Case Study Title: Evaluation of the impact of morbidity and disability prevention control interventions due to lymphatic filariasis Country: Madagascar Specific theme: Health / disabling diseases / disability prevention Presented by: Roby, Project Manager and Holivololona Rabenantoandro Impact evaluation seminar, 2nd - 6th December, Phnom Penh

Context and Project Description For which type of project has this study been implemented? Project providing community-based care management for patients presenting sequelae resulting from lymphatic filariasis in three districts of the Atsinanana region in Madagascar Strategic dual approach:  Medical approach based on the health pyramid and structures  Community-based approach using networks of community workers Why this study / (project context) This evaluation, using a tried and tested WHO survey method, will make it possible to refocus the chosen strategies and approaches as required, but also to feed into and enrich lymphatic filariasis control strategies at national, regional and global level (publication of articles). Impact evaluation seminar, 2nd - 6th December, Phnom Penh

Study Description Objectives of the study: - Evaluate the impact of the washing technique and of surgery on people's functional, socio-economic, and psychosocial capacities - Evaluate the impact of awareness-raising actions on perceptions of the disease and on patients' community and social participation. Description Exploratory prospective cohort study in 3 districts of the Atsinanana region (89 villages), carried out over a 24-month period with a questionnaire administered three times Sample: n= 274 (L=82, H=192) Questionnaire based on the WHODAS II questionnaire adopted by the WHO Comparison of the results at different stages of the study. (Before and after comparison) using statistical analysis Impact evaluation seminar, 2nd - 6th December, Phnom Penh

Main results between survey 1 and 3 (2 years): How would you assess your general state of health over the last 30 days? Demonstrated impact of the study Impact evaluation seminar, 2nd - 6th December, Phnom Penh

Acute episodes of lymphedema in the last 30 days? Demonstrated impact of the study Impact evaluation seminar, 2nd - 6th December, Phnom Penh

Lymphedema-related improvements to daily life in the last 6 months? Demonstrated impact of the study Impact evaluation seminar, 2nd - 6th December, Phnom Penh Lymphedema Survey 1Survey 3 Q3.1 Improvement in daily lifePopulationCol %PopulationCol % Has improved2534,24358,9 Has not changed3041,12737,0 Has become worse1824,734,1 Total Pearson chi2(2) = Pr = 0.000

Other statistically significant results (p<0.05) between survey 1 and survey 3 ( ): Health and functional / economic capacities: Reduced pain (lymphedema patients) Improved functional capacities (standing, walking long distances) for both diseases Improved functional capacities (washing, housework) for patients with lymphedema Improved capacity to work for a living / at school for both diseases Demonstrated impact of the study Impact evaluation seminar, 2nd - 6th December, Phnom Penh

Other statistically significant results (p<0.05) between survey 1 and survey 3 ( ): Social participation and self esteem Improvement in relationships with friends and family, as well as people from outside of the family, for patients with hydrocele Improvement in sexual activity for patients with hydrocele Increased feeling of being the same as other people and a notable drop in feelings of shame. Improvement in family perceptions of people with hydrocele (lymphedema, p=0.14) Demonstrated impact of the study Impact evaluation seminar, 2nd - 6th December, Phnom Penh

Facilitating Factors Factors facilitating implementation Participative study preparation (PNEFL, DRSP, HI NAT, RT) Study protocol defined and approved by the Ministry of Health ethics committee (including methodology, study design etc.) HI and PNEFL co- investigation Availability of the WHODAS questionnaire to draw up the field survey and ensure the recognition of the study results (publications) Good methodological preparation (training of interviewers, testing of the questionnaire etc.) Statistical analysis of the data collected. High levels of commitment from community workers to mobilise patients, even in the middle of the growing season Impact evaluation seminar, 2nd - 6th December, Phnom Penh

The main obstacles/limitations. The study baseline does constitute a genuine baseline for the project as the community-based intervention had already started up High percentage of patients lost to follow up (approximately 15%) Very limited number of lymphedema patients meeting the inclusion criteria (< 4 months of care management and project started) Difficulties in terms of geographical accessibility Patient movements meant interviewers had to travel further The operational team had to devote considerable amounts of time to supervising the interviewers and analysing data 0bstacles

How can this be reproduced? Recommendations for reproducing the study. Study protocol prepared and approved by an ethics committee Involve partners in the study preparation and/or tool development to the greatest possible extent Allocate a substantial budget when conducting a similar study In an ideal world: outsource studies carried out on such a large scale to a reliable consultancy firm to optimise the quality of data collection, supervise the statistical analysis and results analysis Impact evaluation seminar, 2nd - 6th December, Phnom Penh

Study a new project in a new region in order to obtain a genuine baseline before any intervention takes place (map prevalence, first study survey to take place before any intervention) Further study phase planned within the project (9 months) with a larger sample of patients Develop a partnership with a specialised consultancy firm in order to optimise the quality of the study and results analysis and use of new technologies for the surveys (tablets and internet transmission of the data collected) Perspectives: Impact evaluation seminar, 2nd - 6th December, Phnom Penh