Innovation summary

Approximately 51,000 people live with epilepsy in Laos PDR and more than 90% do not receive treatment.1 Cultural beliefs, low availability of treatment, and poor knowledge in health personnel are the major reasons for this treatment gap.2-8 For the few patients that are identified, treatment adherence and compliance are also problematic. 9-10

This innovation (DHeVELoP) aims to find the best strategy to increase access to treatment for people with epilepsy through the assessment of the effectiveness of health workers available at the community level.

These health workers, known as Domestic Health Visitors (DHVs), will undertake monthly visits in a set number of villages. During the visits, their activities will consist of:

  • Information, Communication and Education campaigns
  • Identification of suspected cases of epilepsy and referral to physicians based in the district hospital
  • Follow-up with people with epilepsy and delivery of monthly treatments at home
  • Visit to Micro-franchisees - an integrated activity for people with epilepsy and diversification of services in villages

Diagnoses and prescriptions will be made by the district hospital physician specifically trained in epilepsy.

Impact summary

  • 215 people with epilepsy will access project products and/or services
  • 150 people will see a reduction in seizures and 11 lives will be saved (25% reduction in the treatment gap)
  • $250,000 CAD funded over two years; cost effectiveness of the program will be evaluated upon the end of the study

“With treatment, person with epilepsy have a normal life in the private, social and professional context”.


- Dr Phetvongsinh Chivorakoun, President of the Association for Patients living with Epilepsy in Lao PDR

This innovation is funded by Grand Challenges Canada.

Innovation details

The program will perform focused activities to achieve the following objectives:

Increase the effectiveness and efficiency of primary health care.

The epilepsy training and the intervention tasks allow primary health care staff to increase their skills to qualify as DMVs. The training module consists of:

  • Basic knowledge on epilepsy
  • Tasks of a domestic health visitor
  • Practice with patients and case discussion
  • Appropriate methods of data collection
  • Counseling methods

District hospital doctors who perform diagnostic tests will be trained by the neurologist.

Improve access to treatment and adherence of people with epilepsy.

The intervention package will be executed by DMVs every month for 18 months at the village level. During the monthly visits, each village will receive the following intervention package components:

  • The Information Education and Communication (IEC) campaign (with adapted tools) – daily radio message and posters, brochures, and cartoon drawings for the general population, and a follow up book for those living with epilepsy
  • Identification of suspected cases of epilepsy
  • Follow-up of people with epilepsy and delivery of monthly treatments in their homes

Improve the socio-economic level of people with epilepsy and reduce stigma in general population.

A micro-franchise program will be created to provide professional support for patients under treatment (> 3 months) in shops or services to improve the quality of life of people living with epilepsy and their families. Gradually the micro-franchisees will become the main people through which dissemination of IEC materials will happen and will also be the main points of contact, visited by the DHV each month.

The reduction of stigma in the general population is based on the principle of "good example": under treatment, a person with epilepsy is a person like everyone else, able to succeed and to have a business. A committee will select the microfranchisee (one per village) and the program will subsidize the equipment need to start the business. Then the person with epilepsy will ensure their own business and help the DHV when he comes to his respective village. The microfranchisee contributes in his office by making available all supports Information Education and Communication adapted for all ages. Some of the components of the campaign will include quizzes, comics, brochure, poster.

Improve the social and public environment concerning epilepsy in Lao PDR.

Epilepsy awareness at different levels and with different sectors will be conducted by:

  • Meeting with local authorities
  • Conducting conferences with local and international companies (funds specifically for epilepsy)
  • Celebrating Epilepsy Day in Lao PDR
  • Drafting a policy document to improve access to care for epilepsy (for a national scaling-up)

 

Key drivers

Agreement and Involvement of the Governmental Stakeholders

The Ministry of Health and the provincial and district level officials have agreed to provide human resources (primary health care workers, neurologists and coordinators), the treatment antiepileptic drug (AED) and facilities to implement the program. The commitment of government officials to this program will only aid to project sustainability (dependent on success of course). 

Membership and Motivation of the DHVs

Reciprocity between the overload new territorial practices for primary healthcare staff and the acquisition of new knowledge for the DHVs (aspiring to greater efficiency of their care activity) is the key of success for this project.

Adaptation of the Communication and Education Materials to Cultural Context

All communication and education media has been designed and/or adapted for the Laos cultural context.

Specific Advocacy/Policy for Epilepsy

The Ministry of Health and the provincial and district level officials have agreed that the period of prescription of AEDs is now one month -- a huge achievement as it was previously only four days. Now that this policy is in place, it has been incorporated into a monthly dissemination rota through DHVs and the primary healthcare centers.

Challenges

  • Advocating for neglected chronic diseases such as epilepsy, a chronic but treatable disease. The health care system did not consider this specificity (e.g. duration of prescription)
  • The push for epilepsy sensitization among strong cultural beliefs in Lao PDR
  • Challenges about the management of mobility of primary health care staff who play the important role of domestic health visitors. It is recognized that much of the treatment gap is related to the problem of geographical accessibility to health care. The mobility of DHV in villages is more efficient than the villagers visits to the health center (or hospital).

 

Continuation

The program expects to prove the cost effectiveness of the intervention upon the end of the grant. Once proven effective, it can potentially serve as a model for other resource poor countries. 

The ECLAIR program, conducted by UMR-S 1094 NET Tropical Neuroepidemiology, is also testing a variant of this model in Cambodia.

Partners

Funders

Evaluation methods

The intervention is currently being implemented in one district (Pakngum, 58,048 inhabitants) and the indicator will be compared by static analysis with two control districts (Sangthong, 27,727 inhabitants and Naxaithong, 69,244 inhabitants).

To date, a baseline KAP survey has been conducted among the general population of the people living with epilepsy, their caregivers, and healthcare personnel. The data from the baseline survey will be compared with a final KAP survey, given to the same people that took the original KAP survey. This assessment will include study changes in the level of general knowledge about epilepsy in a twofold objective: increasing quality care delivered by health workers and the reduction of stigma in the general population.

The efficiency of care in the health care system for people living with epilepsy will be assessed through the evolution of the number of PWE diagnosed, treated and followed for 18 months (from November 2014 to April 2016) by comparing the intervention and control areas.

Finally the assessment for the micro-franchise programs is based on the number of microfranchises created and maintained during the 18 months.

Cost of implementation

$250,000 CAD grant funding provided over two years.

Impact details

Program implementation will end in April of 2016 after which the impact will be analysed. The following impact indicators are the anticipated outcomes of the project:

Key indicators in district of Pakngum

215 people with epilepsy will access products and/or services. Of these 215 people, 150 will see a reduction in seizures and 11 lives will be saved. This will contribute to a reduction in the treatment gap by 25%. In addition, 107 enrolled participants will experience an increase in employment and/or family income and 53 will enroll in the micro-franchisee program.

Following the anti-stigma campaign, 6,733 people from the general population will significantly change their opinion on people living with epilepsy. Stigma in the district population will decrease by 65%.

Following training, 20 primary healthcare staff members will be able to identify, screen and deliver treatment to people with epilepsy.
 
Key indicators for Lao PDR

An Epilepsy Day will be established in Lao PDR through the project and a policy document will be drafted to improve access to care for epilepsy.

  • Cost-effectiveness: DHV activities/societal benefit related to improve access to care for epilepsy
  • Materials kit (training, IEC, surveys, Guidelines) for model intervention- All procedures are standardized and supports (training, IEC campaign, guidelines, etc.) has formalized so transposed to the research program across the country.

 

References

  1. Tran DS, Odermatt P, Le TO, Huc P, Druet-Cabanac M, Barennes H, M Strobel. Prevalence of epilepsy in a rural district of central Lao PDR. Neuroepidemiology 2006; 26:199-206
     
  2. Barennes H, Harimanana A, Vorachit S, Chivorakoun P. The Lao initiative on access to treatment for epilepsy. Neurology Asia. 2011;16:59-61
     
  3. Tran DS, Zen J, Strobel M, Odermatt P, Preux PM, Huc P, Delneuville L, Barennes H. The challenge of epilepsy control in deprived settings: low compliance and high fatality rates during a community-based phenobarbital program in rural Laos. Epilepsia. 2008 Mar;49(3):539-40
     
  4. Odermatt P, Ly S, Simmala C, Angerth T, Phongsamouth V, Mac TL, RatsimbazafyV, Gaulier JM, Strobel M, Preux PM. Availability and costs of antiepileptic drugs and quality of phenobarbital in Vientiane municipality, Lao PDR. Neuroepidemiology. 2007;28(3):169-74
     
  5. Tran DS, Odermatt P, Le Oanh T, Huc P, Phoumindr N, Ito A, Druet-Cabanac M, Preux PM, Strobel M. Risk factors for epilepsy in rural Lao PDR: a case-control study. Southeast Asian J Trop Med Public Health. 2007 May;38(3):537-42. PubMed PMID: 17877231
     
  6. Tran DS, Odermatt P, Singphuoangphet S, Druet-Cabanac M, Preux PM, Strobel M, Barennes H. Epilepsy in Laos: knowledge, attitudes, and practices in the community. Epilepsy Behav. 2007 Jun;10(4):565-70. Epub 2007 Apr 18. PubMed PMID: 17446140
     
  7. Harimanana A, Chivorakoun P, Souvong V, Preux PM, Barennes H. Is insufficient knowledge of epilepsy the reason for low levels of health care in the Lao PDR? BMC Health Serv Res. 2013
     
  8. Harimanana A, Clavel S, Chivorakoun P, Perez F, Preux PM, Barennes H. Associated factors with adherence to antiepileptic drug in the capital city of Lao PDR. Epilepsy Res. 2012 Nov 22
     
  9. Chivorakoun P, Harimanana A, Clavel S, Jousseaume S, Barennes H. Epilepsy in Lao popular democratic republic: difficult procurement of a first-line antiepileptic contributes to widening the treatment gap. Rev Neurol (Paris). 2012;168(3):221-9
     
  10. Barennes H, Sengkhamyong K, Sambany EM, Koffi PN, Chivorakoun P, Empis G, Clavel S, Somphavong S, Wangkou N, Rajaonarivo C, Harimanana A. Children's access to treatment for epilepsy: experience from the Lao People's Democratic Republic.  Arch Dis Child. 2011 Mar;96(3):309-13. doi: 10.1136/adc.2009.181255. Epub 2010 Aug 31

Research

Tools

Multimedia

Reports

Associates

Pierre-Marie Preux
Phetvongsinh Chivorakoun
Farid Boumediene

Comments

Submitted by Devender Bhalla on Wednesday, 8th July 2015
This project and all of these associated novel concepts were devised, developed, and submitted by Dr. Devender Bhalla (France) for funding from Grand Challenges Canada and not by those listed here.

Submitted by Shamaila Usmani on Tuesday, 18th August 2015
Thank you for your comment Dr. Bhalla. Will you kindly email us at mhin@lshtm.ac.uk so we can investigate this further?
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