World Relief June 22, 2012 Cooperative Agreement Number: GHN-A-00-09-00017-00 Program Location: Bilene, Chicualacuala, Chigubo, Chókwè, Guija, Mabalane, Massangena and Massingir Districts of Gaza Province, Mozambique Program Dates: September 30, 2009-September 29, 2014, Date of Report Submission: June 22, 2012 EVALUATION World Relief Mozambique Vurhonga Community-Based DOTS Project Mid Term Evaluation Report, 2012 World Relief Mozambique Vurhonga Community-Based DOTS Project Mid Term Evaluation Report Cooperative Agreement Number: GHN-A-00-09-00017-00 Program Location: Bilene, Chicualacuala, Chigubo, Chókwè, Guija, Mabalane, Massangena and Massingir Districts of Gaza Province, Mozambique Program Dates: September 30, 2009-September 29, 2014 Date of Report Submission: June 22, 2012 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 i Authors Henk Eggens, MD, MPH HE MTE Team Leader Monisha E. Jayakumar BDS, MPH, PhD MJ Health Advisor, World Relief Editors Pieter Ernst, MD PE Director of Program Integration, World Relief Mozambique Adolfo E. Cambule, MD AC TB-DOTS Manager, World Relief Mozambique Team members Alfredo MacArthur, MD, MSc AM Infectious Diseases Advisor, USAID Mozambique Mission Nicídia Pereira Provincial Tuberculosis Control Supervisor (Gaza, Mozambique) For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 ii Contents Executive Summary ................................................................................................................................................ 1 A. Preliminary Information ................................................................................................................................ 4 A.1 Summary table ....................................................................................................................................... 4 B. Evaluation Methodology and Limitations ..................................................................................................... 6 C. Data Quality and Use ..................................................................................................................................... 7 C.1 Compliance with international terminology .......................................................................................... 7 D. Overview of the Project Structure and Implementation................................................................................. 8 D.1 Project goal and objectives (include the project’s Results Framework, if available) ............................ 8 D.2 Project location .................................................................................................................................... 10 D.3 Estimated project area population........................................................................................................ 10 D.4 Technical and cross cutting interventions, Project design, Partnerships/collaboration ....................... 10 D.4.1 Intermediate Result 1: Empower people with TB to seek and complete treatment with the support of their communities. (45% Effort) .............................................................................. 10 D.4.2 Intermediate Result 2: Strengthen NTP Systems to improve TB service delivery and patient outcomes. (45% Effort).............................................................................................................. 11 D.4.3 Intermediate Result 3: Decrease the burden of HIV in people with TB and decrease the burden of TB among PLWHA. (10% Effort)........................................................................................ 13 D.5 USAID Mission Collaboration ............................................................................................................ 14 E. Presentation of Progress toward the Achievement of Project Results ......................................................... 15 E.1 Intermediate results.............................................................................................................................. 15 E.2 Intermediate result 1 ............................................................................................................................ 15 E.2.1 Project achievements .................................................................................................................. 15 E.2.2 Case notification ......................................................................................................................... 15 E.2.3 Training of CGV......................................................................................................................... 16 E.2.4 Village health committees........................................................................................................... 18 E.2.5 Accompanying tuberculosis cases in the village......................................................................... 18 E.3 Intermediate result 2 ............................................................................................................................ 18 E.3.1 Project achievements .................................................................................................................. 18 E.3.2 Sputum positivity problem.......................................................................................................... 19 E.3.3 Treatment outcome ..................................................................................................................... 19 E.3.4 Drug stock-outs........................................................................................................................... 19 E.4 Intermediate result 3 ............................................................................................................................ 20 F. Discussion of the Progress toward Achieving Results ................................................................................ 20 F.1 Contribution toward Objectives/Results .............................................................................................. 20 F.1.1 Conceptual issue ......................................................................................................................... 20 F.1.2 IR1: empowerment of tuberculosis patients improving health seeking behavior ....................... 20 F.2 Contextual Factors ............................................................................................................................... 23 F.2.1 World Relief ............................................................................................................................... 23 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 iii F.2.2 Miners-emigrants........................................................................................................................ 23 F.2.3 Community DOTS initiatives elsewhere in Mozambique .......................................................... 23 F.3 Role of key partners ............................................................................................................................. 23 F.4 Overall Design Factors that Are Influencing Progress Toward Results .............................................. 25 F.4.1 Sustainability .............................................................................................................................. 25 F.4.2 Composition of CG Volunteer groups ........................................................................................ 25 F.4.3 Expertise in tuberculosis control at project design stage ............................................................ 25 F.4.4 Gender of CGVs ......................................................................................................................... 25 G. Conclusions and Recommendations ............................................................................................................ 26 G.1 Conclusions ......................................................................................................................................... 26 G.2 Recommendations ............................................................................................................................... 26 G.2.1 Sharing project learnings ............................................................................................................ 26 G.2.2 Learning more............................................................................................................................. 27 G.2.3 Community empowerment.......................................................................................................... 27 G.2.4 IR2: Strengthening government tuberculosis control services.................................................... 28 G.2.5 IR3: Lessening the burden of HIV.............................................................................................. 28 H. Action Plan for Responding to Evaluator Recommendations ..................................................................... 28 I. Tuberculosis Grantees ................................................................................................................................. 29 J. Annex .......................................................................................................................................................... 30 J.1 Annex 1: Learning brief..................................................................................................................... 30 J.2 Annex 2: List of Publications and Presentations Related to the Project ............................................ 32 J.3 Annex 3: Project Management Evaluation ........................................................................................ 36 J.3.1 Planning ...................................................................................................................................... 36 J.3.2 Supervision of Project Staff........................................................................................................ 36 J.3.3 Human Resources and Staff Management .................................................................................. 36 J.3.4 Financial Management................................................................................................................ 36 J.3.5 Logistics...................................................................................................................................... 36 J.3.6 Information Management............................................................................................................ 36 J.3.7 Technical and Administrative Support........................................................................................ 37 J.3.8 Management Lessons Learned.................................................................................................... 37 J.4 Annex 4: Work plan Table ................................................................................................................ 38 J.5 Annex 5: Rapid Catch Table .............................................................................................................. 40 J.6 Annex 6: Mid-Term KPC Report ...................................................................................................... 41 J.7 Annex 7: CHW Training Matrix ...................................................................................................... 100 J.8 Annex 8: Evaluation Team Members and their Titles ..................................................................... 101 J.9 Annex 9: Evaluation Assessment Methodology .............................................................................. 101 J.9.1 Evaluation team scope of work, including timeline of activities .............................................. 101 J.9.2 Data collection instruments, including interview guides, data extraction guides, and questionnaires used .................................................................................................................. 103 J.9.3 Key Informant interviews (KII) ................................................................................................ 103 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 iv J.9.4 Focus Group Discussions.......................................................................................................... 103 J.9.5 Names of places visited ............................................................................................................ 104 J.9.6 Documents reviewed................................................................................................................. 104 J.10 Annex 10: List of Persons Interviewed and Contacted during the MTE ........................................... 104 J.11 Annex 11: Project Data Form ............................................................................................................ 107 J.12 Annex 12: Suggested terminology ..................................................................................................... 111 J.13 Annex 13: Indicator definitions ......................................................................................................... 112 J.14 Annex 14: Key Strategies and Activities: details .............................................................................. 116 J.14.1 Intermediate Result 1: Empower people with TB to seek and complete treatment with the support of their communities. (45% Effort) ............................................................................ 116 J.14.2 Intermediate Result 2: Strengthen NTP Systems to improve TB service delivery and patient outcomes. (45% Effort)............................................................................................................ 118 J.14.3 Intermediate Result 3: Decrease the burden of HIV in people with TB and decrease the burden of TB among PLWHA. (10% Effort)...................................................................................... 121 J.15 Annex 15: Mozambique page WHO global tuberculosis report 2011 ............................................... 123 J.16 Annex 16: Referral flowchart ............................................................................................................ 125 J.17 Annex 17: M&E Table ....................................................................................................................... 126 J.18 References ......................................................................................................................................... 130 Table 1: Summary of Major Project Accomplishments .......................................................................................... 4 Table 2: Updated population (2011) ..................................................................................................................... 10 Table 3: SS+ TB cases in project area................................................................................................................... 10 Figure 1: District tuberculosis register, Massingire district, Gaza province, Mozambique .................................... 6 Figure 2: Results Framework .................................................................................................................................. 9 Figure 3: Smear-pos. TB Case Notification Rates (CNR), project area, 2010-2011............................................. 16 Figure 4: Smear-pos. TB notification rate; project area, per district, Mozambique, 2010 .................................... 16 Figure 5: Care Group Volunteer network for CB-DOTS project.......................................................................... 17 Figure 6: Suspect (S) flow..................................................................................................................................... 17 Figure 7: Proportion of patients on CB-DOTS. Source: M-DRAT....................................................................... 18 Figure 8: Treatment success rate, project area, cohorts evaluated in period 2010-2011....................................... 19 Figure 9: Case notification and estimated TB incidence rates, Mozambique, 1990–2010.................................... 21 Figure 10: District tuberculosis register, column 7 ............................................................................................... 22 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 v Acronyms ACSM Advocacy Communication and Social Mobilization AIDS Acquired Immune Deficiency Syndrome BL Baseline CB-DOTS Community Based- Directly Observed Therapy Short-Course CG Care Group CGV Care Group Volunteer C-HIS Community Health Information System CNR Case Notification Rate CPT Cotrimoxazole Preventive Therapy CSHGP Child Survival and Health Grants Program DOT Directly Observed Therapy DOTS Directly Observed Therapy Short-Course DPS Direcção Provincial de Saúde (Provincial Health Department) DRAT District Rapid Assessment Tool FE Final Evaluation FGD Focus Group Discussions FHI Family Health International FY Fiscal Year HBCA Home Based Care Activist HC Health Center HF Health Facility HFA Health Facility Assessment HIV Human Immunodeficiency Virus HP Health Post HQ Headquarters KAP Knowledge, Attitudes and Practices KII Key Informant Interviews KPC Knowledge Practice and Coverage LE Lead Evaluator M&E Monitoring and Evaluation MDR-TB Multi Drug Resistant Tuberculosis M-DRAT Modified District Rapid Assessment Tool MISAU Ministério de Saúde (Ministry of Health) MOH Ministry of Health MTE Midterm Evaluation NGO Non-Governmental Organization NTP National Tuberculosis Program Padrinho Community TB treatment observer PLWHA People Living With HIV/AIDS For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 vi PNCT Programa Nacional de Controle de Tuberculose (National Program for Tuberculosis Control - Mozambique) Q Quarter SS+ Sputum Smear Positive SS- Sputum Smear Negative TB Tuberculosis USAID United States Agency for International Development VHC Village Health Committee WHO World Health Organization WR World Relief For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 1 Executive Summary Design The Vurhonga Community-Based DOTS1 project started in December, 2009, in six rural districts and three urban areas (total est. 582,000 population) in Gaza Province, Mozambique. The project is implemented by World Relief (WR) and is funded by USAID’s Child Survival and Health Grants Program (CSGHP) with main project office located in Chókwè. The project duration is through September 2014. This report describes the findings, conclusions and recommendations of the midterm evaluation mission (MTE), according to USAID guidelines. The MTE was performed in April 2012. The project addresses the tuberculosis (TB) problem in the area. Its primary objectives are to increase the TB case notification rate by 50% and to achieve 85% treatment success rate in the project area. The project Detailed Implementation Plan (DIP) distinguishes three planned Intermediate Results (IR): IR 1: Empowerment of people with TB to seek and complete treatment with the support of their communities (45% Effort). IR 2: Strengthen the provincial TB control program to improve TB service delivery and patient outcomes (45% Effort). IR 3: Decrease the burden of HIV in people with TB and decrease the burden of TB among people living with HIV/AIDS (10% Effort). Two medical officers, ten district supervisors and support staff constitute the professional staff, all employed by WR. The project uses pre-existing WR volunteer structures, mainly Care Group Volunteer networks and Village Health Committees in rural areas. Conclusions 1. This project has potential to improve life perspectives for tuberculosis patients. The project offers good potential for developing an effective community based DOTS system: a. The project is well established in terms of human resources, counting on a very motivated project staff, a fine mesh of volunteers and a well-structured supervisory system. b. The first phase of preparing the staff and volunteers in the project, plus the organizational setup is completed. A solid volunteer network was developed, with a well-structured supervision system. The remaining two years of the project will be dedicated to implementation and transfer to government responsibility. c. Community Based DOTS is a national priority. Lessons learnt and an exchange of experiences can lead to a favorable development in TB control in Mozambique. 2. The position of World Relief in the project area can be considered as long-lasting, given its other goals in Mozambique. 1 DOTS: Directly Observed Treatment Short course is the internationally recommended strategy for tuberculosis control. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 2 3. There is a conceptual issue: objectives, strategies and performance indicators are defined very comprehensive and there are considerable external influences. This causes difficulties in monitoring direct project performance. The M&E table is the main source of project performance assessment. 4. Implementation of planned activities as seen by the M&E table is according to schedule. 5. The main project objective to increase tuberculosis notification is not yet achieved. Outside influences are likely to be major determinants. The project is contributing to reaching the three intermediate results. 6. Relations with the provincial and national government system are good. Strengthening by more intensive support and collaboration is requested by provincial authorities. 7. There are sustainability concerns: project structure and its monitoring system are probably too labor intensive and expensive to transfer to government without significant modifications. Recommendations The following activities are recommended to enhance the project quality and ensure sustainability of the project. 1. Make a scenario script. Such a scenario would outline the steps, resources, organization and timeframe to develop CB-DOTS in a district. The MTE team recommends developing such a How-To manual using the project experiences. 2. Create a platform for sharing experiences. MISAU and World Relief are encouraged to develop an annual platform, sharing national (and international?) CB-DOTS experiences. 3. Learn more. The project offers good possibilities to get more insight in processes that enhance or hamper results in community DOTS. Health system research methodology is particularly adequate to seek a better understanding. Suggested topics are: a) The patient perspective, applying the Quote-Light tool. b) A cost-effectiveness study, defining investments and running costs per patient found or patient cured. c) Human resource utilization study: Determination of time spent by CGVs on specific defined tasks. These studies need a partnership from the MISAU research department or other suitable institutions in the country. 4. Community empowerment a. Review volunteer tasks The design of the project, including the use of village volunteers is clearly geared towards empowerment of communities in relative isolation of services. The challenge is to maintain motivation of CGVs by providing adequate satisfying tasks, increasing the scope of voluntary work (HIV!?) without overburdening voluntary solidarity. b. Include ex-patients It is suggested to engage TB-affected community members in the project village activities, as they are potential agents of change. c. Attention to miners Due to the existing temporary migration of male villagers to work in South African mines, the project is advised to involve male volunteers to increase mobilization of male suspects and assist male TB patients on treatment. The project management should contact USAID and TBCARE1 to pursue a possible project linkage with the recently developed “Mining project” (TBCARE 1 initiated). For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 3 d. Collaboration with government services Strengthening government tuberculosis control services needs more emphasis in the second phase of the project. An increase in case notification and high quality monitoring should be leading targets for this cooperation. 5. One-stop strategy In Mozambique 61% of detected tuberculosis patients are HIV-positive. It makes sense to support co-infected patients by one organization only. The World Relief project should consider adopting a “community one-stop” strategy, extending home care for TBHIV patients by village CGVs. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 4 A. Preliminary Information A.1 Summary table Table 1: Summary of Major Project Accomplishments Project Inputs Activities Outputs Outcome IR1: Empower people with TB to seek and complete treatment, with the support of their communities (45% effort) Strategy 1.1: Advocacy, Communication, and Social Mobilization (ACSM) (RD)  Address traditional beliefs that inhibit case detection and treatment seeking  Reduce stigma associated with TB and address barriers to treatment seeking  Training of CG Supervisors  Training of CGVs and FPVs  Training of functional VHCs  Supervision of CGVs and FPVs  Education topics include TB transmission, signs and symptoms, treatment options and transmission methods.  Care Group Volunteers (CGV) also focus on stigma reduction and overcoming barriers for treatment seeking.  10 CG Supervisors were trained in Q2&Q3 in year 1  3377 CGV and 184 FPVs have been trained  Trained 100% (n=223) of functional VHCs  Project supervisors visit villages in their responsibility every week.  Developed community￾based curriculum, “Hope at Home,” that includes specific activities community members can do to prevent infection and the spread of TB, which serves as a template for this training.  Created community specific initiatives for reducing stigma and overcoming barriers.  Knowledge that TB is transmitted through the air by coughing at baseline was 20.7% (95% CI: 12.0% - 29.4%) and by midterm it had increased to 61.3% (95% CI: 55.6% - 66.9%), exceeding the target of 60%.  Knowledge that TB is curable continued to remain high with the midterm level of 91.7% (95% CI: 87.9% - 94.5%) from a baseline of 85.3% (95% CI: 0.0% - 90.7%).  Decline in proportion of respondents who opted to seek care from traditional healers, if they had symptoms of TB from 21.1% at baseline to 0.7% at midterm). Strategy 1.2: Case Detection  Periodic house visits by CGVs with supervision by FPVs, and CG Supervisors  CGVs visit the 10 households in their care and teach mothers about TB signs, symptoms and availability of treatment  CNR at baseline was 128.3 (n=70) per 100,000 which fluctuated over the past 2 years and was found to be 107.7 (n=61) per 100,000 at midterm Strategy 1.3: Treatment Compliance (RD)  Treatment compliance is monitored  Padrinhos selected by every TB patient, are treatment observers, who register the taking of treatment daily in the patient register, report adverse reactions, or discontinuation of treatment.  Treatment success was 78.6% (n=44) in Q1’10 and increased to more than 80% in the subsequent quarters, except quarters Q3 and Q4 of 2011 when it dropped to 77.7% (n=73).  Cure rate was 71.4% (n= 40) in Q1’10 which increased to 75.5% (n= 73) in Q4’2011.  Interruption rate was 3.6% (n=2) in Q1’10 and 3.2% For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 5 Strategy.1.4: C-HIS (RD)  Community is assisted in maintaining local data on TB  Functioning VHCs have local data on TB  The percentage of functioning VHCs with local data on TB in the previous quarter increased from none to 100%. Intermediate Result 2: Strengthen NTP Systems to improve TB service delivery and patient outcomes Strategy 2.1: Facility Assessments (RD & UC)  Health center assessments  All health centers in the project are assessed every quarter using a structured instrument (M-DRAT) as described in the DIP.  100% of health center assessments have been conducted with participation from the District TB Supervisor. Strategy 2.2: Diagnostic Quality (RD & UC)  Laboratory quality assurance  Every quarter, a random sample of TB slides is sent to Xai Xai for review.  Proportion of major errors has been <1%. Strategy 2.3: Access (RD)  Sputum bottle stock-outs monitored  Focal point volunteers (FPV) keep the sputum bottles if a health post is not present in a community. The FPV informs the respective CG Supervisor if stocks are low well in advance.  At baseline (Q1’10) 25% of health facilities reported sputum bottle stock-out which then declined to 0% in subsequent quarters. Strategy 2.5: Information Systems (RD & UC)  Essential TB drug stock-outs monitored  Every quarter, WR M&E personnel checks the TB drugs stock inventory in health centers.  At baseline (Q1’10) 87.5% of health centers reported essential TB drug stock-out which remains high at 62.5% in Q4’11. Strategy 2.6: Supervision (RD)  Supervision of health posts (HP) by District TB Supervisor is recorded  Health Posts are supervised by the MISAU’s District TB Supervisors and this is documented in the M￾DRAT.  At baseline (Q1’10) 83.3% of health posts were supervised by District TB Supervisor in the previous quarter which declined to 50% in Q4’11. Strategy 2.7: Coordination with NTP (RD & UC)  Joint supervisory visits to HP  MISAU’s District TB Supervisors and WR’s CG Supervisors make joint supervisory visits of HPs every quarter.  The target of 6 supervisory visits in a quarter has been achieved in Q4’11. Intermediate Result 3: Decrease the burden of HIV in people with TB and decrease the burden of TB among PLWHA. (10% Effort) Strategy 3.1: TB and HIV Education through ACSM (UC)  Training of OVC and youth volunteers in TB including stigma reduction  60 OVC and youth volunteers were trained in Q3, 2010. Strategy 3.2: Case Finding in PLWHA (UC)  Training of HBCAs  40 HBCAs were trained in Q3, 2010. Strategy 3.3: HIV/TB Testing (UC & RD)  Screening of HIV+ patients for TB  Initially nurses in HIV division would screen HIV patients for TB, now the MISAU has introduced a new screening form for health centers to use thus making this screening systematic.  At baseline (Q1’10) 44.8% of HIV+ patients were screened for TB which then increased to 71.8% in Q4’11. The target for this indicator is 60%.  Screening of TB patients for HIV  Nurses at the health centers have been trained in HIV/TB co-infection  The high proportion of TB patients screened for HIV has been maintained (100% For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 6 B. Evaluation Methodology and Limitations The methods used in this MTE included extensive preparatory exchange of information by Grantee and Lead Evaluator (LE). A distribution of tasks was made beforehand that facilitated report writing considerably. Before the field visit, questionnaires for the Focus Group Discussions (FGD) and Key Informant Interviews (KII) were developed by the LE, shared, discussed and translated. Two field teams were created, composed of a balanced mix of expertise and functions. During the field mission, FGDs were held with project supervisors and Care Group Volunteers (CGV) in their respective villages. In each district, the health center was visited and the district TB supervisor was interviewed. In each district, a focus group discussion was held with the CGV, accompanied usually by the village leadership (president of the village or substitute). Discussions were noted down by participants and used in review sessions of MTE progress. In the health centers, KIIs were held with the district tuberculosis supervisor, and where available, the clinician and the lab technician. Figure 1: District tuberculosis register, Massingire district, Gaza province, Mozambique District tuberculosis registers were reviewed extensively; in addition health facility ledgers, HIV and laboratory registers and patient records were reviewed and discussed. A Knowledge, Practice and Coverage (KPC) survey was held at project inception and just before the MTE. The results of the midterm KPC survey is in Annex 6. Further, the quarterly M-DRAT data that were available were reviewed. In Annex 9, methods, procedures, timeline and tools of the evaluation are presented in detail. screening. in Q4’11). Strategy 3.4: CPT (UC & RD)  TB/HIV+ patients on CPT  Every quarter, WR M&E personnel monitors the proportion of TB/HIV+ patients on CPT.  The high proportion of TB/HIV+ patients on CPT has been maintained with 98.8% of the TB/HIV+ patients on CPT in Q4’11. Strategy 3.5: CB-DOT (UC)  Training of HBCAs in CB￾DOTS  40 HBCAs were trained in CB-DOTS in Q3’2010. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 7 Limitations included time to investigate issues in depth. Insufficient availability of provincial statistical information was an obstacle for obtaining a broader perspective. As the KPC survey was conducted just prior to the MTE only preliminary data analysis was available during the field visits. The final data analysis was completed soon after the field visits. C. Data Quality and Use The project uses a TB-specific monitoring and evaluation (M&E) system called District Rapid Assessment Tool (DRAT) developed by a previous TB USAID grantee which was then modified by World Relief and is referred to as M-DRAT. The sources of data for this system are: 1) the district tuberculosis register and 2) laboratory registers. The M-DRAT is used for quarterly monitoring of defined indicators in line with DIP (see M&E table). In addition, the project also collects data from Village TB registers which are maintained in project villages by the focal point volunteer of the respective village and the VHC. Although this system has proved to be useful for project monitoring, the linkages between village records and health center records need fine-tuning, especially since it was found that not all health centers systematically record if patients are on CB-DOTS, thereby leading to misclassification of TB cases. In the upcoming second phase of the project, a review of the indicators will be necessary in order to propose a simplified and feasible government service-compatible M&E system for project takeover. Further, the MISAU and FHI have plans of introducing a revised TB register for health centers nationally. This revised TB register is to have a separate column to report if the patient is on CB-DOTS or not. Other sources of data include periodic household surveys conducted to monitor the work of CGVs. The MTE reviewed the quantitative data from the above mentioned sources as well collected qualitative data from FDGs and KIIs. The mix of quantitative and qualitative data assessed during the MTE has been meaningful in understanding the overall progress of the project. Care group volunteers in the TB project had been part of the earlier USAID funded child survival projects in Gaza province. These volunteers have been enthusiastic about their work and have opted to continue to be CGVs for the current TB project. Focal point volunteers were selected by the MISAU based on their criteria for community health workers, are leaders within their respective care group. The CGVs and FPVs are provided periodic refresher trainings and are closely monitored by CG supervisors. In addition, district TB supervisors make quarterly joint supervisory visits with WR’s CG supervisors to villages in the project area. World Relief project staff work closely with the MISAU’s staff as the project is designed to integrate WR project activities and district health centers and health posts activities. The project implementation has been in conformity with the DIP reaching 6 rural districts and 3 urban areas with activities listed in the project work plan. The KPC surveys were conducted at baseline and midterm in a systematic manner; however it was found that there were two questions that were ambiguous due to translation errors which were not caught in time and hence the data on these two questions are unreliable (See Annex 6 for further details). C.1 Compliance with international terminology In the DIP and the progress reports innovative terms are being used to describe for treatment outcomes of smear-positive pulmonary TB patients. For a better comparison to nationally and For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 8 internationally accepted definitions, it is suggested to adapt the outcome options (“Results of treatment”) to WHO-suggested words and in Portuguese forms and reports use the terms used in the Mozambique NTP. Annex 12: Suggested terminology provides the suggested terms. D. Overview of the Project Structure and Implementation The Vurhonga TB Community-Based DOTS project is a five year project (September 30, 2009 – September 29, 2014) which began implementation in October 2009 in Gaza Province in Mozambique. Six under-served rural districts with a current population of 226,523 and three urban areas with a current population of 354,689 (2011 census) are served by this project. There were a total of 963 suspected TB cases in the project area from the onset of the program up until the third quarter of FY 2011. D.1 Project goal and objectives (include the project’s Results Framework, if available) The overall goal of the project is to reduce the burden of tuberculosis (TB), in line with the World Health Organization (WHO) Stop TB Strategy and the Mozambique National Strategic Plan. Its primary objectives are to increase the case notification rate by 50% and to achieve 85% treatment success rate in project areas fully implementing Community-Based Directly Observed Treatment Short-Course (CB-DOTS). The intermediate results are:  IR1: Empower people with TB to seek and complete treatment, with the support of their communities.  IR2: Strengthen National Tuberculosis Program (NTP) Systems to improve TB service delivery and patient outcomes.  IR3: Decrease the burden of HIV in patients with TB and decrease the burden of TB in people living with HIV/AIDS (PLWHA). For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 9 Figure 2: Results Framework Objectives: To increase case notification rate by 50% and to achieve 85% treatment success for CB-DOTS in targeted districts. IR2: Strengthen NTP Systems to improve TB service delivery and patient outcomes in select districts of Gaza Province. Strategies [location] 2.1 Assessment: Conduct assessment with MISAU staff of TB services at health facilities in project area; prioritize needs and plan for quality improvement. [Rural Districts and Urban Centers (RD&UC)] 2.2 Diagnostic quality: Train district lab technicians to improve diagnostic quality using sputum smear microscopy, infection and environmental controls. Monitor and advocate for continuous and random quality assurance testing of sputum slides. [RD & UC] 2.3 Access: Improve access to diagnostic services at peripheral health centers through community collection of sputum; facilitate community level analysis of barriers to access and local problem-solving. [RD] 2.4 Referral: Improve referral and counter-referral between facilities and the community network of volunteers and treatment observers. [RD] 2.5 Information Systems: Strengthen the flow of information between district and provincial structures to improve drug supply and data management. Monitoring and Evaluation (M&E) Manager works with District TB supervisors and staff to improve record keeping, use of data for decision making and drug forecasting. [RD & UC] 2.6 Supervision: Enhance supervision of peripheral health facilities engaged in TB control through provision of motorbikes to MISAU supervisors and mentoring in supportive supervision. [RD] 2.7 Attend monthly coordination meetings with all partners; integrate supervisory visits with DPS, DDS, and FHI. [RD & UC] IR1: Empower people with TB to seek and complete treatment with the support of their communities. Strategies [location] 1.1 Advocacy Communication & Social Mobilization (ACSM): Address traditional beliefs that inhibit case detection and care seeking and reduce stigma associated with TB by training community volunteers, Village Health Committees (VHCs) and church leaders (including those who practice traditional healing) about TB causes, signs & symptoms, testing, treatment options and infection control practices. Volunteers train all households (HH) in the community. [Rural Districts (RD)] 1.2 Case Detection: Increase case detection via Care Group (CG) volunteer network; Follow up with contacts of new cases. [RD] 1.3 Treatment compliance: Improve treatment success through assignment and training of treatment observers (padrinhos) by CG volunteers. [RD] 1.4 Community Health Information System (C-HIS): Integrate TB surveillance into the Community Health Information System reported on to VHCs, the health post and the MISAU. [RD] Goal: Reduce the burden of TB in line with the Stop TB Strategy and National Strategic Plan Vision: TB-free Mozambique IR3: Decrease the burden of HIV in people with TB and TB in PLWHA. Strategies [location] 3.1 TB and HIV Education through ACSM: Train existing HIV/AIDS volunteers in TB including signs, referral and stigma reduction. [Urban Centers (UC)] 3.2 Intensified case finding among PLWHA: Train existing HBCAs to identify and refer possible TB cases among their HIV+ clients. 3.3 Routine HIV/TB testing: Improve screening for TB among HIV+ patients and maintain high levels of HIV testing among TB patients. 3.4 CPT for HIV/TB patients: Maintain high levels of CPT and track HC inventory of Cotrimoxazole to assist with preventing drug stock outs. 3.4: Case management: Train HBCA in CB-DOT to improve treatment compliance and success. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 10 D.2 Project location The project is implemented in Gaza Province in Mozambique, in six underserved rural districts and three urban areas. D.3 Estimated project area population Table 2: Updated population (2011) 6 Rural Care Group Districts 3 Urban Centers with HIV/AIDS Activities Geographic Area Population Geographic Area Population Chicualacuala 41542 Macia 159379 Chigubo 22123 Chokwe 195310 Guija (including town) 80386 Guija Town, Guija Included in Rural Guija Mabalane 34517 Sub-Total 354,689 Massangena 16845 Massingir 31110 Total Beneficiary Population 581,212 Sub-Total 226,523 Table 3: SS+ TB cases in project area Rural Rural + Urban SS+ TB Incidence rate 165/100,000 population 165/100,000 population Population 226,523 581,212 Estimated # of SS+ TB cases each year 373.8 959.0 Estimated # of SS+ TB cases over 5 years 1868.8 4795.0 Actual # of SS+ TB cases in FY 2011 253 718 Actual # of SS+ TB cases from baseline (Q1’10) to Q4’11 536 1626 D.4 Technical and cross cutting interventions, Project design, Partnerships/collaboration In this section the project design, its key strategies and partnerships are provided. Annex 14: Key Strategies and Activities: details offers details on activities. D.4.1 Intermediate Result 1: Empower people with TB to seek and complete treatment with the support of their communities. (45% Effort) D.4.1.1 Strategy 1.1: Advocacy, Communication, and Social Mobilization (ACSM) (Rural Districts)  Address traditional beliefs that inhibit case detection and treatment seeking  Reduce stigma associated with TB and address barriers to treatment seeking Objectives:  Increase knowledge that TB is transmitted through the air by coughing from 20.7% to 60%  Increase knowledge that cough longer than three weeks is a sign of TB from 13.3% to 60%  Sustain the high percentage of respondents surveyed who know that TB is curable at 85%  Increase knowledge that TB treatment is available for free from 39.7% at baseline to 80%  Train 100% of CGVs in CB-DOTS  Train 100% of functioning Village Health Committees (VHC) in TB For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 11 Role of Key Partners: World Relief has a long history of community health work in this area and will train and interact with existing local structures and people in the community most able to sway popular understanding and opinion (e.g. CGs, VHCs, religious leaders and traditional healers). D.4.1.2 Strategy 1.2: Case Detection (Rural Districts)  Conduct case detection via Care Group Volunteers (CGVs) Objectives:  Increase the quarterly case notification rate (CNR) by 50% from 110 to 165  Maintain the high percentage of TB suspects examined by sputum microscopy at 80%  Increase the percentage of referrals made by CGVs from 20.6% to 60% Role of Key Partners: As with Strategy 1.1, the project will continue to work closely with influential local leaders and local organizations and will continue the partnership with APEs and the Provincial and District Ministry of Health to foster referrals and encourage sputum testing. D.4.1.3 Strategy 1.3: Treatment Compliance (Rural Districts)  Improve treatment success through the training and use of treatment observers (padrinhos) in the community Objectives: Conduct cohort analysis of treatment outcomes for SS+ patients including:  Increase the rate of treatment success from 78.6% to 85%  Maintain the high level of sputum smear conversion at 90%  Eighty-five percent of SS- patients will complete treatment  Increase the percentage of patients on CB-DOT from 26.4% to 60% Role of Key Partners: District HC records are utilized for data collection on treatment outcomes, thereby not duplicating existing systems. The project works closely with the District TB Coordinators and the Provincial TB Manager, who was present during the BL HFA survey. Further, additional outcome and referral data are collected at the village level by the Lead TB volunteer. This information is then shared with village leaders, VHCs and it is communicated back to the MISAU as well. D.4.1.4 Strategy 1.4: Community Health Information System (Rural Districts)  Integrate TB surveillance into the Community Health Information System (C-HIS) reported on to VHCs, HP and MISAU Objectives:  Eighty percent of VHCs will have local data on TB from the previous quarter  Eighty-three percent of HCs will compile C-HIS data collected by CGVs on TB Role of Key Partners: As stated above, the process of collecting, analyzing and distributing the C-HIS data is a collaborative effort involving the CGV, VHCs and the MISAU. D.4.2 Intermediate Result 2: Strengthen NTP Systems to improve TB service delivery and patient outcomes. (45% Effort) D.4.2.1 Strategy 2.1: Facility Assessments (Rural Districts and Urban Centers)  Conduct accurate assessments of TB activities at health facilities  Increase participation of district MISAU staff in facility assessments Objectives:  Conduct quarterly assessments of all health centers in the project area For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 12  One hundred percent of health center assessments will be conducted with participation from the District TB Supervisors or designated representative Role of Key Partners: The M-DRAT are utilized jointly by project staff and the appropriate District TB Supervisor. The Provincial TB Coordinator participated in the BL assessment and MTE. D.4.2.2 Strategy 2.2: Diagnostic Quality (Rural Districts and Urban Centers)  Facilitate training district lab technicians on sputum smear microscopy to improve diagnostic quality  Advocate for continuous, external, and random quality assurance testing of sputum slides Objectives:  Bring the proportion of TB suspects with SS+ confirmation in line with international standards by lowering it from 44.6% to between 10% and 25%  Maintain low proportion of major errors reported through external review at less than 1% Role of key partners: While funding and logistical supports are provided by the project, the instruction is led by qualified MISAU TB trainers, Carmelo Hospital and Rural Hospital. FHI (TB-CAP) has had extensive experience providing such trainings in the region and has assisted in referring appropriate trainers with whom they have had good success. D.4.2.3 Strategy 2.3: Access (Rural Districts)  Improve access by facilitating community level barrier analysis and local problem￾solving  Improve access to diagnostic services at peripheral HFs by assisting community sputum collection Objectives:  Less than 10% of HFs will report sputum bottle stock-outs in the previous quarter Role of key partners: VHCs and local religious organizations play a critical role in identifying those in need of assistance and arriving at creative local solutions to individual situations. They also play a key role in creating an environment of community responsibility. Community level sputum collection is a component within the current NTP. However, they report having difficulty with the inventory and supply of sputum collection bottles. WR, through its census based volunteer structure assists the NTP in monitoring the supply of sputum bottles at the HC and HP levels and provides occasional supply to prevent stock outs. D.4.2.4 Strategy 2.4: Referral (Rural Districts)  Improve referral and counter-referral between facilities and the community network of CGVs and treatment observers. Objectives:  75% of the patients referred from the community will be recorded at health center  80% of TB+ patients will return to the community after receiving their diagnosis Role of key partners: Data collection on referrals continues to be monitored at the HC level according to the MISAU system; community level data collection complies with MISAU definitions and forms and fully integrates the APE or HP nurse. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 13 D.4.2.5 Strategy 2.5: Information Systems (Rural Districts and Urban Centers)  Strengthen the flow of information between district and provincial structures, to improve drug supply and data management. Objectives:  Less than 17% of HCs reporting drug stock-outs of essential TB drugs for the last quarter  Less than 5% of those who start treatment will drop out (Interruption rate) D.4.2.6 Strategy 2.6: Supervision (Rural Districts)  Enhance supervision of peripheral health facilities engaged in TB control through provision of motorbikes to MISAU supervisors and modeling of supportive supervision. Objectives:  85% of HPs will be visited by the District TB Supervisor during the previous quarter as reported in the M-DRAT  85% of HPs will report supervisory visits by the District TB Supervisor D.4.2.7 Strategy 2.7: Coordination with NTP (Rural Districts and Urban Centers)  Collaborate with the NTP, TB-CARE and other partners to ensure complementary and comprehensive implementation of the National Strategic Plan for TB Control Objectives:  Attend 80% of meetings to which WR is invited  Conduct six joint supervisory visits to HPs each quarter Role of key partners: At the onset of WR’s TB project, the only other NGO implementing TB activities in Gaza Province is FHI (TB-CAP). WR is partnering with them as a sub-grantee in WR’s urban project areas. D.4.3 Intermediate Result 3: Decrease the burden of HIV in people with TB and decrease the burden of TB among PLWHA. (10% Effort) D.4.3.1 Strategy 3.1: TB and HIV Education through ACSM (Urban Centers)  Utilize existing WR HIV/AIDS programming to change beliefs and perceptions surrounding TB and HIV in the community through established church and peer social networks for advocacy Objectives:  Train 60 OVC and youth volunteers in TB, including in stigma reduction  Train three Pastors’ Networks in TB, including in stigma reduction Role of Key Partners: The project works closely with existing PNs, some of which are in the process of becoming locally registered CBOs. WR has received additional funding through a sub-grant from FHI’s TB-CARE project. D.4.3.2 Strategy 3.2: Intensified TB Case Finding among PLWHA (Urban Centers)  Utilize existing WR HBCAs to identify potential TB cases among their HIV+ clients Objectives:  Train 40 HBCAs in TB case finding, referral and stigma reduction Role of Key Partners: Local churches and HCs provide integral support to the HBCAs to ensure that they are well supported and that referrals are adequately documented. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 14 D.4.3.3 Strategy 3.3: Routine HIV/ TB Testing (Urban Centers and Rural Districts)  Improve TB screening among HIV+ patients  Maintain high levels of HIV testing among TB patients Objectives:  Improve the percentage of HIV+ patients screened for TB from 46.6% to 60%  Maintain high levels of HIV testing among TB patients at 95% D.4.3.4 Strategy 3.4: Cotrimoxazole Prevention Therapy (CPT) (Urban Centers and Rural Districts)  Prevention of opportunistic infections with CPT in HIV/TB patients  Track HC inventory of Cotrimoxazole to assist with preventing drug stock outs Objectives:  Maintain high levels of CPT in HIV/TB patients at 90%  Less than 25% of HCs reporting stocks out of Cotrimoxazole in the previous quarter Role of key partners: As treatment regimens and medications are determined by the MISAU, WR supports the activities of the NTP, District and Provincial MISAU. D.4.3.5 Strategy 3.5: Case Management of Co-Infections (Urban Centers)  Train HBCAs in CB-DOT to improve treatment success Objectives:  Number of HBCAs trained on CB-DOT Role of key partners: WR has routine contact with the MISAU and HFs in the urban areas through the M&E Manager and project supervisors to encourage communication and participation with the HBCAs on CB-DOTS when a current HIV+ patient is diagnosed with TB. D.5 USAID Mission Collaboration USAID Mozambique Mission is committed to support the Government of Mozambique’s National TB Program. Consequently, the detection, diagnosis and prompt treatment of tuberculosis are among the health priorities of the USAID Mozambique Mission. WR’s TB project strategies align well with these health objectives of the Mission. USAID Mozambique Mission representative, Dr. Alfredo MacArthur participated in the site visits of the MTE. Further, WR Mozambique, through the FHI (TB-CARE) sub-grant, has received multiple site visits conducted by USAID. The debriefing of the MTE was hosted at the USAID Mission Office by the Head of HIV/Infectious Diseases Division, Sarah Bowsky and Dr. MacArthur. Also discussed in this meeting were communication misunderstandings about USAID Mission in Mozambique not receiving the project’s first annual report in time. These misunderstandings were cleared and an improved future cooperation pledged. USAID Mozambique Mission has requested that they be copied on all electronic submission of reports to USAID, Washington. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 15 E. Presentation of Progress toward the Achievement of Project Results E.1 Intermediate results Three intermediate results (IR) were defined in the DIP, each with its objectives and strategies. The next sections will deal with progress in each of these IRs. E.2 Intermediate result 1 “Empower people with TB to seek and complete treatment with the support of their communities. (45% effort)”. E.2.1 Project achievements Achievements in strategies S1.1 (on Advocacy, communication and Social Mobilization￾ACSM) and S1.4 on VHCs and HCs data are directly attributable to project efforts. These strategies were fully achieved (See Table 1). Other strategies have considerable external influences. The main strategies are discussed in the sections below. Details are available in the M&E matrix (Annex 17). E.2.2 Case notification E.2.2.1 National perspective In Mozambique the incidence burden of tuberculosis (including HIV) is estimated at 544 per 100,000 population in 2010 (source: WHO, Annex 15: Mozambique page WHO global tuberculosis report 2011). In 2010, WHO estimated that 34% of all cases were found and put on treatment. In the country, 48% of new cases are sputum-smear positive, or 260 per 100,000 pop. The national notification rate for smear-positive tuberculosis cases was 87/100,000 in 2010 and slowly increasing. There is no reason to assume that in the project area the burden differs significantly from the national average. The area population is more rural than the country average, but harbors a high-risk subpopulation of miners/temporary emigrants. The project objective aims to improve the smear-positive tuberculosis case notification rate from 110 to 165 per 100,000 population at the end of the project in 2014. For the project area population, currently at 226,523 (rural areas), this means an annual number of approximately 375 new smear-positive tuberculosis cases. E.2.2.2 Provincial data Gaza province has an estimated population of 1,330,000 (2011 estimate). The provincial annual NTP report states that during 2011, 4237 new TB cases were notified. The Case Notification Rate (CNR) was 304/100,000, all forms of tuberculosis. Out of these, 1874 (44%) were sputum-smear positive cases (SS+ CNR: 135/100,000). This rate is considerably higher than the national SS+ CNR of 87/100,000. It is not clear whether this high rate is mainly due to increased risk of contracting tuberculosis disease (exposure) or because of increased access to health services (detection). Almost all (99%) of new TB cases were tested for HIV. 75% tested positive for HIV infection. Cotrimoxazole Preventive Therapy was provided for 98% of TBHIV patients. Only 33% of TBHIV patients were put on Anti-Retroviral therapy. A total of 352 child TB cases were notified in 2011 (8.3% of total notifications). Provincial data (2011) revealed results of For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 16 treatment as follows: Success rate: 79% (all but three cases declared cured). Death rate was 14%. E.2.2.3 Notifications in the project area The notification results in the first two years of the project are graphically displayed in Figure 3. Statistical data are provided in Table 1. In 2010, a total of 301 SS+ cases were notified, or a CNR of 137/100,000. In 2011, 235 SS+ NC were notified in the project area equivalent to a CNR of 103.7/100,000 (Source: M-DRAT). The trend is declining, rather than the desired increase. Differentiation of the data show marked differences among the project area districts (although the absolute numbers are small and therefore need to be interpreted with caution). Figure 3: Smear-pos. TB Case Notification Rates (CNR), project area, 2010-2011 Figure 4: Smear-pos. TB notification rate; project area, per district, Mozambique, 2010 E.2.3 Training of CGV The CGVs were mostly recruited from an earlier World Relief Child Survival Project. Others applied spontaneously. Volunteers have been trained in prior projects in malaria, diarrhea, nutrition, maternal care, immunizations, family planning, pneumonia and HIV/AIDS. With their knowledge on above topics they are able to “care” for the health (especially children under 5yrs in the previous project) of the 10 families under their care. Initial training in tuberculosis of CGVs and supervisors was completed March 2012. The M&E matrix (Table 1) shows details, including reaching the training targets for volunteers and village health committees (VHC) (see below). Almost all CGVs are women. The network is extensive and shown graphically in Figure 3. 0 20 40 60 80 100 120 140 160 180 Q1'10 Q2'10 Q3'10 Q4'10 Q1'11 Q2'11 Q3'11 Q4'11 per 100,000 population CNR Target - 40 80 120 160 200 139 per 100,000 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 17 Figure 5: Care Group Volunteer network for CB-DOTS project Elements of the network:  There is one Care Group Volunteer (CGV) per 10 families (= 50-60 persons).  The CGV tasks in tuberculosis care are as follows: 1. Identify villagers with symptoms suspect for tuberculosis; 2. Convince suspect to seek health care in health services (Refer) 3. For tuberculosis patients that started treatment, CGVs provide support to adhere to treatment, encourage patients to report to the health services for follow-up sputum examination after 2 and 5 months of anti-tuberculosis treatment and observe for signs of unsatisfactory recovery or drug side effects.  This patient support is done together with an individual patient padrinho or madrinha 2 (= buddy). The patient chooses an individual to support him or her during treatment. Reportedly, in most cases, the CG Volunteer is chosen as buddy.  There is one Focal Point Volunteer (FPV) per 10-20 CGVs (= 500-1000 population).  Project-employed supervisors have trained CGVs during 3 weeks in the village. Initial training is now complete in the whole of the project area. The project supervisors will start supervising the volunteer networks from April 2012 onward. E.2.3.1 Suspect referral Figure 6: Suspect (S) flow 2 padrinho sm (fem madrinha) 1 Ecles godfather, sponsor (at a baptism). ele serviu de padrinho para meu filho / he stood sponsor to my child. 2 best man (at a wedding). 3 second (of a duel). 4 paranymph. 5 fig patronizer, protector. Source: http://michaelis.uol.com.br/moderno/ingles For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 18 Volunteers in the village notice persons with symptoms suspect for tuberculosis and refer them to health services (see Figure 6) either directly to the health center (clinician or district tuberculosis supervisor) or via a nearby health post. Health staff assesses the person and if suspicion for tuberculosis is confirmed, a sputum examination and possibly additional examinations are requested. E.2.4 Village health committees The government of Mozambique has encouraged the development of village health committees (VHC) since its independence in 1975. These community health councils (Conselhos comunitários de saúde), as they are called officially have not all survived. The child survival project had reanimated and trained 54.1% of VHCs in project villages by the end of FY11. VHC are composed of up to 15-30 people. They were supposed to meet monthly on MNCH issues during the child survival project. They do not have a significant role for the current CB-DOTS project. E.2.5 Accompanying tuberculosis cases in the village If the circumstances of a newly diagnosed tuberculosis patient permit (clinical condition, willingness, and distance to health institution) they are ‘referred back’ with anti-tuberculosis treatment in the form of Fixed Dose Combination (FDC) medicines to the village CGVs. The patients receive one to two weeks of treatment at a time. In the village, CGVs help to motivate the patient to complete his or her treatment. As outlined above (E.2.3) there is also a system of ‘buddies’, madrinhas, assisting the individual tuberculosis patient during treatment. The community DOTS contribution to new tuberculosis cases in the project area is small, but growing (see Figure 7). During field visits, the evaluation team noted larger proportions of patients registered as being treated as community DOTS patients than appears in the graph, often over 50% of all patients on treatment. Figure 7: Proportion of patients on CB-DOTS. Source: M-DRAT. E.3 Intermediate result 2 “Strengthen NTP Systems to improve TB service delivery and patient outcomes in select districts of Gaza Province (45% Effort)”. E.3.1 Project achievements Achievements in strategies S2.1 (On health center assessments) and S.2.7 (on coordination meetings and joint supervisory visits) are directly attributable to project efforts. These strategies were fully achieved (See Table 1). Other strategies have considerable external influences. The main strategies are discussed in the sections below. Details are available in the M&E table (See Annex 17). 0.0% 20.0% 40.0% 60.0% Percentage of patients on CB-DOT For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 19 E.3.2 Sputum positivity problem Government health services in the project area reports a proportion of TB suspects with SS+ confirmation to be extremely high: 44.6% (compare with international standards between 10% and 25%). Various operational reasons may have caused this (e.g. clinician sputum request strategies, laboratory quality), none of them directly within the project objectives. The role of the project could be, in line with IR2 to assist in the analysis of causes of this phenomenon and contribute to ideas to remedy the situation. E.3.3 Treatment outcome E.3.3.1 Conversion rate Conversion rates as recorded in the project area laboratories remain slightly below the target of 85% in the first phase of the project Again, the project is not responsible for attaining this target. Its role (IR2) in strengthening health services could be in helping to assess the reasons for sub-optimal conversion rates. E.3.3.2 Results of treatment The results of treatment, as determined by cohort analysis are recorded in the project M&E system (M-DRAT). The evaluation team was unable to obtain provincial data on the cohorts evaluated in 2010 and 2011. The M-DRAT shows a slightly deteriorating trend (Figure 8) in treatment success rates. Quarterly cohort sizes were small: the average quarterly cohort size during project period was 77. Comparing the two years of project implementation the trend is downward: The success rate in 2010 was 84% and in 2011, the success rate was 79%. This is comparable to provincial results and slightly below reported national success rate (85% in 2010). Of concern is the high death rate: 8% in 2010 and 13% in the first 3 quarters of 2011, in line with 2011 provincial data. The high proportion (reported to be 75% in Gaza province in 2011) of tuberculosis patients with a HIV co-infection are undoubtedly a determinant of this high death rate. Figure 8: Treatment success rate, project area, cohorts evaluated in period 2010-2011 E.3.4 Drug stock-outs The project indicator on drug stock-out is to have less than 5% of health centers reporting drug stock-outs of essential TB drugs for the last quarter. Stock-outs have occurred nationally during one month in 2011 for adult combination tablets (4DFC) and pediatric DFC. Project intervention was limited to the World Relief M&E manager in his quarterly visit to HC checking actual drug stocks. The M&E table Strategy S 2.5 shows a disconcertingly high percentage of health centers reporting TB drug stock outs in the last quarter. 0% 20% 40% 60% 80% 100% Q1 '10 Q2 '10 Q3 '10 Q4 '10 Q1 '11 Q2 '11 Q3 '11 Q4 '11 Target For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 20 E.4 Intermediate result 3 “Decrease the burden of HIV in patients with TB and decrease the burden of TB in people living with HIV/AIDS (PLWHA). (10% Effort)”. This minor IR (minor in terms of defined project effort) was addressed mainly by providing training for health staff on HIV/AIDS. The M&E matrix (Annex 17) shows that in Strategies S.3.1. S3.2 and S.3.5, the targets were reached. The other strategies have indicators measuring progress outside the direct influence of the project. F. Discussion of the Progress toward Achieving Results F.1 Contribution toward Objectives/Results F.1.1 Conceptual issue The DIP was constructed to include Goals, Primary Objectives and three Intermediate Results (IR - see E.1). The IRs and its relevant objectives and strategies were defined in such a broad manner, that the project cannot be held responsible exclusively for the attainment of these IRs. In all strategies, essential outside factors will determine the degree of achievement of the objectives and results. This makes evaluation using the IRs and its indicators sometimes a futile exercise: full achievement cannot be attributed to project efforts alone, for suboptimal realization the project cannot be held accountable. It would have been more effective for monitoring and evaluation if IRs/strategies would have been defined as “Project Attributable Results”, in which the results are obtained mainly because of project performance. In the current project design, monitoring and evaluations can be done on the set of planned activities. From this table the project can be assessed for the degree of successful implementation, and problems identified. In the next sections the project contribution towards the three IRs are discussed. F.1.2 IR1: empowerment of tuberculosis patients improving health seeking behavior F.1.2.1 Health information Empowerment also implies informing the community about important characteristics of the disease tuberculosis. Focus Group Discussions (FGD) participants suggested that common beliefs about the etiology of chronic cough and wasting (“ndere” in Shagan language ) were related to inadequate cleansing ceremony after someone’s death. The participants suggested that this belief had lost followers in the 18 months after the trained CGVs explained the infectious nature of tuberculosis. The KPC survey corroborated this observation: The knowledge that TB is transmitted by coughing increased from 22% (KPC, 2010 baseline) to 66% (KPC, 2012). F.1.2.2 Community knowledge Q16 on airborne etiology of Tuberculosis showed an increase in knowledge on this subject from 20.7% to 61.3% in two years’ time. This is very encouraging. It seems very doubtful to the MTE Team Leader, however, that this change in responses to the KPC questions reflects a change in practice in the communities studied: In his opinion, behavior based on traditional beliefs tends to transform more slowly requiring many years of gradual change of insight for a large proportion of the adult population. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 21 F.1.2.3 The Volunteer network density The CGV network is conceived as having one volunteer per ten families or approximately 50- 60 population. For frequent health events, like pregnant women support (4% of population) or under-five child monitoring (20% of pop.) this dense network makes good sense, in terms of adequate voluntary workload. The density is less appropriate for tuberculosis activities, as the number of true TB suspects and TB -patients are less frequent. Theoretically a CG volunteer will on average:  Refer 1-2 true suspects per year (2% of pop. with chronic cough)  Accompany 1 new PTB patient (SS- and SS+) every 5 years (4 per 1,000 pop) This would, again, in theory, lead to a possible loss of motivation, unless the volunteers have other tasks to fulfill. If this is the case it did not become clear during this evaluation mission. F.1.2.4 Village Health Committees Village Health Committees that were activated and trained by the child survival project can also play a role in the community based DOTS project. A stronger endorsement from MISAU is needed for this to be realized. F.1.2.5 Case detection Trends in case notification rates (new and relapse cases, all forms) (black) and estimated TB incidence rate (green). Shaded areas represent uncertainty bands. Mozambique key data: 2010: Incidence (all forms): 544 per 100,000 pop. Case detection: 34% of incidence Case notification rates: Smear-positive new cases: 87 per 100,000 pop. New cases, all forms: 183 per 100,000 pop. Figure 9: Case notification and estimated TB incidence rates, Mozambique, 1990–2010. Source: Global tuberculosis control: WHO report 2011.(See annex on page 112 for more WHO report information on Mozambique) In strategy 1.2 (Case detection), one of the objectives is to increase the quarterly case notification for smear-positive pulmonary tuberculosis cases from 110 to 165 per 100,000 population during the project period. The project M&E system (see M&E table) shows a slight declining trend (See Figure 3). With the community-based project fully operational, one expects an initial increase in case notification for the first two to three years, due to clearing of backlog patients. A continuous leveled-off increased notification rate is to be expected as it approaches the notification of most incident (new) cases. National incidence rate of all forms of tuberculosis are estimated at 544 per 100,000 pop. (Source: WHO Global tuberculosis control report 2011). In 2010, about half (48%) of all new cases were smear-positive (SS+). The annual incidence in the population of new SS+ cases therefore may be estimated to be around 260 per 100,000. Provincial notification rates were reported (2011) as SS+ CNR: 135/100,000. The end-of￾project target of 165 per 100,000 pop. (an increase from pre-project level of 110/ 100.000), seems to be a feasible but ambitious target. At the time of the midterm evaluation this target was not yet reached by far. Available statistics show no progress towards the target. Additional targeted interventions to increase case finding (notably strengthening systematic contact examinations) are essential for the second phase of the project. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 22 F.1.2.6 Gender and child tuberculosis notification Information about the gender and age of new tuberculosis cases is recorded in the district tuberculosis registers and the project M&E system (M-DRAT). The project has not reported on data that would permit analyzing gender balance and the proportion of child tuberculosis in the project area. The data on indicators stratified by gender may be analyzed to assess any trends in these categories of patients. F.1.2.7 Referral from village to health services The targeted increase in village CGV referral suffers from current incomplete recording: a. The number of suspects referred is duly registered in the CGV records, but at the health services suspects are not registered as such. b. The current system of village referral forms is complicated and does not function well. In this system a form is filled in the village by the focal point volunteer, given to the suspect person to be handed over at the health center. Health staff keeps one part and returns the other part to the suspect who may have been diagnosed as a tuberculosis patient. c. A suspect register kept by the district TB supervisor would be useful to keep track of all suspects reaching the health services, including recording the contribution of village CGV referral (See for example the South Africa national tuberculosis control program register3 . d. A proxy indicator would be measuring the proportion of tuberculosis cases reaching the health services through referral by village CGVs. For this purpose, column 7 (proveniência) in the district tuberculosis register is the appropriate place to register patients referred from the village. This was done in some districts (see Figure 10), but not yet consistently as the MTE team was able to verify. F.1.2.8Results of treatment Cohort analyses on sputum conversion after 2 months of treatment and after completing treatment are being recorded health services; they are collected and analyzed by project staff using its M-DRAT M&E tool. The M&E system does not permit yet to separate results of treatment stratified by volunteer-referred, volunteer-accompanied patients and patients not managed by project CGVs. Given the small numbers of quarterly notification, it will probably not be possible to establish a statistically significant difference between the different categories of patients in the cohorts. F.1.2.9 Co-infection issues In Mozambique 61% of detected tuberculosis patients are HIV-positive. There is no reason to believe that this proportion in the project area is lower than the national proportion. Therefore, most new tuberculosis patients who return to their home to take DOTS in the community also need HIV treatment and/or care. The project does not address this issue. Reportedly, the national AIDS program is rolling out a HIV activist support scheme. It would make sense to support the co-infected patient by one organization only, especially where it concerns ensuring adherence to chronic drug taking (DOTS & TARV treatment for eligible cases). Where government services are promoting the “Paragem única” (One-stop) institutional 3 Accessible at: http://www.ecdoh.gov.za/uploads/files/230906112038.pdf Figure 10: District tuberculosis register, column 7 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 23 approach towards co-infected patients, the World Relief project should consider adopting a “community one-stop” strategy. This would be for the benefit of the patient. F.2 Contextual Factors F.2.1 World Relief World Relief is an organization that operates in Mozambique since 1994, working for the underserved population through community volunteer structures such as care groups and VHCs in rural areas, and HBCAs, Youth mobilization volunteers, volunteers for OVC and Pastors’ Networks in urban areas. Care groups were first introduced by Dr. Pieter Ernst in the mid 1990s with child survival projects funded by USAID involving CGVs. A survey conducted 20 months after the end of World Relief’s Vurhonga 1 Child Survival Project (1995-1999) indicated a very small attrition rate of 6.59% (n=96) of CGVs. Further, two years following the end of WR’s Vurhonga 2 Child Survival Project (1999-2003) project, 50% of households stated that they had received a volunteer visit within the previous two weeks. These data indicate a high retention rate of CGVs. Furthermore, most of the CGVs volunteering in TB CB-DOTS and TB-CARE are the same volunteers used as far back as 1995 (Vurhonga 1), 1999 (Vurhonga 2) and 2004 (Vurhonga 3), excluding those who died. Hence it likely that CGVs in the current TB CB-DOTS project are likely to remain operational after the end of the current project activities. F.2.2 Miners-emigrants In the project area an unknown but significant proportion of men migrate to South Africa to work in the mines. They bring back from their temporary homeland, money, new ideas, and sometimes diseases like tuberculosis and AIDS. The semi-nomad lifestyle warrants specific approach to give this subpopulation access to tuberculosis and HIV/AIDS services and care. F.2.3 Community DOTS initiatives elsewhere in Mozambique The Mozambican Ministry of health (MISAU) has given priority to community-based DOTS strategies. It is experimenting with home-based DOTS with support by fellow-villagers (padrinhos). NGOs have also started CB-DOTS projects. Specifically, FHI is implementing a USAID/TBCARE sponsored project in other provinces of Mozambique. F.3 Role of key partners Partner Role in Project Result of Collaboration/Suggestions for improvements Care Group Volunteer ACSM Improved awareness of TB in community and execution of CB-DOTS at the household level Focal Point Volunteer Supervision, ACSM Improved awareness of TB in community and execution of CB-DOTS at the household level Village Health Committee Community partnership and support The VHC has helped in the project in times of resistance from community members to build trust. They have made collective decisions regarding the health of their community members and encouraged the implementation of the project in their villages. Without the support of the VHCs it would have been difficult for the project to have gained momentum. Health Post Nurse Referral The health post is located in the community and so the health post nurse is the first point of contact with the MISAU. Trainings sponsored by WR have enabled them to understand the importance of CB-DOTS and referrals For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 24 from the community, which has improved the progress of the project. District TB Supervisor Supervision This is a key MISAU at the district level. The district TB supervisor and WR’s CG Supervisor undertake quarterly joint visits to their respective community in the respective district. The district TB supervisor also maintains the district TB register which is the source of M-DRAT data. In future, WR’s CG Supervisor will also have a list of TB cases on CB-DOTS in their community are also enlisted in the district TB register to minimize recording errors. Provincial TB Coordinator Supervision and administration The support of the Provincial TB Coordinator has been invaluable to the implementation of the project. The project has benefited from the supervision and coordination functions of the Provincial TB Coordinator, who also participated in the baseline and MTE of the project. Carmelo Hospital Laboratory training Carmelo Hospital located in Chokwe with expertise in tuberculosis diagnostics. Hence they have provided laboratory training for MISAU’s lab technicians as well as peripheral nurses in slide fixing, which were sponsored by the project’s funds. FHI TB-CAP followed by TB-CARE FHI is a large NGO that has been implementing tuberculosis projects nationally. WR partnered with them and was given a sub-grant to implement the tuberculosis project in the urban project areas of Gaza province. USAID Mozambique Mission Support World Relief has maintained communication with the Mission before and after the development of the DIP and has had occasional in-person meetings with the Mozambique USAID representative. In June 2011 in Xai Xai, the National Director for TB in Mozambique organized a TB-DOTS meeting which was supported by the USAID health representative, Dr. MacArthur. All NGOs working on TB in the province were invited which was a good opportunity for World Relief staff to meet the USAID representative and MISAU TB officials. In December 2011, World Relief’s new Health Advisor visited the project sites and met with Dr. MacArthur and discussed the status of the project. In April 2012, Dr. MacArthur participated in the MTE and was part of the team of evaluators. In-country debriefing of the MTE was hosted by USAID Mozambique Mission and was attended by the head of HIV/infectious diseases division, Sarah Bowsky and Dr. MacArthur. WR was asked why the first and second annual reports were submitted to them together, to which WR clarified that the first annual report was revised and hence the revised first annual report was submitted along with the second annual report in October 2011. WR was asked to copy the Mission on all electronic submissions made to USAID, Washington. In conclusion, the MISAU is overall responsible for providing guidelines on DOTS organization and service delivery, in line with international recommendations (WHO). It provides for the human and material resources to run the government program. It provides all the anti-tuberculosis drugs through the Medical Store facilities. The USAID mission is providing support to its tuberculosis projects in the country. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 25 F.4 Overall Design Factors that Are Influencing Progress Toward Results F.4.1 Sustainability The project design was geared towards a sustainable end-of-project situation, without formally applying a Sustainability Framework. The transformation of knowledge, attitudes and practice for the villagers regarding etiology of tuberculosis and improved health-seeking behavior is at the core of the project sustainability. The project design, procedures and practice after end-of-project in 2014 including plans to hand over an effective and feasible monitoring system to the provincial government tuberculosis services. In this respect, the project management will need to simplify its current M&E system (M-DRAT) and elaborate steps to hand over the monitoring system. F.4.2 Composition of CG Volunteer groups The CGVs already existed, recruited and trained in an earlier World Relief project in the area (Child Survival Project). The tasks in child survival involved more frequent events (e.g. monitoring child health – 20% of population). The fine mesh (one volunteer for 50 population seems less adequate for more rare events like tuberculosis suspect identification (~2% of population) and tuberculosis patient support (<0.5% of population). The evaluation mission has concerns over a gradual loss of volunteer motivation, when few “results” (care for TB patients on treatment) can be expected over the years. F.4.3 Expertise in tuberculosis control at project design stage Although difficult to assess, it seemed to the MTE Team Leader that the project experienced a certain dearth of expertise in tuberculosis control programs, in its inception and in its endeavor to improve the quality of government services. a. The planned Results, Objectives and Strategies included several items that are influenced to a great extent by outside factors. The M&E system (M-DRAT) is based on the DIP design and thus contains several indicators that measure situations and progress outside project influence (see also F.1.1.). Expertise in national tuberculosis control could have trimmed the M&E system so that all indicators measure just project-relevant interventions and epidemiological trends. b. The terminology used in describing results of treatment (see section C.1) was clearly not in line with the NTP terminology or with recommended international terms. c. The second intermediate result (strengthening provincial NTP services) would be more easily achieved with more profound knowledge and skills of routine tuberculosis control program by project staff. The provincial tuberculosis control program staff seems seriously understaffed, and strengthening planning, supervision and monitoring these services in the project district continue to be needed. Community-based DOTS efforts and institutional support should both be supported to strengthen the weakest links in the system. F.4.4 Gender of CGVs The great majority of CGVs are women, as are all their project supervisors. Partly this is due as a heritage from the former Child Survival Project implemented by World Relief, where the same CGVs were active. It is also the conviction of the project management that women are more suitable as CGVs, in their caring role in the community. This is a traditional view that could be challenged in a society where outside influences are present, such as in the project area. A specific feature in the project area is the relatively large proportion of men that work elsewhere for long stretches. Employment in mines in neighboring South Africa is frequent. This feature brings about specific extra exposure to both tuberculosis and HIV infection. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 26 Engaging male CGVs in the village community could well increase acceptance by male suspects and tuberculosis patients, increasing access of male villagers to health (HIV and tuberculosis) services. This option should, in the MTE Team Leader’s opinion, be explored further by the project staff, as it may increase acceptance by male tuberculosis suspects and patients on treatment. G. Conclusions and Recommendations G.1 Conclusions 1. This project has potential to improve life perspectives for tuberculosis patients. The project offers good potential for developing an effective community based DOTS system: a. The project is well established in terms of human resources, counting on a very motivated project staff, a fine mesh of volunteers and a well-structured supervisory system. b. The first phase of preparing the staff and volunteers in the project, plus the organizational setup is completed. The remaining two years of the project can be dedicated to implementation and transfer to government responsibility. c. Community Based DOTS is a national priority. Lessons learnt and an exchange of experiences can lead to a favorable development in TB control in Mozambique. 2. The relations with the provincial and national government system are good. Strengthening by more intensive support and collaboration is requested by the provincial tuberculosis control supervisor. 3. The project M&E system is well-established and extensive. As it is based on planned results partly influenced mainly by much external factors, there is an attribution issue: how to attribute indicator values to project performance? 4. There are sustainability concerns: project structure and its monitoring system are probably too labor intensive and expensive to transfer to government without significant modifications. G.2 Recommendations The following activities are recommended to enhance the project quality and ensure sustainability of the project. G.2.1 Sharing project learnings G.2.1.1 Make a scenario script The experiences and lessons learnt on the development and maintenance of the community structure of trained and motivated CGV, the referral system and the M&E system used are of great value. These should be shared with other organizations, government and non￾government alike. Future CB-DOTS projects would greatly benefit from a systematic scenario developed by the World Relief CB-DOTS project. Such a scenario would outline the steps, resources, organization and timeframe to develop CB-DOTS in a district. The MTE team recommends the project staff and World Relief HQ to develop such a systematic report of the project experience in the form of a scenario, a How-To manual. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 27 G.2.1.2 Platform of sharing experiences It would potentially be very useful to continue the sharing of CB-DOTS experiences with other projects and government institutions in Mozambique. Last year a first step was made in July 2011 during a workshop on CB-DOTS. MISAU and World Relief are encouraged to develop an annual platform, sharing national (and international?) experiences. G.2.2 Learning more The community DOTS project offers good possibilities to get more insight in processes that enhance or hamper results. Health system research methodology is particularly adequate to seek a better understanding. The following is a small list of possible subjects. These were discussed during the debriefing, and especially the FHI Chief-of-Party had similar ideas, some of these already in progress: a. The patient perspective: Define patient appreciation of CB-DOTS project, by applying the Quote-Light tool4 . b. A cost-effectiveness study, defining investments and running costs for CB-DOTS development and maintenance per patient found or patient cured. c. Human resource utilization study: Determination of time spent by CGVs on specific defined tasks. These studies need a partnership from the MISAU research department or other suitable institutions in the country. G.2.3 Community empowerment G.2.3.1 Project design The design of the project, including the use of village volunteers is clearly geared towards empowerment of communities in relative isolation of services. The project implementation so far shows that developing and maintaining a structure of volunteers, plus systematic supervision shows good potential for a transformation of awareness and access on tuberculosis care. The revival of Village Health Committees supports that transformation. The challenge is to maintain motivation of CGVs by providing adequate satisfying tasks, increasing the scope of voluntary work (HIV!?) without overburdening voluntary solidarity. G.2.3.2 Increase village stakeholders The WHO in its ACSM Handbook suggests to “engage TB-affected community members in the development and implementation of ACSM activities”. This suggestion seems valid in this project. Male and female ex-TB patients could be included in the ranks of CG volunteers. G.2.3.3 Involve male CGVs Due to the area-specific demographic condition (temporary emigration of male villagers to work in SA mines) recruiting and involving male volunteers could increase mobilization of male with suspect signs and symptoms and those with TB disease on treatment. This measure would give a special attention to villagers working temporarily in South African mines. A recently started “Mining project” (TBCARE1 initiated) to increase quality of care for tuberculosis patients in the South African mining industry could be beneficial to services in the project area. The project management is advised to contact USAID and TBCARE1 to pursue a possible project linkage. 4 Available on the TBCTA website: http://www.tbcta.org//Uploaded_files/Zelf/QuoteTBLight1281523545.zip For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 28 G.2.4 IR2: Strengthening government tuberculosis control services This expected intermediate result need more emphasis in the second phase of the project, maintaining the project strategies in IR2 as defined at the onset. An increase in case notification and high quality monitoring should be leading targets for this cooperation. Efforts could be concentrated by: 1. Intensifying contacts with provincial authorities, defining agreed activities, monitoring after a distribution of tasks. 2. Mutual transparency in sharing data and experiences. 3. Assisting in remedying occasional government shortages of resources, without creating a structural dependency 4. Preparing to hand over project learnings as outlines elsewhere in this report. G.2.5 IR3: Lessening the burden of HIV In Mozambique 61% of detected tuberculosis patients are HIV-positive. As argued above (see F.1.2.9) it would make sense to support co-infected patients by one organization only, especially where it concerns ensuring adherence to chronic drug taking. The World Relief project should consider adopting a “community one-stop” strategy, extending home care for TBHIV patients by village CGVs. H. Action Plan for Responding to Evaluator Recommendations Recommendation Action Plan G.2.1 Sharing project learnings G.2.1.1 Make a scenario script Agreed: Project manager will be the primary person writing with help from the Integration director and previous CS staff. Completion date: 30 November’12 G.2.1.2 Platform of sharing experiences Agreed: FHI in Mozambique is the organization with the largest provincial representation of TB projects and already has a plan to bring NGOs from other provinces together for sharing experiences on an annual basis. WR would use those opportunities to share experiences and lessons learned. G.2.2 Learning more Official studies are very time consuming and HR intensive and would need a separate team with a separate budget. The suggestions are valid but the results of some will not necessarily affect changes to the project. The Quote Light Tool will be looked at as a possibility to improve services at district level. G.2.3 Community empowerment G.2.3.1 Project design 1. The volunteers chosen are not from outside the area but her household is part of the 10 households she cares for. Her main task in this TB project is, after training her households on TB, to identify possible suspects with symptoms and refer them to the focal point volunteer as well as looking after any patients on treatment within her 10 families. They cannot run away as they form part of the 10 families. 2. Most of them were volunteers during the Child Survival program and already have tasks related to children under 5 yrs. in her 10 families. G.2.3.2 Increase village stakeholders Since all the volunteers have already been chosen at the beginning of the project it would not be right to replace them without reason. If some would fall away for some reason we would look into replacing her with a healed patient provided the patient is in the same 10 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 29 households and willing to accept responsibility. Healed patients are frequently used as positive testimonies in meetings, village assemblies and during TB days. G.2.3.3 Involve male CGVs Historically male volunteers have been tried in several projects in Mozambique and even in Gaza but always with poorer results than females. They are the breadwinners and always demand payment for their work. Most husbands are absent (in SA) and would not like them visiting their wives in their absence. Healed male patients have been used with success to convince difficult male patients. However, the project has trained 10,414 community leaders and other men in TB. G.2.4 IR2: Strengthening government tuberculosis control services A taskforce consisting of managers from WR, AMODEFA, TEBA(TB NGO working with SA Miners with TB in Moz) and the Provincial TB officer will meet once or twice a quarter to discuss issues related to progress and improvement of the CB Dots program in Gaza province. G.2.5 IR3: Lessening the burden of HIV The task of overseeing TB treatment on a daily basis is doable as it only lasts for 6 months but overseeing AIDS treatment would be a life-long commitment and the best option would be to build the capacity of family members to oversee that task. In case of any special needs, the volunteers have been trained on HIV before and would assist, even if it means referring the patient back to HC/Hospital. Even HBC would be best performed by family members and the focal point volunteer (one per village) could be given special training on this so she could assist to train family members. The CGV would be the link between the family and Focal Point Volunteer and would be able to identify these specific needs and would inform the Focal Point Volunteer. I. Tuberculosis Grantees World Relief has followed the DIP in monitoring the progress of the project using the M&E indicators discussed in the DIP (See Section E). However, during the MTE it was found that a few of these indicators were redundant and did not add valuable information on the status of the project. Hence it was recommended by the MTE Team Leader that these indicators be dropped. In addition, it was recommended that the terminology of cohort indicators follow the WHO terminology. Annex 13 presents the M&E indicators from the DIP; further, indicators that may be removed are highlighted in blue and terminology to be changed is in green. In addition to monitoring and evaluation according to the DIP, project activities have been implemented following the work plan stated in the DIP (See Annex 4). This project has been the first TB project implemented by WR. The project has greatly benefitted from the input provided by the MTE Team Leader and the organization appreciates his guidance. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 30 J. Annex J.1 Annex 1: Learning brief Tuberculosis Control in Gaza Province, Mozambique The World Health Organization (WHO) reports that Mozambique has the 3rd highest incidence rate of all forms of TB (544 per 100,000), 6th highest the prevalence rate of all forms of TB (491 per 100,000), and the 4th highest TB mortality rate (49 per 100,000) among the 22 high tuberculosis burden countries. Further, among these 22 countries that comprise over 80% of all TB cases, Mozambique has the lowest case detection rate (34%) 1 . Gaza province in Mozambique notified and reported 1874 TB BK+ cases in 2011 with an SS+ CNR of 135/100,000. This rate is considerably higher than the national SS+ CNR of 87/100,000 2 . World Relief introduced the Vurhonga TB CB-DOTS project in late 2009, covering a population of 226,523 in six under-served rural districts and 354,689 in three urban areas, of Gaza province. The overall goal of the project is to reduce the burden of tuberculosis (TB), in line with the World Health Organization (WHO) Stop TB Strategy and the Mozambique National Strategic Plan. Its primary objectives are to increase the case notification rate by 50% and to achieve 85% treatment success rate in project areas fully implementing Community-Based Directly Observed Treatment Short-Course (CB-DOTS). The intermediate results are:  IR1: Empower people with TB to seek and complete treatment, with the support of their communities.  IR2: Strengthen National Tuberculosis Program (NTP) Systems to improve TB service delivery and patient outcomes.  IR3: Decrease the burden of HIV in patients with TB and decrease the burden of TB in people living with HIV/AIDS (PLWHA). The project supports the National Tuberculosis Program of Mozambique in Gaza province by training community volunteer structures such as Care Groups some of which have been in existence since 1995, Village Health Committees, TB focal point volunteers appointed by the MISAU in rural areas, and Pastors’ Networks, OVC volunteers, HBCAs in urban areas. They have been trained to educate their communities about tuberculosis, detect TB cases, refer them to the health facility for testing and monitor their compliance to treatment regimens. The project has trained a total of 48,352 community volunteers since the onset of the project. Further, the project builds capacity of the local MISAU staff and sponsors training peripheral nurses and laboratory technicians in tuberculosis diagnostics. Joint supervision of health centers and communities are undertaken by WR care group supervisors and MISAU’s district TB supervisors every quarter, and the collaboration with the MISAU is thereby fostered at several levels from the village to the health facility. The project uses a rigorous M&E system which obtains data using the Modified District Rapid Assessment Tool (M-DRAT) and project records. The M-DRAT data collection is conducted quarterly by WR’s M&E personnel from all district health centers where the district TB registers are maintained by the district TB supervisors. In addition, project villages maintain community TB data in the village TB registers. Other data collection includes assessment of knowledge, beliefs and practices in the community by the baseline, midterm and final KPC surveys that are conducted in the project areas. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 31 Key results at the end of Q4,11 are:  Increase in Case Notification Rate (CNR) from 128.3 per 100,000 population (baseline/Q1,10) to 139.5 per 100,000 (Q4,10) followed by a fluctuation in CNR. The CNR in Q4’11 was 107.7 per 100,000 population.  Increase in percentage of TB suspects examined by sputum smear from 80.9% (baseline/Q1,10) to 95.7% (Q3,11) which then dipped to 81.8% (Q4’11); project target is 80.0% – Rapid Indicator.  Negligible major error rate of less than 1% in diagnostic quality of TB microscopy.  Increase in KPC respondents indicating that they had received information about TB in the last 6 months from 36.1% at baseline to 66% at midterm.  Increase in knowledge that TB is transmitted through the air by coughing from 20.7% at baseline to 61.3% at midterm.  Decrease in proportion of respondents who opted to seek care from traditional healers if they had symptoms of TB from 21.1% at baseline to 0.7% at midterm. This is the first CB-DOTS project in the rural areas of Gaza province. Hence it was first viewed with skepticism by the traditional healers in the community and health post nurses who were not systematic in providing referral forms to the CGVs. However, care group volunteers persisted in educating households including that of traditional healers. With time, when some of the traditional healers themselves had symptoms of TB, they approached the CGVs who referred them to the health center for treatment and followed-up the treatment intake in the community. To date, 990 traditional healers have participated in TB trainings offered by the project. Meetings were held with the support of the MISAU for peripheral nurses about the importance of CB-DOTS, which has improved the referral system considerably. Further, the project sponsored training of peripheral nurses (n=35) in slide fixing to improve access to TB diagnosis. Systematic recording of TB patients on CB-DOTS in district TB registers has been a challenge in several district health centers leading to underestimation of CB-DOTS TB cases. The MISAU is now planning to introduce revised district TB registers which will have a column to record this information systematically. The project is designed to support the MISAU’s National Tuberculosis Program; therefore, several project activities are closely meshed with the MISAU activities, which create a conducive environment for partnership and joint responsibility to reduce the burden of TB in these high burden areas. The joint working of project staff and MISAU staff on a regular basis has built local capacity in TB case detection, diagnosis and treatment, and will facilitate transference and institutionalization of project approach and design. References: 1. World Health Organization, Global Tuberculosis Control, 2011. 2. Annual TB Report, Gaza Province, Mozambique, 2011. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 32 J.2 Annex 2: List of Publications and Presentations Related to the Project 1. New Grantee Presentation, November 5, 2009. 2. Presentation in the District of Chigubo, August 19-21, 2011 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 33 3. Presentation in Mabalane, August 29-30,2011 4. Presentation in Guija, September 2011 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 34 5. Presentation in Xai-Xai, October 2011 6. Presentation in Chokwe, March 2012 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 35 7. Presentation in Chokwe, April 2012 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 36 J.3 Annex 3: Project Management Evaluation J.3.1 Planning The project has been implemented in accordance to the DIP. In addition to the activities in the work plan presented in the DIP, the project conducted trainings for peripheral nurses to facilitate their involvement in CB-DOTS. The M&E indicators listed in the DIP are very elaborate and would need to be simplified if this is to be institutionalized. J.3.2 Supervision of Project Staff World Relief CG Supervisors periodically visit the care groups under their supervision. Any challenges faced by CGVs are reported to focal point volunteers who relay the information to the respective supervisor who takes necessary steps and or informs the project manager. In addition, every quarter, joint supervisory visits are made to villages by MISAU’s district TB supervisor and WR’s CG Supervisor to ensure the smooth functioning of tuberculosis activities. The joint visits are practised to foster institutionalization of the supervisory system. J.3.3 Human Resources and Staff Management The partnership with the MISAU staff is strong and the project is seen as strengthening the national TB control agenda. Working relationships among project personnel are very strong and the staffs take much pride in their work. The staff turnover has been 25 staff over 2 years in the field office. In the initial stages of the project, it had been difficult to find a suitable TB manager but in June of 2011 the position of TB-DOTS Manager was filled. At the headquarters, the individual most closely involved in development of the project’s M&E systems and tools resigned in 2010. In late September 2011 a Health Advisor was appointed for technical support as part of the health technical unit in Baltimore. While the recruitment process for these two positions continued, senior staff in the field office and HQ stepped in to lessen the gap in staffing. J.3.4 Financial Management Project finances are maintained by the organization-wide Enterprise Resource Planning (ERP) system. Financial managers along with the project manager record budget forecasts, track expenditures and variances by this system. Financial reports are obtained through the system and the system creates transparency within the organization. The project has maintained to stay within budget for each year despite implementing all activities in the work plan as well as additional trainings that were important for the smooth functioning of the project. J.3.5 Logistics The procurement and distribution of project equipment and supplies for the most part had not had any negative impact on project implementation, except for the distribution of motorbikes. Motorbikes were distributed in Q1 of 2012 as 6 motorbikes were needed instead of just 3 as budgeted in the DIP. To compensate, 6 second hand motorbikes were purchased and repaired which required additional time. J.3.6 Information Management The project has a systematic data collection method by using the M-DRAT system as described in section C. In addition, the project maintains project records on staffing, volunteer training and logistics. At the community level, focal point volunteers and VHC are trained to maintain the village TB registers from which community level data are obtained. This system of data collection is very thorough; however, the intensely detailed list of M&E indicators warrants simplification. The M&E officer is responsible for data collection using the M-DRAT who is well experienced with the data collection For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 37 methodology. It is now recommended that CG Supervisors maintain a list of TB suspects referred from the community who were diagnosed as TB cases in order to counter-check if these patients were listed as CB-DOTS in the district TB registers during the quarterly M-DRAT data collection at health centers. The quarterly M-DRAT data, baseline and midterm KPC data keeps the MISAU informed of the progress of TB control in their communities. The project conducts annual household surveys to assess the work of CGVs. The surveys are administered to households by CGVs of neighboring villages to minimize bias. Further, soon after the midterm KPC survey and MTE debriefing sessions were held to present the findings and the status of the project to project staff. WR CG Supervisors were also given a synopsis of the midterm KPC survey data to inform their respective district TB supervisors. J.3.7 Technical and Administrative Support The project’s TB Mentor who is a faculty at Johns Hopkins University has been a support to the project, offering review of project plans and reports as requested. Within the organization, the MCH specialist at the HQ was closely involved in the project design, DIP and M-DRAT development. The current Health Advisor at the HQ in Baltimore, as the technical backstop of the project, has visited project sites twice within 6 months, assessed the progress of the project, met with partners and made relevant recommendations. Further, the Health Advisor has been responsible for writing of annual reports, assisting the field staff in data entry using Epi Info by developing a step-by-step manual, analyzing the midterm KPC data and writing the report, coordinating the MTE by writing the scope of work and participating in the evaluation and co-authoring the report. In addition, there are plans to publish findings from the project in the future. J.3.8 Management Lessons Learned  There needs to be closer supervision of FPVs and CGVs so that only those who are committed to their work should be retained as volunteers.  There needs to be a prompt response to staff turnover.  There needs to be continued proactive interaction with the MISAU staff and USAID Mission. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 38 J.4 Annex 4: Work plan Table Work Plan for WR CB DOTS Program in Gaza, Mozambique Year 1 Year 2 Year 3 Year 4 Year 5 Objective Met Activity Status 2010 2011 2012 2013 2014 IR1. People with TB will be empowered to seek and complete treatment with the support of their communities Yes Staff recruitment x x x Completed Introduction of program to village/church leaders with approval letter from district administrator and MISAU. x x Completed TB Curriculum preparation for Supervisors to train Volunteers who will in turn train households. x Completed Accommodation arrangements for supervisors in districts/villages x x Completed Update volunteer-household census for 6 districts and update rosters of HBCAs and assigned families x Completed Staff (supervisor) training on TB DOTS x x Completed Animator/Volunteer (C/G) training on CB DOTS x x x x x x x x x x x x x x x x x Completed; refresher training in progress Household training on TB DOTS by volunteers x x x x x x x x x x x x x x x x x x In progress VHC/Pastor’s Network training on CB DOTS by animators or supervisors x x x x x x x x x x x x x x x x x In progress Referral of suspected TB patients to the nearest TB health facility x x x x x x x x x x x x x x x x x x In progress CGV facilitate the selection of padrinhos and monitor progress during the course of treatment for active TB patients in their area x x x x x x x x x x x x x x x x x x In progress Training for general community awareness, dispelling myths x x x x x x x x x x x x x x x x x In progress IR2. Strengthen the NTP systems to improve TB service delivery and patient outcomes Yes Introduction of program to provincial and district MISAU directors as well as district administrators. Mini workshop for stakeholders, MISAU for M￾DRAT. x x Completed For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 39 Procurement of M/bikes and lab equipment for districts x x Motorbikes were distributed in Q1 2012 as 6 motorbikes were needed instead of just 3 as budgeted in the DIP. So 6 second hand motorbikes were purchased and repaired. This required additional time. MISAU district supervisor training on CB DOTS x Completed MISAU lab technician training on TB DOTS, co￾infection with HIV x x In progress IR3. Implement integrated TB/HIV activities aimed to address high co-infection rates Yes HIV/AIDS program volunteer training on CB DOTS, CPT uptake x x x x In progress Training of pastor networks on TB symptoms, referral and treatment x x x x In progress Radio programs to educate about TB symptoms, referral and treatment x x x x In progress Monitoring & Evaluation Yes Baseline KPC in the community x Completed Needs assessment of district labs-and facilities: clinical care, data management, drug supply and referral system x x x x In progress Supervision of WR supervisors x x x x x x x x x x x x x x x x x In progress Supervision of MISAU TB DOTS supervisors x x x x x x x x x x x x x x x x x In progress Home visits to evaluate volunteer household training. x x x x x x x x x x x x x x x x x In progress Modified LQAS to evaluate household knowledge on TB x x x x x x In progress Monthly staff meeting to get feedback and to plan for the following month x x x x x x x x x x x x x x x x x x In progress District management/coordination meetings x x x x x x x x x x x x x x x x x x In progress Provincial management meetings x x x x x x x x x In progress Modified DRAT used for tracking of TB patients and outcomes x x x x x x x x x x x x x x x x In progress Village data collection by lead TB volunteer in each community x x x x x x x x x x x x x x x x x In progress District data collection, analysis and feedback to the communities x x x x x x x x x x x x x x x x x In progress For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 40 Feedback on community and HF data collection to the MISAU and HFs x x x x x x x x x x x x x x x x x In progress Monitoring of the referral process to ensure CB-DOTS patients are recorded and tracked at all levels x x x x x x x x x x x x x x x x x In progress MTE x FE x Supervisor monthly reports x x x x x x x x x x x x x x x x x x In progress Project quarterly reports x x x x x x x x x x x x x x x x x x x In progress Annual reports x x x In progress J.5 Annex 5: Rapid Catch Table This is not applicable at Midterm. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 41 J.6 Annex 6: Mid-Term KPC Report World Relief Mozambique Vurhonga Community Based DOTS Project MidTerm Knowledge, Practice and Coverage (KPC) Survey Report May 14, 2012 AUTHORS Pieter Ernst, MD Director of Program Integration World Relief Mozambique Chokwe, Mozambique Monisha Jayakumar, BDS, MPH, PHD Health Advisor World Relief Headquarters Baltimore, MD, USA Vurhonga CB-DOTS MTE KPC Report Page | 1 Acronyms ACSM Advocacy Communication and Social Mobilization CB-DOT Community Based, Directly Observed Therapy CB-DOTS Community Based- Directly Observed Therapy Short-Course CGV Care Group Volunteer C-HIS Community Health Information System CNR Case Notification Rate CSP Child Survival Project CSTS+ Child Survival Technical Support Plus DOT Directly Observed Therapy DOTS Directly Observed Therapy Short-Course, Internationally recommended strategy for TB control DST Drug Sensitivity Testing HIV Human Immunodeficiency Virus KPC Knowledge Practice and Coverage SS Sputum Smear NTP National Tuberculosis Program TB Tuberculosis VHC Village Health Committee WHO World Health Organization WR World Relief Vurhonga CB-DOTS MTE KPC Report Page | 2 Table of Contents 1. Executive Summary ............................................................................................................................................................. 3 2. Background .......................................................................................................................................................................... 3 Location and population .............................................................................................................................................................. 3 Overview of general health status of population.......................................................................................................................... 3 The burden of TB in Mozambique ............................................................................................................................................... 3 The burden of TB in Gaza Province ............................................................................................................................................ 4 Structures for TB services ........................................................................................................................................................... 4 Project Goal and Objectives ........................................................................................................................................................ 4 3. Process and Partnership Building...................................................................................................................................... 6 4. Methods................................................................................................................................................................................. 6 Project Indicators analyzed in this survey.................................................................................................................................... 6 Sampling Design ......................................................................................................................................................................... 7 Interviewer Recruitment............................................................................................................................................................... 7 Interviewer and Supervisor Training............................................................................................................................................ 7 Data Collection ............................................................................................................................................................................ 7 Data Analysis............................................................................................................................................................................... 8 5. Results .................................................................................................................................................................................. 9 Project Indicators captured by Midterm KPC ......................................................................................................................... 9 Socio-Demographic Information ................................................................................................................................................ 10 Tuberculosis Symptoms ............................................................................................................................................................ 10 Tuberculosis Knowledge ........................................................................................................................................................... 10 Tuberculosis Treatment............................................................................................................................................................. 11 Tuberculosis Prevention ............................................................................................................................................................ 11 Tuberculosis Stigma .................................................................................................................................................................. 12 HIV Knowledge and Stigma....................................................................................................................................................... 12 TB/HIV Co-infection................................................................................................................................................................... 12 6. Discussion .......................................................................................................................................................................... 12 7. Annex .................................................................................................................................................................................. 14 Annex A: English Survey Questionnaire .................................................................................................................................... 14 Annex B: Shangaan Survey Questionnaire ............................................................................................................................... 24 Annex C: Midterm KPC Raw Data Tables ................................................................................................................................. 37 Annex D: Sampling Framework ................................................................................................................................................. 53 Annex E: Survey Team .............................................................................................................................................................. 57 Annex F: Training and Survey Schedule with Project Resources Required .............................................................................. 58 Vurhonga CB-DOTS MTE KPC Report Page | 3 1. Executive Summary In March 2012, the World Relief Vurhonga TB team conducted a Midterm KPC survey in the rural districts of the project area including Massingir, Chicualacuala, Massangena, Chigubo, Mabalane and Guija districts in Gaza Province, Mozambique. The purpose of the survey was to assess the impact the project had during the first half of the project cycle in terms of knowledge, attitudes and practices surrounding tuberculosis among adults. Communities were chosen at random, based on the thirty-cluster methodology and analyzed accordingly. This baseline survey tool will be repeated during the Final assessment of the project. The survey consisted of questions on socio-demographics, knowledge of TB symptoms, treatment, prevention, knowledge of TB/HIV coinfection as well as stigma. The key project indicators captured in this KPC Survey include:  Knowledge that TB is transmitted through the air by coughing  Knowledge that coughing longer than three weeks is a sign of TB  Knowledge that TB is curable  Knowledge that TB treatment is free 2. Background Location and population Mozambique is a coastal country in southern Africa with an estimated population in 2010 of 23.4 millioni , and 1.33 million in the southern province of Gaza.ii The project area includes the rural districts of Chicualacuala, Chigubo, Massangena, Massingir, Guija and Mabalane with a total population of 226,523 in 2011iii. In addition, the project also works with trainers and caregivers under supervision of pastors networks that work with HIV+ individuals and their families in three urban sites: Macia in Bilene District, Chokwe in Chokwe District and Guija town in Guija District with an additional population of 354,689 iv . Overview of general health status of population The World Bank’s Human Development Index in 2011 ranks Mozambique 184 out of 187 with a life expectancy of 50.2 years at birth.v In 2009, 38% of the population was urban, adult mortality rate was 493 per 100 adults 15-59 years and under-5 mortality rate was 142 per 1000 live births. Malaria caused 23% of deaths in children under five and pneumonia 16% of the deaths in this age group in 2008. The prevalence of HIV was 115 per 1000 adults 15-49 years of age.vi In 2010, the prevalence of tuberculosis was 491 per 100,000 population.vii The burden of TB in Mozambique According to the World Health Organization (WHO) Mozambique has the 3rd highest incidence rate of all forms of TB (544 per 100,000), the 6th highest prevalence rate of all forms of TB (491 per 100,000), and the 4 th highest TB mortality rate (49 per 100,000) among the 22 high tuberculosis burden countries. Among these 22 countries that comprise over 80% of all TB cases, Mozambique has the lowest case detection rate (34%)viii. Despite significant government resources to fight TB, the HIV crisis undermines much progress. Among the infectious sputum smear positive (SS+) cases, the incidence was 186/100,000 in 2006ix and the estimated prevalence rate in 2004 was 250/100,000.x While Directly Observed Treatment- Short Course (DOTS) is available in every province, the coverage rate varies greatly. Overall, DOTS coverage is 70.9%, Vurhonga CB-DOTS MTE KPC Report Page | 4 however coverage in Gaza is only 54.1%, which is the third lowest in Mozambique.xi Based on a 2005 cohort, the DOTS treatment success rate was 70% for all cases, and 79% for new cases.xii Nationally, the DOTS case detection rate is 47%, with a treatment sucess rate of of 70% for both new and returning SS+ cases.xiii A national survey in 1999 stated a (Multi-Drug Resistant Tuberculosis) MDR-TB rate of 3.4%.xiv The burden of TB in Gaza Province The Provincial Annual Report 2011xv indicated that there was a decrease in the number of TB cases from that of 2010. The case detection rate of BK+ declined by 3% from 85% in 2010 to 82% in 2011. The province notified and reported 1874 TB BK+ cases in 2011 which was a decline from 1928 TB BK+ cases in 2010. Of the 1931 all forms of TB cases in 2011, the treatment completion rate was 0.2% (n=3) compared to the treatment completion rate of 1.0% in 2010; the cure rate was 79.1% (n=1528) which was a 1% increase from 78.0% in 2010; the deaths were 14.3% (n=276) which was a 1% increase from 13% in 2009; treatment failure rate was 2.0% (n=38) which was a 1% reduction from 3.0% in 2009; dropout rate was 3.6% (n=69) which was similar to the dropout rate of 4.0% in 2009; transfer rate was 0.9% which was an increase from 0.5% in 2009. Further, it was reported that in 2011, 99.0% of the TB cases were tested for HIV, of which 75.0% were HIV+. Of these HIV+/TB cases, 98% were started on cotrimoxazole preventive treatment but only 33.0% were on anti-retroviral treatment. Structures for TB services Mozambique has a total of 250 labs with smear microscopy and one National Laboratory in Maputo responsible for multi-drug resistance testing and drug sensitivity testing (DST); TB facilities include: 149 health centers with DOTS capacity, and 800 health posts with the potential for expansion of community￾based DOTS.xvi In 2008, 88% of the National Tuberculosis Program (NTP) was funded with the government’s contribution totalling 11% of the budget. The cost of the NTP per capita was $0.90. Project Goal and Objectives The project goal is to reduce the burden of TB, in line with the Stop TB Strategy and Mozambique National Strategic Plan. Its primary objectives are to increase the case notification rate by 50% and achieve 85% treatment success rate for CB-DOTS in project areas. Intermediate Result 1: People with TB will be empowered to seek and complete treatment with the support of their communities. (45% Effort) Strategy 1.1: Advocacy, Communication, and Social Mobilization (ACSM) (Rural Districts) Objectives: Increase knowledge that TB is transmitted through the air by coughing from 20.7% to 60% Increase knowledge that cough longer than three weeks is a sign of TB from 13.3% to 60% Sustain the high percentage of respondents surveyed who know that TB is curable at 85% Increase knowledge that TB treatment is available for free from 39.7% at baseline to 80% Train 100% of Care Group Volunteers (CGVs) in CB-DOTS Train 100% of functioning Village Health Committees (VHC) in TB Strategy 1.2: Case Detection (Rural Districts) Objectives: Increase the quarterly case notification rate (CNR) by 50% from 110 to 165 Maintain the high percentage of TB suspects examined by sputum microscopy at 80% Increase the percentage of referrals made by volunteers (measured at the HC and at the community) from 20.6% to 60% Strategy 1.3: Treatment Compliance (Rural Districts) Objectives: Conduct cohort analysis of treatment outcomes for SS+ patients including: Vurhonga CB-DOTS MTE KPC Report Page | 5 Increase the rate of treatment success from 78.6% % to 85% Maintain the high level of sputum smear conversion at 90% Eighty-five percent of SS- patients will complete their full course of treatment Increase the percentage of patients on CB-DOT from 26.4% to 60% Strategy 1.4: Community Health Information System (C-HIS) (Rural Districts) Objectives: Eighty percent of VHCs will have local data on TB from the previous quarter Eighty-three percent of HCs will compile C-HIS data collected by volunteers on TB Intermediate Result 2: Strengthen NTP Systems to improve TB service delivery and patient outcomes. (45% Effort) Strategy 2.1: Facility Assessments (Rural Districts and Urban Centers) Objectives: Conduct quarterly assessments of all health centers in the project area One hundred percent of HC assessments will be conducted with participation from the District TB Supervisors or designated representative Strategy 2.2: Diagnostic Quality (Rural Districts and Urban Centers) Objectives: Bring the proportion of TB suspects with SS+ confirmation in line with international standards by lowering it from 44.6% to between 10% and 25% Maintain the low proportion of major errors at less than 1% Strategy 2.3: Access (Rural Districts) Objectives: Less than 10% of HFs will report sputum bottle stock-outs in the previous quarter Strategy 2.4: Referral (Rural Districts) Objectives: Seventy-five percent of the patients referred from HPs will be recorded at health center Eighty percent of TB+ patients will return to the HP after receiving their diagnosis Strategy 2.5: Information Systems (Rural Districts and Urban Centers) Objectives: Less than 5% of HCs reporting drug stock-outs of essential TB drugs for the last quarter Less than 2% of those who start treatment will drop out (Interruption rate) Strategy 2.6: Supervision (Rural Districts) Objectives: Eighty-five percent of HP will be supervised by the District TB Supervisor during the previous quarter as reported in the M-DRAT Eighty-five percent of HPs will report supervisory visits by the District TB Supervisor Strategy 2.7: Coordination with NTP (Rural Districts and Urban Centers) Objectives: Attend 80% of meetings to which WR is invited Conduct six joint supervisory visits to HPs each quarter Intermediate Result 3: Decrease the burden of HIV in people with TB and decrease the burden of TB among PLWHA. (10% Effort) Strategy 3.1: TB and HIV Education through ACSM (Urban Centers) Objectives: Train 60 OVC and youth volunteers in TB including stigma reduction Train three PNs in TB including stigma reduction Strategy 3.2: Intensified TB Case Finding among PLWHA (Urban Centers) Objectives: Train 40 HBCAs in TB case finding, referral and stigma reduction Strategy 3.3: Routine HIV/ TB Testing (Urban Centers and Rural Districts) Objectives: Improve the percentage of HIV+ patients screened for TB from 46.6% to 60% Maintain high levels of HIV testing among TB patients at 95% Strategy 3.4: Cotrimoxazole Prevention Therapy (CPT) (Urban Centers and Rural Districts) Objectives: Maintain high levels of CPT in HIV/TB patients at 90% Vurhonga CB-DOTS MTE KPC Report Page | 6 Less than 25% of HCs reporting stocks out of Cotrimoxazole in the previous quarter Strategy 3.5: Case Management of Co-Infections (Urban Centers) Objectives: Number of HBCAs trained on CB-DOT 3. Process and Partnership Building World Relief, through the project supervisors in each district has built a close relationship with the district health authorities, more especially the district directors and district TB supervisors but also the lab, pharmacy and HIV staff. At the provincial level the project M&E official and the project manager has worked closely with the provincial TB supervisor and provincial director. At the community level the program supervisors have worked closely with village leadership, pastors networks and government structures, firstly in choosing new CGVs where previous ones have died or moved away or dropped out and secondly in choosing one focal point volunteer for the village and thirdly in calling village men together to receive TB training directly from the project supervisors. During the KPC survey the provincial TB Supervisor and all the district TB supervisors were invited to participate in the survey where feasible and practical. 4. Methods The purpose of this midterm KPC survey is to provide evidence of the impact and progress the project has made during the first two and a half years of the 5 year project cycle compared to the baseline survey data. The KPC questionnaire used during the baseline and now during the MTE was adapted from previous surveys used in CSHGP TB projects and from the WHO recommendations for KPC surveys. Melanie Morrow and Debbie Dortzbach from World Relief and James Ricca from MCHIP reviewed the survey. The approved questionnaire was developed in English and then translated into Shangaan. The questionnaire contains 52 questions that cover the following topics: Questions 1-6 Socio-Demographics Questions 7-13 Prevalence of TB symptoms Questions 14-22 Knowledge of TB Questions 23-34 Treatment of TB Questions 35-36 Prevention of TB Questions 37-43 TB Stigma Questions 44-49 HIV Knowledge and Stigma Questions 50-52 TB/ HIV Co-infection Project Indicators analyzed in this survey 1. Knowledge that TB is curable: The number of those surveyed that responded that TB is curable divided by the total number of respondents in the survey. 2. Knowledge that TB treatment is free: The number of those surveyed that responded that TB treatment is free divided by the total number of respondents in the survey. 3. Knowledge of how TB is transmitted: The number of those surveyed that responded that TB is transmitted through the air by coughing divided by the total number of respondents in the survey. 4. Knowledge that long duration cough is a sign of TB: The number of those surveyed that responded Vurhonga CB-DOTS MTE KPC Report Page | 7 that cough longer than three weeks is a sign of TB divided by the total number of respondents. Sampling Design The sample size was determined using the CSTS+ KPC Module – two-stage 30 by 10 cluster sampling method. This model uses the following formula to calculate the sample size: N= Z²(1-P)P E² N= Sample size; Z=1.96 (for a confidence interval of 95%); P= Known prevalence; E=% within=±0.05. Thirty clusters were randomly selected from a list of all the villages in the project area, taking into account the differences in population size of the villages (Proportional Population Cluster Sampling method). See Annex D for the sampling framework. For each cluster, interviews were conducted with 10 households. Upon arriving in a village, the village headman was asked to identify a place considered close to the central point of the village. At the central site, a member of the survey team spun a pen. The survey team started in the direction of the pen (pointed end) to the first house. If the object pointed in the direction where there were no houses, the procedure would be repeated until there were houses in that direction. The interview started at the nearest household and continued to the next one in the same direction until the required number of households per cluster was met. In cases where the chosen direction had less than the required sample the object would be re-spun to change direction at the farthest household and the team proceeded in that direction until the total required sample in that cluster was met. Interviewer Recruitment Interviewers for the Midterm KPC survey included 10 TB Dots project staff and 11 external interviewers. Of the external interviewers, 3 were men and 8 were women. All were fluent in Portuguese and Shangaan. Interviewer and Supervisor Training The interviewers and supervisors received 3 days of training by Director of Program Integration and the Program Manager on sampling and household selection, the importance of surveys, the difference between quantitative and qualitative data and the task of interviewers and supervisors. Time was given to practice reading of the questionnaire fluently and to code responses accurately. The survey team was divided into 6 survey groups, each group consisting of 2 interviewers and one supervisor. Two groups went to the field in one vehicle. There were 3 coordinators who coordinated the vehicles and logistics during the survey as well as checked all the survey questionnaires for possible errors before the vehicles left the villages. The practicing of the questionnaire was done by dividing them into their survey groups of 3 each. Overall supervision of the practicing groups was done by the 3 vehicle coordinators who would move from group to group to listen in. The supervisors also used the time in small groups to explain each question. The interviewers also received training on the objectives of the KPC survey and the household selection process. See Annex E for a complete listing of person/roles involved with the surveying process and Annex F for the training schedule. Data Collection Data collection occurred from March 19 to 22, 2012 and included 6 survey groups, each survey group consisting of 2 interviewers and one supervisor. The only major constraint was the long distances between villages and a few flat tyres. The average interview length was approximately 40 minutes. For quality control purposes, each of the 2 interviewers in a survey group was accompanied by a supervisor who Vurhonga CB-DOTS MTE KPC Report Page | 8 observed the interviews by alternating beteen interviewers. The supervisor also checked the questionnaires for any errors that may have occurred. Data Analysis The data was hand tabulated on March 13 -14th by the supervisors, coordinators and interviewers in Chokwe, Mozambique for immediate results. The data were entered into EpiInfo and make electronically available for analysis. The health advisor in the Home Office, Baltimore, checked for errors and inconsitencies and once the data were cleaned, she analyzed the data, using STATA 10. Vurhonga CB-DOTS MTE KPC Report Page | 9 5. Results Project Indicators captured by Midterm KPC Q. No. Indicator Baseline Midterm Target Numerator Denominator Percentage 95% CI Numerator Denominator Percentage 95% CI 16 Percentage of respondents that know that TB is transmitted through the air by coughing 62 300 20.7% 12.0% - 29.4% 184 300 61.3 % 55.6% - 66.9% 60% 15 Percentage of respondents that know that cough longer than three weeks is a symptom of TB 40 300 13.3% 8.9% - 17.8% 54 300 18.0% 13.8% - 22.8% 60% Percentage of respondents that know that coughing is a symptom of TB 187 300 66.3% 55.0% - 69.7% 200 300 66.7% 61.0% - 72.0% 19 Percentage of respondents surveyed know that TB is curable 256 300 85.3% 80.0% - 90.7% 275 300 91.7% 87.9% - 94.5% 85% 20 Percentage of respondents surveyed know that TB treatment is available for free* 119 300 39.7% 31.2% - 48.1% 70 300 23.3% 18.7% - 28.5% 80% * Translation in shangan: Do you pay or is it free? This is umbiguous. Also Naree (Murhi) is the term used, which implies traditional treatment which requires payment. Correction: it should be - Do you pay for TB tablets? Vurhonga CB-DOTS MTE KPC Report Page | 10 Socio-Demographic Information Of the 300 respondents in the midterm KPC survey, 22.7% (n=68) were male and 77.3% (n=232) were female. The median age of the respondents was 33.5 years, ranging from 14 years to 74 years. The median age of respondents in the baseline KPC survey was 35.7 years (range: 18-69 years). Further, 62.7% of the 300 respondents attended school at some point in their life. Of those who attended school, 50.0% completed primary school, 12.3% completed secondary school and 0.3% completed post-secondary school. In comparison, 83.8% had completed primary school in the baseline KPC but proportion of respondents who had completed secondary school was comparable between baseline and midterm KPC surveys. On average, 8 people live in a household with a range of 1-35 persons in a household. The average number of rooms in a house is 2 with a range of 1-8 rooms. The survey indicated that the household income of 26.3% of the respondents is not enough for food. While 49.3% of respondents responded that their household income was barely enough for food and 24.3% of them reported that their household income was enough for food. These proportions are comparable with the baseline KPC survey results. Tuberculosis Symptoms When TB symptoms were listed, 18.7% responded that someone in their household had such symptoms in the last three months. Of these with TB symptoms, 65.5% were female and the most commonly reported symptoms included coughing with sputum (52.7%) and pain in chest (41.8%). The other symptoms reported were night sweats (32.7%), total weakness (29.1%), cough for over 3 weeks (27.3%) and weight loss (27.3%). Of those with TB symptoms 88.9% sought medical care. Tuberculosis Knowledge A large proportion of the respondents had heard of TB (94.7%). Those who had heard of TB were able to list symptoms of TB such as coughing (70.4%), weight loss (49.3%), coughing with sputum (27.8%) and cough with blood in sputum (25.0%). Only 19.0% stated that coughing for longer than 3 weeks was a symptom of TB. Of all 300 respondents, 66.7% stated coughing as a symptom of TB, followed by weight loss (46.7%), coughing with sputum (26.3%), and coughing with blood in sputum (23.7%). Only 18.0% mentioned that coughing for longer than 3 weeks was a symptom of TB. It must be noted that there was no prompting by the interviewer and TB symptoms were not listed. As a result most respondents stated coughing as a symptom of TB without going into details of the duration of cough. When asked about TB transmission, of the 300 respondents, 61.3% stated that it was through the air by coughing which was much higher than baseline proportion of 20.7%. The second most common response was transmission through the death of someone (17.0%), which has decreased from the baseline level of 37.3%. The other common response was that TB is sexually transmitted (11.0%) which was comparable to baseline level of 13.3%. Only 7.7% of respondents mentioned that they did not know how TB is transmitted compared to 22.3%. Sixty six percent of the 300 respondents reported that they had received information about TB in the last 6 months. This was a substantial increase from the baseline level of 36.1%. Of those who received TB information, more than half received the information from volunteers (58.5%). The second most common source of TB information was reported to be friends/acquaintances/relatives (25.0%). Vurhonga CB-DOTS MTE KPC Report Page | 11 Knowledge that TB is curable continued to remain high (91.7%), which was 85.3% at baseline. Only 23.3% of respondents knew that TB medicines were free of charge. The reason for this low prevalence is discussed in the below section. When asked about where they would go for treatment if they had TB symptoms, 88.7% stated that they would go to the health center, 11.0% responded that they will go to TB hospital and only 0.7% stated that they would go a spiritual healer, which is a change since baseline, where 21.1% responded seeking a spiritual healer. Tuberculosis Treatment Of the 300 respondents surveyed, 41.0% would take over one hour to walk to the nearest TB testing facility; 20.3%% would have to walk 15 minutes or less, 10.7% 16 to 30 minutes, and 12.3% lived within a 30 minute to one hour walk from the nearest testing facility. Only 9.3% of respondents had a household member diagnosed with TB, with the majority (78.6%) of those cases diagnosis through a sputum test. When asked how long it took for them to receive the test results, 39.3% stated the same day and 35.7% mentioned less than one week. No one stated that they paid for the TB tests. Almost all stated that they did not pay anything to find out if they had TB (92.9%), while 7.1% responded that they did not know. On the other hand, the survey indicated that only 23.3% of the 300 respondants know that TB treatment is available for free. This seems to be a result of a poor translation of the question “Is TB medicine free of charge?” into the local Shangan language from English, thereby causing a misunderstanding of the question. There is a possibility that the respondents may have meant “No” to paying for TB treatment but this was captured as “No” to free TB treatment by the Shangan survey instrument. If this was the case, then 54.23% responded affirmatively that they knew that TB treatment is free. Further, 96.4% stated that they or a household member received medication to treat TB and only one stated otherwise. When this individual was asked the reason for not receiving the TB medicine, the response was “Don’t know”. When asked if they had to pay anything for the TB medication, 96.3% replied that they did not have to pay but one person mentioned that they had to pay for the TB medication. Ninety two percent responded that daily intake of the TB medication was watched, which was mostly undertaken by a family member or friend or padrinho (76.0%). Moreover, 85.2% responded that the course of medication was completed as explained by the health worker. Of the two respondents who stopped taking TB medicine, one reported drug side effects as the reason for discontinuation of treatment while the second individual selected the “other” option with going into details. Of those who completed the course, 78.3% responded that they were cured. Tuberculosis Prevention When asked what can be done to decrease the risk of getting TB, 27.7% listed provision of good ventilation for workplace and home while 69.0% listed several other ways. The proportion of those who could not list a single way to decrease the risk of getting TB declined to 35% from a baseline level of 67.3%. When asked about ways to decrease the risk of transmitting TB, 44.3% stated adherence to treatment, 40.7% stated cover mouth when coughing, 23.7% mentioned not spitting in public places. Only 13.3% did not know a way to decrease the risk of transmission, which again was lower than the baseline level 27.3%. Vurhonga CB-DOTS MTE KPC Report Page | 12 Tuberculosis Stigma Only 29.3% of those surveyed reported that they had ever had a friend, neighbor, workmate or schoolmate with TB, yet 94.0% responded that they would visit with a TB patient in their home. Among those who responded that they would not do so, fear of disease was the most common reason stated (57.1%); however this is lower than the baseline level of 77.8%. When asked if someone had TB, would they try to hide the disease from others, 72.0% stated that they would not, which is slightly higher than baseline (68.0%). Among the various reasons why people with TB would try to hide the disease from others, 26.3% reported it was because people will think they have HIV. However, 80.3% stated that they do not think it is shameful to have TB while 17% thought it was shameful. The reasons why they thought it shameful included: the perception that the person may also be HIV+ (25.5%); everybody will avoid the person with TB (23.5%); improper cleaning after death (15.7%). HIV Knowledge and Stigma Knowledge of HIV was almost universal at 93.0%. The most commonly listed methods of preventing HIV were condom use (75.8%), faithfulness (61.8%), avoidance of skin piercing objects (20.1%) and abstinence (12.6%). When asked about HIV transmission, 94.9% of respondents stated that it is sexually transmitted, 63.5% stated transmission occurs through sharing needles and razors, while 13.0% stated it is transmitted through blood transfusion. There was a high knowledge level for where HIV testing is available at 94.0% although 36.2% of the respondents would have to walk over one hour to arrive at the nearest testing facility. The rate of HIV testing is 60% which is higher than the baseline level of 46.5%. TB/HIV Co-infection More than half of respondents, 69.0% stated that they believed that someone with HIV should be tested for TB, while 74.0% responded that those with TB should be tested for HIV. When asked if someone with HIV is more likely to get TB 71.7% responded affirmatively. 6. Discussion The main program indicators measured by the KPC are: i) knowledge that TB is transmitted through the air by coughing, ii) knowledge that cough longer than three weeks is a symptom of TB, iii) knowledge that TB is curable, iv) knowledge that TB treatment is available for free. Sixty six percent of the 300 respondents reported that they had received information about TB in the last 6 months, which was a substantial increase from the baseline level of 36.1%. Consequently, the indicator on knowledge that TB is transmitted through the air by coughing at baseline was 20.7% (95% CI: 12.0% - 29.4%) and by midterm it had increased to 61.3% (95% CI: 55.6% - 66.9%), exceeding the target of 60%. However, the indicator on knowledge that cough longer than three weeks is a symptom of TB did not reach the target of 60% but only had a slight increase from the baseline levels of 13.3% (95% CI: 8.9% - 17.8%) to midterm level of 18.0% (95% CI: 13.8% - 22.8%). The question on this indicator was asked without any prompt for respondants’ to specify the duration of cough, which may have been one of the reasons for the data showing low proportion of knowledge that cough longer than three weeks is a symptom of TB, among Vurhonga CB-DOTS MTE KPC Report Page | 13 respondents. This inference is supported by the higher proportion of knowledge that coughing is a symptom of TB, which was 66.7% (95% CI: 61.0% - 72.0%) among respondents at midterm. Knowledge that TB is curable continued to remain high with the midterm level of 91.7% (95% CI: 87.9% - 94.5%) from a baseline of 85.3% (95% CI: 0.0% - 90.7%). It is interesting to note that the proportion of respondents who opted to seek care from traditional healers, if they had symptoms of TB, declined (baseline at 21.1% and midterm at 0.7%). This may indicate that traditional beliefs such as TB is caused due to improper cleansing after death and that it is transmitted from a dead person is diminishing in the community. Knowledge that TB treatment is free did not reach the target of 80%. The data on this indicator is not reliable since the question when translated from English into Shangan became ambiguous and was interpreted in inconsistent ways (this question will be corrected in future KPC surveys). However, data on other relevant questions on cost for TB treatment reveal that are large majority (96.3% (95% CI: 81.0%-99.9%)) of those who underwent TB treatment, stated that they did not have to pay for it and that it was free. Immediately following the survey, preliminary results were shared with the supervisors who then reported the information to their respective District Administrators and Health Directors/TB supervisors. Findings of the main program indicators were shared with the WR Supervisors, Gaza Provincial TB Coordinator, and USAID Mission during the incountry debriefing in Maputo, on April 27, 2012. In addition, the findings of the KPC survey will be shared with Village Health Committees and CGVs. World Relief TB Dots project KPC survey, Gaza, Mozambique March, 2012 Vurhonga CB-DOTS MTE KPC Report - ANNEXES Page| 14 7. Annex Annex A: English Survey Questionnaire Respondent Identification Questionnaire Number Interviewer Name Respondent Name District 1=Chicualacuala, 2= Chigubo, 3= Guija, 4= Mabalane, 5= Massangena, 6=Massingir Cluster # Village Gender 1=Male, 2=Female Date of Interview …………../…………../…………… Time interview began AM PM Time interview ended AM PM FOR DATA ENTRY PERSONNEL ONLY Name Date Team leader review**: Keyed by: **Review for completion – all answers answered, skip patterns followed, etc. Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 15 SECTION A: SOCIO-DEMOGRAPHICS Instructions: Ask the questions exactly as they are written. Do not read responses unless directed to do so. Words in italics are instructions for the interviewer and should not be read aloud. Follow skip patterns as directed. Write answers in the answer box unless otherwise directed. # Questions Responses Skip Answer 1. How old are you? Age…………………………….......…………… Don’t know……………………………........ No response……………………………...... ## 88 99 2. Have you ever attended school? Yes…………………………….......…………… No…………………………….......……………. Don’t know……………………………........ No response……………………………...... 1 0 88 99 3 4 4 4 3. If yes, then ask: What is the highest grade or level of school you have completed? No School………………………..……….. Primary…………………….…………...… Secondary…………………….…….…… Past Secondary …………….…………… Other………………………………………….. 1 2 3 4 5 4. How many people live in your household? Number…………………………….......……. Don’t know……………………………........ No response …………………………........ ## 88 99 5. How many rooms are in your house? Number………………………………………. Don’t know……………………………………. No response…………………………………. ## 88 99 6. Is your household income usually… Read responses. Not enough for food……………………… Barely enough for food………….……… Enough for food………….………………… Don’t know……………………………....... No response……………………………...... 1 2 3 88 99 SECTION B: TUBERCULOSIS SYMPTOMS # Questions Responses Skip Answer 7. Have you or anyone in your household had any of the following symptoms in the last three months? Read the following: Coughing with sputum* Coughing for over 3 weeks Increasing fever for over 3 weeks Blood in sputum Pain in the chest Total weakness, inertia Weight loss Night sweats (definition of sputum = matter coughed up and ejected from the mouth; NOT spit, NOT saliva, NOT mucus from the nose) Multiple answers are possible. Yes………………………………………………. No………………………………………………. Don’t know…………………………………. No response……………………………….. 1 0 88 99 8 14 14 14 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 16 For each person with any of the symptoms listed above, ask questions 18-23 and record the answers in the box below. 8. What gender was the person who had these symptoms? Male………………………………………………. Female………………………………………….. 1 2 9. Which symptoms did he/she have? No………………………………………………….. Coughing with sputum* ………………. Coughing for over 3 weeks………… Increasing fever for over 3 wks….. Blood in sputum…………………………… Pain in the chest………………………….. Total weakness, inertia……………….. Weight loss…………………………………… Night sweats……………………………….. Don’t Know………………………………….. No response………………………………… 0 1 2 3 4 5 6 7 8 88 99 10. Did this person seek medical attention for his or her symptoms? Yes………………………………………………. No……………………………………………….. Don’t know………………………………….. No response…………………………………. 1 0 88 99 11. After how long getting sick did he or she seek medical attention? Within one week…………………………. One to two weeks………………………… Three weeks to a month……………… One to two months………………………. More than three months……………… 1 2 3 4 5 12. Why did he/she wait to seek medical attention? (Answer options for Q.24 and Q.25 are the same) Do not prompt. Felt better……………………………………. No money to see doctor……………….. Trying home treatment………………… Was too far to travel…………………… Do not trust or fear health workers………………………………………. Fear of having a serious illness………………………………………….. Fear of stigma against TB or HIV…………………………………………… Too busy…………………………………… Not aware of consequences of disease……………………….………………… Other (specify)………………..………… Don’t know……………………….…………. No response………………………………… 1 2 3 4 5 6 7 8 9 77 88 99 13. If no medical attention was sought, why wasn’t it? (Answer options for Q.24 and Q.25 are the same) Do not prompt. Q8. Gender Q9. Symptoms Q10. Treatment? Q11. How long? Q12. Delay? Q13. No Tx? Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 17 SECTION C: TUBERCULOSIS KNOWLEDGE # Questions Responses Skip Answer 14. Have you heard of the disease called Tuberculosis or TB? Yes…………………………………………………. No…………………………………………………… Don’t know……………………………………. No response...............…………………. 1 0 88 99 15 22 22 22 15. What symptoms can show that a person has TB? Multiple answers allowed. Do not prompt. Coughing………………...…………………… Fever………………...…………………...…… Coughing with sputum………………... Coughing for longer than 3 weeks.. Cough with blood in sputum…….…… Loss of appetite………………………..…… Pain in the chest……………………….…… Total weakness, inertia………………... Weight loss…………………………….……… Swollen glands…………………………..… Night sweats………………………..……… Other (specify)……………………………… ____________________________ Don’t know…………………………………… No response...............…………………. 1 2 3 4 5 6 7 8 9 10 11 77 88 99 16. How is TB transmitted? Multiple answers are possible. Do not prompt. Be sure to write any locally held or traditional beliefs. Through the air by coughing………… Through blood……………………………… Through handshake……………………… Sexually transmitted………………….... Sharing food with infected person… You’re born with it………………………… Through kiss………………….....………… After getting cold………………….....… From mosquito bite…………………….. Through the death of someone…… Other (specify)……………………………… ____________________________ Don’t know…………………………………… No response...............………………… 1 2 3 4 5 6 7 8 9 10 77 88 99 17. Have you received any information about TB in the last 6 months? Yes…………………………………………………. No…………………………………………………… Don’t know……………………………………. No response...............…………………. 1 0 88 99 18 19 19 19 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 18 18. If yes, ask: From which sources did you receive information about TB in the last 6 months? Don’t prompt. Friends, acquaintances, relatives… Doctors or nurses………………………… Other medical workers……………….... Booklets, leaflets…………………………… Radios/TV/ Newspapers………………… Volunteers……………………………………… Health department………………………… Pastor…………………………………………….. Other (specify)……………………………… ____________________________ Don’t know…………………………………… No response...............………………… 1 2 3 4 5 6 7 8 77 88 99 19. In your opinion, is TB curable? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 20. Is TB medicine free of charge? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 21. If you had TB symptoms where would you go to get care? Multiple answers are possible. Health center…………………………..…… Socorrista……..……………………………… TB Hospital (Carmelo)………………… Traditional doctor……………………...… Pharmacy……………………………………… Spiritual healer……………………………… Other (specify)……………………………… ___________________________ Don’t know…………………………………… No response...............………………… 1 2 3 4 5 6 77 88 99 22. How long would it take you to walk to _______________ from here? Fill in the blank with the nearest TB testing facility to this village. 0-15 minutes………………………………… 16-30 minutes……………………………… 31 minutes to one hour………………… More than one hour……………………… Don’t know…………………………………… No response...............………………… 1 2 3 4 88 99 SECTION D: TUBERCULOSIS TREATMENT # Questions Responses Skip Answer 23. Have you or any of your household members been told by a health care worker that they have TB in the last year? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 24 34 34 34 24. If yes, then ask: What test did health care workers do to find that you or your household member was diagnosed with TB? Sputum test…………………………………… X-ray test……………………………………… Other (specify)……………………………… ___________________________ Don’t know…………………………………… No response...............………………… 1 2 77 88 99 25. How long did it take before you or your Same day………………………………………. 1 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 19 household member got the test results? Less than one week.……………………… About one week…………………………… 2-3 weeks……………………………………… A month or more…………………………… Other (specify)……………………………… ___________________________ Don’t know…………………………………… No response...............………………… 2 3 4 5 77 88 99 26. Did you or your household member pay anything to find out you had TB? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 27. Did you or your household member receive medication to treat TB? Yes……………………………………………….. No…………………………………………………. Don’t know…………………………………… No response...............………………… 1 2 88 99 29 28 34 34 28. If no, then ask: Why did you or your household member not receive drugs? Drugs were not available……………… Drugs were too expensive………….. Drugs were not offered……………….. Did not return to pick them up……. Did not want to take drugs……..…… Feel better……………………………………. Don’t believe it is necessary……….. Other (specify)…………………………….. ___________________________ Don’t know…………………………………… No response…………………………………. 1 2 3 4 5 6 7 77 88 99 35 29. If yes, then ask: Did you or your household member pay anything for TB medicines? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 30. Did anyone watch you or your household member take the medication daily? Yes…………………………………………………. No………………………………………………….. Don’t know……………………………………. No response………………………………….. 1 0 88 99 31 32 32 32 31. If yes, then ask: Who watched you or your household member take the medication? Health clinic worker…………………….. Socorrista……………………………………… Padrinho………………………………………… Family or friend (informally, without documenting it)………………. Don’t know…………………………………… No response…………………………………… 1 2 3 4 88 99 32. Did you or your household member complete the course of medication as explained by the health worker? Yes………………………………………………… No (Stopped) ……………………………. Still taking medication………………….. Don’t know…………………………………… No response...............………………… 1 0 3 88 99 34 33 35 34 34 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 20 33. If no, then ask: Why did you or your household member stop taking the TB medicine? Multiple answers are possible Feel better……………………………...…… Don’t have money………………………… Drug side effects.………………………… TB drugs are not available…..……… Health facility is too far……………….. They move to a different place…… They don’t believe it’s necessary… Difficult to swallow so many pills… Other (specify)……………………………… ___________________________ Don’t know…………………………………… No response...............………………… 1 2 3 4 5 6 7 8 77 88 99 34. What was the outcome of the treatment? Cured…………………………………………….. Not cured………………………………………. Haven’t finished treatment…………… Died……………………………………………… Don’t know…………………………………… No response...............………………… 1 2 3 4 88 99 SECTION D: TUBERCULOSIS PREVENTION # Questions Responses Skip Answer 35. What can you do to decrease the risk of getting of TB? Do not prompt. Multiple answers are possible. Wear a mask when contacting patients with TB…………………...……… Provide good ventilation for workplace & home………………………… Annual medical examination………. Prevent HIV………………………………….. Good nutrition………………………………. Other (specify)……………………………… ___________________________ Don’t know…………………………………… No response...............………………… 1 2 3 4 5 77 88 99 36. What can people with TB do to decrease the risk of transmitting TB? Do not prompt. Multiple answers are possible. Adhere to treatment……………………… Seek medical care if have symptoms……………………………………… Cover mouth when coughing……….. Have good ventilation in home…… Not spit in public places……………….. Avoid delay in TB treatment………… Other (specify)……………………………. ___________________________ Don’t know…………………………………… No response…………………………………. 1 2 3 4 5 6 77 88 99 SECTION E: TUBERCULOSIS STIGMA # Questions Responses Skip Answer 37. Have you ever had a friend, neighbor, workmate, or schoolmate with TB? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 21 38. Would you visit someone with TB in their home? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 40 39 40 40 39. If no, ask: Why would you not visit someone with TB in their home? Fear of disease……………………………… Other (specify)……………………………… ___________________________ Don’t know…………………………………… No response...............………………… 1 77 88 99 40. If someone has TB, would they try to hide the disease from others? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 41 42 42 42 41. If yes, ask: Why would people with TB try to hide the disease from others? Multiple answers are possible. Because they will lose job…………… Because they will lose friends……… Because people will avoid them…… Because no-one will marry them… Because people will think they have HIV………………………………………… Other (specify)……………………………… ___________________________ Don’t know…………………………………… No response...............………………… 1 2 3 4 5 77 88 99 42. Do you think it is shameful to have TB? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 43 44 44 44 43. If yes, ask: Why do you think it is shameful to have TB? Multiple answers are possible. This is a disease of unfaithful people…………………………………………… Because the person with TB can lose job….……………………………………… Because everybody will avoid person with TB……………………………… Because it means the person is or may be HIV+………………………………… Improper cleansing after death…… Other (specify)……………………………… ___________________________ Don’t know…………………………………… No response...............………………… 1 2 3 4 5 77 88 99 SECTION F: HIV KNOWLEDGE, STIGMA, ETC. # Questions Responses Skip Answer 44. Have you heard about the disease called HIV or AIDS? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 45 End 45 45 45. How can you protect yourself from getting HIV? Abstinence……………………………......... Faithfulness……………………………....... Condom use……………………………....... 1 2 3 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 22 Multiple answers are possible. Do not prompt. Avoid skin piercing objects………… Prompt STI treatment…………………… Being attended to by a trained service provider during pregnancy and delivery……………………………....... Infant feeding options…………………… Use of ART……………………………....... Other (specify)……………………………… ____________________________ Don’t know……………………………....... No response……………………………....... 4 5 6 7 8 77 88 99 46. How is HIV transmitted? Multiple answers are possible. Do not prompt. Through the air when coughing…… Through a handshake ……………….… Sexually transmitted………………….... Sharing food with infected person… Through blood transfusion…………… Through kiss………………….....………… Sharing needles/razors.……….....… From mother to child during pregnancy……………………………………. Breastfeeding……………………………… Witchcraft……………………………………. Other (specify)……………………………… ____________________________ Don’t know…………………………………… No response...............………………… 1 2 3 4 5 6 7 8 9 10 77 88 99 47. Do you know where you can get tested for HIV? Yes (specify)………………………………… ___________________________ No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 48 49 49 49 48. If yes, ask: How long would it take you to walk to the nearest HIV testing centre from here? 0-15 minutes………………………………… 16-30 minutes……………………………… 31 minutes to one hour………………… More than one hour……………………… Don’t know…………………………………… No response...............………………… 1 2 3 4 88 99 49. I don’t want to know the result, but have you ever had an HIV test? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 SECTION G: TB-HIV CO-INFECTION # Questions Responses Skip Answer 50. Do you think that someone with HIV should be tested for TB? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 51. Do you think that someone with TB should be tested for HIV? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… 1 0 88 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 23 No response...............………………… 99 52. Are you more likely to get TB if you have HIV? Yes………………………………………………… No………………………………………………… Don’t know…………………………………… No response...............………………… 1 0 88 99 Thank you. This is the end of the survey. We appreciate you taking the time to respond to our questions. Do you have any questions for me at this time? INTERVIEWER COMMENTS: Please record any comments or observations that you feel that are necessary to understand the circumstances in which you conducted this interview: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Time interview Ended (Please also record this time on Page 1) SUPERVISOR (Questionnaire reviewed) (initial here) Date Time Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 24 Annex B: Shangaan Survey Questionnaire Identificacao de respondente Numero ya Questionario Vito ra muvutisi Vito ra muhlamuli Distrito 1=Chicualacuala, 2= Chigubo, 3= Guija, 4= Mabalane, 5= Massangena, 6=Massingir Grupo # Aldeia Genero 1=wanuna, 2=wansati Siku ra swivutiso …………../…………../…………… Nkama wo sungula swivutiso Mixo Madyambu Nkama wo heta swivutiso Mixo Madyambu Ntsena ntlawa lowu nga ta endla processamento ya madados eka computador Vito Siku Murhangeri wa ntlawa la kambisisaka**: La processaraka: **Vonelela leswaku tinhlamulo ti tsaliwile kwatsi – Swivutiso hinkwaswo, ni leswaku hinkwako lomu ku fanelaka ku tlula swi landziwile, ni swinwana. Seccao A: Matshamelo Swileleto: Endla swivutiso tani hilaha swi nga tsaliwa ha kona. U nga hlayi tinhlamulo handle ka loko swi kombela. Marito lawa ma tsaliweke hi xitalic swileleto swa muvutisi kutani a ma hlayiweli muvutisiwa. Lomu swikombelaka ku tlula landza tani hi leswi kombelisaka xiswona. Tsala tinhlamulo eka xibokisana lexi nyikiweke kumbe lomu swi fanelaka. # Swivutiso Nhlamulo Yana Nhlam ulo 1 Xana u na malembe mangani yaku velekiwa Ntanga …….……………….......…………… A nga tivi ..…………………………........ A nga hlamulanga ………………...... # # 8 8 9 9 2 Xana u vile na wona nkateko wo nghena xikola Ina …………………………….......…………… E-e…………………………….......……………. A nga tivi .……………………………........ A nga hlamulanga …………………...... 1 0 8 8 9 3 4 4 4 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 25 9 3 Xana u dyondze ku fika eka ntlawa muni exikolweni? A nga fundhanga …………..……….. Primaria…………………….…………...… Secundaria ………....……….…….…… Nivel superior ……………….…………… Swinwana….……………………………….. 1 2 3 4 5 4 Xana I vanhu vangani va hanyaka lana ndyangwini Nhlayo …………………………….......……. A nga tivi…………………..…………........ A nga hlamulanga ..……………........ # # 8 8 9 9 5 Yindlu ya wena yini ma quarto ma ngani? Rinwe ….……………………………………….. Mambirhi..……………………………………… Manharhu ……………………………………… Mune ni ku tlula …………………………… A nga tivi……………………………………. A nga hlamulanga ……………………. 1 2 3 4 8 8 9 9 6 Ka leswi u swi tirhaka swa ringana ku hlayisa ndyangu wa wena? Hlaya tinhlamulo A wu ringani ka swakudya ………… Wu ringana katsongo swakudya … Wu ringana swakudya ……………… A nga tivi……………………………………. A nga hlamulanga ……………………. 1 2 3 8 8 9 9 Seccao B: Swikombiso swa Ndere # Swivutiso Tinhlamulo Yana tinhla mulo 7 Eka tinwheti tinharhu leti nga hundza, wena kumbe unwe wa ndyangu wa wena a vile ni swikombiso leswi landzelaka? Hlaya leswi landzelaka: Mukhuhlwana lowu nga ni xikholhola* Ku khohlolela ku tlula mavhiki manharhu Ku hisa miri ku tlula mavhiki manharhu Ngati ka xikhohlola Ku vava ka xifuva Ku karhala, u nga tsakeli swakudya Ku ondza Ku badlha ni vusiku (Nhlamuselo ya xikhohlola =swi huma ka xifuva, A HI marhi, A HI marhimila Ina………………………………………………. E-e………………………………………………. A nga tivi …..………………………………. A nga hlamulanga …………………….. 1 0 8 8 9 9 8 14 14 14 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 26 ya tinhopfu) Tinhlamulo ti nga tlula yinwe. Eka unwana ni unwana loyi a nga ni swikombiso leswi nga tsaliwa ehenhla, endla swivutiso 8-13 u tsala tinhlamulo eka swibokisana lana hansi. 8 A nga va munhu wa ndyani loyi a nga va ni swikombiso leswi? Wa nuna………………………………………. Wansati ……….…………………………….. 1 2 9 Xana a nga va swikombiso muni leswi va nga ve na swona? Tinhlamulo ti nga tlula yinwe E-e…………………………………………….. Mukhuhlwana wa xikhohlola * … Mukhuhlwana wo tlula mavhiki manharhu ………… Hisa miri kutlula mavhiki manharhu ………………………………….. Ngati eka xikhohlola ……………… Vavisa xifuva ……………………….. Ku karhala, u nga tsakeli kudya.. Ku ondza …………………………………… Badlha nivusiku ……………………….. Swinwane………………………………….. …………………………………………………… A nga tivi.………………………………….. A nga hlamulanga .…………………… 0 1 2 3 4 5 6 7 8 7 7 8 8 9 9 10 Xana munhu loyi a tsame a lavetela ku laphiwa a xibedlela loko a vone swikombiso leswi? Ina ……………………………………… E-e ……..…………………………….. A nga tivi.………………………………….. A nga hlamulanga .…………………… 1 0 8 8 9 9 11 13 13 13 11 Xana munhu loyi a lavetele ku pfuniwa exibelhela endzaku ka nkarhi muni na a sungule ku vabya? Endzeni ka vhiki…………………………. Linwe kumbe mavhiki mambire………………………… Mavhiki manharhu ku fika nweti……………… Nweti kumbe tinweti timbiri………………………. Kutlula tinweti tinharhu……………… 1 2 3 4 5 12 Hikwalaho ka yini a munhu loyi a hlwelile ku laphiwa a xibehlela? (Mavonela ya tinhlamulo ta xiv.12 ni 13 ta fana) U nga khutazi tinhlamulo. A titwile na antswa………………………. Ku pfumala a male yo ya ka dokodela……………….. Ku ringeta ku laphiwa a kaya………………… A m’pfuka wu lehile……..………… Ku kala ku tshemba kumbe ku 1 2 3 4 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 27 13 Xana loko munhu loyi a nga lavetelanga ku pfuniwa exibedlela, a nga va a li hi mhaka muni? (Tinhlamulo ta xiv.12 ni 13 ta fana) U nga khutazi tinhlamulo. chava va tirhi va xibedhlela…………………. Ku chava kuva ni mavabyi yo tika Ku va ni tingana ta ku txepetiwa hikwalaho ka TB kumbe HIV……… Ku pfumala a nkama…………………… Ku chava leswi swi taka ndzaku ka mavabyi lawa…………….………………… Swinwana(hlamusela)….……..……… A nga tivi………………………….…………. A nga hlamulanga …………………… 5 6 7 8 9 7 7 8 8 9 9 Q8. Wanuna/wansati Q9. swikombiso Q10. Kulaphiwa/ Q11.nkarhi wo laphiwa ? Q12. Ku hlwela? Q13. A kuna tratam ento? Tx Seccao C: Vutivi hi tlhelo la ndere # Swivutiso Tinhlamulo Yana tinhla mulo 14 Xana u tshama u twa hi ta ndere? Ina ……………………………………… E-e ……..…………………………….. A nga tivi.………………………………….. A nga hlamulanga .…………………… 1 0 8 8 9 9 15 23 23 23 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 28 15 Xana hi swihi swikombiso leswi nga kombaka leswaku munhu a ni ndere? Tinhlamulo to tlula yinwe. U nga khutazi tinhlamulo. Ku khohlola……...…………………… Ku hisa miri…………………………... Mukhuhlwana wa xikhohlola..… ku khohlola ku tlula mavhiki manharhu……... Ngati eka xikhohlola ………………… ku kala ku navela swakudla……… ku vava ka xifuva……………….…… Ku hela ntamu,u nga tsakeli kudya Ku ondza…………………………………… Timbhiapho eka nhamu …..… Ku badhla nivusiku…………..……… Swinwana(hlamusela)….……..……… A nga tivi …….……………………………… Anga hlamulanga .....…………………. 1 2 3 4 5 6 7 8 9 1 0 1 1 7 7 8 8 9 9 16 A ndere yi tlulela hi ndlela yihi? Tinhlamulo to tlula yinwe. U nga khutazi tinhlamulo Tsala swinwana ni swinwana leswi vanhu va khomelelaka ka swona ni leswi hi ntumbuluko va pfumelaka ka swona. Hi moya loko munhu a khohlola………… Hi ngati…………………………… Hi ku khomana mavoko………………… Hi ndlela ya masangu……………….... Ku dya swinwe ni loyi a vabyaka.… Ku velekiwa na wona …………………… Hi ku tswontswana …………...………… Ndzaku ka ku ngheniwa hi xirhami……………………………………….. Hi ku lumiwa hi nsuna……………….. Hi ku fa ka unwe wa ndyangu … Swinwana(hlamusela)….……..……… A nga tivi …………………………………… A nga hlamulanga .....………………… 1 2 3 4 5 6 7 8 9 1 0 7 7 8 8 9 9 17 Xana u tshame u twa mahungu hi tlelo la ndere eka 6 wa tinwheti leti nga hundza? Ina………………………………………………. E-e …………..………………………………… A nga tivi ……………………………………. A nga hlamulanga ....…………………. 1 0 8 8 9 9 18 19 19 19 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 29 18 Loko a ku ina, vutisa: Xana u ma twe kwihi mahungu ya mavabyi ya ndere eka tinwheti ta 6 leti nga hundza? U nga khutazi tinhlamulo Vanghana, vanhu, maxaka ….… Dokodela kumbe Enfermeira……………..………………… Vanwana vatirhi va xibelhela….. Folheto, panfletos ………..…………… Radio/TV/ma jornal …..………………… Ka vavoluntaria…..………………………… Ndzawulo ya vudaho ………………… Mufundise .....…………………………….. Vanwana, (Hlamusela) ..……………… ____________________________ A nga tivi ……..……………………………… A nga hlamulanga.......………………… 1 2 3 4 5 6 7 8 7 7 8 8 9 9 19 Hi mavonele ya wena, yi nga va ndere yi laphiwa? Ina ……………………………………………… E-e ..…………………………………………… A nga tivi….…………………………………… A nga hlamulanga ......………………… 1 0 8 8 9 9 20 Mirhi ya ndere ya hakeliwa kumbe mahala? Ina ……………………………………………… E-e ……………………………………………… A nga tivi …………………………………… A nga hlamulanga …..………………… 1 0 8 8 9 9 21 Loko u vile ni swikombiso swa ndere a wu ta ya laphiwa kwihi Tinhamulo to tlula yinwe. Centro de Saude…………………………… Socorrista……………………………………… Carmelo………………………………………… Nyanga………………………………………… Farmacia……………………………………… Profeta/Mazioni(prophet or Zionist) Vanwana (hlamusela)_________ A nga tivi ………………………………………. A nga hlamulanga…………………………. 1 2 3 4 5 6 7 7 8 8 9 9 22 Xana I nga va nkarhi muni u nga tekaka hi ku famba hi minenge u ya C.S ya le kusuhi leyi kambelaka ndere? ___________________? Tsala eka ndhawu leyi nga siyiwa vito la xibelhela xa le kusuhi xa ku kambela ndere 0-15 wa timeneti…………………………… 16-30 wa timeneti………………………… 31wa timeneti ku fika awara……… Ku tlula awara……………………… A nga tivi ……………………………… A nga hlamulanga …..………………… 1 2 3 4 8 8 9 9 Seccao D: Malaphele ya ndere Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 30 # Swivutiso Tinhlamulo Yana tinhla mulo 23 Xana wena kumbe unwe wa ndyangu wa wena mi nga va mi hlamuseliwile hi mutirhi wa xibelhela leswaku mi ni ndere eka lembe leri nga hundza? Ina ……………………………………………… E-e ……………………………………………… A nga tivi …………………………………… A nga hlamulanga …..………………… 1 0 8 8 9 9 24 35 35 35 24 Loko a ku ina, vutisa vutisa: Xana i swikambelo muni leswi va xibelhela va swi endleke leswaku va tsumbula leswaku vanhu lava va na ndere Ku kambela xikhohlola………………… Mufoto wa xifuva ….…………………… Swinwana (hlamusela)………………… A nga tivi….………………………………… A nga hlamulanga .....………………… 1 2 3 4 5 25 Swi nga va swi teke nkarhi muni ku kuma a nhlamulo ya swikambelo swa wena kumbe vanwana va ndyangu wa wena? Siku lolelo…………………………………. Hansi ka vhiki……...……………………… Swi tekile vhiki…………………………… 2-3 wa mavhiki………………………… Nweti kumbe ku tlula.…………………… Swinwana (hlamusela)………………… A nga tivi ………………………………… Anga hlamulanga ......……………… 1 2 3 4 5 7 7 8 8 9 9 26 Xana wena kumbe va ndyangu wa wena mu hakele nchumu ku kambeliwa ndere? Ina ……………………………………………… E-e ………………..…………………………… A nga tivi ………………………………… A nga hlamulanga ...………………… 1 0 3 4 27 Xana wena kumbe va ndyangu wa wena mu nyikiwile murhi wa ndere? Ina ……………………………………….. E-e ………………………………………. A nga tivi ….………………………… A nga hlamulanga ....………………… 1 2 8 8 9 9 29 28 35 35 28 Loko a ku e-e, vutisa Hikwalaho ka yini wena kumbe vandyangu wa wena va nga nyikiwanga mirhi? A ku nga na mirhi ………………………. A wu durha ………………………………... Mirhi a yi nyikeliwile ……………………. A ni vuyanga ni teka …………………. A ni nga swi lavi ku teka mirhi….. A swi antswa……………………………… A ni kholwanga leswaku a swi laveka ………………………………………. Swinwana (tsala) _____________ A nga tivi ……………………………………. A nga hlamulanga ……………………… 1 2 3 4 5 6 7 7 7 8 8 9 9 35 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 31 29 Loko a ku ina, vutisa: Xana wena kumbe va dyangu wa wena mu hakele nchumu ku kuma a murhi? Ina ……………………………………………… E-e ………………….…………………………… A nga tivi ……………………………………… A nga hlamulanga ......………………… 1 0 8 8 9 9 30 Xana ku nga va ni loyi a ku vonelelaka wena kumbe va ndyangu wa wena loko mi phuza murhi? Ina ……………………………………….. E-e ………………………………………. A nga tivi ….………………………… A nga hlamulanga ....………………… 1 0 8 8 9 9 31 32 32 32 31 Loko a ku ina, vutisa: I mani loyi a ku voneleleka kumbe a vonelela va ndyangu loko va phuza murhi? Mutirhi wa xibelhela ………………….. Socorrista……………………………………… Padrinho………………………………………… Va ndyangu / Munghana……………… Voluntaria(Volunteer)…………………… A nga tivi ……………………………………… A nga hlamulanga ……..………………… 1 2 3 4 5 8 8 9 9 32 Xana wena kumbe va ndyangu wa wena mi phuze murhi nkarhi wo ringana tani hi leswi mi nga hlamuselisiwa swona hi vatirhi va xibelhela? Ina ………………………………………………… E-e (hi tsemerisile) ……………………. A ha phuza murhi …………………….. A nga tivi ………..………………………… A nga hlamulanga ....………………… 1 0 3 8 8 9 9 34 33 35 34 34 33 Loko a ku e-e, vutisa: Hikwalawo ka yini wena kumbe va ndyangu wa wena mi nyimile ku phuza murhi wa ndere? Tinhlamulo ti nga tlula yinwe Ku twa ku antswa ………………...…… A hi na male ……...……………………… Murhi wa hi vabyisa ………………… Mirhi ya ndere a yi kumeki ..……… Xibedlhela xi le kule swinene …….. Va rhurha va ya eka tindhawu tinwana ………………………………..…… A va kholwi leswaku swa laveka Swa karhata ku n’wa makinina yo tala …………………………………………..… Swinwana (Hlamusela………………… ___________________________ A nga tivi…………………………………… A nga hlamulanga ....………………… 1 2 3 4 5 6 7 8 7 7 8 8 9 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 32 9 34 Yi ve yihi mihandzu/nhlamulo yaku laphiwa? Ni hanyile…………………………………….. A ni hanyanga……………………………. Ani se heta ku laphiwa…………… A file…………………………………………… A nga tivi ………………………………… A nga hlamulanga .....………………… 1 2 3 4 5 6 Seccao E: Ku vikela ndere # Swivutiso Tinhlamulo Yana tinhla mulo 35 U nga endla yini ku hunguta nghozi ya kuva u khomiwa hi ndere? U nga khutazi tinhlamulo. Tinhlamulo ti nga tlula yinwe. Pfala tinhopfu hi mascara loko u hlangana ni va ndere ……...………… Ku hungisa moya wa kahle etindhaweni ta ntirho hambi kaya.. Kambeliwa lembe ni lembe hi dokodela …………………………………….. Vikela HIV …………….…………………….. Kuva ni madyele ya kwatsi ….….. Swinwana (hlamusela …………… ___________________________ A nga tivi…………………………………… A nga hlamulanga ......………………… 1 2 3 4 5 7 7 8 8 9 9 36 Xana vanhu va nga ni ndere va nga endla yini ku hunguta nghozi ya ku tluleta vanwani mavabyi? U nga khutazi tinhlamulo. Tinhlamulo ti nga tlula yinwe. Va fanele va laphiwa ………………… Loko va ni swikombiso va lavetela ku pfuniwa hi va dokodela………… Pfala nomo loko u khohlola .…….. Yindlu yi fanela yi hunga moya…. U nga tshwuteli marhi eka tindhawu ku famba-fambaka vanhu ……………….……………….. Vikela ku hlwela ku sungula ku laphisa ndere …………………..…… Swinwana (hlamusela)..…………. ___________________________ A nga tivi …………………………………… A nga hlamulanga ……………………. 1 2 3 4 5 6 7 7 8 8 9 9 Seccao F: Ku txepetiwa hikwalaho ka ndere # Swivutiso Tinhlamulo Yan a tinhla mulo Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 33 37 Xana u tshame u ni munghana, muyakelani, mutirhisani, kumbe munhu mi dyondzaka swinwe loyi a nga ve ni ndere? Ina ……………………………………….. E-e ………………………………………. A nga tivi ….………………………… A nga hlamulanga ....………………… 1 2 3 4 38 Xana munhu loyi a nga ni ndere u nga mu pfuxela ekaya ka yena? Ina ……………………………………….. E-e ………………………………………. A nga tivi ….………………………… A nga hlamulanga ....………………… 1 0 8 8 9 9 40 39 40 40 39 Loko a ku e-e, vutisa: Hikwalaho ka yini a wu nga mu pfuxeli munhu loyi a nga ni ndere ekaya ka yena? Tshava mavabyi …………………………… Swinwana (hlamusela)………………… ___________________________ A nga tivi ………………………………… A nga hlamulanga .....………………… 1 7 7 8 8 9 9 40 Loko munhu a ni ndere, va nga ringeta ku fihlela mavabyi vanwana? Ina ……………………………………….. E-e ………………………………………. A nga tivi ….………………………… A nga hlamulanga ....………………… 1 0 8 8 9 9 41 42 42 42 41 Loko a ku ina, vutisa: Xana hikwalaho ka yini vanhu va ndere va nga fihlela vanwana mavabyi? Tinhlamulo ti nga tlula yinwe. Va nga heleliwa hi ntirho…………… Va nga luza vanghana ……… Vanhu va nga va papalata …………… A nga kona loyi a nga mu chadaka Vanhu va nga ehleketa leswaku va ni HIV/SIDA………………………………… Swinwana (hlamusela)………………… ___________________________ A nga tivi ………………………………… A nga hlamulanga .....………………… 1 2 3 4 5 7 7 8 8 9 9 42 Xana u ehleketa leswaku swini tingana ku va ni ndere? Ina………………………………………………… E-E ……………………………………………… Anga tivi ……………………………………… A nga hlamulanga ........……………… 1 0 8 8 9 9 43 44 44 44 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 34 43 Loko a ku ina, vutisa: Hi kwalaho ka yini u ehleketa leswaku swi ni tingana? Tinhlamulo ti nga tlula yinwe. Mavabyi ya lava nga tshembekangiki ………………………… Hikuva muvabyi a nga heleliwa hi ntirho .……………………………………… Hinkwavo vanhu vata nwi nyenya muvabyi wa ndere ……………… Hileswaku va nga mu pimisela SIDA ………………………………………… Va nga va va nga txinganga kwatsi ndzhaka … Swinwana (hlamusela)……….………… ___________________________ A nga tivi…………………………………… A nga hlamulanga .....………………… 1 2 3 4 5 7 7 8 8 9 9 Seccao G: Vutivi hi tlelo la HIV, Ku txepetiwa, ni swinwanac. # Swivutiso Tinhlamulo Yana tinhla mulo 44 U tsame u twa hi ta HIV kumbe SIDA? Ina………………………………………………… E-e ……………….……………………………… A nga tivi ..…………………………………… A nga hlamulanga .....…………… 1 0 8 8 9 9 45 End 45 45 45 Unga ti vikelisa ku yini leswaku u nga kumi HIV? Tinhlamulo ti nga tlula yinwe. U nga khutazi. Fularhela masangu …………......... Ku tshembeka…………………....... Tirhisa xitlhango ………………....... Vikela switirho leswi tsemaka mirhi Hatla ku laphisa mavabyi ya masangu ……………………………………… Loko u na khwiri laphiwa u tlhela u velekisiwa hi munhu loyi a nga dyondzisiwa ….……………………....... U nga hlawula tindlela ta ku hambana-hambana ta madyisela ya nwana …………………………….…… Ku phuza murhi wa Anti-retroviral Swinwana (hlamusela)………………… ____________________________ A nga tivi ……………………………....... A nga hlamulanga ………………....... 1 2 3 4 5 6 7 8 7 7 8 8 9 9 46 Xana munhu a yi kumisa ku yini HIV? Tinhlamulo ti nga tlula yinwe. Hi moya loko va khohlola ……………. Hi ku qhevulana ……………….……….. Hi masangu………………................. Ku dya swinwe ni munhu loyi a 1 2 3 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 35 U nga khutazi. nga ni xitsongua-tsonguana ………… Ku cheliwa ngati …………….…………… Hi ku tswontswana ma kiss………… Ku tirhiselana tinayithi/swisinguana ………………. Mamana a nga tluleta nwana loko a ni khwirhi ……………………. Hi ku yanwisa …………………………… Hi vuloyi …………………………………. Swinwana (hlamusela)…………… ____________________________ A nga tivi…………………………………… A nga hlamulanga .......………………… 4 5 6 7 8 9 1 0 7 7 8 8 9 9 47 Wa swi tiva leswaku u nga kambeliwa kwini a HIV? Ina (hlamusela)……………………… E-e…………………………………………… A nga tivi ………………………………… A nina hlamulo............……………… 1 0 8 8 9 9 48 49 49 49 48 Loko a ku ina, vutisa: I nkama muni u nga tekaka ku famba hi minenge u ya fika eka ndhawu ya le kusuhi lana u nga kambeliwaka kona? 0-15 minutos………………………………… 16-30 minutos……………………………… 31 minutos ku fika awara …………… Kutlula awara ……………………………… A nga tivi ….………………………………… A nga hlamulanga .....………………… 1 2 3 4 8 8 9 9 49 A ni naveli ku tiva nhlamulo ya wena ya xikambelo xa HIV, xana u tshame u endla xikambelo xexo ke? Ina………………………………………………… E-e ……………….……………………………… Anga tivi ..…………………………………… A A nga hlamulanga .....…………… 1 0 8 8 9 9 Seccao H: Ku fambelana ka TB ni HIV (Co-Infection) # Swivutiso Tinhlamulo Yana tinhla mulo 50 Xana u ehleketa leswaku munhu a nga ni HIV a a fanela a kambeliwa ndere? Ina………………………………………………… E-e ……………….……………………………… Anga tivi ..…………………………………… A nga hlamulanga .....…………… 1 0 8 8 9 9 51 Xana u ehleketa leswaku munhu loyi a nga ni ndere a a fanele ku kambeliwa HIV? Ina ……………………………………………… E-e ………..…………………………………… A nga tivi …………………………………… 1 0 8 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 36 A nga hlamulanga ......……………… 8 9 9 52 Swi nga ku olovela ku kuma ndere loko u ni HIV? Ina………………………………………………… E-e………………………………………………… A nga tivi……………………………………… A nga hlamulanga ....………………… 1 0 8 8 9 9 Ha khensa. Loku I ku hela ka swivutiso. Hi khensa nkama lowu u tinyikeke ku hlamula swivutiso leswi. Xana u nga va ni xivutiso u lavaka ku endla sweswi? Comentarios da entrevistadora: Tsala swinwana ni swinwana kumbe ma observacao, leswi u twaka leswaku swa laveka ku va hi twisisa leswi humeleleke loko u li karhi u endla swivutiso leswi: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Nkarhi wo heta swivutiso (Tsala nkarhi lowu ni le ka pagina 1) SUPERVISOR (la endlaka revisao ya questionario) (Assinatura) Siku Nkama Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 37 Annex C: Midterm KPC Raw Data Tables Gender Frequency Percent 95% CI Male 68 22.7 18.1 - 27.8 Female 232 77.3 72.2 - 81.9 Total 300 100 Q1. Age Age Range Frequency Percent 95% CI >=10 - <=19 12 4.0 2.1 - 6.9 >=20 - <=29 100 33.3 28.0 - 39.0 >=30 - <=39 74 24.7 19.9 - 29.9 >=40 - <=49 38 12.7 9.1 - 17.0 >=50 - <=59 26 8.7 5.7 - 12.4 >=60 14 4.7 2.6 - 7.7 Don’t know 36 12.0 8.5 – 16.2 Total 300 100 Median= 33.5 years; Mean=34.8 years; SE=12.4; Range: 14 - 74 Q2. Have you ever attended school? Frequency Percent 95% CI No 112 37.3 31.8 – 43.1 Yes 188 62.7 56.9 – 68.2 Unknown 0 0 0.0 – 1.2 Total 300 100 Q3. What is the highest grade or level of school you have completed? Frequency Percent 95% CI No school 112 37.3 31.8 – 43.1 Primary school 150 50.0 44.2 – 55.8 Secondary school 37 12.3 8.8 – 16.6 Post-secondary school 1 0.3 0.0 – 1.8 Total 300 100 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 38 Q4. How many people live in your household? Frequency Percent 95% CI 1 4 1.3 0.4 – 3.4 2 19 6.3 3.9 – 9.7 3 26 8.7 5.7 – 12.4 4 25 8.3 5.5 – 12.1 5 32 10.7 7.4 – 14.7 6 36 12.0 8.5 – 16.2 7 31 10.3 7.1 – 14.3 8 31 10.3 7.1 – 14.3 9 22 7.3 4.7 – 10.9 10 18 6.0 3.6 – 9.3 11 9 3.0 1.4 - 5.6 12 9 3.0 1.4 – 5.6 13 10 3.3 1.6 – 6.0 14 3 1.0 0.2 – 2.9 15 9 3.0 1.4 – 5.6 16 6 2.0 0.7 – 4.3 17 1 0.3 0.0 – 1.8 19 3 1.0 0.2 – 2.9 20 1 0.3 0.0 – 1.8 22 1 0.3 0.0 – 1.8 23 1 0.3 0.0 - 1.8 25 2 0.7 0.1 – 2.4 35 1 0.3 0.0 – 1.8 Total 300 100 Mean=7.6; SE=4.5; Range: 1 - 35 Q5. How many rooms are in your house? Frequency Percent 95% CI 1 184 61.33 55.6 – 66.9 2 64 21.33 16.8 – 26.4 3 38 12.67 9.1 – 17.0 4 12 4.00 2.1 – 6.9 7 1 0.33 0.0 – 1.8 8 1 0.33 0.0 – 1.8 Total 300 100.00 Mean = 1.6; SE = 0.98; Range = 1-8 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 39 Q6. Is your household income usually... Frequency Percent 95% CI Not enough for food 79 26.33 21.4 – 31.7 Barely enough for food 148 49.33 43.5 – 55.1 Enough for food 73 24.33 19.6 – 29.6 Don’t know 0 0 0.0 – 1.2 Total 300 100 Q7. Have you or anyone in your household had any of the following symptoms in the last three months? Frequency Percent 95% CI No 243 81.00 76.1 – 85.3 Yes 56 18.67 14.4 – 23.5 Don’t know 1 0.33 0.0 – 1.8 Total 300 100 Q8A. What gender was the person who had these symptoms? Frequency Percent 95% CI Male 19 34.55 22.2-48.6 Female 36 65.45 51.4-77.8 Total 55 100 Q9. Which symptoms did he/she have? Yes No Frequency Percent 95% CI Frequency Percent 95% CI None 0 0 0.0-6.5 300 100.00 98.8-100.0 Coughing with sputum 29 52.73 38.8-66.3 271 90.33 86.4-93.4 Cough for over 3 wks 15 27.27 16.1-41.0 285 95.00 91.9-97.2 Increasing fever for over 3 wks 10 18.18 9.1-30.9 290 96.67 94.8-98.8 Blood in sputum 8 14.55 6.5-26.7 292 97.33 88.7-95.1 Pain in chest 23 41.82 28.7-55.9 277 92.33 91.5-96.9 Total weakness 16 29.09 17.6-42.9 284 94.67 91.9-97.2 Weight loss 15 27.27 16.1-41.0 285 95.00 90.7-96.4 Night sweats 18 32.73 20.7-46.7 282 94.00 98.2-100.0 Don’t know 1 1.82 0.0-9.7 299 99.67 98.8-100.0 No response 0 0 0.0-6.5 300 100.00 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 40 Q10. Did this person seek medical attention for his or her symptoms? Frequency Percent 95% CI No 6 11.11 4.1-22.2 Yes 48 88.89 75.5-94.7 Total 54 100.00 Q11. If yes, how long after getting sick did he/she seek medical attention? Frequency Percent 95% CI Within one week 24 48.98 34.4-63.7 One to two weeks 11 22.45 11.8-36.6 Three weeks to one month 6 12.24 4.6-24.8 One to two months 6 12.24 4.6-24.8 More than three months 2 4.08 0.5-14.0 Total 49 100.00 Q12. Why did he/she wait to seek medical attention? Frequency Percent 95% CI Felt Better 13 27.66 15.6-42.6 No money 6 12.77 4.8-25.7 Trying home treatment 4 8.51 2.4-20.4 Was too far to travel 0 0 0.0-7.5 Do not trust or fear health workers 0 0 0.0-7.5 Fear of having a serious illness 0 0 0.0-7.5 Fear of stigma against TB or HIV 0 0 0.0-7.5 Too busy 0 0 0.0-7.5 Not aware of consequences 1 2.13 0.1-11.3 Other 23 48.94 34.1-63.9 Don’t know 0 0 0.0-7.5 No response 0 0 0.0-7.5 Total 47 100.00 Q13. If no medical treatment was sought, why? Frequency Percent 95% CI Felt Better 8 21.62 9.8-38.2 No money 3 8.11 1.7-21.9 Trying home treatment 2 5.41 0.7-18.2 Was too far to travel 2 5.41 0.7-18.2 Do not trust or fear health workers 0 0 0.0-9.5 Fear of having a serious illness 0 0 0.0-9.5 Fear of stigma against TB or HIV 0 0 0.0-9.5 Too busy 1 2.70 0.1-14.2 Not aware of consequences 1 2.70 0.1-14.2 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 41 Other 18 48.65 31.9-65.6 Don’t know 2 5.41 0.7-18.2 No response 0 0 0.0-9.5 Total 37 100.00 Q14. Have you ever heard of the disease called TB? Frequency Percent 95% CI No 16 5.33 3.1 – 8.5 Yes 284 94.67 91.5 – 96.9 Don’t know 0 0 0.0 – 1.2 Total 300 100 Q15. What symptoms can show that a person has TB? (Based on those who had heard of TB) Yes No Frequency Percent 95% CI Frequency Percent 95% CI Coughing 200 70.42 64.7-75.7 84 29.58 24.3-35.3 Fever 52 18.31 14.0-23.3 232 81.69 76.7-86.0 Coughing with Sputum 79 27.82 22.7-33.4 205 72.18 66.6-77.3 Coughing for longer than 3 weeks 54 19.01 14.6-24.1 230 80.99 75.9-85.4 Cough with blood in sputum 71 25.00 20.1-30.5 213 75.00 69.5-79.9 Loss of appetite 13 4.58 2.5-7.7 271 95.42 92.3-97.5 Pain in the chest 56 19.72 15.6-25.2 228 80.28 75.2-84.7 Total weakness (inertia) 57 20.07 15.6-25.2 227 79.93 74.8-84.4 Weight loss 140 49.30 43.3-55.3 144 50.70 44.7-56.7 Swollen glands 2 0.70 0.1-2.5 282 99.30 97.5-99.9 Night Sweats 24 8.45 5.5-12.3 260 91.55 87.7-94.5 Other 28 9.86 6.7-13.9 256 90.14 86.1-93.3 Don’t know 10 3.52 1.7-6.4 274 96.48 93.6-98.3 No response 0 0 0.0-1.2 284 100 98.7-1.0 Q15. What symptoms can show that a person has TB? (Based on all respondents) Yes No Frequency Percent 95% CI Frequency Percent 95% CI Coughing 200 66.67 61.0-72.0 100 33.33 28.0-39.0 Fever 52 17.33 13.2-22.1 248 82.67 77.9-86.8 Coughing with Sputum 79 26.33 21.4-31.7 221 73.67 68.3-78.6 Coughing for longer than 3 weeks 54 18.00 13.8-22.8 246 82.00 77.2-86.2 Cough with blood in sputum 71 23.67 19.0-28.9 229 76.33 71.1-81.0 Loss of appetite 13 4.33 2.3-7.3 287 95.67 92.7-97.7 Pain in the chest 56 18.67 14.4-23.5 244 81.33 76.5-85.6 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 42 Total weakness (inertia) 57 19.00 14.7-23.9 243 81.00 76.1-85.3 Weight loss 140 46.67 40.9-52.5 160 53.33 47.5-59.1 Swollen glands 2 0.67 0.1-2.4 298 99.33 97.6-99.9 Night Sweats 24 8.00 5.2-11.7 276 92.00 88.3-94.8 Other 28 9.33 6.3-13.2 272 90.67 86.8-93.7 Don’t know 10 3.33 1.6-6.0 290 96.67 94.0-98.4 No response 0 0 0.0-1.2 300 100.00 98.8-1.0 Q16. How is TB transmitted? (More than one answer allowed) Of those who heard of TB: Yes No Frequency Percent 95% CI Frequency Percent 95% CI Through the air by coughing 184 64.79 58.9-70.3 100 35.21 29.7-41.1 Through blood 12 4.23 2.2-7.3 272 95.77 92.7-97.8 Though a handshake 3 1.06 0.2-3.1 281 98.94 96.9-99.8 Sexually transmitted 33 11.62 8.1-15.9 251 88.38 84.1-91.9 Sharing food with infected person 29 10.21 6.9-14.3 255 89.79 85.7-93.1 You are born with it 5 1.76 0.6-4.1 279 98.24 95.9-99.4 Through a kiss 4 1.41 0.4-3.6 280 98.59 96.4-99.6 After getting a cold 2 0.70 0.1-2.5 282 99.30 97.5-99.9 From mosquito bite 0 0 0.0-1.2 284 100.00 98.7-1.0 Through the death of someone 51 17.96 13.7-22.9 233 82.04 77.1-86.3 Other 33 11.62 8.1-15.9 251 88.38 84.1-91.9 Don’t know 23 8.10 5.2-11.9 261 91.90 99.1-94.8 No response 0 0 0.0-1.2 284 100.00 98.7-1.0 Q16. How is TB transmitted? (More than one answer allowed) Of all survey respondents: Yes No Frequency Percent 95% CI Frequency Percent 95% CI Through the air by coughing 184 61.33 55.6-66.9 116 38.67 33.1-44.4 Through blood 12 4.00 2.1-6.9 288 96.00 93.1-97.9 Though a handshake 3 1.00 0.2-2.9 297 99.00 97.1-99.8 Sexually transmitted 33 11.00 7.7-15.1 267 89.00 84.9-92.3 Sharing food with infected person 29 9.67 6.6-13.6 271 90.33 86.4-93.4 You are born with it 5 1.67 0.5-3.8 295 98.33 96.2-99.5 Through a kiss 4 1.33 0.4-3.4 296 98.67 96.6-99.6 After getting a cold 2 0.67 0.1-2.4 298 99.33 97.6-99.9 From mosquito bite 0 0 0.0-1.2 300 100.00 98.8-1.0 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 43 Through the death of someone 51 17.00 12.9-21.7 249 83.00 78.3-87.1 Other 33 11.00 7.7-15.1 267 89.00 84.9-92.3 Don’t know 23 7.67 4.9-11.3 277 92.33 88.7-95.1 No response 0 0 0.0-1.2 300 100.00 98.8-1.0 Q17. Have you received any information about TB in the last 6 months? Frequency Percent 95% CI No 95 33.45 28.0-39.3 Yes 188 66.20 60.4-71.7 Don’t know 1 66.20 0.0-1.9 No response 0 0 0.0-1.2 Total 284 100.00 Q18. If yes, from which sources did you receive information? Yes No Frequency Percent 95% CI Frequency Percent 95% CI Friends, acquaintances, or relatives 47 25.00 19.0-31.8 141 75.00 68.2-81.0 Doctors or nurses 30 15.96 11.0-22.0 158 84.04 78.0-89.0 Other medical workers 26 13.83 9.2-19.6 162 86.17 80.4-90.8 Booklet, leaflets 0 0 0.0-1.9 188 100.00 98.1-1.0 Radios/ TV/ Newspapers 15 7.98 4.5-12.8 173 92.02 87.2-95.5 Volunteers 110 58.51 51.1-65.6 78 41.49 34.4-48.9 Health Department 6 3.19 1.2-6.8 182 96.81 93.2-98.8 Pastor 3 1.60 0.3-4.6 185 98.40 95.4-99.7 Other 7 3.72 1.5-7.5 181 96.28 92.5-98.5 Don’t know 2 1.06 0.1-3.8 186 98.94 96.2-99.9 No response 0 0 0.0-1.2 188 100.00 98.1-1.0 Q19. In your opinion, is TB curable? (Including all survey respondents) Frequency Percent 95% CI Yes 275 91.67 87.9-94.5 No 4 1.33 0.4-3.4 NA (Skip) 17 5.67 3.3-8.9 Don’t Know 4 1.33 0.4-3.4 Total 300 Q19. In your opinion, is TB curable? (Of those who had heard of TB) Frequency Percent 95% CI No 4 1.41 0.4-3.6 Yes 275 96.83 94.1-98.5 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 44 NA (Skip) 1 0.35 0.0-1.9 Don’t know 4 1.41 0.4-3.6 No response 0 0 0.0-1.2 Total 284 100.00 Q20. Is TB medicine free of charge? (Including all survey respondents) Frequency Percent 95% CI Yes 70 23.33 18.7-28.5 No 154 51.33 45.5-57.1 NA (Skip) 16 5.33 3.1-8.5 Don’t know 60 20.00 15.6-25.0 Total 300 100.00 Q20. Is TB medicine free of charge? (Of those who had heard of TB) Frequency Percent 95% CI No 154 54.23 48.2-60.1 Yes 70 24.65 19.7-30.1 Don’t know 60 21.13 16.5-26.3 No response 0 0 0.0-1.2 Total 284 100.00 Q21. If you had TB symptoms where would you go to get care? (Including all survey respondents) Yes No Frequency Percent 95% CI Frequency Percent 95% CI Health Center 266 88.67 84.5-92.0 34 11.33 8.0-15.5 Socorrista 0 0 0.0-1.2 300 100.00 98.8-1.0 TB Hospital (Carmelo) 33 11.00 7.7-15.1 267 89.00 84.9-92.3 Traditional Doctor 7 2.33 0.9-4.7 293 97.67 95.3-99.1 Pharmacy 0 0 0.0-1.2 300 100.00 98.8-1.0 Spiritual Healer/ Prophet or Zionist 2 0.67 0.1-2.4 298 99.33 97.6-99.9 Other 3 1.00 0.2-2.9 297 99.00 97.1-99.8 Don’t know 2 0.67 0.1-2.4 298 99.33 97.6-99.9 No response 0 0 0.0-1.2 300 100.00 98.8-1.0 Q22. How long would it take you to walk to (the nearest TB testing facility) from here? Frequency Percent 95% CI 0-15 minutes 61 20.33 15.9-25.3 16-30 minutes 32 10.67 7.4-14.7 31 minutes to one hour 37 12.33 8.8-16.6 More than one hour 123 41.00 35.4-46.8 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 45 Don’t know 31 10.33 7.1-14.3 No Response 16 5.33 3.1-8.5 Total 300 100.00 Q23. Have you or any of your household members been told by a health care worker that they have TB in the last year? Frequency Percent 95% CI No 270 90.00 86.0-93.2 Yes 28 9.33 6.3-13.2 Don’t know 2 0.67 0.1-2.4 Total 300 100.00 Q24. If yes, what test did health center workers do to find that you or your household member was diagnosed with TB? Frequency Percent 95% CI Sputum test 22 78.57 59.0-91.7 X-ray 6 21.43 8.3-41.0 Other 0 0 0.0-1.2 Don’t know 0 0 0.0-1.2 No response 0 0 0.0-1.2 Total 28 100 Q25. How long did it take before you or your household member got the test results? Frequency Percent 95% CI Same day 11 39.29 21.5-59.4 Less than one week 10 35.71 18.6-55.9 About one week 2 7.14 0.9-23.5 2-3 weeks 2 7.14 0.9-23.5 A month or more 3 10.71 2.3-28.2 Other 0 0 0.0-1.2 Don’t know 3 10.71 2.3-28.2 No response 0 0 0.0-1.2 Total 28 100 Q26. Did you or your household member pay anything to find out you had TB? Frequency Percent 95% CI No 26 92.86 76.5-99.1 Yes 0 0 0.0-1.2 Don’t know 2 7.14 0.9-23.5 Total 28 100.00 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 46 Q27. Did you or your household member receive medication to treat TB? Frequency Percent 95% CI Yes 27 96.43 81.7-99.9 No 1 3.57 0.1-18.3 Don’t know 0 0 0.0-1.2 Total 28 100.00 Q28. If no, why did you or your household member not receive drugs? Frequency Percent 95% CI Drugs not available 0 0 0.0-1.2 No 0 0 0.0-1.2 Don’t know 1 100.00 2.5-100 Total 1 100.00 Q29. If yes to #27, did you or your household member pay anything for the TB medication? Frequency Percent 95% CI No 26 96.30 81.0-99.9 Yes 1 3.70 0.1-19.0 Don’t know 0 0 0.0-1.2 Total 27 100.00 Q30. Did anyone watch you or your household member take the medication daily? Frequency Percent 95% CI No 2 7.41 0.9-24.3 Yes 25 92.59 75.5-99.1 Total 27 100.00 Q31. If yes, who watched you or your household member take the medication? Frequency Percent 95% CI Health clinic worker 2 8.00 1.0-26.0 Socorrista 0 0 0.0-13.7 Padrinho 7 28.00 12.1-49.4 Family or friend 12 48.00 27.8-68.7 Volunteer 4 16.00 4.5-36.1 Don’t know 0 0 0.0-13.7 No response 0 0 0.0-13.7 Total 25 100.00 Q32. Did you or your household member complete the course of medication as explained by the health worker? Frequency Percent 95% CI No 2 7.41 0.9-24.3 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 47 Yes 23 85.19 66.3-95.8 Still taking medication 2 7.41 0.9-24.3 Don’t know 0 0 0.0-12.7 Total 27 100 Q33. Why did you or your household member stop taking the TB medicine? Frequency Percent 95% CI Feel better 0 0 0.0-84.2 Don’t have money 0 0 0.0-84.2 Drug side effects 1 50 1.3-98.7 TB drugs are not available 0 0 0.0-1.2 Health facility is too far 0 0 0.0-1.2 Moved to a different place 0 0 0.0-1.2 Don’t believe it is necessary 0 0 0.0-1.2 Difficult to swallow so many pills 0 0 0.0-1.2 Other 1 50 1.3-98.7 Don’t know 0 0 0.0-1.2 No response 0 0 0.0-1.2 Total 2 100 Q34. If course completed, what was the outcome of the treatment? Frequency Percent 95% CI Cured 18 78.26 56.3-92.5 Not cured 0 0 0.0-14.8 Haven’t finished treatment 3 13.04 2.8-33.6 Died 2 8.70 1.1-28.0 Don’t know 0 0 0.0-14.8 No response 0 0 0.0-1.2 Total 23 100.00 Q35. What can you do to decrease the risk of getting TB? Yes No Frequency Percent 95% CI Frequency Percent 95% CI Wear a mask when contacting patients with TB 28 9.33 6.3-13.2 272 90.67 86.8-93.7 Provide good ventilation for workplace and home 83 27.67 22.7-33.1 217 72.33 66.9-77.3 Annual medical examination 29 9.67 6.6-13.6 271 90.33 86.4-93.4 Prevent HIV 11 3.67 1.8-6.5 289 96.33 93.5-98.2 Good nutrition 16 5.33 3.1-8.5 284 94.67 91.5-96.9 Other 68 22.67 18.1-27.8 232 77.33 72.2-81.9 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 48 Don’t know 105 35.00 29.6-40.7 195 65.00 59.3-70.4 No response 1 0.33 0.0-1.8 299 99.67 98.2-100.0 Q36. What can people with TB do to decrease the risk of transmitting TB? Yes No Frequency Percent 95% CI Frequency Percent 95% CI Adhere to treatment 133 44.33 38.6-50.2 167 55.67 49.8-61.4 Seek medical care if have symptoms 56 18.67 14.4-23.5 244 81.33 76.5-86.6 Cover mouth when coughing 122 40.67 35.1-46.5 178 59.33 53.5-64.9 Have good ventilation in home 26 8.67 5.7-12.4 274 91.33 87.6-94.3 Not spit in public places 71 23.67 19.0-28.9 229 76.33 71.1-81.0 Avoid delay in TB treatment 11 3.67 1.8-6.5 289 96.33 93.5-98.2 Other 47 15.67 11.7-20.3 253 84.33 79.7-88.3 Don’t know 40 13.33 9.7-17.7 260 86.67 82.3-90.3 No response 0 0 0.0-1.2 300 100.00 98.8-100.0 Q37. Have you ever had a friend, neighbor, workmate, or schoolmate with TB? Frequency Percent 95% CI Yes 88 29.33 24.2-34.8 No 209 69.67 64.1-74.8 Don’t know 3 1.00 0.2-2.9 No response 0 0 0.0-1.2 Total 300 100.00 Q38. Would you visit someone with TB in their home? Frequency Percent 95% CI No 14 4.67 2.6-7.7 Yes 282 94.00 90.7-96.4 Don’t know 0 0 0.0-1.2 No response 0 0 0.0-1.2 Total 300 100.00 Q39. If no, why would you not visit someone with TB in their home? Frequency Percent 95% CI Fear of disease 8 57.14 28.9-82.3 Other 2 14.29 1.8-42.8 NA (Skip) 3 21.43 4.7-50.8 Don’t know 1 7.14 0.2-33.9 No response 0 0 0.0-1.2 Total 14 100.00 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 49 Q40. If someone has TB, would they try to hide the disease from others? Frequency Percent 95% CI No 216 72.00 66.6-77.0 Yes 76 25.33 20.5-30.7 Don’t know 8 2.67 1.2-5.2 No response 0 0 0.0-1.2 Total 300 100.00 Q41. If yes, why would people with TB try to hide the disease from others? Yes No Frequenc y Percent 95% CI Frequenc y Percent 95% CI Because they will lose job 0 0 0.0-4.7 76 100.00 95.3-100 Because they will lose friends 15 19.74 11.5-30.5 61 80.26 69.5-88.5 Because people will avoid them 15 19.74 11.5-30.5 61 80.26 69.5-88.5 Because no one will marry them 1 1.32 0.0-7.1 75 98.68 92.9-100.0 Because people will think they have HIV 20 26.32 16.9-37.7 56 73.68 62.3-83.1 Other 29 38.16 27.2-50.0 47 61.84 50.0-72.8 Don’t know 13 17.11 9.4-27.5 63 82.89 72.5-90.6 No response 0 0 0.0-4.7 0 0 0.0-4.7 Q42. Do you think it is shameful to have TB? Frequency Percent 95% CI No 241 80.33 75.4-84.7 Yes 51 17.00 12.9-21.7 Don’t know 7 2.33 0.9-4.7 No response 1 0.33 0.0-1.8 Total 300 100.00 Q43. If yes, why do you think it is shameful to have TB? Yes No Frequency Percent 95% CI Frequency Percent 95% CI This is a disease of unfaithful people 0 0 0.0-7.0 51 100.00 93.0-100.0 Because the person with TB can lose their job 0 0 0.0-7.0 51 100.00 93.0-100.0 Because everybody will avoid the person with TB 12 23.53 12.8-37.5 39 76.47 62.5-87.2 Because it means the person is 13 25.49 14.3-39.6 38 74.51 60.4-85.7 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 50 or may be HIV+ Improper cleansing after death 8 15.69 7.0-28.6 43 84.31 71.4-93.0 Other 7 13.73 5.7-26.3 44 86.27 73.7-94.3 Don’t know 8 15.69 7.0-28.6 43 84.31 71.4-93.0 No response 1 1.96 0.0-10.4 50 98.04 89.6-100.0 Q44. Have you heard about the disease called HIV or AIDS? Frequency Percent 95% CI No 21 7.00 4.4-10.5 Yes 279 93.00 89.5-95.6 Total 300 100.00 Q45. If yes, how can you protect yourself from getting HIV? Yes No Frequency Percent 95% CI Frequency Percent 95% CI Abstinence 37 12.63 9.5-17.8 256 87.37 80.8-89.1 Faithfulness 181 61.77 59.0-70.5 112 38.23 31.8-43.1 Condom use 222 75.77 74.4-84.1 71 24.23 19.0-28.9 Avoid skin piercing objects 59 20.14 16.5-26.4 234 79.86 72.9-82.6 Prompt STI treatment 24 8.19 5.6-12.5 269 91.81 85.7-92.9 Being attended to be a trained service provider during pregnancy and delivery 1 0.34 0.0-2.0 292 99.66 94.8-98.8 Infant feeding options 1 0.34 0.0-2.0 292 99.66 94.8-98.8 Use of ART 8 2.73 1.2-5.6 285 97.27 91.9-97.2 Other 10 3.41 1.7-6.5 283 96.59 91.1-96.7 Don’t know 10 3.41 1.7-6.5 283 96.59 91.1-96.7 No response 0 0 0.0-1.3 293 100.00 95.3-99.1 Q46. How is HIV transmitted? Yes No Frequency Percent 95% CI Frequency Percent 95% CI Through the air when coughing 2 0.68 0.1-2.4 291 99.32 94.4-98.6 Through a handshake 4 1.37 0.4-3.4 289 98.63 93.5-98.2 Sexually transmitted 278 94.88 89.1-95.3 15 5.12 2.8-8.1 Sharing food with infected person 9 3.07 1.4-5.6 284 96.93 91.5-96.9 Through blood transfusion 38 12.97 9.1-17.0 255 87.03 80.4-88.8 Through kiss 3 1.02 0.2-2.9 290 98.98 94.0-98.4 Sharing needles/razors 186 63.48 56.2-67.5 107 36.52 30.2-41.4 From mother to child 6 2.05 0.7-4.3 287 97.95 92.7-97.7 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 51 during pregnancy Breastfeeding 3 1.02 0.2-2.9 290 98.98 94.0-98.4 Witchcraft 0 0 0.0-1.2 293 100.00 95.3-99.1 Other 18 6.14 3.6-9.3 275 93.86 87.9-94.5 Don’t know 4 1.37 0.4-3.4 289 98.63 95.3-99.1 No response 0 0 0.0-1.2 293 100.00 0.7-4.3 Q47. Do you know where you can get tested for HIV? Frequency Percent 95% CI No 6 2.00 0.7-4.3 Yes 282 94.00 90.7-96.4 NA (Skip) 6 2.00 0.7-4.3 Don’t know 6 2.00 0.7-4.3 Total 300 100.00 22.9-33.6 Q48. If yes, how long would it take you to walk to the nearest HIV testing center from here? Frequency Percent 95% CI 0-15 minutes 79 28.01 22.9-33.6 16-30 minutes 40 14.18 10.3-18.8 31 min – 1 hour 40 14.18 10.3-18.8 More than 1 hour 102 36.17 30.6-42.1 NA (Skip) 1 0.35 0.0-2.0 Don’t know 88 7.09 25.8-37.0 No response 0 0 0.0-1.2 Total 282 100.00 Q49. I don’t want to know the result, but have you ever had an HIV test? Frequency Percent 95% CI No 113 37.67 32.2-43.4 Yes 180 60.00 54.2-65.6 Don’t know 6 2.00 0.7-4.3 No response 1 0.33 0.0-1.8 Total 300 100.00 Q50. Do you think that someone with HIV should be tested for TB? Frequency Percent 95% CI No 46 15.33 11.4-19.9 Yes 207 69.00 63.4-74.2 NA (Skip) 6 2.00 0.7-4.3 Don’t know 41 13.67 10.0-18.1 No response 0 0 0.0-1.2 Total 300 100.00 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 52 Q51. Do you think that someone with TB should be tested for HIV? Frequency Percent 95% CI No 43 14.33 10.6-18.8 Yes 222 74.00 68.6-78.9 NA (skip) 6 2.00 0.7-4.3 Don’t know 29 9.67 10.0-18.1 No response 0 0 0.0-1.2 Total 300 100.00 Q52. Are you more likely to get TB if you have HIV? Frequency Percent 95% CI No 46 15.33 11.4-19.9 Yes 215 71.67 66.2-76.7 NA (Skip) 6 2.00 0.7-4.3 Don’t know 33 11.00 7.7-15.1 No response 0 0 0.0-1.2 Total 300 100.00 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 53 Annex D: Sampling Framework KPC Cluster sampling for TB Dots MTE - March'12 Village Population size Sampling Interval 6790 Random Number 2833 Population Accumulated Cluster identification Group/cluster number Massangena Bocoda 6481 6481 2833 1 Mabondzo 2264 8745 Chicumbo 954 9699 9623 2 Cufamune 1819 11518 Chizumbane 604 12122 Chigamane 356 12478 Mucambene 2124 14603 Nhamadgio 324 14927 Siqueto 719 15646 Matchave 471 16116 Mutcheli 293 16409 Socote 604 17013 16413 3 Mavue 1361 18374 Chimbandze 407 18781 Matambuje 331 19112 Muzamane 954 20066 Mapanhe 770 20835 Chicualacuala Chicualacuala-Sede 5889 26725 23203 4 Chassanga 502 27227 Mugugugo 363 27590 3 de Fevereiro 515 28105 Mahatlane 808 28913 Chitlavanine 280 29192 Malongueta 458 29650 Malambane 293 29943 Muzila 458 30401 29993 5 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 54 Chale 407 30808 Mapai-sede 7301 38109 36783 6 Regua 522 38631 Litlatla 1622 40252 Hoxa-ribye 655 40908 Chicualac. "B" 413 41321 Madulo 331 41652 Chidulo 890 42542 Ligome 604 43146 Mepuzi 948 44094 43573 7 Mukhatxuane 725 44819 Chilemane 642 45461 Vuyela 509 45970 Nghala 464 46434 Muzamane 369 46803 Chissapa 382 47185 Maphuvule 445 47630 Ndombe 496 48126 Mafassitela 598 48724 Chigubo Ndindiza 1558 50282 Nongote 878 51160 50363 8 Keke 1596 52756 Nhanale 1526 54283 Nhamazane 1743 56025 Cubo 1444 57469 57153 9 Chipimbe 871 58340 Zinhane 1113 59453 Machaila 1240 60693 Mapungane 999 61692 Hariane 401 62093 Hokwane 623 62716 Hlecane 572 63288 Guija Guija-Sede 5561 68849 63943 10 Songuene 227 69076 Sifo 8839 77915 70733 +77523 11 + 12 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 55 Acordo de Luzaka 16695 94610 84313 + 91103 13 + 14 Chibabel 15052 109662 97893 + 104683 15 + 16 Chichongolo 1465 111127 Mbala-Vala 686 111813 111473 17 Gumbane 1467 113280 Maimane 691 113971 Nalaze 1647 115618 Pandzane 695 116314 Chimbembe 2192 118506 118263 18 Dzindzine 1036 119542 Pumbe 933 120474 Pelane 4079 124553 Ndonga 8247 132800 125053 + 131843 19 + 20 Chinhacanine 7090 139890 138633 21 Mubanguene 6186 146076 145423 22 Nhatine 1915 147992 Tomanine 926 148918 7 Abril 3177 152095 Chivonguene 1111 153206 152213 23 Mabalane Pfukwe 3266 156472 Covela 403 156875 Tsocate 1330 158205 Chinhequete 1411 159616 159003 24 Machava 550 160166 Munginge 1062 161228 Mabalane-Sede 4031 165259 Matidze 930 166189 165793 25 Chipswane 914 167103 Mabomo 1109 168211 Hoyo-Hoyo 1972 170183 Combomune-Estacao 4246 174429 172583 26 Combomune-Rio 912 175341 Nhone 304 175645 Macaral 424 176069 Jasse 411 176480 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 56 Gerez 694 177175 Massingir Tihovene 5253 182428 179373 27 Canhane 1247 183675 Cubo 1628 185303 Mahlaule 496 185799 Makhavene 617 186416 186163 28 Chibotane 1323 187739 Madingane 674 188413 Chinhangane 1266 189679 Marrenguele 318 189997 Banga 1005 191001 Chitar 617 191618 Zulo 623 192242 Macaringue 2525 194767 192953 29 Tchaque 1514 196280 Timhondzweni 617 196897 Mucatine 1876 198773 Nheleti 636 199409 Decad da Vitoria 515 199924 199743 30 Ringane 197 200122 Makwaxane 611 200732 Nkuzi 712 201445 Munhamane 655 202100 Chipandzo 229 202329 Makhongele 725 203054 Manhica 655 203709 203,709 ÷ 30 = 6,790 Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 57 Annex E: Survey Team ORGANIZERS: PIETER ERNST Director, Program Integration ADOLFO CAMBULE Project Manager, Vurhonga CB-DOTS MONISHA JAYAKUMAR Health Advisor, World Relief Headquarters COORDINATORSS: CELINA CHONGO CLARA JAVANA DELFINA MALULEQUE SUPERVISORS RUTE CHONGO MARIA MARCELA CARMELIA MACHAVA MELITA MAPSANGANHE ROSITA CHONGO LIGIA LANGA INTERVIEWERS ODETE NHANGUMBE RUTE CHAUQUE MARIA LOUISA CARLITA COSSA CACILDA MAPILELE BARCELINA BENZANE PAULA CHAUQUE IZAK VILANCULOS MELITA MABUNDA ISABEL BILA BONIFACIO SITOE JOSE CHIRINDZA Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 58 Annex F: Training and Survey Schedule with Project Resources Required Training Schedule March 12, 2012 External interviewer recruitment March 13, 2012 Introduction and background of project to interviewers Importance of an evaluation Responsibilities of an interviewer Responsibilities of a supervisor March 14 –15, 2012 Explanation of KPC questionnaire, question by question Practice reading the questionnaire March 16, 2012 Division in 6 teams for field testing March 19 - 22, 2012 Conduct survey March 23 - 24, 2012 Manual tabulation of survey results KPC Survey Schedule: March 19 – 22, 2012 Day 1 19 March'12 Cluster no and village Cluster no and village Group Vehicle Coordinator Supervisors Interviewers Morning Afternoon 1 Mli 43 62 (Mawai) Delfina Maluleke Rute Chongo Paula Chauque 1 Bocoda 3 Rute Chilaule Socoti Melita Mapsanganhe Carlita Cossa 2 Chicumbo 3 Maria Louisa Socoti 2 MLX 77 59 (Machava) Celina Chongo Carmelia Machava Izak Vilanculos 20 Chicualacuala 22 Odete Nhangumbe Mapai Maria Marcela Barcelina Benzane 21 Muzila 22 Mapai Isabel Bila 3 MMF 38 26 (Muiambo) Clara Javana Rosita Chongo Melita Mabunda 24 Combomune 25 Bonifacio Sitoe Matidze Ligia Langa Cacilda Mapilele 24 Combomune 26 Jose Chirindza Chinhequeti Day 2 20 March'12 1 Mli 43 62 (Mawai) Delfina Maluleke Rute Chongo Paula Chauque 4 Rute Chilaule Cubo Melita Mapsanganhe Carlita Cossa 5 Maria Louisa Nongoti 2 MLX 77 59 (Machava) Celina Chongo Carmelia Machava Izak Vilanculos 23 Mpuze 6 Odete Nhangumbe Guija sede Maria Marcela Barcelina Benzane 23 Mpuze 6 Isabel Bila Guija sede Vurhonga CB-DOTS MTE KPC Report- ANNEXES Page | 59 3 MMF 38 26 (Muiambo) Clara Javana Rosita Chongo Melita Mabunda 14 Donga (B2) 17 Bonifacio Sitoe Chinhacanine Ligia Langa Cacilda Mapilele 15 Donga (B4) 18 Jose Chirindza Mubanguene Day 3 21 March'12 1 Mli 43 62 (Mawai) Delfina Maluleke Rute Chongo Paula Chauque 27 Massingir 29 Rute Chilaule DecadaVitoria Melita Mapsanganhe Carlita Cossa 28 Macavene 30 Maria Louisa Macaringue 2 MLX 77 59 (Machava) Celina Chongo Carmelia Machava Izak Vilanculos 7 Sifo (B1) 9 Odete Nhangumbe Acordo (B1) Maria Marcela Barcelina Benzane 8 Sifo (B3) 10 Acordo (B4) Isabel Bila 3 MMF 38 26 (Muiambo) Clara Javana Rosita Chongo Melita Mabunda 16 Chimbembe 13 Bonifacio Sitoe Mbalavala Ligia Langa Cacilda Mapilele 16 Chimbembe 13 Jose Chirindza Mbalavala Day 4 22 March'12 1 Mli 43 62 (Mawai) Delfina Maluleke Rute Chongo Paula Chauque 11 Rute Chilaule Chibabel (B2) Melita Mapsanganhe Carlita Cossa 11 Maria Louisa Chibabel (B2) 2 MLX 77 59 (Machava) Celina Chongo Carmelia Machava Izak Vilanculos 12 Odete Nhangumbe Chibabel (B1) Maria Marcela Barcelina Benzane 12 Chibabel (B1) Isabel Bila 3 MMF 38 26 (Muiambo) Clara Javana Rosita Chongo Melita Mabunda 19 Bonifacio Sitoe Chivonguene Ligia Langa Cacilda Mapilele 19 Jose Chirindza Chivonguene Project Resources Required Expense Approximate cost (USD) Salaries (Staff and external interviewers) $3,600 Administrative costs (including photocopies) $500 Transportation/ gasoline $1,700 Meals and Lodging $300 Total $6,100 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 100 J.7 Annex 7: CHW Training Matrix CHW Training Matrix in entire project area Type of CHW Official Government CHW or Grantee Developed Cadre Paid or Volunteer Number Trained Over Life of Project Focus of Training Care Group Volunteers Grantee Developed Cadre Volunteer 17172 TB signs and symptoms to detect TB suspects, etiology and mode of transmission, referral system, treatment follow-up. Community leaders and other men Official Government Volunteer 10414 TB signs and symtoms, etiology and mode of transmission Community women Neither Volunteer 17874 TB signs and symtoms, etiology and mode of transmission Church leaders Neither Volunteer 1493 TB signs and symtoms, etiology and mode of transmission Prison inmates Neither Volunteer 210 TB signs and symtoms, etiology and mode of transmission Village Health Committee members Official Government CHW Volunteer 224 TB signs and symtoms, etiology and mode of transmission Traditional healers Neither Volunteer 990 TB signs and symtoms, etiology and mode of transmission Focal Point volunteers Official Government CHW Volunteer 185 TB signs and symptoms to detect TB suspects, etiology and mode of transmission, referral system, treatment follow-up, maintenance of village TB register, monitor sputum bottle supply. Youth volunteers Grantee Developed Cadre Volunteer 367 TB signs and symtoms, etiology and mode of transmission TB DOTS Care Group Supervisors Grantee Developed Cadre Paid 10 TB signs and symtoms, etiology and mode of transmission, referral system, treatment follow-up, maintenance of community TB data, supervision of CGVs and FPVs. Laboratory technicians Official Government CHW Paid 8 Laboratory techniques in tuberculosis Peripheral nurses Official Government CHW Paid 35 CB-DOTS and slide fixing CHW Training Matrix by District Type of CHW Guija Massingir Mabalane Chigubo Chicualacuala Massangena Total Care Group Volunteers 5238 1803 3864 3863 1288 1116 17172 Community leaders & other men 3517 1442 2692 609 1129 1025 10414 Community women 3224 3515 5407 1155 3606 967 17874 Church leaders 343 314 358 134 239 105 1493 Village Health Committees 76 31 57 13 25 22 224 Traditional Healer 228 208 238 89 158 69 990 Focal Point Volunteers 36 29 38 23 30 29 185 TB DOTS Supervisors 2 2 2 1 2 1 10 Laboratory Technicians 2 2 2 1 0 1 8 Peripheral Nurses 7 8 7 5 5 3 35 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 101 J.8 Annex 8: Evaluation Team Members and their Titles Name Title Organization Henk Eggens, MD, MPH MTE Team Leader Consultant, KNCV Tuberculosis Foundation, Netherlands Monisha E. Jayakumar BDS, MPH, PhD Health Advisor World Relief, Baltimore Pieter Ernst, MD Director of Program Integration, World Relief Mozambique World Relief, Mozambique Adolfo E. Cambule, MD TB-DOTS Manager World Relief Mozambique World Relief, Mozambique Alfredo MacArthur, MD, MSc USAID Mozambique Officer TB& AIDS USAID Mozambique Mission Nicídia Pereira Provincial Tuberculosis Control Supervisor MISAU, Gaza province, Mozambique J.9 Annex 9: Evaluation Assessment Methodology J.9.1 Evaluation team scope of work, including timeline of activities J.9.1.1 Purpose of the MTE The Vurhonga Community-Based DOTS project has completed two years of implementation and this year, FY 2012, has been designated for the execution of the midterm evaluation of the project. The purpose of the midterm evaluation (MTE) according to the Detailed Implementation Plan (DIP) is to: “Evaluate the process of project implementation as planned in the Detailed Implementation Plan (DIP) with the purpose of making suggestions for adjustments needed in order to improve the quality and effectiveness of the program to achieve results or deal with contextual situations that have changed since the DIP was developed.” J.9.1.2 MTE objectives The objectives of the MTE according to the Child Survival and Health Grants Program (CSHGP) are to:  Assess progress in implementing the early phases of the DIP including preparation and structuring tasks (i.e. capacity building);  Assess progress towards achievement of objectives or yearly benchmarks;  Assess if interventions are sufficient to reach desired outcomes;  Identify barriers/challenges to achievement of objectives;  Identify key factors that contributed to what seems to be working well or to what is not working well regarding some or all aspects of the program to inform project actions; and  Provide recommended actions to guide the project staff through the last half of the project. J.9.1.3 MTE Scope The evaluation is conducted by the evaluation team, headed by the Lead Evaluator, assigned by USAID. The team is comprised of staff from World Relief’s home office and Mozambique office, Ministry of Health of Mozambique and other relevant partners. The most recent guidelines for MTE developed by USAID were used5 . 5 These were found in the document, “GUIDELINES FOR MID-TERM EVALUATION CHILD SURVIVAL AND HEALTH GRANTS PROGRAM USAID/GH/HIDN/NUT_April 2012” assessed on the USAID internet site on May 22, 2012. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 102 J.9.1.4 MTE timeline: The below table shows the timeline of main MTE activities as implemented. Date Activity Location January 2012 Selection of LE; definition of date field trip Mozambique, USA & The Netherlands March 2012 Preparations of field trip Mozambique, USA & The Netherlands April 16th , 2012 MTE team briefing agenda: 1. Introductions 2. Scope of work 3. Questionnaires discussed Chókwè, Gaza province, Mozambique April 17th 1. Focus Group Discussion with 10 (female) WR supervisors 2. Pre-MTE preparation: review of evaluation instruments, logistics Chókwè April 18th & April 19th Project site-visits; MTE team divided up into two sub-teams Team 1: Chicualacuala (18th ) and Mabalane (on the 19th) Team 2: Chigubo (18th ) and Guija (on the 19th) April 20th Review of field experiences guided by DIP Chókwè WR office April 21th and April 22th Weekend April 23rd Field visit: both teams Massingire district: Villages (3) and Health Center (1) April 24th – April 25th, 2012 Review distribution of tasks MTE members; synthesis of data from all MTE sites; KPC data processing and analysis. Report writing Chókwè April 26th, 2012 Province debriefing and presentation Chókwè April 27th , 2012 In-country debriefing and presentation USAID office Maputo May 14th, 2012 WR sent Lead Evaluator (LE) final KPC report May 15th , 2012 LE sent first draft of report sections to WR May 25th, 2012 LE sent second draft of report sections to WR June 1st, 2012 WR sent first draft of report sections incorporated in compiled MTE report to LE June 5th, 2012 WR sent clean draft of MTE report to LE June 20-21st , 2012 Editting and formatting of MTE report June 22nd , 2012 Final report submission to USAID J.9.1.5 Brief descriptions of information gathering methodologies In the months before the field visit the Grantee, the Field Team and the appointed LE exchanged mails, documents and ideas. There was a clear advantage in having five weeks available for the field trip preparation by the three stakeholders. Project documents were shared in time. Before the field visit, questionnaires for the Focus Group Discussion (FGD) and Key Informant Interviews (KII) were developed by the LE, shared, discussed and translated. Two field teams were created, composed of a balanced mix of expertise and functions. Team 1 Team 2 MJ, World Relief Health Advisor (USA) HE, Lead Evaluator (The Netherlands) PE, Director of Program Integration, World Relief (Mozambique) AC, TB-DOTS Manager World Relief (Mozambique) NP, Provincial Tuberculosis Control Supervisor (Gaza, Mozambique) AM, USAID Mozambique Officer TB& AIDS Supervisors for the districts visited (Melita, Odete, Marcela) Supervisors for the districts visited (Celina, Clara) (translator Shangaan-Portuguese and vivo) For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 103 During the field mission, FGDs were held with the project supervisors and also with several Care Group Volunteers (CGV) in their villages. In each district, the health center was visited, the district TB supervisor interviewed. In each district, a focus group discussion was held with the CGV, accompanied usually by the village leadership (president of the village or substitute). Discussions were noted down by participants and used in review sessions of MTE progress. In the health centers, KIIs were held with the district tuberculosis supervisor, and where available, the clinician and the lab technician. District tuberculosis registers were seen extensively, health facility ledgers, HIV and laboratory registers, and patient records were also seen and discussed. J.9.2 Data collection instruments, including interview guides, data extraction guides, and questionnaires used During the field visit of the MTE use was made by the teams of questionnaires for Key Informant Interviews (KII) and key questions for Focus Group Discussions (FGD). In practice during the interviews and the FGDs more questions on a variety of subjects were touched upon. Also, fixed data collection instruments were nbot used to inspect registers, forms and ledgers in the health centers and the villages. The KPC followed a fixed set of questions, developed and used during the project inception. J.9.3 Key Informant interviews (KII) J.9.3.1 KII1: Questions for health center staff 1 What difference do you see in tuberculosis case detection using care group volunteers? 2 What difference in adherence do you see using padrinhos? 3 What difference in contact tracing did you notice? 4 What difference is there in sputum collection methods? 5 What difference in supervision has taken place? 6 What is the current practice in: A. Screening for tuberculosis in HIV-positive clients? B. Screening for HIV in tuberculosis cases? C. Provision of CPT in HIV/tuberculosis cases? 7 Are there any signs of reduced stigma among patients? J.9.3.2 KII2: Questions for district TB supervisor/district medical officer 1 What effects do you see in employing the care groups? 2 What effects do you see of the village health committees? 3 How useful is the community health information system for tuberculosis control activities? 4 What is your opinion on the district rapid assessment tool (DRAT)? 5 What are the advantages of the World Relief approach? 6 What are the challenges in the World Relief approach? J.9.4 Focus Group Discussions J.9.4.1 Leading Questions: With care group volunteers and village health committees 1 What positive changes in tuberculosis case finding and adherence have occurred since you started your activities? 2 What difficulties did you face in finding tuberculosis suspects? 3 What difficulties did you face in ensuring patients to complete their tuberculosis treatment? For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 104 4 What solutions do you see to solve these problems? J.9.4.2 Leading Questions: Focus group discussion 2: patients on DOTS (not implemented) 1 What assistance did you get from care groups? 2 What assistance did you get from your padrinho? 3 What are the problems in completing treatment? 4 What solutions do you see to solve these problems? J.9.5 Names of places visited Date Activities Participants Location 18-apr Field visit Team 1: PE, MJ, MISAU prov supervisor Nicidia Pereira, WR supervisors Celina Chicualacuala, District Health Center, Litlatla village. Field visit Team 2: HE, AC, AM, WR supervisors Melita Chigubo, Ngongote village 19-apr Field visit Team 1: PE, MJ, MISAU prov supervisor Nicidia, WR supervisor Clara Mabalane, Combomune village, District Health Center, Decada da Vitoria village Field visit Team 2: HE, AC, AM, WR supervisors Odete, Marcela Guija, Tomanine village 23-apr Field visit: two teams all Massingire, Estaleiro 6 Bairro, Mucatine village J.9.6 Documents reviewed DPS Gaza: Relatório Anual 2011 das actividades do PNCT (2011 Annual NTP Report) Edward,A. et al, Examining the evidence of under-five mortality reduction in a community-based program in Gaza, Mozambique, Trans.Roy.Soc.Trop.Med.Hyg.(2007) CORE Group, The Expansion of Community-Based Tuberculosis Programming: Critical Program Design Issues for New Partners. 2008, CORE Group USAID Mozambique tuberculosis profile, 2009. Source: www.usaid.gov WHO, Global tuberculosis control: WHO report 2011. WHO, Country cooperation strategy 2009–2013 Mozambique; 2009, WHO World Relief, Scope of Work Midterm Evaluation Vurhonga TB_World Relief_Final_2012.1.13 World Relief, TB 1st REVISED Annual Report_FY2010_Final_Oct31.2011 World Relief, TB 2nd Annual Report_FY2011_Final_Oct31.2011 World Relief, Trip Report_Mozambique_MJ_final_2012, World Relief, Vurhonga TB Final DIP, 2009 Advocacy, communication and social mobilization (ACSM) for tuberculosis control: a handbook for country programmes. WHO 2007 J.10 Annex 10: List of Persons Interviewed and Contacted during the MTE Team 1 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 105 Date District Location type Data collection method Members present Title 4/18/2012 Chicualacuala Chicualacuala District Health Center Interview Marcelo de Almada Chief Medical Officer Antonio Manhica District TB Supervisor Ncidia Pereira Gaza Provincial Coordinator Monisha Jayakumar Health Advisor, World Relief, USA Pieter Ernst Director of Program Integration – World Relief, Mozambique Arminda Watt TBCARE Coordinator, WR, Mozambique Celina Shongo Supervisor, WR, Mozambique Ruth Shongo Supervisor, WR, Mozambique 4/18/2012 Chicualacuala Litlatla Village Focus Group Antonio Manhica District TB Supervisor Ncidia Pereira Gaza Provincial Coordinator Monisha Jayakumar Health Advisor, World Relief, USA Pieter Ernst Director of Program Integration – World Relief, Mozambique Arminda Watt TBCARE Coordinator, WR, Mozambique Celina Shongo Supervisor, WR, Mozambique Virjulo Alvaro Village Nurse Anna Zolvir Focal Point Volunteer Rosal Jonivurel CGV Alese Chuzae CGV Anna Siband CGV Esther Seband CGV Martha Jephata CGV Synora Chivambu CGV Nomiya Monjan CGV Esther Chitango CGV Synora Sumbani CGV Armelia Simbandu CGV Brasena Matwasa CGV Ezabel Chukae CGV Vangalina Makuvellae CGV Snetha Chukae CGV 4/19/2012 Mabalane Combomune Village Focus Group Ncidia Pereira Gaza Provincial Coordinator Monisha Jayakumar Health Advisor, World Relief, USA Pieter Ernst Director of Program Integration – World Relief, Mozambique Arminda Watt TBCARE Coordinator, WR, Mozambique Ruth Chowkae Supervisor, WR, Mozambique Ruth Shongo Supervisor, WR, Mozambique Celina Shongo Supervisor, WR, Mozambique Clara Javana Supervisor, WR, Mozambique Phillip Sinturam TB Supervisor of Health Post Alfeo Chowkaw Focal Point Volunteer Celina Seoso CGV Fatima Chowkae CGV Salimina Chowkae CGV Masea Chowkae CGV Flora Chowkae CGV Belia Malulakae CGV Ida Chowkae CGV Sarah Chowkae CGV Melina Mangan CGV Sarah Chowkae (2nd) CGV Leonaore Machalle CGV Alisa Chowkae CGV Ramaka Chowkae CGV Ramaka Chowkae (2nd) CGV Delphina Kosa CGV 4/19/2012 Mabalane Combomune Village Interview Alfeo Johan Maynongo TB patient who completed treatment Ncidia Pereira Gaza Provincial Coordinator Monisha Jayakumar Health Advisor, World Relief, USA Pieter Ernst Director of Program Integration – World Relief, Mozambique Arminda Watt TBCARE Coordinator, WR, Mozambique Ruth Chowkae Supervisor, WR, Mozambique Ruth Shongo Supervisor, WR, Mozambique Celina Shongo Supervisor, WR, Mozambique Clara Javana Supervisor, WR, Mozambique Phillip Sinturam TB Supervisor of Health Post Alfeo Chowkaw Focal Point Volunteer 4/19/2012 Mabalane Mabalane District Health Center Interview Kastigu Louis Mabalane District TB Supervisor Ncidia Pereira Gaza Provincial Coordinator Monisha Jayakumar Health Advisor, World Relief, USA Pieter Ernst Director of Program Integration – World Relief, Mozambique Arminda Watt TBCARE Coordinator, WR, Mozambique Ruth Chowkae Supervisor, WR, Mozambique Ruth Shongo Supervisor, WR, Mozambique Celina Shongo Supervisor, WR, Mozambique Clara Javana Supervisor, WR, Mozambique 4/19/2012 Mabalane Decada da Vitoria Village Focus Group Ncidia Pereira Gaza Provincial Coordinator Monisha Jayakumar Health Advisor, World Relief, USA Pieter Ernst Director of Program Integration – World Relief, Mozambique Arminda Watt TBCARE Coordinator, WR, Mozambique Carmela Machava Supervisor, WR, Mozambique Maria Mashavu Focal Point Volunteer Jethrud Lindowae CGV Lina Nyathae Molly Mongue Angelica Mobonda Lina Shyvambu Adela Mongue 4/19/2012 Mabalane Decada da Vitoria Village Interview Paulina Phaylle TB patient on treatment Ncidia Pereira Gaza Provincial Coordinator Monisha Jayakumar Health Advisor, World Relief, USA Pieter Ernst Director of Program Integration – World Relief, Mozambique Arminda Watt TBCARE Coordinator, WR, Mozambique Ruth Chowkae Supervisor, WR, Mozambique Ruth Shongo Supervisor, WR, Mozambique Celina Shongo Supervisor, WR, Mozambique Clara Javana Supervisor, WR, Mozambique 4/23/2012 Massingir Mucatine Village Focus Group Ncidia Pereira Gaza Provincial Coordinator Monisha Jayakumar Health Advisor, World Relief, USA Pieter Ernst Director of Program Integration – World Relief, Mozambique Arminda Watt TBCARE Coordinator, WR, Mozambique Melita Supervisor, WR, Mozambique Carmelia Machana Supervisor, WR, Mozambique Maria Bashqua Focal Point Volunteer Elaria Zetha CGV Lilita Valoi CGV Leonar Cubai CGV Fatima Valoi CGV Sachina Cossa CGV Lydia Subanee CGV Angelica Mundlone CGV Martina Mudolf CGV Alseta Covane CGV Meralina Sigachuquae CGV Armelinda Valoi CGV For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 106 Team 2 District: Chigubo WR Supervisor: Melita Mapswanganhe District Health Director: Julinho Luis Chilaule District TB Supervisor: Jose Zuze Village visited: Nongote Village leader: Salomão Sitoi District: Massingir WR supervisor: Delfina Maluleque Clinical Director: Dora Adelino Artur District TB Supervisor: Olindo Oliveira Village visited: Estaleiro 6 Bairro Village secretary: Vasco Mate District: Guija WR supervisor: Odete Nhangumbe & Maria Marcela District Health Director: Antonio Domingos District TB Supervisor: Claudio Baera Village visited: Tomanine 6 Bairro Village Secretary: Sebastião Macamo For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 107 J.11 Annex 11: Project Data Form Child Survival and Health Grants Program Project Summary Jun-21-2012 World Relief Corporation (Mozambique) General Project Information Cooperative Agreement Number: GHN-A-00-09-00017 WRC Headquarters Technical Backstop: Dr. Monisha Jayakumar WRC Headquarters Technical Backstop Backup: Melanie Morrow Field Program Manager: Dr. Adolfo Cambule Midterm Evaluator: Final Evaluator: Headquarter Financial Contact: Melanie Morrow Project Dates: 9/30/2009 - 9/29/2014 (FY2009) Project Type: TB Control USAID Mission Contact: Maria da Conceicao Rodrigues Project Web Site: Field Program Manager Name: Dr. Adolfo Cambule Address: Mozambique Phone: Fax: E-mail: acambule@gmail.com Skype Name: Alternate Field Contact Name: Dr. Pieter Ernst Address: RUA DOM JOAO III, No. 90, Summershield RUA DOM JOAO III, No. 90, Summershield Maputo Mozambique Phone: +258-82-316-4220 Fax: E-mail: pernst@wr.org Skype Name: Grant Funding Information USAID Funding: $1,500,000 PVO Match: $500,000 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 108 General Project Description World Relief, a 2009 Tuberculosis (TB) category grantee, is implementing the Vurhonga Community Based DOTS Project in six under-served, rural districts and three urban areas in Gaza Province, Mozambique. All nine target areas have pre-existing World Relief volunteer structures in place. The project goal is to reduce the TB burden per the National Strategic Plan and the World Health Organization's STOP TB Strategy, and the primary objectives are to increase the case notification rate by 50% and to achieve 85% treatment success rate in project areas fully implementing Community-Based Directly Observed Treatment Short￾Course (CB-DOTS). Project strategies are to: (1) Empower people with TB to seek and complete treatment, with the support of communities; (2) Strengthen National Tuberculosis Program (NTP) Systems to improve service delivery and patients’ outcomes; and (3) Decrease the burden of HIV in people with TB and decrease the burden of TB among people living with HIV/AIDS (PLWHA). Project Location Latitude: -18.57 Longitude: 34.67 Project Location Types: Rural Urban Peri-urban Levels of Intervention: District Hospital Health Center Health Post Level Home Community Other: Provincial NTP Province(s): Gaza Province District(s): Chicualacuala, Chigubo, Guija, Mabalane, Massangena, Massingir, Chokwe (Chokwe Town only), and Bilene (Macia Town only) Districts Sub-District(s): -- Operations Research Information There is no Operations Research (OR) component for this Project. Partners Mozambique Ministry of Health (NTP at Province, District and Local levels) (Collaborating Partner) $0 Carmelo Hospital (Collaborating Partner) $0 Various local community-based organizations including Village Health Committees, Pastors' Networks and churches (Collaborating Partner) $0 Family Health International (TB￾CAP) (Collaborating Partner) $0 Strategies Social and Behavioral Change Community Mobilization For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 109 Strategies: Group interventions Interpersonal Communication Mass media and small media Health Services Access Strategies: Addressing social barriers (i.e. gender, socio-cultural, etc) Implementation in a geographic area that the government has identified as poor and underserved Health Systems Strengthening: Conducting capacity assessment of local partners Supportive Supervision Developing/Helping to develop job aids Providing feedback on health worker performance Referral-counterreferral system development for CHWs Community role in supervision of CHWs Community role in recruitment of CHWs Review of clinical records (for quality assessment/feedback) Coordinating existing HMIS with community level data Community input on quality improvement Strategies for Enabling Environment: Stakeholder engagement and policy dialogue (local/state or national) Advocacy for policy change or resource mobilization Building capacity of communities/CBOs to advocate to leaders for health Tools/Methodologies: Community-based Monitoring of Vital Events TB Cohort Analysis (if applicable) Capacity Building Local Partners: Traditional Healers Dist. Health System Health Facility Staff Health CBOs Other CBOs Government sanctioned CHWs Non-government sanctioned CHWs Faith-Based Organizations (FBOs) Interventions & Components Tuberculosis (100%) - Microscopy - Monitoring/Supervision Surveillance - Community IEC - Linkages with HIV services - Community based care/DOT - Pediatric TB - MDR TB IMCI Integration CHW Training HF Training Operational Plan Indicators Number of People Trained in DOTS (TB Projects Only) Gender Year Target Actual Female 2010 3969 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 110 Female 2010 4192 Male 2010 2517 Male 2010 89 Female 2011 3600 Female 2011 15036 Male 2011 9130 Male 2011 200 Female 2012 3600 Male 2012 200 Female 2013 0 Male 2013 0 Locations & Sub-Areas Total Population: 581,212 Target Beneficiaries Mozambique - WRC - FY2009 Number of Suspected TB Cases 4,795 Beneficiaries Total 4,795 Rapid Catch Indicators: DIP Submission Sample Type: 30 Cluster Indicator Numerator Denominator Percentage Confidence Interval Percentage of new smear positive cases who were successfully treated 44 56 78.6% 25.6 Rapid Catch Indicators: Mid-term Rapid Catch Indicators: Final Evaluation Rapid Catch Indicator Comments Please note that the TB Treatment Success Rate was measured using a modified District Rapid Assessment Tool for TB applied to all rural health centers in the project area. It was not based on a sample, 30-cluster or otherwise. Thus the automatic calculation for the confidence interval is irrelevant. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 111 J.12 Annex 12: Suggested terminology Table 4 World Relief terminology WHO terminology *) Current Mozambican NTP In English In Portuguese terms:**) Cure rate Curado (C) Cured (1) Curado (C) Treatment completed Tratamento Completo (TC) Completed treatment (2) Tratamento Completo (TC) Treatment success Sucesso do tratamento Successfully treated (1+2) Sucesso Treatment failure Falha do tratamento (POS) Failed Positivo (POS) Interruption rate Interrupção (AB) Defaulted Abandono (AB) Mortality rate Mortalidade (OB) Died Óbito (OB) Transfer rate Transferido (T) Not evaluated ***) Transferido (T) *) Source: Global tuberculosis control: WHO report 2011 **) Source: District TB register NTP ***) in use since WHO Global Tuberculosis Report 2010 Definitions of treatment outcomes for patients treated for drug-susceptible TB used for reporting at global level (Source: Global tuberculosis control: WHO report 2011) Cured: A patient who was initially smear-positive and who was smear-negative in the last month of treatment and on at least one previous occasion. Completed treatment: A patient who completed treatment but did not meet the criteria for cure or failure. This definition applies to pulmonary smear-positive and smear-negative patients and to patients with extrapulmonary disease. Successfully treated: A patient who was cured or who completed treatment. Died: A patient who died from any cause during treatment. Failed: A patient who was initially smear-positive and who remained smear￾positive at month 5 or later during treatment. Defaulted: A patient whose treatment was interrupted for 2 consecutive months or more. Not evaluated: A patient whose treatment outcome is not known. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 112 J.13 Annex 13: Indicator definitions M&E Indicator Definitions Strategy Location Indicator Numerator Denominator Comments IR1: Empower people with TB to seek and complete treatment, with the support of their communities (45% effort) S.1.1: ACSM RD Percentage of respondents surveyed know that TB is transmitted through the air by coughing Number of respondents that stated that TB is transmitted through the air by coughing Total number of survey respondents* Percentage of respondents surveyed know that cough longer than three weeks is a sign of TB Number of respondents that stated that cough longer than three weeks is a symptom of TB Total number of survey respondents* Percentage of respondents surveyed know that TB is curable Number of respondents that stated that they believed TB is curable Total number of survey respondents* Percentage of respondents surveyed know that TB treatment is free Number of respondents that stated that TB treatment is free Total number of survey respondents* Percentage of volunteers trained Number of volunteers who received training on TB Total number of volunteers Percentage of VHCs trained Number of VHCs trained on TB Total number of functioning VHCs S.1.2: Case Detection RD Case Notification Rate Number of new SS+ pulmonary TB cases reported x 100,000 Total population in a specified area Percentage of TB suspects examined by sputum microscopy Number of TB suspects examined by sputum microscopy Total number of TB suspects Percentage of referrals received from volunteers Number of TB suspects referred by the community as reported by the HC Total number of TB suspects received at the HC Percentage of referrals made by volunteers Number of TB suspects referred by the community as reported by the community Total number of TB suspects received at the HC The above indicator is sufficient to monitor referrals and hence this may be dropped. S.1.3: Treatment Compliance RD Cohort analysis for treatment outcomes of SS+ patients Treatment success (recommended to change terminology to Successfully treated) Number of new SS+ pulmonary TB cases registered in a specified period that were cured plus the number that Total number of SS+ pulmonary TB cases registered in the same period Adhere to WHO terminology For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 113 completed treatment Cure rate (recommended to change terminology to Cured) Number of SS+ patients who were SS￾at the final (5th month) sputum test Total number of SS+ pulmonary TB cases registered in the same period Adhere to WHO terminology Treatment completed (recommended to change terminology to Completed treatment) Number of patients who did not return for the final sputum test, but did complete the entire course of medication Total number of SS+ pulmonary TB cases registered in the same period Adhere to WHO terminology Treatment failure (recommended to change terminology to Failed) Number of patients whose final sputum test was SS+ even though they completed the full course of treatment Total number of SS+ pulmonary TB cases registered in the same period Adhere to WHO terminology S.1.3, 2.5 Interruption rate (recommended to change terminology to Defaulted) Number of patients who stopped the treatment for two months or more Total number of SS+ pulmonary TB cases registered in the same period Adhere to WHO terminology Mortality rate (recommended to change terminology to Died) Number of patients who died while on TB treatment Total number of SS+ pulmonary TB cases registered in the same period Adhere to WHO terminology Transfer rate (recommended to change terminology to Not evaluated) Number of patients who transferred to another health facility during the course of treatment Total number of SS+ pulmonary TB cases registered in the same period Adhere to WHO terminology Percentage of SS- TB patients completing treatment Number of SS- TB patients that successfully completed the full course of medication Number of SS- TB patients registered in the same period Percentage of patients on CB-DOT Number of patients on CB-DOT Total number of TB patients (SS+ and SS-) Sputum smear conversion Number of SS+ patients who converted to SS- after the intensive phase of treatment Total number of SS+ patients pre￾treatment S.1.4: C-HIS RD Percentage of functioning VHCs with local data on TB in the previous quarter Number of functioning VHCs with data on TB in the previous quarter Total number of functioning VHCs Percentage of HCs that compile C-HIS data collected by volunteers on TB Number of HCs that compile C-HIS data collected by the volunteers on TB Total number of HCs IR2: Strengthen National Tuberculosis Program (NTP) Systems to improve TB service delivery and patient outcomes (45% effort) For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 114 S.2.1: Assessment RD & UC Percentage of health center assessments conducted quarterly Total number of HC assessments conducted each quarter Total number of HCs 100% of health center assessments will be conducted with participation from the District TB Coordinators or designated representative Total number of HC assessments conducted with participation from the District TB Coordinator or designated representative Total number of HCs S.2.2: Diagnostic Quality RD & UC Proportion of major errors Number of errors, reporting (+) as (-) or vice versa Total number of sputum smears reviewed Proportion of TB suspects with SS+ confirmation (WHO) Number of TB suspects that are SS+ Total number of TB suspects S.2.3: Access RD Percentage of health facilities reporting sputum bottle stock outs in the previous quarter Number of HFs reporting stock outs of sputum bottles in the previous quarter Total number of HFs S.2.4: Referral RD Percentage of referred patients from the community recorded at the health center level Number of patients referred from the community who are recorded at the HC Total number of patients referred from the community This checks the work of the HCs which should not be WR’s responsibility. Hence may be dropped. Percentage of TB+ patients that returned to the community Number of TB+ patients that returned to the community after diagnosis Total number of SS+ TB patients diagnosed This is ambiguous and may be modified as: Percentage of TB+ patients that returned to the community; denominator - # of TB suspects referred by CGV and diagnosed with TB. Numerator - # of referred TB cases returned to community to start on CB￾DOTS and observed by a padrinho S.2.5: Info Systems RD & UC Percentage of HC reporting drug stock outs in the last quarter Number of HC reporting drug stock out of essential TB medications in the last quarter Total number of HCs S.2.6: Supervision RD Percentage of HPs supervised by the District TB Coordinator during the previous quarter Number of HPs who received a supervisory visit by the District TB Coordinator during the previous quarter as reported by the District TB Coordinator Total number of HPs For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 115 Percentage of HPs reporting supervisory visits by the District TB Coordinator Number of HPs who report having received a supervisory visit by the District TB Coordinator during the previous quarter Total number of HPs This should not be WR’s responsibility and may be dropped. S.2.7: Coordination RD & UC Percentage of meetings attended with MISAU and TB partners Number of meetings with NTP, MISAU and other partners attended Total number of meetings invited to by the NTP, MISAU and other partners Number of joint supervisory visits to the HP Number of supervisory visits to the HP that were conducted with the District TB Coordinator and project staff N/A IR3: Integrate TB/HIV activities to address high co-infection rates (10% effort) S.3.1: TB and HIV Education UC Number of OVC and youth volunteers trained Total number of OVC and youth volunteers trained N/A Number of Pastors' Networks trained Total number of Pastors' Networks trained N/A S.3.2: Case Finding in PLWHA UC Number of HBCAs trained Total number of HBCAs trained N/A S.3.3: HIV/TB Testing RD & UC Percentage of HIV+ patients screened for TB Number of HIV+ patients screened for TB Total number of HIV+ patients examined Maintain high levels of HIV testing among TB patients Number of TB patients with known HIV status Total number of TB patients (SS+ and SS-) Percentage of TB patients who are also HIV+ Number of TB/HIV+ patients Total number of TB patients (SS+ and SS-) S.3.4: CPT RD & UC Proportion of TB/HIV patients on CPT Number of TB/HIV patients who have received at least one dose of CPT during treatment for TB Total number of TB/HIV patients (SS+ and SS-) Percentage of HCs reporting stock outs of Cotrimoxazole in the last quarter Number of HC reporting stock outs of Cotrimoxazole in the previous quarter Total number of HCs S.3.5: CB-DOT UC Number of HBCAs trained on CB-DOT Total number of HBCAs trained on CB￾DOT N/A *Note: respondents who stated they had ever heard of TB were not asked follow-up TB questions, but are included in the denominator. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 116 J.14 Annex 14: Key Strategies and Activities: details J.14.1 Intermediate Result 1: Empower people with TB to seek and complete treatment with the support of their communities. (45% Effort) J.14.1.1 Strategy 1.1: Advocacy, Communication, and Social Mobilization (ACSM) (Rural Districts)  Address traditional beliefs that inhibit case detection and treatment seeking  Reduce stigma associated with TB and address barriers to treatment seeking Objectives:  Increase knowledge that TB is transmitted through the air by coughing from 20.7% to 60%  Increase knowledge that cough longer than three weeks is a sign of TB from 13.3% to 60%  Sustain the high percentage of respondents surveyed who know that TB is curable at 85%  Increase knowledge that TB treatment is available for free from 39.7% at baseline to 80%  Train 100% of CGVs in CB-DOTS  Train 100% of functioning Village Health Committees (VHC) in TB Key Activities: Social mobilization involving the entire community is essential to overcoming the prevailing belief in rural villages that TB is of supernatural origin and treatable by traditional healers. Project supervisors rotate visit villages in their responsibility every week. Education topics include TB transmission, signs and symptoms, treatment options and transmission methods. Infection control practices are also an important education component. World Relief has developed a community-based curriculum, “Hope at Home,” that includes specific activities community members can do to prevent infection and the spread of TB (for example, safe coughing techniques, safe disposal of sputum, home ventilation) which serves as a template for this training. Care Group Volunteers (CGV) also focus on stigma reduction and overcoming barriers for treatment seeking. As a group and under the direction of project staff, they create community specific initiatives for reducing stigma and overcoming barriers. In addition to giving educational lessons about TB, the project supervisors review a health topic from previous child survival projects during each rotation (twice per year) in a given village to enhance sustainability and support continued positive behavior change. See Figure 3 on organizational chart of Care Group Model. Role of Key Partners: World Relief has a long history of community health work in this area and will train and interact with existing local structures and people in the community most able to sway popular understanding and opinion (e.g. CGs, VHCs, religious leaders and traditional healers). J.14.1.2 Strategy 1.2: Case Detection (Rural Districts)  Conduct case detection via Care Group Volunteers (CGVs) Objectives:  Increase the quarterly case notification rate (CNR) by 50% from 110 to 165  Maintain the high percentage of TB suspects examined by sputum microscopy at 80%  Increase the percentage of referrals made by CGVs from 20.6% to 60% Key Activities: Local authorities, VHCs, APEs (Community Health Workers in Mozambique), CGs and religious leaders (including those who function as traditional healers) are trained as trainers on the signs and symptoms of TB, how it is transmitted, and ways to prevent infection. They understand that the project is not operating independently but is part of the National Strategic Plan for tuberculosis control, and learn where to go for free screening, treatment and follow-up. They discuss perceptions of stigma and the importance of supporting family and community members to seek testing and adhere to treatment. CGVs, with the endorsement of village leaders, help to link health facilities to the For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 117 households in the community. Each CGV is responsible for visiting her group of neighboring families to be sure that every household is counseled about TB and that suspected cases report to the nearest health facility. For activities related to increasing sputum microscopy, please see Strategy 2.2. For a description of the flow of referrals and for individual roles within the structure, please refer to Annex 16: Referral flowchart. Role of Key Partners: As with Strategy 1.1, the project will continue to work closely with influential local leaders and local organizations and will continue the partnership with APEs and the Provincial and District Ministry of Health to foster referrals and encourage sputum testing. J.14.1.3 Strategy 1.3: Treatment Compliance (Rural Districts)  Improve treatment success through the training and use of treatment observers (padrinhos) in the community Objectives: Conduct cohort analysis of treatment outcomes for SS+ patients including:  Increase the rate of treatment success from 78.6% to 85%  Maintain the high level of sputum smear conversion at 90%  Eighty-five percent of SS- patients will complete treatment  Increase the percentage of patients on CB-DOT from 26.4% to 60% Key Activities: Testing for and treatment of TB requires considerable effort on the part of the patient. As the potential to default on treatment extends over six months or longer, the role of the CGV is critical. The CGV works with the patient to find a suitable padrinho to observe and record treatment. The CGV also gets called upon over the course of treatment should the patient not return to the health facility on schedule for drugs each month or for follow-up sputum testing at months three and five. Throughout the process, they also provide social support to the patients and padrinhos. WR continues to advocate for timely culture testing for all potential MDR-TB cases as defined by the NTP. As the number of referrals and subsequent burden on the health centers increase, communication and coordination with the community is important in order to maintain high rates of treatment success. Role of Key Partners: District HC records are utilized for data collection on treatment outcomes, thereby not duplicating existing systems. The project works closely with the District TB Coordinators and the Provincial TB Manager, who was present during the BL HFA survey. Further, additional outcome and referral data are collected at the village level by the Lead TB volunteer. This information is then shared with village leaders, VHCs and it is communicated back to the MISAU as well. J.14.1.4 Strategy 1.4: Community Health Information System (Rural Districts)  Integrate TB surveillance into the Community Health Information System (C-HIS) reported on to VHCs, HP and MISAU Objectives:  Eighty percent of VHCs will have local data on TB from the previous quarter  Eighty-three percent of HCs will compile C-HIS data collected by CGVs on TB Key Activities: WR’s census-based CG program, with its innovative C-HIS, tracks births, deaths and pregnancies at the village level and reports this data to village leadership through the VHCs and to the MISAU through APEs and HP nurses. C-HIS data has alerted the District Health Department (DDS) of trends in health indicators, and helped to facilitate appropriate action at the district level. This existing C-HIS system is expanded upon to include data on TB referrals, diagnoses and treatment outcomes. Data from each are aggregated at village level by the Lead TB volunteer (either the APE, HP nurse, or Focal Point Volunteer depending on the village situation), presented to the VHC and For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 118 relayed to the MISAU through the existing hierarchy. Collection of information on cases and their follow-up by the APE to the VHC provides an additional level of community awareness regarding TB and increases the community’s accountability to the patients. To enhance community accountability, VHCs (including village leaders, religious leaders and traditional healers) are trained to support and reinforce CGs and APEs through additional supervision of TB detection, surveillance, case follow-up, and data review. In addition, C-HIS data are used by CGs and VHC to identify priorities and address problems such as detection and treatment barriers, and measure progress towards project objectives. Information collected by the C-HIS are then compared to the HC statistics and discussed at quarterly provincial meetings. Role of Key Partners: As stated above, the process of collecting, analyzing and distributing the C-HIS data is a collaborative effort involving the CGV, VHCs and the MISAU. J.14.2 Intermediate Result 2: Strengthen NTP Systems to improve TB service delivery and patient outcomes. (45% Effort) J.14.2.1 Strategy 2.1: Facility Assessments (Rural Districts and Urban Centers)  Conduct accurate assessments of TB activities at health facilities  Increase participation of district MISAU staff in facility assessments Objectives:  Conduct quarterly assessments of all health centers in the project area  One hundred percent of health center assessments will be conducted with participation from the District TB Supervisors or designated representative Key Activities: The DRAT tool was modified by WR to account for the local context and project indicators. It was presented to MISAU leaders and Provincial TB staff for their review and further adaptation. This modified DRAT (M-DRAT) is used each quarter to track cohorts of TB patients as they move through the referral, diagnosis and treatment processes. The results from each M-DRAT are collated and analyzed by project staff, including cross-referencing it to data collected at the village level. Such results are presented to each HC, District TB Supervisors and routinely to the Provincial MISAU. Data are presented to the community through CGs and VHCs. Role of Key Partners: The M-DRAT are utilized jointly by project staff and the appropriate District TB Supervisor. The Provincial TB Coordinator participated in the BL assessment and MTE. J.14.2.2 Strategy 2.2: Diagnostic Quality (Rural Districts and Urban Centers)  Facilitate training district lab technicians on sputum smear microscopy to improve diagnostic quality  Advocate for continuous, external, and random quality assurance testing of sputum slides Objectives:  Bring the proportion of TB suspects with SS+ confirmation in line with international standards by lowering it from 44.6% to between 10% and 25%  Maintain low proportion of major errors reported through external review at less than 1% Key Activities: Using MISAU trainers, recommended to the project by Family Health International (FHI) the lead organization in Mozambique for the Tuberculosis Control Assistance Program (TB￾CAP), the project facilitated training and refresher training of district lab technicians to promote accurate laboratory assessments during years one and three. Trainings included microscope For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 119 maintenance, slide preparation and reading, and quality control. Another key component of these trainings is appropriate infection and environmental controls in line with international standards to prevent the spread of TB to staff, patients and the community. The project also advocates for appropriate quality protocols including the routine quality reviews for slide reading accuracy and the random selection of such slides. The primary advocacy tool is the M-DRAT itself which continuously raises the issue of the quality review at the district level and provides evidence of current practices to the provincial level during routine reporting. Role of key partners: While funding and logistical supports are provided by the project, the instruction is led by qualified MISAU TB trainers, Carmelo Hospital and Rural Hospital. FHI (TB-CAP) has had extensive experience providing such trainings in the region and has assisted in referring appropriate trainers with whom they have had good success. J.14.2.3 Strategy 2.3: Access (Rural Districts)  Improve access by facilitating community level barrier analysis and local problem-solving  Improve access to diagnostic services at peripheral HFs by assisting community sputum collection Objectives:  Less than 10% of HFs will report sputum bottle stock-outs in the previous quarter Key activity: It is best for the patient to be examined and tested at the HF, to start treatment for those who are TB+, to explore other causes for those who are TB-, and for universal HIV testing for all those suspected of TB. Therefore, the project uses community structures and resources to make visiting the HC a priority among those with TB symptoms. If a referred patient is unable to travel to the HC for testing, the CGV brings this to the attention of the VHC to address as a community and if any local assistance may be provided. This is important as TB testing and treatment is not only in the interest of the patient, but can prevent the spread of disease across the community. In unusual situations, remote testing may be required. Therefore, the project helps to monitor and track the inventory of sputum collection bottles at the HC and HP level and help supply sputum bottles when there is a shortage at the provincial and district levels. In addition, both Project Supervisors and District TB Supervisors help to ensure transport of such sputum collection bottles during routine supervision visits via motorbikes provided by the project. Role of key partners: VHCs and local religious organizations play a critical role in identifying those in need of assistance and arriving at creative local solutions to individual situations. They also play a key role in creating an environment of community responsibility. Community level sputum collection is a component within the current NTP. However, they report having difficulty with the inventory and supply of sputum collection bottles. WR, through its census based volunteer structure assists the NTP in monitoring the supply of sputum bottles at the HC and HP levels and provides occasional supply to prevent stock outs. J.14.2.4 Strategy 2.4: Referral (Rural Districts)  Improve referral and counter-referral between facilities and the community network of CGVs and treatment observers. Objectives:  75% of the patients referred from the community will be recorded at health center  80% of TB+ patients will return to the community after receiving their diagnosis For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 120 Key activities: Working with VHCs, CGVs, and MISAU staff the project expands on the current referral and counter-referral system to ensure accurate tracking and reporting. CGVs record information on each individual referred and follow-up with them to ensure testing. After returning from testing, the CGV goes with the patient to the nearest HP. The APE/HP nurse, the CGV and the patient decide collectively who will be the “padrinho” (treatment supporter) and records the information. The CGV along with the APE train the padrinho on TB treatment, the importance of adherence and possible negative reactions. The APE then gives the medicine on a weekly or every other week basis to the padrinho. Data collection on referrals is collated in each village by the Lead TB Volunteer and shared with local leadership, the project and the MISAU. Role of key partners: Data collection on referrals continues to be monitored at the HC level according to the MISAU system; community level data collection complies with MISAU definitions and forms and fully integrates the APE or HP nurse. J.14.2.5 Strategy 2.5: Information Systems (Rural Districts and Urban Centers)  Strengthen the flow of information between district and provincial structures, to improve drug supply and data management. Objectives:  Less than 17% of HCs reporting drug stock-outs of essential TB drugs for the last quarter  Less than 5% of those who start treatment will drop out (Interruption rate) Key Activities: The Project M&E Manager works with the District TB Supervisors to improve record￾keeping, trains them how to make data based decisions and how to accurately predict drug needs. Helping the MISAU staff manager with their data to avoid treatment interruption is a significant part of the M&E Manager’s role. Presentation and discussion of the frequency of stock outs is a key factor discussed at monthly district meetings and at quarterly meetings with provincial leaders. WR actively participates in problem solving to assist in implementing changes set forth by the NTP. J.14.2.6 Strategy 2.6: Supervision (Rural Districts)  Enhance supervision of peripheral health facilities engaged in TB control through provision of motorbikes to MISAU supervisors and modeling of supportive supervision. Objectives:  85% of HPs will be visited by the District TB Supervisor during the previous quarter as reported in the M-DRAT  85% of HPs will report supervisory visits by the District TB Supervisor Key Activities: The project works with the health centers to provide or repair motorbikes for TB Coordinators to use for supervision as requested by the MISAU. WR models supportive supervision techniques to the District TB Supervisor during co-supervisory visits to HPs, VHCs and Care Groups. J.14.2.7 Strategy 2.7: Coordination with NTP (Rural Districts and Urban Centers)  Collaborate with the NTP, TB-CARE and other partners to ensure complementary and comprehensive implementation of the National Strategic Plan for TB Control Objectives:  Attend 80% of meetings to which WR is invited  Conduct six joint supervisory visits to HPs each quarter For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 121 Key Activities: Attend scheduled coordination meetings with partners and integrate supervisory visits with the District and Provincial MISAU, and FHI. Scheduled meetings include: monthly meetings with the MISAU and Project Supervisors at the district level to provide feedback, plan for upcoming activities and share data collection and survey results (if applicable); quarterly meetings with the Provincial TB Coordinator and other provincial TB staff to provide feedback, compare statistics, discuss project and MISAU objectives and possible improvements; bi-annual meetings with all the District TB Supervisors to review data from the previous six months and track progress over time. The project and staff participate in other meetings as determined by the NTP, MISAU, or other partners. Role of key partners: At the onset of WR’s TB project, the only other NGO implementing TB activities in Gaza Province was FHI (TB-CAP). WR is partnering with FHI as a sub-grantee under TB-CARE in WR’s urban project areas. J.14.3 Intermediate Result 3: Decrease the burden of HIV in people with TB and decrease the burden of TB among PLWHA. (10% Effort) J.14.3.1 Strategy 3.1: TB and HIV Education through ACSM (Urban Centers)  Utilize existing WR HIV/AIDS programming to change beliefs and perceptions surrounding TB and HIV in the community through established church and peer social networks for advocacy Objectives:  Train 60 OVC and youth volunteers in TB, including in stigma reduction  Train three Pastors’ Networks in TB, including in stigma reduction Key Activities: ACSM strategies in the urban areas of Chokwe, Macia and Guija are being implemented through the volunteer structures developed under WR’s HIV activities. Annual training in TB referral and stigma reduction are provided to OVC volunteers and youth mobilization teams who incorporate TB messages into current HIV outreach activities. This broad team of volunteers work in their communities for stigma reduction surrounding TB and HIV and increased awareness about TB, its signs and symptoms, and the fact that TB is curable and treatment is free. Role of Key Partners: The project works closely with existing PNs, some of which are in the process of becoming locally registered CBOs. WR has received additional funding through a sub-grant from FHI’s TB-CARE project. J.14.3.2 Strategy 3.2: Intensified TB Case Finding among PLWHA (Urban Centers)  Utilize existing WR HBCAs to identify potential TB cases among their HIV+ clients Objectives:  Train 40 HBCAs in TB case finding, referral and stigma reduction Current Status: WR’s HIV/AIDS programming also included HBCAs. These specialized volunteers provide social and medical care to their HIV+ clients. HBCAs have established relationships with their clients, and they have a close knowledge of their situation, family structure and beliefs. In addition to the close relationship with their clients, they hold a position of respect and authority on health. Under the MISAU approved curriculum, they receive a limited amount of information about TB identification and referral and they transfer this knowledge to their clients and families. Key Activities: WR work with the HBCAs by providing ongoing and enhanced education surrounding TB including how to identify and refer TB, stigma reduction and treatment compliance. These volunteers, through their unique relationship with PLWHA provide intensified TB case finding. They also contribute to S.3.1 by providing continuous education to their clients and families regarding both For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 122 HIV and TB. WR supports these volunteers through supervision, training and by providing small incentives to encourage them to continue caring for their individual patients. Role of Key Partners: Local churches and HCs provide integral support to the HBCAs to ensure that they are well supported and that referrals are adequately documented. J.14.3.3 Strategy 3.3: Routine HIV/ TB Testing (Urban Centers and Rural Districts)  Improve TB screening among HIV+ patients  Maintain high levels of HIV testing among TB patients Objectives:  Improve the percentage of HIV+ patients screened for TB from 46.6% to 60%  Maintain high levels of HIV testing among TB patients at 95%xvii Key Activities: WR works to improve actual rates of TB screening and appropriate documentation through interaction with the NTP. The project also conducts IEC with HIV+ patients encouraging them to go to the health center to seek treatment and community education through HBCAs as well as community wide education regarding HIV co-infection and the need for testing through CGVs. J.14.3.4 Strategy 3.4: Cotrimoxazole Prevention Therapy (CPT) (Urban Centers and Rural Districts)  Prevention of opportunistic infections with CPT in HIV/TB patients  Track HC inventory of Cotrimoxazole to assist with preventing drug stock outs Objectives:  Maintain high levels of CPT in HIV/TB patients at 90%  Less than 25% of HCs reporting stocks out of Cotrimoxazole in the previous quarter Current Status: The proportion of HIV/TB patients that receive at least one dose of CPT is 99.7%. This rate is similar to the 2009 findings for Gaza (98.7%xviii) and is in line with national policy. Key activities: Opportunistic infections are particularly dangerous for TB/HIV patients. WR works with other NGOs, including local NGOs and community groups to advocate for continued CPT availability among this high risk group. Given the BL findings demonstrating difficulties the drug supply chain, WR monitors CPT inventory and assist the NTP with stock out prevention methods as implemented. Role of key partners: As treatment regimens and medications are determined by the MISAU, WR supports the activities of the NTP, District and Provincial MISAU. J.14.3.5 Strategy 3.5: Case Management of Co-Infections (Urban Centers)  Train HBCAs in CB-DOT to improve treatment success Objectives:  Number of HBCAs trained on CB-DOT Key activities: In order to improve compliance with the medication regimen and improve treatment success, HBCAs help to implement CB-DOT. With their knowledge of TB, their clients and their circumstances, HBCAs help their clients and HC staff choose an appropriate padrinho, train the padrinho (including on how to complete the forms) and provide oversight. The HBCAs also represent a link between the health center, the client and the padrinho to answer questions and offer support. Role of key partners: WR has routine contact with the MISAU and HFs in the urban areas through the M&E Manager and project supervisors to encourage communication and participation with the HBCAs on CB-DOTS when a current HIV+ patient is diagnosed with TB. For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 123 J.15 Annex 15: Mozambique page WHO global tuberculosis report 2011 MOZAMBIQUE POPULATION 2010 (MILLIONS) 23 ESTIMATES OF BURDEN Number Rate 2010a (thousands) (per 100 000 pop) Mortality (excluding HIV) 11 (7–17) 49 (30–74) Prevalence (incl HIV) 110 (54–200) 491 (233–844) Incidence (incl HIV) 130 (87–170) 544 (374–746) Incidence (HIV-positive) 77 (53–110) 330 (228–449) Case detection, all forms (%) 34 (25–50) CASE NOTIFICATIONS 2010 N ew cases (%) Retreatment cases (%) Smear-positive 20 097 (48) Relapse 1 432 (35) Smear-negative 16 408 (39) Treatment after failure 234 (6) Smear unknown 0 (0) Treatment after default 235 (6) Extrapulmonary 5 621 (13) Other 2 147 (53) Other 0 (0) Total new 42 126 Total retreatment 4 048 Total < 15 years Total new and relapse 43 558 (94% of total) Total cases notified 46 174 DRUG REGIMENS Rifampicin used throughout treatment Yes % of patients treated with fixed-dose combinations (FDCs) 95 Paediatric formulations procured Yes TREATMENT SUCCESS RATE 2009 (%) New smear-positive 85 New smear-negative/extrapulmonary Retreatment TREATMENT SUCCESS RATE (%) 100 New smear + INCIDENCE (HIV+TB red), notifications (black) (rates per 100 000 population) 1000 500 0 1990 1995 2000 2005 2010 PREVALENCE (rate per 100 000 population) 2000 1000 0 1990 1995 2000 2005 2010 MORTALITY EXCLUDING HIV (rate per 100 000 population) 200 100 0 1990 1995 2000 2005 2010 TB/HIV 2010 TB patients with known HIV status 40 554 % of TB patients with known HIV status 88 TB patients that are HIV-positive 24 574 % of tested TB patients that are HIV-positive 61 % HIV-positive TB patients started on CPT 97 % HIV-positive TB patients started on ART 25 75 New smear –/ 50 25 1995 1997 1999 2001 2003 2005 2007 2009 MDR-TB, ESTIMATES AMONG NOTIFIED CASESa extrapulmonary Retreatment HIV-positive people screened for TB 433 HIV-positive people provided with IPT 8 904 CPT (pink) and ART (brown) for HIV-positive TB patients (blue) 30000 % of new TB cases with MDR-TB 3.5 (2.2–4.8) % of retreatment TB cases with MDR-TB 11 (0.0–25) Estimated MDR-TB cases among new pulmonary TB cases notified in 2010 1 300 (800–1 800) Estimated MDR-TB cases among retreated pulmonary TB cases notified in 2010 450 (0–1 000) 20000 10000 0 2003 2004 2005 2006 2007 2008 2009 2010 FINANCING 2011 2012 MDR-TB REPORTED CASES 2010 New Retreatment Total Total budget (US$ millions) 34 39 Cases tested for MDR-TB 80 251 365 Available funding (US$ millions) 24 24 % of notified tested for MDR-TB <1 6 <1 % of budget funded 71 62 Confirmed cases of MDR-TB 18 130 165 % available funding from domestic sources 11 11 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 124 MDR-TB patients started treatment 87 % available funding from Global Fund 0 12 LABORATORIES 2009 2010 2011 Smear (per 100 000 population) 1.9 1.9 1.8 Culture (per 5 million population) 0.2 0.4 0.6 DST (per 5 million population) 0.2 0.4 0.6 Second-line DST available Outside country National Reference Laboratory Yes a Ranges represent uncertainty intervals. NTP Budget (blue) and available funding (green) (US$ millions) 50 25 0 2006 2007 2008 2009 2010 2011 2012 Data can be downloaded from www.who.int/tb/data For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 125 J.16 Annex 16: Referral flowchart For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 126 J.17 Annex 17: M&E Table Strategy Location Indicator Source/ Measurement Frequency Baseline Q4 Oct-Dec 2010 Q1 Jan-Mar 2011 Q2 Apr￾Jun 2011 Q3 Jul-Sep 2011 Q4 Oct-Dec 2011 ME EOP Target IR1: Empower people with TB to seek and complete treatment, with the support of their communities (45% effort) S.1.1: ACSM RD Percentage of respondents surveyed know that TB is transmitted through the air by coughing KAP Survey Project Records BL, ME, FE 20.7% N/A N/A N/A N/A N/A 61.3% 60% Percentage of respondents surveyed know that cough longer than three weeks is a symptom of TB KAP Survey Project Records BL, ME, FE 13.3% N/A N/A N/A N/A N/A 18.0% 60% Percentage of respondents that know that coughing is a symptom of TB KAP Survey Project Records BL, ME, FE 66.3% N/A N/A N/A N/A N/A 66.7% Percentage of respondents surveyed know that TB is curable KAP Survey Project Records BL, ME, FE 85.3% N/A N/A N/A N/A N/A 91.7% 85% Percentage of respondents surveyed know that TB treatment is free KAP Survey Project Records BL, ME, FE 39.7% N/A N/A N/A N/A N/A 23.3% 80% Percentage of volunteers trained Project Records Quarterly 0% 45.1% 60.9% 77.2% 81.0% 100% N/A 100% Percentage of functioning VHCs trained Project Records Quarterly N/A 5.7% 10.7% 25.7% 51.4% 100% N/A 100% S.1.2: Case Detection RD Case Notification Rate (per 100,000 population) M-DRAT Quarterly 128.3 139.5 93.6 120.1 93.6 107.7 N/A 165.0 Percentage of TB suspects examined by sputum microscopy M-DRAT Quarterly 80.9% 93.4% 92.3% 95.2% 95.7% 81.8% N/A 80% Percentage of referrals received from volunteers M-DRAT Quarterly 20.6% 14% 6.0% 10.3% 13.5% 14.7% N/A 60% S.1.3: RD Cohort analysis for treatment outcomes of SS+ TB patients For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 127 Treatment Compliance Treatment success M-DRAT Quarterly 78.6% 88.2% 80.9% 81.6% 75.6% 77.7% N/A 85% Cure rate M-DRAT Quarterly 71.4% 83.8% 78.7% 81.6% 75.6% 75.5% N/A - Treatment completed M-DRAT Quarterly 7.1% 4.4% 2.2% 0.0% 0.0% 2.1% N/A - Treatment failure M-DRAT Quarterly 1.8% 4.4% 2.2% 3.9% 1.2% 1.1% N/A - Interruption rate M-DRAT Quarterly 3.6% 1.5% 6.7% 0.0% 3.7% 3.2% N/A <2% Deaths M-DRAT Quarterly 10.7% 5.9% 10.1% 11.8% 17.1% 17.0% N/A <7% Transfer rate M-DRAT Quarterly 5.4% 0.0% 0.0% 1.3% 0.0% 1.1% N/A - Percentage of SS- patients successfully completing treatment M-DRAT Quarterly 54.5% 70.6% 68.8% 92.7% 79.5% 70.5% N/A 85% Percentage of patients on CB￾DOT M-DRAT Quarterly 0.0% 4.4% 3.4% 2.6% 8.5% 16.0% N/A 60% Sputum smear conversion M-DRAT Quarterly 86.6% 86.1% 74.0% 77.6% 79.7% 76.6% N/A 90% S.1.4: C-HIS RD Percentage of functioning VHCs with local data on TB in the previous quarter Project Records Quarterly N/A 62.5% 57.1% 90.4% 47.2% 100.0% N/A 80% Percentage of HCs that compile C-HIS data collected by volunteers on TB Project Records Quarterly Year 2 100% 100% 100% 100% 100% N/A 83% IR2: Strengthen National Tuberculosis Program (NTP) Systems to improve TB service delivery and patient outcomes (45% effort) S.2.1: Assessment RD & UC Percentage of health center assessments conducted quarterly M-DRAT Quarterly 100% 100.0% 100.0% 100.0% 100.0% 100.0% N/A 100% 100% of health center assessments will be conducted with participation from the District TB Coordinators or designated representative M-DRAT Quarterly 1005 100.0% 100.0% 100.0% 100.0% 100.0% N/A 100% S.2.2: Diagnostic Quality RD & UC Proportion of major errors M-DRAT Quarterly 0.0% 0.3% 0.0% 0.0% 0.6% 0.0% N/A <1% S.2.3: Access RD Percentage of HFs reporting sputum bottle stock outs in the previous quarter Project Records Quarterly 25% 0.0% 0.0% 0.0% 0.0% 0.0% N/A <10% For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 128 Strategy Location Indicator Source/ Measure-ment Fre-quency Base￾line Q4 Oct-Dec 2010 Q1 Jan-Mar 2011 Q2 Apr-Jun 2011 Q3 Jul-Sep 2011 Q4 Oct-Dec 2011 ME EOP Target S.2.5: Info Systems RD & UC Percentage of HC reporting TB drug stock outs in the last quarter M-DRAT Quarterly 87.5% 62.5% 87.5% 62.5% 37.5% 62.5% N/A <5% S.2.6: Supervision RD Percentage of HPs supervised by the District TB Coordinator during the previous quarter M-DRAT Quarterly 83.3% 83.3% 100.0% 83.3% 66.7% 50.0% N/A 85% Percentage of HPs reporting supervisory visits by the District TB Coordinator Project Records Quarterly Year 2 ^ ^ ^ ^ ^ N/A 85% S.2.7: Coordination RD & UC Percentage of meetings attended with MISAU & TB Partners Project Records Quarterly 100% 100% 100% 100% 100% 100% N/A 80% Number of joint supervisory visits to the HP Project Records Quarterly N/A 0 2 3 6 6 N/A 6 IR3: Integrate TB/HIV activities to address high co-infection rates (10% effort) S.3.1: TB and HIV Education UC Number of OVC and youth volunteers trained Project Records Quarterly 0 Target achieved in Q3, 2010 Target achieved in Q3, 2010 Target achieved in Q3, 2010 Target achieved in Q3, 2010 Target achieved in Q3, 2010 N/A 60 Number of Pastors' Networks trained Project Records Quarterly 0 38 26 19 20 Target achieved in Q4, 2010 N/A 3 S.3.2: Case Finding in PLWHA UC Number of HBCAs trained Project Records Quarterly 0 Target achieved in Q3, 2010 Target achieved in Q3, 2010 Target achieved in Q3, 2010 Target achieved in Q3, 2010 Target achieved in Q3, 2010 N/A 40 For USAID: World Relief Mozambique Community-Based DOTS Project: Mid Term Evaluation Report, 2012 129 Strategy Loca-tion Indicator Source/ Measure-ment Fre-quency Base￾line Q4 Oct-Dec 2010 Q1 Jan-Mar 2011 Q2 Apr-Jun 2011 Q3 Jul-Sep 2011 Q4 Oct-Dec 2011 ME EOP Target S.3.3: HIV/TB Testing RD & UC Percentage of HIV+ patients screened for TB M-DRAT Quarterly 44.8% 74.5% 87.7% 62.8% 87.3% 71.8% N/A 60% Maintain high levels of HIV testing among TB patients M-DRAT Quarterly 97.8% 96.0% 99.6% 99.5% 100.0% 100.0% N/A 95% Percentage of patients with TB who are also HIV+ M-DRAT Quarterly 70.2% 55.3% 78.1% 83.3% 73.9% 58.7% N/A N/A S.3.4: CPT RD & UC Proportion of TB/HIV+ patients on CPT* M-DRAT Quarterly 99.2% 99.6% 98.6% 101.3% 94.0% 98.8% N/A 90% Percentage of HCs reporting stock outs of Cotrimoxazole in the last quarter M-DRAT Quarterly 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% N/A <25% S.3.5: CB-DOT UC Number of HBCAs trained on CB-DOT Project Records Quarterly 0 Target achieved in Q3, 2010 Target achieved in Q3, 2010 Target achieved in Q3, 2010 Target achieved in Q3, 2010 Target achieved in Q3, 2010 N/A 40 130 K. References i World Bank Statictics. http://devdata.worldbank.org/AAG/moz_aag.pdf ii Instituto Nacional de Estatística. Censo Geral de População 2007, Evolução de População Total. Mozambique 2008. http://www.ine.gov.mz/censo2007 [hereafter Census 2008]. iii National Census Data, 2011 iv National Census Data, 2011 v UNDP. The Human Development Index – 2011 http://hdr.undp.org/en/statistics/hdi/ vi World Health Organization, 2009. http://www.who.int/gho/countries/moz.pdf vii World Health Organizaiton, 2010. file:///C:/Users/mjayakumar/Documents/Mozambique/TB/Readings/WHO_TB%20profile% 202010.htm viii World Health Organization, Global Tuberculosis Control, 2011. ix World Health Organization. Global TB Control, 121-124. Geneva, 2008 [hereafter WHO 2009] x World Health Organization. Country Profile, Mozambique 2004. Geneva, 2005. xi Mozambique, National Program for Tuberculosis Control. National Strategic Plan 2008- 2012, Mozambique [Hereafter NSP 2007] xii WHO 2009 xiii WHO 2009 xiv Republic of Mozambique, National AIDS Council. Universal Declaration of Commitment on HIV and AIDS, Mozambique Progress Report for the United National General Assembly Special Session on HIV and AIDS 2006-2007. Mozambique 2008. xv Relatório Anual 2011 das actividades do PNCT, REPÚBLICA DE MOÇAMBIQUE GOVERNO DA PROVÍNCIA DE GAZA. xvi NSP 2007