwise.
NB: Apart from the actual migratory movements, there are also population movements within the zone itself, ioward farms and hamlets, which are recognizedby the health workers (cf. table 12).
The flrgures above are self-explanatory. In any case, that means the therapeutic and geographical coverage are yet to be attained (or have not reached the acceptable level), due to the interferences broughi about by population movements. The inhabitants leave the villages without asking for permission (pardon, without prior notice) and return without being registered. In addition, the dispersed nature of habitats worsens the problem, by making it difficult to know what goes on in a given house, at the other end of the village. In the same way, the immigrants arrive and settle where ihey want, without any notice and without scruple. Additionally, they are not taken into account in the evaluation of population figures. The Fulani animal raisers, in transhumance, are not predictable and, at best, cannot be controlled due to their legendary mobility. 23
And yet it has been proved that all these migrants are not counted, and worse still, not treated with ivermectin. So automatically, they undermine data reliability and thus affect CDTI efficacy. This is no longer an assumption, since the health workers recognize this. That is why they propose a counting of all those who "missed" treatment, and a systematic treatment of the latter, as the following table shows:
Table 14: Breakdown of health workers, according to the response to the question: "What solutions to migratory influx?)
Value Absolute Relative Opinion value Value Actively look for all immigrants take a 3 42.9% census of them and treat them. Treat immigrants any time they are found I 14.3% Take census of migrants and immigrants I 14.3% Enhance recovery before each treatment I 14.3%
Treat as people come in 1 14.3% Total 7 100%
Health workers are conscious that migration influx must be addressed and controlled for better ivermectin coverage, both from the geographical and therapeutic viewpoints, in order to improve the entomo-epidemiological prof,rle in the area. They propose, to this end, various strategies: Looking actively for immigrants, taking a census of them and treating them Qa3%); treating immigrants each time they are found Qa3%); enhancing recovery before each treatment (l4.3oh); treating people as they arrive (14.3%).
NB: The situation is of much concern to the health workers, but one may ask why they have not applied these measures to date? Not even one of these measures. Or can it be that there are no means for ensuring application? This is what will be examined, by analyzing and assessing the involvement of health workers in CDTI, and the conditions in which the latter is carried out.
III APPRECIATION OF THE INVOLVEMENT OF'HEALTH PERSONNEL
a Involvement in the Programme
The duration of the involvement of health workers in the Programme, and the quality of training received to this end, may be determinant in the mastery of CDTI.
Table l5: Breakdown of health workers, according to the response to the question: "For how long have you been involved in the Programme?"
Value Absolute Relative Opinion frequency Frequency I 2 years I rt.t% 3 years 2 22.2% 4 years I tt.t% 5 years J 33.3% 24
13 years 2 22.2% Total 9 100%
All the health workers that were interviewed have been involved in the Programme for the past 2 years, at least. Those who have been involved for the past 3 years account for 22.2%o. ll.l% of them have been working for 4 years, while 33.3% have been working for 5 years . 22.2% of them said they had been working for the past l3 years.
It could be said that the health workers involved in the CDTI progamme in this endemic area have been working for a relatively sufficient period of time to master the strategy. But the question is: Were all of them trained for the job?
The following table will help answer the question.
Tabte 16: Breakdown of health workers, according to the response to the question: "Were you trained for this Programme?"
Value Absolute Relative Opinion frequency frequency Yes 6 66.1% No 3 333% Total 9 r00%
Sixty-six point seven percent of the health workers were trained for CDTI, whereas 33.3% were not.
We learnt that even those who had training had some lapses, simply because the training lasted for two and a half days in the Kara region, while it lasted 5 days for some in other regions of the counfiry. If to this insufficient training for the 66.7%o, we add the lack of training for the remaining 33.3yo, we see that the technical training for community treatment agents was, somehow, not sufficient.
What do the health workers themselves say of this training?
Table l7: Breakdown of health workers, according to the response to the question: "How do you find this training?"
Value Absolute Relative Opinion frequency Frequency Excellent 2 28.6% Satisfactory 3 429% Average I 14.3% Poor I 14.3% Total 7 t00%
The views were actually divergent on this issue: if 28.6% of them thought training was excellent, 14.3o thought it was poor, and another 14.3% found it to be average. 25
Even if for the majority (71.5%), this training was satisfactory, the question still remains if all of them are knowledgeable about CDTI.
o CDTI implementation
Table l8: Breakdown of respondents, according to the response to the following question: "Do you know the CDTI strategy?"
Value Absolute Relative Opinion frequency Frequency Yes 9 rc0% No 0 0% Total 9 r00%
According to the figures above, 100% of the respondents state that they know the CDTI strategy. One is tempted to ask this serious question: Are the respondents sincere? Otherwise how do the 3 agents who were not trained (cf. table 16) claim to actually know the CDTI strategy?
NB: We found health workers, who, apparently, had no mastery of the strategy, and the National team made us understand that there are new health workers who had been recruited and posted to the zone, without any training. One may therefore doubt the efficacy of their output. In such conditions, would they consider CDTI as part of their duties?
Table 19: Breakdown of respondents according to the question: "Is CDTI part of your action plan?"
Value Absolute Relative Opinion frequency frequency Yes 7 r00% No 0 0% Total 7 t00%
The response to this question is straightforward: 100% of the respondents answered in the affrrmative.
The Coordinator had already said this during the briefing: In Togo, it has been decided that onchocerciasis control should be integrated as one of the 7 compulsory activities of a health worker. In this case, the latter should be involved in CDTI without complaining.
So, what are the CDTI results in the health zone under their control?
Table 20: Breakdown of health workers, according to the response to the question: "What do you think of the CDTI results in your health zone?
Value Absolute Relative Opinion frequency Frequency Very good I rt.r% Good 4 44.4% Quite good 4 44.4% Total 9 100% 26
Only one health worker out of the 9 interviewed found the results to be very good. 44.4% deem them to be good, while another 44.4% think they are quite good.
NB: None of them said the results were bad (not even those who confessed to have had no training). What then could the conclusion be? To the open question: "...if the results are bad, how do you explain it, and what solutions do you propose?" The respondents said the following:
- "...there is need to treat the entire target population, since a percentage of it is still "missed" it." And to do this, they believe it is necessary to do sensitization with villagers on the usefulness and advantages of ivermectin.
However, they put forth the difficulties they encounter in the implementation of CDTI. These include:
The refusal of the population to be treated/or to take ivermectin tablets; The lack of sensitization for beneficiaries; The lack of supervision, follow-up and valuation of field activities, due mainly to lack of means and incentives; Inadequacy of distribution period (2 rounds), set for November, but which coincides with the harvesting period.
Is there a perrnanent stock of ivermectin in this health zone for treating the entire population? "How do you supply the health centres with ivermectin?" To this open question, there were several responses that were not mutually exclusive. Generally, the health workers have several ways of ensuring supply:
- from the Provincial health directorate (12.5%) - per supply chits (12.5%) - permanent stock (12.5%) - from the district (12.5%) - per verbal order (12.5%) - through the ICP (12.5%) - from the head nurse, at the approach of distribution (10%)
Are these different channels of supply effective? If yes, do we have permanent availability of stock of the drug, in the best of conditions, at the time of distribution? Let us veriff this per the table below:
Table 2l: Breakdown of respondents, according to the response to the question: "Do you sometimes experience breaks in ivermectin stock?"
Value Absolute Relative Opinion frequency Frequency Yes 4 44.4% No 5 55.6% Total 9 t00% 27
Sometimes they experience breaks in stock of ivermectin, as four health workers (44/%), out of the 9, state. The remaining 55.60/0, however state they never experience this.
Does this state of affairs not compromise treatment? How do the health workers solve this problem?
Table 22: Breakdown of respondents, according to the response to the question: "How do you solve this problem?"
Opinion Absolute Relative Value frequency frequency Going to look for the drug I 33.3%
Telephoning 1 33.3% Taking measures before I 333% scheduling distribution
Thirty-three point three percent of respondents go to look for the drug at the storage point. Another 33.3% prefer telephoning, but where do they telephone? 33.3% others take measures at the time distribution is programmed.
NB: With regard to the data above, it appears that the health workers, in the event of break in stock, always try to solve the problem. Why then, can't they think about this much earlier, to avoid a situation of total break in stock?
ORGANISATION OF TREATMENT
Table 23: Breakdown of respondents, according to the response to the question: "What do you think of the organisation of treatment in your area?
Opinion Absolute Relative Value frequency Frequency Good 8 88.9% Bad I tt.t% Total 9 100%
A great majority (88.9%) deems distribution to be good, whereas ll.l% think it is bad
The question could be asked as to what evaluation criteria the health workers based their assessment on, especially when it is generally known that no evaluation has been done to date to determine the extent of geographical and therapeutic coverage of the area in ivermectin. (Given that there are those who "missed", emigrants, immigrants, absentees and refusals).
If there are people who "missed" treatment, it is maybe because the distribution period was not appropriate. This is what is verified hereafter. 28
Table 24: Breakdown of respondents, according to the question: "Which period is distribution usually carried out?"
Opinion Absolute Relative Value frequency frequency Dry season 5 55.6% Rainy season 3 333% Others I tt.t%
Distribution is usually carried out during the dry season as affirmed by 55.6% of respondents
But since there are two rounds of distribution each year, some (33.3%) say that it is done in the dry season. However, ll.l% of respondents talk of other seasons (periods of celebration, vacation periods corresponding to the dry and rainy seasons). At the same time they give their views on the appropriateness of these periods.
Table 25: Breakdown of health workers, according to the response to the question: "Do you think this period is the most appropriate?"
Opinion Absolute Relative Value frequency frequency Yes 9 t00% Non 0 0% Total 9 t00%
Hundred percent of the respondents answered this question in the affirmative, but the following observation has to be made: In response to the open question as to "...whether the results are bad; how do you explain this, and what solutions do you propose?" The health workers made the following observation: the period of distribution is not appropriate (2nd round), which is set for November and which coincides with the harvesting period. In this case, is the 100% response, affirming that the distribution period is appropriate, in line with the actual situation?
Table 26: Breakdown of respondents, according to the response to the question: "How many treatment rounds are carried out each year in your health area?"
Opinion Absolute Relative Value frequency Frequency 2 8 889% J I tt.t% Total 9 100%
Eighty-eight point nine percent (i.e. 8 out of 9 respondents) say there are 2 treatment rounds a year; Il.l% say that it is rather 3.
This is proof that some health workers, actually, have little knowledge about CDTI, and do not or are yet to master the strategy. We had these proofs on the field, and these were not isolated cases, since the National Coordinator recognized this situation. 29
This is the situation of the health workers themselves, those who are supposed to supervise and evaluate the work of distributors, so that CDTI is implemented, as it should. Are they capable of performing? The same question is put to community distributors (CDs) and the population. Following are the figures.
Table2T Breakdown of CDs, according to responses to the question: "How many distribution rounds do you carry out in a year?"
Opinion Absolute Relative Value Frequency Frequency 2 22 t00% Total 22 r00%
The distributors clearly stated that they usually undertake 2 distribution rounds ayear. They even add that these periods are separated by a six-month lapse. It could be concluded, therefore, that distribution is carried out in accordance with strategy standards.
APPRECIATION OF THE WORI( OF DISTRIBUTORS
Here is the appreciation of health workers on the work of distributors.
Table 28: Breakdown of respondents, according to the response to the question: "How do you assess the work of CDs?"
Opinion Absolute Relative Value frequency Frequency Insufficient 4 M.4% Good 5 55.6% Total 9 100%
In regard to the data, it appears that 44.4o/o of health workers believe that the work of CDs is inadequate, as against 55.60A, who think their work is good. These appreciations may be compared (that of health workers on the work of CDs), and those of beneficiary populations.
Table 29: Breakdown of populations, according to the response to the question" "What are your views about the work of distributors?"
Opinion Absolute Relative Value Frequency Frequency Good 136 94.4% Bad 8 s.6% Total t44 100%
To this question, the answers of the respondents are as follows
136 out of 144 (94.4%) of the population think that the distributors do their work. Only 5.6Yo of them (i.e. 8 out of 144) think the work is not well done. 30
Thus, we have 94oh of beneficiary populations and 55.5% of health workers, who positively appraise the work of CDs. Could it be said, then, that the lapses or insufficiencies are at their level? We would now like to know if the choice of CDs is appreciated the same way; or what do the protagonists/social partners think of it?
Table 30: Breakdown of health workers, according to the response to the question: "How are the CDs selected? Opinion Absolute Relative Value Frequenc frequency v By the community 2 2.2% By the chief of village I tt.t% By the health workers 6 66.6% Total 9 r00%
Sixty-six point seven percent of the health workers think that the choice of CDs is made by health workers themselves , 22.2o/o think it is rather the community that selects the CDs, while ll.l% say that it is the village chiefs who decide.
These data will be compared with the responses to the same question, given by the beneficiary populations, and those of the CDs themselves.
Table 31: Breakdown of CDs on the question: "Who selected you?"
Opinion Absolute Relative Value Frequenc Frequency Y Health worker 8 36.4% Chief of village 4 18.2% Community l0 45.s% Total 22 100%
According to those concerned themselves
36.4% said that it is the health worker who chose them 45.5% stated that it is the beneficiary community that selected them. 185% of them acknowledge the responsibility of the village chief in the selection.
NB: None of them said they were not selected by anyone
Table 32: Breakdown of populations, according to the response to the question: "How was the CD selected?"
Opinion Absolute Relative Value Frequency Frequency By community 45 34.1% By village chief 29 22.0% 3l
By health worker 47 36.6% Was not chosen 2 r.2% Others 9 6.8% Total 132 r00%
Here are the responses to this question
Thirty-five point six think that CDs are selected by the health worker. 34.1% of them think that it is the community that makes the choice. For 22Yo of the population, the chief of village alone chose the CD. On the other hand, l.5oh of the respondents state that the CD was not chosen by anybody, and 6.8%o do not know.
A comparison of the figures shows that 66.70/o of the health workers and35.6o/o of the population attest to the fact that it is the health worker who chooses the CD. 22.2% of the health workers and 34.1%o of the villagers think it is the community.
22.0% of beneficiaries and ll.l% of health personnel think it is rather the chief of village, who selects the CDs.
NB: 6.8% and 1.5%o of populations know very little about this, and think that nobody chose the CD. This is a pointer to the fact that a portion of the population has a devalued perception of CDs. In addition, 22% of the populations and ll.l% of health workers think that it is the chief of the village who is responsible for this choice. On the field, however, we noticed cases (at Koutougou, Wartema, Goulbi and Solla) which prove that actually the village chiefs arbitrarily made choices, including choosing their own sons, nephew or other members of their family. And since the CDs are considered as "salaried" workers, one easily gets involved in favoritism, comrption, etc... This discredits the role of the CDs, who pay dearly for it.
But, beyond the doubts, suspicions etc... can the CDs continue their work? And why, or why not?
Table 33: Breakdown of populations, according to the response to the question: "Would you like the distributor to continue his work?"
Value Absolute Relative Opinion Frequency Frequency Yes 131 97.0% Non 4 3% Total 135 100%
The populations, almost unanimously, wished the CDs continued their work, given that 131 out of 135 (i.e. 97%) respondent answered "yes" to the question. However, there are 3o/o of them who do not agree with this view. They may be likened to the 5.6% who deem the work of the CDs unsatisfactory, and the 1.5% others, who think that the CDs were chosen through some other way (neither by the chief of the village, nor by the community or by the health worker); maybe by themselves, of course. 32
In any case, those who wished that the Community distributors continued their work, justiff their case by arguments, the main trends of which are outlined here:
they offer some amount of well-being; they are good people/volunteers; they have been chosen to do this work; their work is bearing fruit, since the effects of the disease are dwindling, though it is yet to be eradicated; their work is useful/necessary, because it saves life and sight.
It could be concluded that the work of CDs is rather seen to be positive by the majority of beneficiaries.
On the other hand, those who hold a counter view, and want the CDs replaced, put forth their reasons
the CDs do not want to come to us do the door-to-door distribution, though we find it difficult to go to them. The CDs prefer to serve those they know, which is to our disadvantage; The CD is not the only person in the village, but has been imposed by the chief.
This is how some villages express their views concerning the work of CDs. Maybe they are courageous to "say aloud what others think". The non-authenticity of the choice of some community distributors explains these feelings of rejection, animosity and the lack of collaboration or lack of patronage of CDTI of part of the population.
In any case, do we have CDs in all the villages?
Table 34: Breakdown of health workers with regard to the question: "Are there CDs in all the villages?" Value Absolute Relative Opinion Frequency Frequency Yes 9 t00% No 0 0% Total 9 r00%
All the health workers that were interviewed affirmed that there are community distributors in all the villages.
The mere presence of CDs in a village is not sufficient, though, even if it is necessary. The most important thing is for the distribution to be done in the required cbnditions.
In light of the above, we are going to examine the responses of health workers to the question: "Do all the selected CDs continue to do their work?" 33
Table 35: Breakdown of health workers on their responses to the above question.
Value Absolute Relative Opinion Frequency Frequency Yes 3 375% No 5 62.s% Total 8 t00%
Thirty-seven percent of the respondents say CDs continue to do their work, and 62.5oh of them, on the contrary, say some CDs have abandoned their job for specific reasons. What are these reasons?
The main one is lack of incentives; the CDs work as volunteers, leaving their farms (while others are on their farms, they go there to distribute drugs). And so for lack of incentives they abandon the job.
As a matter of fact, in some villages, the CDs are reported to have resigned or absent (this is the case of Wartema Kpaha, Andjide...)
This brings us logically to the question: "..What are the grievances the CDs submit to health workers?"
The grievances are many, but here are the recurrent ones. They relate to
Incentives; means of hansport; unwillingness or refusal of beneficiaries to take the drug; lack of collaboration of villagers, though they promised this. Refusal to gather and requirement to do house-to-house distribution; Lack of promotional items like T-shirts, caps, etc...
NB: The CDs drew our attention to this last point, on several occasions, apart from the issue of incentives.
In such conditions, what are the suggestions and recommendations the health workers put forth?
improving working conditions; sensitizing the populations at all level; guaranteeing the permanent availability of ivermectin; involving all actors in follow-up, supervision (including treatment agents, provincial directorate of health, village chiefs, traditional practitioners, religious leaders, teachers, students etc...)
c It is worth noting that the same suggestions are made by the health personnel at all levels, and also the Prefects. 34
IV. COMMUNITY DISTRIBUTORS
Bio-social characteristics
Table 36: Breakdown of CDs by age.
Opinion Absolute Relative Value Frequency Frequency t7-35 15 68.2% 36-40 4 18.2% 48-51 J 13.6% Total 22 100%
Given the figures above, it appears that:
68.2% of CDs are above 35 years; 18.2% are between 36 and 40; 18.6% are between 48 and 51 years.
The majority of community distributors are relatively very young. And yet in these areas, we discovered through our socio-ethnological profile, that only age is respected. Could the lack of respect the villagers put up, towards the CDs, not be attributed to this?
Table 37: Breakdown of CDs by gender
Opinion Absolute Relative Value frequency Frequency
Female 1 4.5% Male 2l 9s.5% Total 9 r00%
Ninety-five percant of the CDs are male, and only 4o/o are female (l out of 22).
The socio-ethnological profile of the area showed clearly that men enjoy supremacy over women. Male supremacy is seen in all spheres of social life in these communities, and only the level of education of women can liberate them from this phallocratic (and misogynic) propensity.
Table 38: Breakdown of CDs according to level of education
Opinion Absolute Relative Value frequency Frequency Primary 5 22.7% Secondary t7 773% Total 22 t00%
All the CDs are schooled at least to the primary level 35
22.7% are primary school graduates; 77.3% have secondary school education.
Considering the selection criteria for choosing CDs (reading/writing ability), one may conclude that the criteria are met for all the CDs (respondents), and that even in the extreme cases of arbitrary selection, at least these basic criteria are respected. We discovered arbitrary selection cases (at Wartema), obliging ones (at Koutougou) and obscure ones (at Solla). These are, certainly, not isolated cases. J
Observation:
We learnt that the uneven educational level is critical to the image capital of women in the Tamberma region. Maybe it is necessary to know this, and to take it into account for altering the CDTI strategy in order to improve it.
Table 39: Breakdown of CDs by tribe
Opinion Absolute Relative Value frequency Frequency Tamberma 6 27.3% Lamba l5 68.2% Kabiye I 4.s% Total 22 rc0%
It could be concluded, from the above data, that:
- 68.2% of CDs are Lamas - 27.3% are of the Tamberma tribe; - 4.5% are Kabiyes
Knowing that in this region, there is ethnic rivalry, and that there are nine ethnic groups here, it might be necessary to know if communication would not be a barrier. Do the community distributors understand the dialects spoken in the area? What languages are spoken in the area, and which of them do the CDs speak?
Table 40: Breakdown of CDs by languages spoken in the area
Opinion Absolute Relative Value frequency Frequency Tamberma 6 273% Lamba r6 72.7% Total zz t00%
Two main languages are spoken in the village
In 16 out of 22 villages (72.7%) the Lamba language is spoken; In 6 out of l6 villages (27.3%) the Tambern.ra language dominate; 36
Therefore, of the 9 ethnic groups in the area, only two are likely to have communication among its population.
What languages are spoken by the CDs?
Table 4l: Breakdown of CDs according to the language(s) spoken.
Value Absolute Relative Opinion frequency Frequency Tamberma 8 36.4% Lamba l6 72.7% Fulani 1 45% Cotocoli I 4.5% Kabiye 1 4.s%
Naouda 1 4.5%
There are several minor languages in the area. The CDs, who speak mainly the Lamba language (72.7%) or Tamberma (36.4%o), try to speak the minor ones. For example, the Tambermas understand and speak the language of the Lambas, so there is no linguistic barrier between the two broad ethnic groups. The community distributors of Lamba origin are able to work easily in Tambera area and vice versa. It is only with the minority languages that there are sometimes obstacles; but some CDs assured us that there is always a way out. For example, a CD of Lamba origin is able to converse with Fulani, who understand the Cotocoli language that the CD also speaks.
INVOLVEMENT IN PROGRAMME
Value Absolute Relative Opinion frequency Frequency 0-1 year 2 9.r% 2-5 years t4 63.7o/o 6-10 years 4 18.2% 12 years + 2 t8.25% Total 22 t00%
Almost all the respondents among the CDs have been working for at least 2 years
63.7% have been working for between 2 and 5 years; 18.zyo of CDs have been working for between 6 and 10 years; 18.2% have a long working experience of more than 12 years.
Only one out of nine (9.1%) has been working for less than ayear. The respondents are supposed to have in-depth knowledge about CDTI, since all of them have been in it for at least ayear. But does not this knowledge depend on training received? 31
Table 42: Breakdown of distributors according to the response to the question: "Did you undergo training?"
Value Absolute Absolute opinion frequency Frequency Yes t7 77.3% No 5 22.7% I Total 22 t00%
The figures in the above table show that
l7 CDs out of the 22 (77 .3%) were trained for this job; 22.7% (5 out of 22)) did not undergo any training for CDTI.
This was verified during the interviews that we had with respondents. Some CDs have little or insufficient knowledge, since they do not know all the categories of persons, who may not be treated with ivermectin.
Table 43: Breakdown of CDs according to the response to the question: "How many distributors are there in the village, apart from you?"
Value Absolute Relative Opinion frequency Frequency 0 3 14.3%
1 7 33.3% 2 7 33.3% 3 2 9.s% 4 I 4.8% ll I 4.8% Total 2r 100%
This figure varies between I and l2 CDs, according to the size of the village. For example, Kpaha is a big agglomeration with 12 residential areas; if there is need for two distributors per area, then there should be 24 of them. But they are actually only 12, and so complain of the workload being too heavy. All the CDs are calling for an increase in their numbers, especially in some villages, where they are forced to do door-to-door distribution, though they do not have any means of transport. More distributors would mean fewer problems in the distribution of ivermectin.
The lack of working tools is one of the main problems
Table 44: Breakdown of CDs, according to their work needs.
Value Absolute Relative Opinion frequency Frequency Means of transport l8 81.8% Stationery 22 100% 38
Measuring apparatus 20 909% Drugs t7 71.3% Miscellaneous 9 40%
All the 22 CDs talked about the need for stationery: they are forced to buy the latter themselves. Some of them could not show any stationery when asked for. Some of them also do not have any measuring apparatus, and make do with a graduated stick; Almost all of them (81.8%) need means of transport; given that at times they are forced to go door-to-door, and to do long distances to get to some homes. And then, there is the problem of break in stock, which worsens the situation.
o ORGAIIISATION OF TREATMENT
Table 45: Breakdown of CDs according to the response to the question: "Should all inhabitants be treated?"
Value Absolute Relative Opinion frequency Frequency Yes 2 9.r% No 20 90.9% Total 22 t00%
The community distributors responded NO in their majority to this question.
On the other hand,2 CDs out of 22 (9.1o/o), state categorically that all inhabitants of a given village have to be treated. This shows that there are still CDs who are ignorant of the CDTI strategy.
Furthermore, even those CDs, who said that not all inhabitants needed to be treated, do not necessarily know the categories of persons that should not be treated.
Table 46: Breakdown of Community Distributors in relation to the question: "If no, who should not be treated?"
Value Absolute Relative Opinion frequency Frequency Children under 5 years 2t 955% Children<9Oc 19 86.4% Pregnant women 22 100% Persons seriously ill t7 77% Nursing mothers l8 8r%
The CDs do not know necessarily know all the category of persons who may/must not be treated with ivermectin. One or two categories have always been missing from the supplied list.
For example:95.5oh gave children under 5, whereas 86.4% gave children under 90cm. 39
"Seriously ill persons" was a point given by 77% of the respondents, while 86% mentioned "nursing mothers". Only the "pregnant women" category was mentioned by all the CDs (respondents). It could be concluded that the CDs need to upgrade their knowledge through refresher courses.
Table 47: Breakdown of Community distributors relating to the question: "What do you do for absentees?"
Value Absolute Relative Opinion frequency Frequency They are attended to 22 r00% They are not attended to 0 0% Total 22 t00%
All the Community Distributors (respondents) stated that absentees are attended to. But we tend to doubt this, in as much as some tainted their answers by recognizing that only those who report are attended to. And so what about those who do not report? Again, among the absentees, there may certainly be migrants: these are mostly people who leave without informing anybody, and return in same manner. So when are such people attended to?
Table 48: To the question: "Do you know whether distribution is carried out at the same rate in the neighbouring village?", respondents had the following answers.
Value Absolute Relative Opinion frequency Frequency No 6 27.3% Yes 9 40.9% Do not know 7 3r.8% Total 22 r00%
The Community Distributors interviewed had varied opinions on this
40.9% of them said distribution was done at the same rate in the villages; 27.3% had negative responses, while 31.8% didn't know. One is tempted to put these last categories together.
Table 49: Breakdown of CDs, in relation to the question: "Do you sometimes undertake distribution in another village?"
Value Absolute Relative Opinion frequency Frequency Yes 4 1,8.2% No l8 81.8% Total 22 r00%
Sometimes it happens that CDs do distribution in another village. This applies to some of them for vanous reasons 40
because at the start-up of CDTI there were not enough distributors; following the illness of a CD; because the designated CD resigned.
Eighty-one percent of the respondents said this has not yet happened. It could be concluded, however, that the number of CDs in the area is not sufficient.
Table 50: Breakdown of CDs in relation to the kind of support they get from health personnel
Value Absolute Relative Opinion frequency Frequency Advice 2l 95.5% Logistics 8 36.4% Supervision l5 68.2% Incentives l8 81.8% Others 3 13.6%
From the above, CDs get various forms of assistance from health personnel
95.5% of them get advice; 68.2% of them benefit from supervision; 36.4% get logistics; health personnel give some kind of motivation to 31.8%o of the CDs, whereas I3.6Yo of them get some other kind of assistance.
NB: The health personnel have not done any evaluation yet of the work of CDs. Assistance covers logistics, incentives, advice and supervision. Only evaluation would help in determining ivermectin coverage, both geographical and therapeutic, and yet this is what is lacking.
What support does the community give to CDs? To this question, all the distributors had the same response: "Nothing". The community gives neither assistance nor collaboration to the CDs. This is another weak point of CDTI. The CDs would, despite everything, like to continue their work, which they deem indispensable, for as they put it themselves, "even if we are not given any material satisfaction, we are morally satisfied for saving the life and sight of the people".
All the same, the CDs have grievances that they expressed in the form of suggestions and wishes:
to have stationery supplies; to have means of transport; undergo appropriate training; continue CDTI until onchocerciasis is totally eradicated; ensure permanent availability of ivermectin; institute periodic evaluation of activities; give objects of social valorization (caps, T-shirts etc...)
Does the fact that these needs are not satisfied influence their output? 4l
V. BENEFICIARY POPULATION
r] BIO-SOCIAL CHARACTERISTICS
Table 5l: Breakdown of population according to ethnic groupings
Value Absolute Relative Opinion frequency Frequency Lambas Tamberas Sollas Kabiyes Naoudas Fulani Hausas Koukas Kotokolis
Table 52: Breakdown of respondents by gender
Population Absolute Relative Gender frequency Frequency Male 75 49.1% Female 76 s0.3% Total 151 r00%
Of a sample of 151 individuals, the breakdown by gender is as follows:
49.7% of them are male and50.3o/o are female.
Table 53: Breakdown of respondents according to marital status
Population Frequency Frequency Marital Stanus Opinion Married t28 84.8% Divorced 3 2% Widowed 49 6% Single (bach./spins.) 1l 7.3% Total 151 t000h
84.8% of respondents are married; 2o/o of them are divorced, and 60/o are single (bachelors/spinsters) 42
The married individuals form the majority, often with one family, of which they are the only "masters on board" to decide on the therapeutic course to take in the event of disease. They therefore, have the heavy responsibility of making their family patronize CDTI.
Table 54: Breakdown of population according to level of education
Population Absolute Relative Level of frequency Frequency Education Primary 47 31.5% Secondary t4 9.4% Higher education I 0.7% Unschooled 87 58.4% Total 22 t00%
From the figures above, it could be concluded that majority of the population of this area is illiterate (s8.4%)
A greater portion of the population had primary education (31.5%), and 9.4Yo of them attained the secondary education level. Does the high illiteracy rate justiff the inhabitants' adherence to traditionaVancestral practices to the extent that they refuse modern health services?
Table 55: Breakdown of population according to place of birth
Population Absolute Relative Place of birth frequency Frequency In the village tt2 76.7% In the prefecture(endem.zone) 184 2.7% Elsewhere (in Togo) 24 16.4% In a foreign country 6 4.1% Total t46 r00%
According to information on the place, the population is distributed as follows
76.7% were born in the village; 27%o were born in a prefecture village; 16.4% were born elsewhere in Togo; 4.1%o were born in a foreign country.
Almost 80% of respondents were born in the Prefecture, in the endemic zone. This means they are really concerned by the situation in the area. 43
Table 56: Breakdown of respondents according to the response to the question: "Since when/for how long have you been living here?"
Population Absolute Relative Residence frequency Frequency From birth 82 s7.3% 0-l year 3 2.t% 1-2 years 3 2.1% 3-4 years 6 4.2% 5-9 years t4 9.8% [0-19 years l4 9.8% 20 years + 2l 4.7%
More than 72Yo of the population has been living in the zone for at least 20 years, and more than 81% have been living here for at least 10 years. Those who have been there for only 2 years are just a handtul: 6 out of l5l (4.2%).
Generally, it is the people whose residence at the sites is generative (longitudinal), who are the first and actual people concerned, since CDTI is meant for them.
How do they react in relation to the strategy? How do they perceive and appreciate it? But before this, how do they appreciate health services in general?
APPRECIATION OF HEALTH SERVICES
In case of illness, where do the villagers go for consultation?
Table 57: Breakdown of villages according to their choice of place for health services.
Place of care/ Absolute Relative population frequency Frequency Home 59 s7.3% Traditional healer 2 t.9% Health centre 4t 39.8% Others I t% Total 103 r00%
It appears, from the above data, that the inhabitants, in the event of illness, get care at home in the majority of cases, and also at the traditional healer's and sect practitioners (60%). Modern health services are used by only 39.8% of the villagers. The actual fact is that the villagers are apt for consultation anywhere apart from the health centre. It was discovered that there were health centres in some villages, but the inhabitants do not necessarily patronize them.
How do inhabitants appreciate the health services offered in the health centres? 44
Table 58: Breakdown of population according to the response to the ff. question: "How do you find the services in the health centres?"
Health services/ Absolute Relative population frequency Frequency Efficacy 131 94.9% Availability rt7 83.0% Financial accessibiliW 49 34.5% Geographical accessib. 58 40.8% Good reception 136 95.t8% Poor reception 3 2.9%
The villagers recognise that treatment at the health centres are
effective (94.9 %) always available (83 %) with good reception (95.18 %)
But only 34.5% think services are affordable, financially, and 40.8% think the centers are geographically accessible.
Inhabitants of a village, such as Hounde, (in the heart of the mountain) cannot easily go to the centre of Kpaha, especially with a sick person (or a woman in labour), since it is behind a high mountain.
KNOWLEDGE, PERCEPTION AIID APPRECIATION OF CDTI
Table 59: Breakdown of villagers with respect to the question: "Have you heard about onchocerciasis?"
Opinior/populations Absolute Relative frequency frequency Yes 134 89.3% No l6 r0.7% Total 150 r00%
The villagers (89.3%) stated that they have heard about onchocerciasis. Only 16 villagers out of 150 (i.e. 10.7%) had no knowledge of it. So it could be concluded that this disease is well known to the villagers.
Table 60: Breakdown of villagers according to symptoms by which Oncho could be recognized.
Opinions/populations Absolute Relative (values) frequency Frequency Itching 57 62.6% Leopard skin 22 25.6% Lizard skin 28 32.6% 45
Nodules 8 9.t% Pruritus 6 63% Blindness 45 48.4%
Somehow, the villagers have varied degrees of knowledge about onchocerciasis and the signs by which it could be recognized. Thus:
62.6% of the villagers make mention of itching; 25.6% of them talk about leopard skin; 32.6% others recognize the disease by the lizard skin symptom; Lastly 48.8% think blindness is another sign.
To the question as to what is the most serious consequence of this disease, the responses are as follows:
Table 61: Breakdown of population
Opinion/population Absolute Relative frequency Frequency Blindness 107 89.2% Others 13 10.8% Total r20 t00%
Eighty-nine percent of the villagers know that blindness is the most serious consequence of the onchocerciasis disease. 10.8% of them do not know this. This category may be bunched together with the 10.7o/o (cf. table 53), who claim they have never heard about onchocerciasis.
We actually discovered on the field men and women, who apparently, do not want to know anything, and so did not want to answer any questions (in Hounde, Tapounte, Solla, Tchitchira-maison).
Table 62: Breakdown of population according to responses to the question: "Do you know people who are infected with the Oncho disease?"
Opinions/populations Absolute Relative frequency frequency Yes 79 s6.8% No 60 43.2% Total 139 r00%
Considering the above figures, it appears that 56.80/o of the respondents said they knew people suffering from onchocerciasis in the village, while 43%o of them did not know any patients. Those who knew patients did, for several reasons:
seeing people who have been blind for a long time; by the presence of people who have eye problems (poor eye sight); villagers with whitish rash on the skin; the ruggedness of the skin; 46
villagers themselves suffer from it; information given by onchocerciasis personnel
The onchocerciasis disease is known and recognizable by some obvious signs, and many villagers know this today, despite the presence in their midst of the "rebellious" and "ignorant" ones.
Table 63: Breakdown of populations in relation to the response to the question: "Is there any drug for treating this disease?"
Opinions/populations Absolute Relative frequency frequency Yes r27 9t.4% No t2 8.6% Total 139 r00%
Ninety-one point four percent of the people know today that there is a drug for treating onchocerciasis, while l2%o still do not know this (cf. table 59) and the others (10.8%) who do not know that blindness is the most serious consequence of this disease (cf. table 61).
But the important thing is not knowing that the drug exists; what is important is for one to take it or accept to take it. This is what is verified below:
Table 64: Breakdown of populations according to the response to the question: "Do you take the drug in this village?"
Population Absolute Relative Opinion frequency Frequency Yes r32 99.2% No I 03% Total 133 100%
On the basis of the data above, it could be said that 99.2%o (village respondents) take ivermectin, as against 0.8% who do not. It remains to be ascertained if distribution is correctly carried out under required conditions. First of all, who gives this drug?
Table 65: Breakdown of populations relating to the question: "'Who gives the drug?"
Population Absolute Relative Opinion frequency Frequency Yes 4 18.2% No l8 81.8% Total 22 r00%
Eighty-two percent of the villagers stated that it was the CD of the village who gave them drugs during distribution rounds. 47
On the other hand, l'7 .3o/o of the inhabitants are served by a health worker, while the CD of another village gives drugs to 0.8% of the respondents.
NB: It happens that a CD of a village distributes drugs in another village, especially when there are abandonment and resignation of distributor, due to lack of incentives.
It remains to be determined in what circumstances the health worker is forced to do the work, in replacement of the CD.
Table 66: Breakdown of respondents in relation to the question: "Does the CD give you the drug each year?"
Population Absolute Relative Opinion frequency frequency Yes 133 93.7% No 09 6.3% Total t42 t00%
Ninety-three point seven percent of the villagers affirm that the CDs do their work each year, while 6.7Yo of them think otherwise. Does this mean that sometimes there are lapses in ivermectin distribution in a given village? In comparing this assumption with the appreciation of the health workers and inhabitants on the work done by CDs, the following conclusion could be drawn:
44.4% of the health workers (cf. table 28) deem the work of CDs inadequate; 5.6%o of the villagers think the work of CDs is poor.
When these figures and data are compared and contrasted, it could be said that the CDs do not work as they should. But even if the CD does not do his work, do the inhabitants accept to take the drug?
Table 67: Breakdown of villagers in relation to the question: "Does everybody accept to take the ivermectin tablets?"
Population Absolute Relative Opinion frequency Frequency Yes r29 92.8% No l0 7.2% Total 139 100%
According to the above table, the villages (92.8%) agree that every body accepts to take the drug, while 7.Zoh of them think otherwise.
It is true that some people reject this treatment outright, for we were told (at Tapounte, Tchitchira- maison) that some individuals refused it. At Solla were even shown persons, who threw the tablets away in the river after distribution. 48
Table 68: Answers to the question: "Did you take the tablets last year?"
Population Absolute Relative Opinion frequency frequency Yes 138 9s.8% No 6 4.2% Total r44 r00%
95.8% of respondents affirm that they took ivermectin tablets the previous year (2000); 4.2%o of the inhabitants confess they didn't.
This could confirm the assumption that a section of the population is yet to patronize CDTI. And since most of the inhabitants claim to have taken tablets the previous year, we found out how many tablets were given them.
Table 69: Breakdown of villagers in relation to the number of tablets taken the previous year.
Population Absolute Relative Opinion frequency Frequency I 3 2.8% 2 5 4.7% 3 t7 15.9% 4 453 49.5% 6 8 75% 8 20 18.7%
The responses to this question embarrassed a lot of our respondents, who do not actually remember the number of tablets taken. The extreme differences in number of tablets left us bewildered. Nevertheless, it could be concluded that, generally, 49.5% (i.e. almost half) gave a response close to the reality: the figure 8.
Table 70: Breakdown of inhabitants in response to the question: "Have you taken ivermectin this year?" Population Absolute Relative Opinion frequency frequency Yes 133 93% No l0 7% Total 143 100%
It may be observed that 93o/o of the villagers took (or claimed to have taken) the drug this year (2001) There are always people who "missed" it. Thus,TYo of the respondents confessed they did not take it.
Since the drug was taken, it is proper to know what they think of it. 49
Table 7l : Breakdown of villagers in relation to the question: "What do you think of this drug?"
Population Absolute Relative Opinion frequency frequency Efficacious t2t 89.6% It does good l8l 86.1% Negative after effects 55 45.1%
The respondents have varied appreciation on ivermectin:
89.6% of them think it is efficacious; 86.1% think it does them some good; 45.1% think the after effects are negative.
Observation:
Those who are of the view that the drug does them some good give the following reasons:
- it clears up vision; - it gives some relief, and makes the body much lighter; - it gives some energy/strength, and awakens.
On the other hand, those who believe the drug has side effects give the following reasons:
at the beginning, it causes itching; sometimes it causes swelling of the face and feet
Despite these physiological hazards, ivermectin is accepted and taken by the populations, according to their statements, at least.
o Other appreciations of CDTI by populations.
Table 72: Breakdown of population according to the mode of distribution applied (or preferred)
Breakdown Absolute Relative Opinion frequency frequency Door-to-door 66 48.9% Public place 6 4.7% Village school 22 t7.t% Chiefs compound 62 46.3% Other places tl 85%
According to the villagers, the following distribution modes are practised
489% mentioned door-to-door; 4.7%o said the public place; 17 .l% stated it was done in the village school; 46.3% said the chiefs compound; 8.5o% mentioned other places. 50
The door-to-door mode and the distribution done in the chiefs yard are the two distribution modes that are the most used; then comes distribution at the school, the public place and that of other places. There are often cases of misunderstanding, as in the following examples:
some villagers (the aged and the sick) prefer the door-to-door mode, their argument being that their condition does not allow them to travel to the places of distribution. The problem is that the CD is often accused of encroaching on the privacy of people who do not respond to the distribution gathering. The meeting in the chiefs yard or at the school allows for controlling the presence or absence of inhabitants. In addition, people are served and supervised in drug administration (since sometimes they are forced to take the tablets, by giving them a cup of water). This is an affront to the stubborn ones, who reject CDTI, because they think their freedom is being trampled on. Drug distribution on the farm is considered by some as a violation of their rights.
In any case, the CDs are not better off in this. It is clear, from all the foregoing, that the community distributors find themselves cornered, though available and of good will. It could be asked what the inhabitants do in return, based on the following data?
Table 73: Breakdown of inhabitants according to the response to the question: "Does the community give any assistance to the CDs?"
Population Absolute Relative Opinion frequency frequency Yes ll 8.2% No 123 9r.8% Total 22 100%
The villagers do not give any assistance to the community distributors. The responses given above are proof of this.
123 out of 134 village respondents confess that the inhabitants do not assist; 8.2oh say they give assistance.
The villagers were sincere and consistent with themselves, because they actually do nothing to encourage distributors, neither do they give emoluments as incentives, and so the latter complain bitterly. This means that the inhabitants did not keep their promise of respecting agreements of partnership, which were entered into at the start-up of CDTI. It is, without doubt, these lapses, coupled with the other problems (lack of incentives, Iack of means of transport and working tools) that perhaps explain the somewhat c insufficient work quality of CDs, the resignation and abandonment of posts of some of them.
Consequently, to the question of what advice the villagers would give toward improving CDTI in the zone, the former threw back the ball in the court of Oncho Programme officers. And as if to rationalize the shrugging off of their responsibility, they use metaphoric statements or proverbs such as: "HE WHO CALLS THE PIPER PAYS THE TUNE''. 5l
OBSERVATION
We have just taken a trip through the basin of the Oti and its tributaries (Keran and Kara), a somewhat special endemic area. This took us, as researchers, to capture images and sounds, as well as listen to speeches and their meaning, to exchange looks into faces (looks of those who may never be able to see again, for blinded forever). We conversed with people in sinrations such as:
those who are ill, certainly already bitten by black flies (and waiting to go blind); others who are yet to be affected, and who are worried, in anguish and ready for everything in order to avoid the irreparable situation; those who "missed" treatment, and are infected or not, but who do not want to do anything to be saved or spared from the onchocerciasis disease; and the actors in their actions, in a bid to implement CDTI, with their hopes and aspirations and despair, their pain and joy, and armed with the willingness to save the life and sight of their loved ones, other villagers and of themselves.
This, to us, is wandering in another world, where for several years, the inhabitants have been confronted with the Oncho disease (with its army of savanna black flies) on two battlefronts: vector control and treatment with ivermectin. And we actually saw helicopters in spraying action on the Keran (at Nyande, at Goulbi - Tchitchira sector). We also saw community treatrnent agents distributing ivermectin at Koutougou (Tapounte sector) - two problem-prone sectors, where onchocerciasis is causing havoc by undermining all projections and expectations.
What are the lessons after wandering in such a world?
First of all, this study gave us a singular opportunity to discover and experience the reality of a national tragic situation, in its bare and day-to-day nature. We realized that CDTI meets a real, visible urgent and priority need (here Oncho can make one forget malaria and AIDS). Therefore CDTI needs, necessarily, to continue. Next, if despite all that has been done and continues to be done, the situation in this endemic area has not yet given satisfactory entomo-epidemiological profile, then there are questions to be answered. There are causes, some of which we identified. Finally, there are rays of hope that the results could further be improved, in order to reverse the trends. This is because the victims, apart from those "who missed out", see Oncho the same way as the doctors and entomologists perceive it. It suffices to assist these villagers and actors (health personnel and community heatrnent agents) in their bid to rectiff or improve some aspects of the CDTI strategy, (as presently being experimented), and to add other strategies that better take into account field realitieVspecificities.
What does all this mean?
Beneficiaries
The specificity of how they organize their lands, in a given cultural context, needs to be taken into account. The dispersed nature of habitats, the long distances between houses, and the inaccessibility of some villages, which makes movement of health workers and community treatment agents difficult. The inhabitants are closely attached to ancestral practices; this 5Z makes their complete acceptance of the use of modern health services difficult. However, these people are not so adamant to the modern way of doing things. They, especially, see the merits, the necessity, efficacy and advantages of CDTI. Majority of them understand that ivermectin may help them overcome their woes, and save their lives and eyesight. By raising awareness, their frank and free-will patronage could be obtained. In any case, no sensitization was done, and no environmental study was conducted prior to the start-up of the Programme. These are being envisaged, after several years, when the Programme is drawing to a close.
Actors
Health personnel have not yet mastered the strategy, and also lack the means for carrying out their work. They only do what they can with the means they have. Most of them know this, and so their grievances may be expressed in one sentence: They need the necessary tools to do their work, and also their working conditions need to be improved. It is true that some of them do not even have fuel for their supervision/evaluation trips, because we had to give them money to buy fuel, whenever our arrival in a village had to be announced in advance. Their economic/financial problems have worsened with the non-payment of salaries in Togo. The health personnel have other problems: Their dearth of knowledge and lack of mastery of CDTI. All the health workers involved in the Programme were not trained to that effect, and those who were trained have difficulty in coping, because since 1997 they have not undergone any training, not even a refresher course. In these conditions, will the health workers be involved and perform as they should?
And as they are not very effective, this naturally affects the quality of work of community treatment agents. Since the health worker himself is not competent, the treatment agent will also be incompetent and will poorly treat inhabitants. One should therefore not be surprised about the results obtained.
Community Treatment Aqents
Several among them do not know really know the CDTI strategy. For instance, they do not know the categories of persons that should not take ivermectin. This is a very serious shortcoming. If the villagers complain about negative side effects of the drug, then may be this needs to be researched also. Again if the effrcacy of the drug is questioned by some beneficiaries, the fault could be attributed to the treatment agents, who might have overlooked the doses and the distribution of the drug. Distribution is not supervised by the health workers, so this gives room to all kinds of lapses and shortcomings. The other serious shortcoming is that no evaluation of the activities of treatment agents has been carried out to date, to determine the geographical and therapeutic coverage of treatment with ivermectin, and neither has supervision been systematically instituted.
The only support the treatrnent agents have is their will to work, and the only remuneration they derive is the moral satisfaction of rendering indispensable and useful service. They do not have any incentives nor do they have aid (in kind) from the villagers. Mere "thanks" cannot satisfo them completely. They do not have working tools (stationery, measuring apparatus and sometimes drugs). They often buy copybooks, pens and others from their own pocket, which are almost always empty. The Treatment Agents are sometimes forced to conduct the door-to- 53
door distribution with no means of transport, either to look for absentees or those who deliberately refuse to attend distribution sessions. They at times go as far as to the farms to serve villagers. And upon all this, they are sometimes insulted and met with humiliating words. Under such conditions, can the treatment agents carry out their duties as expected of them?
The problem of migration
There are migration movements almost every day in the area: a
inhabitants go to other places to farm during the rainy season; strangers (gold winners, especially) move in during the dry season, when the water levels subside and dry up. So population movements may be observed all year round. Some sectors are hard hit by this migration. These are, for example, Tchitchira and Tapounte, while villages like Goulbi, Nyande and other experience large-scale immigration, and are practically invaded by gold winners, and by the Fulani animal raisers and their herds during the rainy season. Where migration is intense, the population is reduced and so the rate of black fly bites is also high; this may give inaccurate results, with respect to treatment with ivermectin, especially with those who are treated (doctors and entomologists know this better than we do). Where immigration is intense, the number of non-treated inhabitants increases, and this in the long run, may also have a negative impact, by undermining or annihilating completely the efficacy of treatment (this must also be known by doctors and entomologists).
Other factors
There are other factors that are not being managed yet. These include:
the way mythicaUreligious bodies address the onchocerciasis disease, thus directing the population onto another therapeutic course altogether; the level of ignorance of some sections of the population, and the interference this brings to bear on the coherence in CDTI implementation; the lack of collaboration on the part of inhabitants, by not keeping their promise of assisting community treatment agents.
This is about how the socio-demographic picture of the endemic zone looks like, which makes the continuation of CDTI a necessity. But the latter needs a new impetus, with adequate and appropriate strategic orientations.
We hope this study will throw some more light into the darkness of this area. a Thank you. 54
CONTRIBUTION OF THE STUDY : LESSONS LEARNT SOME SUGGESTIONS AND RECOMMENDATIONS
a 55
This study helped identiff factors that could explain why the entomological and epidemiological situation of the area has always not been satisfactory. These factors may be several and varied, but only the most salient will be mentioned here.
Population-related factors
It appeared that the physical (geographical), social and cultural realities of the area, o including demographic aspects, do not create favourable conditions for effective implementation of CDTI. Then come into play other realities that dictate the type of attitudes and behaviours that compromise the coherence of the strategy. This is obvious. Even if the beneficiaries appreciate the efficacy of modern health services, the conception they have of the disease does not make for total acceptance of treatment with ivermectin by some sections of the society. The inhabitants have erroneous ideas about the status of community treatment agents, and as such they refuse to assist them in their duties; this breaks the agreement of partnership that was entered into before the start-up of CDTI.
Factors relating to health workers
All the health workers involved in CDTI (in the Kara region) had insufficient training (for a period of two and a half days), whereas this lasts for 5 days in other places of the country. Worse still, some did not have this training at all, and since no re-training has been organized for them to date, they have a lot of shortcomings. They have not implemented any strategy for evaluating activities of the community treatment agents, whom they hardly assist in supervision and follow-up. In this case, it is difficult to appreciate the geographical and therapeutic coverage of ivermectin, and to take stock of the situation after one year of distribution. Health workers experience a serious dearth of logistics for their effective work on the field (e.g. fuel and incentives, including other things).
In any case, the health workers are not able to, effectively and effrcaciously, train and mentor community treatment agents in their activities.
Factors relating to Communitv Treatment Agents
Most of the community treatment agents do not at all master the strategy, because they had no training to that effect (apart from some hours or minutes of briefing, given by the health worker, who is not well trained either, and does not know the strategy very well). There are sufficient treatment agents, but they are solicited for distribution in farms, houses, and hamlets and dispersed farmhouses. They do not have means of transport, so I automatically, the geographical and therapeutic coverage of ivermectin is a problem or unreliable. They have neither incentives nor assistance from the inhabitants, who see them as salaried workers that are paid to disturb people (this is especially the case of those who hate CDTI, and who refuse to go for distribution sessions). s6
On the whole, the treatment agents cannot really get involved seriously and effectively in the Prgoramme.
Migration-relAted issue
This is no longer an assumption: there are actually population movements in the zone in question. The inhabitants confirmed this, as well as some health workers and community treatment agents, who had to treat some immigrants (The Fulanis at Goulbi, for instance with whom we conversed in the Cotocoli language):
the migrants move within the zone and elsewhere; they do not inform anybody before traveling (of course they have the right to that), and they do not announce their return either. The immigrants behave the same way, except that they can easily be made out, since it is known for sure where gold winners are, for example. The other problem is with the Fulanis (animal raisers), since they are unpredictable due to their mobility.
The health workers formally recognize that there is a link between these population movements and geographicaUtherapeutic coverage of ivermectin in the area. This is because the migrants are not counted, taken into account and treated.
Other factors
MythicaVreligious movements (or sects) are found in the area (sectors of Tchitchira and Tapounte especially, where the "ATINKARE" sect from Benin or Nigeria operates). They take advantage of the onchocerciasis disease and offer miraculous healing to the inhabitants. Some Oncho-affected villagers have fallen victim to this, and have refused ivermectin, but today they are blind, unfortunately. The existence of these mythicaVreligious movements is confirmed by members of the National team. They agree that health workers often find it diflicult to communicate messages (IEC, family planning, vaccination etc...), due to the activities of some sects. The ignorance of some sections of the population, which have erroneous ideas on community treatment agents, who go to the extent of refusing all collaboration for the smooth running of CDTI.
These are, generally, the most obvious factors that the study brought to the fore, and which could explain why the entomologicaVepidemiological situation of the zone is not yet satisfactory. All these factors, have, in a way been unfavourable to or impeded CDTI implementation. Of course the latter, has had some impact on beneficiaries.
a 57
IMPACT OF CDTI ON THE BENEFICIARIES
Strons ooints
CDTI has surely impacted the inhabitants, since 89.3% (cf. Table 59) of the villagers know how to recognize the disease, and also the links, i.e. the causal relationships (black fly bites and the disease). I Besides the villagers know there is a drug for treating onchocerciasis - 91.4% (see table 63); Not only do villagers know ivermectin, but they also take it regularly;99.2% of them have adopted this behaviour; 68% know the categories of persons, who are not to be treated with ivermectin; They attest to the efficacy of the drug and its good effects for those who take it regularly: 89.5o/o say this. The villagers (...%) express the wish of seeing CDTI continued, and consequently the work of treatment agents. Another positive point is the building of local capacities, when one meets treatment agents imbued with the willingness to do the work, despite problems and difficulties encountered, including acts of humiliation from inhabitants. Finally, mention could be made of the fact that the health workers have integrated CDTI into their action plans, and consider/accept it as part of minimum activities to be conducted by a health worker.
These strong points keep CDTI moving, despite the weak points.
Weak points
- The first point here is the lack of an environmental study, prior to the start-up of CDTI in the endemic area; - The lack of sensitization of beneficiaries at the beginning and during CDTI implementation; - The inadequacy of training given to health workers and to treatment agents involved in the strategy; - The lack of collaboration from the part of villagers; - The lack of clarity in the selection of distributors; - The absence of incentives for distributors; - The dearth of logistics given to health workers and treatment agents for carrying out their duties; - The inability of actors in managing the problem of migration.
I On the basis of the foregoing, the following suggestions and recommendation are made. 58
SUGGESTIONS AND RECOMMENDATIONS
a First of all, this study, which is just a draft, needs to be redone over a much longer period (at least 2 months), and at an appropriate period, i.e. at the beginning of the dry season, due to the following reasons:
- It is one of the periods of the year when village populations are supposed to be present in the villages. - Immigrant numbers are high at this time; - Inhabitants who go outside the area to farm elsewhere come back home during this period; - This is the period when paths are relatively passable, when the team of researchers would not have the problems they encounter in the rainy season; - Ca.r), out large-scale sensitization of beneficiary populations, in partnership with the following:
o Political and administrative authorities (Prefects, Canton chiefs, village chiefs, elders and health personnel). . Religious leaders (priests, imams, traditional healers, diviners, sect leaders etc..); . Opinion leaders of the various social strata (age groups, clans, lineage, associations); o Offer training/re-training to health workers and community treatrnent agents. o Institute regular refresher courses to enable actors to periodically update their knowledge. o Ensure that the drug is permanently available at each health zone. o Introduce incentives (motivation) for actors (health workers and treafinent agents). o Provide treatment agents with means of transport. o Provide treatment agents with working equipment (stationery and measuring apparatus). o Organize brainstorming days with all actors (National team, health workers, treatment agents, village chiefs and village representatives) to examine the ways and means of ensuring a better application of CDTI. o Identi& new community treatment agents (especially women and young ladies in the Tamberma area) in order to increase their numbers. o Finally, undertake a census of migrants, on a yearly basis, in order to reckon and take their numbers into account in the treatment effort, and also to control their departure.
Observation
The study was based on the assumption that vector control is carried out very well, as it should, and a that it is efficacious. But, given the physical and geographical realities of the area, we may take the liberry of expressing, save doubts, some reservations about this success story.
To the extent feasible, and on the basis of all the inputs for appreciation, it would be desirable to review the conditions under which larviciding and ground treatment are carried out. This will help avert, finally, any hypothesis in this area. 59
CONCLUSION
The first goal of this study is to try and identiff factors that could explain the entomo-epidemiological situation of an endemic area. Thus, after several years of a dual control effort (vector control and chemotherapy), the results do not seem satisfactory.
The field surveys lasted, on the whole, 12 days. The data analysis and interpretation revealed some a quite significant elements:
The physical (geographical) realities of the area may constitute critical handicaps to the work of treatment agents and health workers; The ethnic and/or clan differences bring up social logics and family trajectories, which, at a certain level of actual social experiences, could undermine CDTL Cultural and religious practices have an impact on this situation, since they do not encourage the inhabitants to embrace modernity.
There are also migratory movements, which, given the population dynamics they maintain, may undermine the data by influencing the geographical and therapeutic coverage of ivermectin.
The beneficiary populations have with them some persons who "missed out", and who do not wholly accept CDTI, through their behaviour that is incompatible with its coherence.
The actors do not always have the needed inputs for their work; in addition, they were not trained for this work.
But, CDTI has a positive impact on the beneficiary inhabitants, despite all these negative aspects, in that it has made majority of the people adopt desirable and expected behaviours.
It is for these reasons that CDTI must continue to help these inhabitants face the repeated assaults of the savanna black flies.
These inhabitants, who desire to live, need to be helped.
I