Introduction and Situation Analysis
Zimbabwe is a landlocked country in Southern Africa measuring 391.000 km2 and with a population of 13 million (source: CIA). The country shares borders with Zambia. The white population is estimated to be around 40,000. The official language is English; however, the majority of the population speak Shona or Ndebele. Just over 50% of the population are in the economic active group of 15-64 years old, while 40% are under the age of 15 years. Life expectancy is 40 years (estimates vary from 37-44 years).
Despite large mineral and agricultural resources, the countrys economy has suffered in recent years from political instability, involvement in the war in the Democratic Republic of Congo, the AIDS pandemic (30% of antenatal clinic attendees had been shown to be HIV positive) and from outside economic pressures of multilateral organisations, such as the World Bank and the International Monetary Fund. Inflation rose from an annual rate of 32% in 1998 to 500% in 1999.
The prevalence of epilepsy in Zimbabwe at the time of the Demonstration Project in 2003 was unknown. In 1970 Levy et al reported a prevalence rate of 7.4/1000 based on a community-based survey of 17 000 rural inhabitants, but more recent studies in other African countries report an average prevalence rates of 15/1000.
The Hwedza District is a rural area that measures 2.560 km2 and has a population of 90,350. At the time of the Demonstration Project the health infrastructure counted one mission hospital, one rural hospital, 4 government rural health centres and 5 district council clinics. There were 2 doctors until 2003, but during that year and in 2004 there were no doctors. There was a well developed primary health care structure with 5-10 state registered nurses, a similar number of certified nurses and 9 Environmental Health Technicians (one at each of the aforementioned hospitals, rural centres and clinics). In 2000, before the project was initiated, there were 489 patient contacts for epilepsy (multiple contacts per patient, but these were not registered by name), and 4 new patients registered that year. Thus a prevalence of 0.45/1.000 and incidence of 4.4/1.000 was indicated. It was likely that a significant treatment gap (of around 90%) existed.
To demonstrate that it is possible to improve the quality of life of people with epilepsy in rural Zimbabwe by:
- Establishing the prevalence of epilepsy and its treatment gap in a rural area.
- Discerning the influence of epilepsy on the quality of life of people with epilepsy in such an area.
- Positively influencing the physical quality of life of these people with epilepsy through a pharmaco-economic intervention (ensuring availability and accessibly of medical care and medications).
- Positively influencing the social quality of life of these people with epilepsy through a psychosocial intervention (a health education campaign for health staff, patients and their families, and the public).
The project consists of three phases:
- Epidemiological survey
- Intervention to improve treatment
- Epidemiological Survey
The questionnaire used for the prevalence survey was based on the survey used in the demonstration project for China. People identified as possibly having epilepsy were evaluated by Primary Health Care Workers at the local clinics and given a confirmatory diagnosis if appropriate. One of the principal investigators randomly reviewed a sample of those found to have epilepsy by the Primary Health Care Worker, as a quality assurance.
A rural community prevalence for epilepsy of 13.3/1,000 was found, which is similar to other African countries. A treatment gap of 93% confirmed clinical impressions. The vast majority of people with epilepsy in the district were not receiving treatment.
- Intervention to Improve Treatment
People found to have epilepsy were asked to fill out a questionnaire about their quality of life. In addition, interviews with people with epilepsy and their caregivers were conducted to correlate with the questionnaire results, and two focus group discussions were held.
Some result details:
- Population of Hwedza: 90,350 persons
- Number of people randomly sampled: 6,274
- Number screened as possibly having epilepsy: 636
- Number screened as positive for epilepsy: 84
- Prevalence: 84/6274 (13.4/1000)
- Attendance before intervention: 83
- Attendance after intervention (2003): 198
- Previous treatment gap: 93.1%
- Treatment gap after intervention: 83.6%
- Increase in persons with epilepsy being treated: 138.5%
- Estimated reduction of persons with epilepsy not treated: 10.2%
Primary healthcare nurses and environmental health technicians attended a one day workshop, which included sessions related to background knowledge, diagnosis, management of epilepsy, psychosocial issues and attitudes.
Subsequently they were involved in public talks both in health centres and villages. The technicians trained village health workers (lay members in the community with an interest in health and health care) and supplied them with literature in the local language. The nurses and the district health education officer gave presentations in schools. In addition, a seminar was held with participation of one teacher from each school in the area, to enable this teacher to act as an epilepsy resource person for the school and for parents. Each of these teachers was asked to organise at least one activity related to epilepsy in the school (i.e. produce a play, speak at a public function, organise a competition, etc.).
- Training primary health care workers to diagnose epilepsy (generalised convulsive seizures) is effective and safe. In quality assurance visits by the principal investigator no patients were found to have been treated inappropriately. Recommendations were made to the National Drug and Therapeutic Committee as well as the Ministry of Health and Child Welfare to adopt a national policy of primary health care worker training to diagnose and treat forms of epilepsy.
- It was proven to be possible to apply training and public education interventions in the most unfavourable environments.
Organizational Context and Management Structure
The project was managed by the Zimbabwe Committee of the Global Campaign Against Epilepsy. Principal investigators were appointed and a sub-committee, including the District Nursing Officer and the District Medical Officer, was set up. An administrative assistant was appointed to implement and convey decisions.
In addition to the projects described above other projects were initiated, which are (more or less) based on protocols that were developed in collaboration with and/or under the aegis of the Campaign, but with no or limited involvement of the Campaign in the execution of the projects.