Rapid Monitoring of Treatment Coverage: The Supervisor's Coverage Tool

Rapid Monitoring of Treatment Coverage: The Supervisor's Coverage Tool
Training material Dept. of Control of Neglected Tropical Diseases

Outline of Training Sessions
Background 9 Steps of the SCT Country Experiences Discussion of ‘best implementation practices’

Supervisor's Coverage Tool (SCT)
Coverage Surveys Coverage Surveys Coverage Evaluations District-level, statistically rigorous, Implemented periodically Coverage Monitoring Supervisor's Coverage Tool (SCT) Feedback from Program Managers: Coverage Surveys are time consuming and expensive → can’t be done everywhere all the time Coverage surveys are too late to improve current round MDA Teams found simplicity of LQAS appealing Supervisors complained of having no tools for supervision Coverage evaluation surveys are an incredibly useful tool for NTD programs – not only can they be used to validate the reported coverage but they are crucial to confirming that the MDA achieved effective coverage and for identifying challenges related to the distribution and compliance that need to be overcome to improve MDA. However in our experience working with WHO to implement these coverage evaluations we received feedback from NTD program managers that: Coverage evaluation surveys take a while to plan and complete and thus by the time the results are available it is too late to fix the current MDA; can only be used to improve future rounds Coverage evaluation surveys are too expensive to be conducted with great frequency There is a lack of tools to supervise the MDA, particularly at the sub-district and CDD level There is a clear need for a tool that can bridge the gap between no monitoring or evaluation of program coverage (which, as the presentations demonstrated this morning, can present a threat to program success) and coverage evaluation surveys. In other words, we might think of coverage evaluations as the Range Rover of coverage surveys – they are powerful, well-designed and well-made, and in many instances only a range rover can get you to where you need to be. However sometimes you don’t need a range rover and a bicycle will be sufficient for getting the job done. By this I’m referring to coverage monitoring which is meant to be something that is simple, inexpensive and rapid and can be implemented on a routine basis. Simple, inexpensive, & rapid for routine use

Supervisor's Coverage Tool
Quick, simple, inexpensive tool for monitoring and supervising MDA; implemented by first-level supervisors Objective Primary Uses Classifying coverage as likely above/below the threshold Supervising CDDs and sub-district planners/organizers Detecting issues with compliance and the drug distribution Identifying sub-districts in need of mop-up activities The Coverage Supervision Tool was developed with the primary objective that it be a quick, simple and inexpensive tool for monitoring and supervising MDA, which district-level supervisors could implement.

Supervisor's Coverage Tool
Conducted by first-level or sub-district level supervisors Who? When? < 2 weeks of the MDA round (to allow time for immediate action and mop-up if necessary) Where? Targeted supervision areas (sub-district or smaller) How? LQAS; interviewing 20 people selected randomly from within the Supervision Area The SCT will ultimately be generalized to function in urban settings, but for simplicity at the start we recommend restricting to rural areas. The majority of this presentation will focus on HOW to select the 20 different villages and from within each village HOW to select the 20 individuals to interview

As a monitoring and supervisory tool the SCT can be used to ensure: Villages/communities are not missed And to conduct mop-up activities when necessary Identify problems with the supply and drug distribution systems And to strengthen these systems to improve performance of the next MDA round Individual compliance is high And where it isn’t, to identify and address reasons for the non-compliance CDDs are accurately recording their work And when they aren’t to identify and address the reasons for the discrepancy

SCT – Quick Overview Inadequate Borderline Good Action Plan

How is SCT unique from other monitoring tools?
Rapid Coverage Monitoring In-Process Monitoring Sampling Random Purposive Team Internal ? External

Overview: Step 1: Identify population to survey Step 2: Identify supervisory areas (SA) Step 3: Obtain a list of all households using a) registers or b) household enumeration Step 4: Randomly select 20 households Step 5: Selection of Individuals Step 6: Interview Individuals Step 7: Interpretation of Results Step 8: Develop an Action Plan Step 9: Implement the Action Plan Emphasize that the list of villages should be mutually exclusive and exhaustive (that is every HH in the sub-district should fall into one and only one village). For this reason census enumeration areas are preferred if available.

SCT: Planning Checklist: Questionnaire (at least 1 per SA per team)
Random number table (ideally laminated) Coin (for random selection) Chalk Examples of the medication (and any additional visual aids – e.g., dose pole) SCT Quick Guide Clipboard (1 per team) Household enumeration sheets Notebook for scrap paper Pencils Action Plan handout (at least 1 per SA) Emphasize that the list of villages should be mutually exclusive and exhaustive (that is every HH in the sub-district should fall into one and only one village). For this reason census enumeration areas are preferred if available.

SCT: Planning Team Composition SCT is an internal monitoring tool
Designed for district and sub-district supervisor implementation Team composition: SCT Implementer and >1 Enumerator Emphasize that the list of villages should be mutually exclusive and exhaustive (that is every HH in the sub-district should fall into one and only one village). For this reason census enumeration areas are preferred if available.

SCT: Planning Cost: $0-$1,000 per supervisory area*
*depends on how well-integrated SCT is with the program’s existing supervisory activities and the cost of training Days: ½ - 1 day per SA Emphasize that the list of villages should be mutually exclusive and exhaustive (that is every HH in the sub-district should fall into one and only one village). For this reason census enumeration areas are preferred if available.

SCT: Planning Mop-up Review reported coverage and identify low coverage or challenging areas from previous round to conduct SCT Pre-MDA Planning Data aggregation and reporting Conduct mop-up, if indicated by the SCT MDA Implement SCT towards the end of, or immediately following, MDA Emphasize that the list of villages should be mutually exclusive and exhaustive (that is every HH in the sub-district should fall into one and only one village). For this reason census enumeration areas are preferred if available.

Identify the Survey Population
STEP 1: Identify the Survey Population

Step 1: Identify the Survey Population
Survey Population = The population for which an estimate of preventive chemotherapy coverage is desired Disease Survey Population Lymphatic filariasis Everybody living in the survey area Onchocerciasis Schistosomiasis May vary, based on national treatment priorities and could include: School age children(5-14 years) High risk adults Soil-transmitted helminthiasis (STH) Preschool age children (1-4 years) School age children (5-14 years) Women of child-bearing age Everybody living in the survey area at the time of MDA (for LF) Trachoma Note that when the coverage population for a coverage survey is used this is typically referred to as “Therapeutic” or “Drug” Coverage.

Is it possible to use the SCT to monitor >1 drug package? YES, however this is only possible when the drug packages are being distributed at the same time through an integrated MDA. In such instances it will be necessary to clearly define the survey populations for each drug package. - e.g., DEC and ALB - everybody PZQ - children 5-14 years Note that when the coverage population for a coverage survey is used this is typically referred to as “Therapeutic” or “Drug” Coverage.

Complete Exercise 1 (in the accompanying Participant’s Guide) What are the diseases targeted? How are drugs distributed (school vs. community)? What are drugs? What are age groups targeted? 17

Identify the Supervision Area(s)
STEP 2: Identify the Supervision Area(s)

Step 2: Identify Supervision Areas
Supervision Area (SA) = corresponds to the smallest administrative or geographic unit for which a first-level supervisor is responsible. This typically the catchment area of someone who supervises the community drug distributors.

District SA1 SA2 SA3 SA4 SA5 SA6 SA7 SA8 SA9 SA11 SA10 Each SA represents the catchment area of a supervisor

How to determine which SA(s) to pick for the Supervisor's Coverage Tool? You suspect MDA coverage was poor Recent migration or expansion make denominator estimates uncertain You want to supervise the work of the drug distributors or their direct supervisors Random selection

How to Use a Random Number Table
For the SCT a random number table may be needed for the following Steps: Step 2. Identify the supervision area Step 4. Randomly select 20 households Step 5. Select one person to interview Print a copy of the random number table (shared with this presentation) for each participant. Ideally this should be a laminated copy so that they can use it in the field.

Random Number Table Instructions: Make sure each item (e.g. , supervision area/household/segment) in your list is assigned a number. Determine how many digits are needed in your random number. The total number of digits will be equal to the maximum number items from which you are selecting. For example if the district has 127 supervision areas then the random number will need to have 3 digits (1-2-7). Close your eyes and use a pointed object, such as a pen or pencil, to touch the random numbers in the table. Your starting point is the number closest to where you touched the random number table. Print a copy of the random number table (shared with this presentation) for each participant. Ideally this should be a laminated copy so that they can use it in the field.

Random Number Table Instructions Continued: Read the number of the digits required from left to right, starting with the number that is closest to the tip of your pen. Numbers that are larger than the total number of items (e.g., supervision areas/households/segments) will be discarded and the process should be repeated until you get a number that is less than or equal to the total number. If, in selecting a random number from the table, the end of the row is reached before the desired number of digits is obtained, the selection of remaining digits should continue with the beginning of the next row.

How to Use A Random Number Table
Example: Suppose there are a total of 72 SAs listed in the district, therefore you need to pick a random number between 1 –72. Because the total number has 2 digits (7 – 2) you will need to read 2 digits from the random number table. Close your eyes and touch the random number table with the tip of a pen and read the number that is closest. Suppose your pen lands on the number “8” and the next number to the right of it is “1”. This means your selected number is 81. Because the number 81 is > 72, you must continue reading the table to the right. The next number is 19. Since 19<72, this number is valid and means that the 19th SA is selected.

How to Use A Random Number Table
Complete Exercises 2a & 2b (in the accompanying Participant’s Guide)

STEP 3: Obtain a list of all households using a) registers or b) household enumeration

Step 3: Obtain a list of all households using a) registers or b) household enumeration
Keep in Mind: Only 20 people selected per survey population per SA Want everyone in the survey population to have a similar chance of being chosen Selection needs to be random

Does an accurate SA register(s) exist?
Step 3: Obtain a list of all households using a) registers or b) household enumeration Does an accurate SA register(s) exist?

Step 3: Obtain a list of all households using a) registers or b) household enumeration Does an accurate SA register(s) exist? How do I know if the register/census accurate? Is the register routinely updated? Are migrant or foreign-born populations that currently live in the village included in the register? Does the register cover the entire SA? Was register completed independently of a health campaign? The concern with registers that are completed as part of the health campaign (e.g. MDA) is that, if people living on the outskirts of town are excluded from the MDA campaigns then they will not be included on the register. If these people are not on the register then they do not have a chance of being included in the SCT if registers are used. This creates a very big and important bias: people who are less likely to receive the medicine are also less likely to be included in the SCT. As a result the SCT results will be biased in favor of coverage that is too high. If the answers to all of these questions are “Yes” then the register may be accurate

Step 3: Obtain a list of all households using a) registers or b) household enumeration Does an accurate SA register(s) exist? Should we use registers? Pros of using a register/census: Can result in large time saving Simple to select one HH Cons of using a register/census: If register/census is inaccurate the survey results could be biased Ultimately, the decision to use an existing register/census is up to the supervisor conducting the SCT but should be consistent throughout the SA

Step 3: Obtain a list of all households using a) registers or b) household enumeration Does an accurate SA register(s) exist? No Yes Scenario A) Registers Obtain all registers in the SA Assign a sequential number to each HH in the register

Step 3: Obtain a list of all households using a) registers

Upon arriving in an SA, request to see the village register/census Check if each household in the register is assigned a sequential number If households are not numbered, the SCT team should number each household in the register with pencil If multiple registers are required to cover everyone in the SA, the households should be numbered sequentially across the registers, with no skipped numbers and no repeats

HHs: #1 - #152 HHs: #153 - #383 HHs: #384 - #471 152 HHs 88 HHs 231 HHs The SA has a total of 471 households If multiple registers are required to cover everyone in the SA, the households should be numbered sequentially across the registers, with no skipped numbers and no repeats

Complete Exercises 3a (in the accompanying Participant’s Guide)

Scenario B) HH Enumeration
Step 3: Obtain a list of all households using a) registers or b) household enumeration Does an accurate SA register(s) exist? No Yes No Scenario A) Registers Obtain all registers in the SA Assign a number to each HH in the register Scenario B) HH Enumeration Enumerate all households in the SA

Scenario B) HH Enumeration
Does an accurate supervisory area (SA) register(s) exist? Is the register(s) routinely updated to include new households? Does the register(s) cover the entire SA? Are migrant or foreign-born populations that currently live in the village included in the register? Was register completed independently of the MDA*? Yes, to all No, to one or more Scenario A) Registers Obtain all registers in the SA Assign a number to each HH in the register Scenario B) HH Enumeration Enumerate all households in the SA

A Rapid Household Census Approach Each member of the survey team should pair up with a local volunteer Divide the village into sections so that each pair is assigned one section of the village Assign each pair a letter code (e.g. “A”, “B”) Each pair numbers ALL the households in their section using chalk to write the household code on each door (e.g. ‘A-1”, “A-2”, “A-3”, …”A61”,”A62”) After each team has numbered all houses in their section, the lists are combined to determine the TOTAL number of houses in the village. Be sure to tie this step into the segments we defined in Step 3. For example, if we divided village A into 3 segments for the purposes of selecting a village (i.e., we put 3 slips of paper in the hat for Village A) then when you get to village A you already know that 3 segments are needed. In fact, it is important that the team ALWAYS divides the village into the same number of segments as were identified in Step 3. There may be the tendency, upon arrival in the village, to decide that it is larger than you expected and want to divide it into more segments, but doing so would affect the sampling probability and could lead to bias. It is helpful to explain why we segment. If we did not use segmentation the method for selection would be to first enumerate ALL households in the village and then to randomly select one (using a random number table). For medium to large villages this could be incredibly time-consuming. Segmentation is employed to save time while maintaining random sampling. By segmenting it is only necessary to count 50 households. It is good to emphasize that natural lines of division are used so that it is very clear into which segment a household falls. Each household in the village should fall clearly within one and only one segment.

Example ⌂ SECTION 2 SECTION 1 SECTION 3 Road 3 market Road 1 Road 2
School Road 4 SECTION 2 SECTION 1 SECTION 3

Example Continued… Assign a code to each household in the segment and write this code on house with chalk (if acceptable): “Team code” + Number Example B -1 B-2 B-3 B-4 . B78

Example Continued… Combine each team’s list A-1 A-47 B-74 C-63 A-2
HH Code HH Count Picked? A-1 A-47 B-74 C-63 A-2 A-48 B-75 C-64 A-3 A-49 B-76 C-65 A-4 A-50 B-77 C-66 A-5 A-51 B-78 C-67 A-6 A-52 C-1 C-68 A-7 B-1 C-2 C-69 A-8 B-2 C-3 C-70 A-9 B-3 C-4 C-71 A-10 B-4 C-5 A-11 B-5 C-6 A-12 B-6 C-7 A-13 B-7 C-8 A-14 B-8 C-9 A-15 B-9 C-10 Rather than combine onto one page, each team can fill out the first column on their own sheet in the field and then the sheets can be combined (stabled? Clipped?) and the HH count column added

Example Continued… Fill in the cumulative household count A-1 1 A-47
HH Code HH Count Picked? A-1 1 A-47 47 B-74 126 C-63 193 A-2 2 A-48 48 B-75 127 C-64 194 A-3 3 A-49 49 B-76 128 C-65 195 A-4 4 A-50 50 B-77 129 C-66 196 A-5 5 A-51 51 B-78 130 C-67 197 A-6 6 A-52 52 C-1 131 C-68 198 A-7 7 B-1 53 C-2 132 C-69 199 A-8 8 B-2 54 C-3 133 C-70 200 A-9 9 B-3 55 C-4 134 C-71 201 A-10 10 B-4 56 C-5 135 A-11 11 B-5 57 C-6 136 A-12 12 B-6 58 C-7 137 A-13 13 B-7 59 C-8 138 A-14 14 B-8 60 C-9 139 A-15 15 B-9 61 C-10 140 Rather than combine onto one page, each team can fill out the first column on their own sheet in the field and then the sheets can be combined (stabled? Clipped?) and the HH count column added

Household Enumeration Sheet

Large Supervision Areas When the selected SA is large (e.g., >5,000 people) and there is no accurate village register(s), enumerating all households in the SA can become time-consuming and difficult. Instead the SCT implementer may choose to conduct the SCT in one or more subunits within the SA. But, as a result, the coverage classification resulting from the SCT will no longer be representative of the entire SA. For more information on this refer to Annex G of the SCT Guidelines. It is important to stress the advantages and disadvantages of this approach. While conducting the SCT in a smaller subunit within the SA may lead to time and cost savings, it is important to recognize the drawbacks associated with this approach. Firstly, when the SCT is conducted in just a subunit, the resulting coverage classification will only be representative of that subunit and not the SA as a whole. Secondly, if the subunit is chosen randomly (as in the examples above) then people living in subunits with smaller populations will have a greater likelihood of being selected compared to the other subunits. Because of these concerns, it is recommended that this subunit approach only be used in extreme cases where implementing the SCT by the standard approach of enumerating all households is not possible.

(in the accompanying Participant’s Guide)
Step 3: Obtain a list of all households using a) registers or b) household enumeration Complete Exercises 3b (in the accompanying Participant’s Guide)

Randomly select 20 households
STEP 4: Randomly select 20 households

Step 4: Randomly Select 20 Households
Pick 20 unique random numbers between: 1 – total #of households in the SA The selected numbers correspond to the nth households in the register or on the cumulative list from the rapid enumeration If the register contains lists of individuals it will be possible to select one person directly from the register (which we will explain in a subsequent slide) Note: if the SA spans multiple villages it is necessary to enumerate all households in the entire SA first and then select the 20 random numbers once the total number of households is known A brief pause to practice using a Random Number Table

Step 4: Randomly Select 20 Households
Once the 20 households have been selected, the team should have a local guide take them to each of the selected households. If there are multiple teams, the 20 households can be divided between the team members. If the register contains lists of individuals it will be possible to select one person directly from the register (which we will explain in a subsequent slide) A brief pause to practice using a Random Number Table

Example using rapid SA enumeration
Randomly select the required # of households HH Code HH Count Picked? A-1 1 A-47 47 B-74 126 C-63 193 A-2 2 A-48 48 B-75 127 C-64 194 A-3 3 X A-49 49 B-76 128 X C-65 195 A-4 4 A-50 50 B-77 129 C-66 196 A-5 5 A-51 51 B-78 130 C-67 197 A-6 6 A-52 52 C-1 131 C-68 198 A-7 7 B-1 53 C-2 132 C-69 199 A-8 8 B-2 54 C-3 133 C-70 200 A-9 9 B-3 55 C-4 134 C-71 201 A-10 10 B-4 56 C-5 135 A-11 11 B-5 57 C-6 136 A-12 12 B-6 58 C-7 137 A-13 13 B-7 59 C-8 138 A-14 14 B-8 60 C-9 139 A-15 15 B-9 61 C-10 140

Alternative approach to household enumeration:
While the process of household enumeration and random selection described in Steps 3 and 4 is considered the best practice, in some settings this approach may not be programmatically feasible. In such settings, it is acceptable to use a modified ‘random walk’ approach, as was traditionally used by the Expanded Programme for Immunizations (EPI), to select the 20 random households for inclusion.

Alternative approach to household enumeration:
Modified Random Walk Find the center of town and spin a bottle Walk in the direction that the bottle is pointing and count every house in your path to the edge of town Pick a random number between 1 and the total number of households in step #2; this number will represent your starting house Select one person randomly from this starting household to interview for the SCT Proceed to the nearest neighbor household and select one person to interview for the SCT Continue using this nearest neighbor approach until 20 people from 20 different household have been interviewed

(in the accompanying Participant’s Guide)
Alternative approach to household enumeration: the modified random walk Complete Exercises 4 (in the accompanying Participant’s Guide)

Selection of individuals
STEP 5: Selection of individuals

Step 5: Selection of Individuals
Upon arrival at the selected household : Introduce team and explain the purpose of visit List all the individuals living in the household who are part of the survey population (regardless of whether they are present at the time of the visit) Randomly pick one of these individuals to interview by drawing slips of paper from a hat or using a random number table

Survey Population F 11yrs M 8yrs F 7yrs M 33yrs F 30yrs F 16yrs F 11yrs M 8yrs F 7yrs Suppose your survey population is children 5 – 14 years old

Integrated SCT Go to the selected HH, list all members in survey population #1 (e.g., all ages), and pick ONE person randomly to interview Next list all people in survey population #2 (5-14 yrs) and pick ONE to interview Survey Pop. #1(everyone ) Survey Pop. #2 (5-14) Martin – 65 Josefa – 64 Juana – 29 Maria-13 Louis-12 Abdel-8 Maria-13 Louis-12 Abdel-8 A-3

What if there is nobody in Survey Population (5-14 years)? M 33yrs F 30yrs F 16yrs Proceed to next house in the village/register until you find a household that has >1 child 5-14 years

If the selected individual is not present…
Will they return later the same day? Return later in the day to interview the person Can they be reached locally or via cell phone? Can someone else in the HH respond on their behalf? Interview the person locally or via cell phone Allow the HH member to provide a proxy response Advance to the next numbered HH as replacement Yes No

HH Code HH Count Picked? A-1 1 A-47 47 B-74 126 C-63 193 A-2 2 A-48 48 B-75 127 C-64 194 A-3 3 X A-49 49 B-76 128 X C-65 195 A-4 4 A-50 50 B-77 129 C-66 196 A-5 5 A-51 51 B-78 130 C-67 197 A-6 6 A-52 52 C-1 131 C-68 198 A-7 7 B-1 53 C-2 132 C-69 199 A-8 8 B-2 54 C-3 133 C-70 200 A-9 9 B-3 55 C-4 134 C-71 201 A-10 10 B-4 56 C-5 135 A-11 11 B-5 57 C-6 136 A-12 12 B-6 58 C-7 137 A-13 13 B-7 59 C-8 138 A-14 14 B-8 60 x C-9 139 A-15 15 B-9 61 C-10 140

Complete Exercises 4 & 5 (in the accompanying Participant’s Guide)

Interview the selected individuals
STEP 6: Interview the selected individuals

Step 6: Interview Individual
Use the data collection form to interview the selected individual(s) to determine whether or not they were offered and if so, swallowed the drug(s) It is important to bring samples of the drug(s) to show the interviewee and help aid with recall 63

Discuss each question. Particularly the difference between offered and swallowed.

Step 6: Interview Individual
Complete Exercise 6 (in the accompanying Participant’s Guide)

Step 7: Interpret the results

Step 7: Interpretation of Results
Survey populations for which coverage thresholds are set Coverage thresholds specified by WHO The numbers in the columns correspond to the number of people (out of the 20 interviewed) answering “yes” to the coverage question SCT Decision Rule Table Disease Survey Population Threshold for coverage Decision Rules: Based on the number covered out of 20 people sampled Good Coverage* Cannot Conclude Coverage was Good Inadequate Coverage* Lymphatic Filariasis Everybody 65% >=16 11-15 <=10 Onchocerciasis STH / Schistosomiasis SAC (5-14yrs) 75% >=18 13-17 <=12 Trachoma 80% >=19 14-18 <=13 This is the decision rule table for the Supervisor's Coverage tool. Spend time describing each column in the table. It is helpful if each participant is given a laminated page with this table on one side and the interpretation (next slide) on the other side. “Good” Coverage = it is very likely (~9 times out of 10) that the coverage in the SA is above the threshold “Inadequate” Coverage = it is very unlikely (~9 times out of 10) that coverage in the SA is below the threshold “Cannot conclude coverage was good” = when the number covered falls within this range we can not conclude if coverage is above or below the threshold but rather consistent with the threshold (i.e., likely close to the threshold) Walk through a couple of examples such as: if I am conducting a coverage survey for LF using the entire population as the target and find 17 people took the drug, what is the conclusion? What if I find 10 people took the drug? and 13 people? For a more clear interpretation of good/inadequate/consistent with threshold, see the following slide. *Based on alpha = 0.1

Cannot conclude coverage was good
(> the threshold) Cannot conclude coverage was good Inadequate (< the threshold) Coverage Conclusion: Suggested Next Steps: Interpretation: It is very likely that the true coverage in the SA is at or above the target threshold. Not enough information to conclude with statistical confidence if coverage was above or below threshold. It is very likely that the true coverage in the SA is below the target threshold. Do these results agree with the reported coverage (e.g., is the reported coverage also above the threshold)? If not, try to identify reasons for the discrepancy. Share these positive findings with those involved in the MDA. If persons were identified who should have swallowed the drugs but did not, review the reasons why and take whatever steps are indicated to raise coverage even higher than it already is. Try to understand reasons why coverage may have been poor by looking at the “no” responses from the SCT. Investigate why coverage may have been poor by looking at the “no” responses from the SCT (e.g., was it insufficient supply? poor compliance? drug distributor performance? insufficient social mobilization?). Does the reported coverage show that coverage is above the target threshold? If so, it is important to identify reasons for the discrepancy; consider conducting a data quality self-assessment. Is a mop-up campaign needed? Spend some time reading through the interpretations on this guide. See if the group can come up with additional next steps that they would take

This number is compared with the decision rule table
Once the interviewer has completed his or her data collection form he/she should tally the results and enter the total at the bottom of the form (as depicted). The number of “yes” responses is what is compared with the decision rule table to classify coverage. It is important to remember that the WHO target thresholds are based on the number of people who swallowed the drug, so the second question is the most relevant. The number swallowed should also correspond with the administrative coverage (generally speaking). Have the group discuss how they would interpret these results using the decision rule table. This number is compared with the decision rule table Note that the target thresholds are based on the % who swallowed MDA; this is the number that should correspond with the reported coverage

Exercise 8 Discuss the following scenarios as a group. Determine the appropriate interpretation, according to the decision rule table, and follow-up recommended Scenario 1: You are using the SCT to classify coverage for lymphatic filariasis, interpret the following results: Number who were offered the drug: 17 Number who swallowed the drug: Reported coverage for the implementation unit: 88% In this example the SCT results suggest that coverage is above the target threshold (65%), which agrees with the administrative coverage. Furthermore there does not appear to be an issue with non-compliance because everyone who was offered the drug swallowed it.

Scenario 2: You are using the SCT to classify coverage for soil-transmitted helminthiases. Interpret the following results: Number who were offered the drug: 19 Number who swallowed the drug: 16 Reported coverage for the implementation unit: 70% In this example the SCT results suggest that the drug distribution system is working well (many people offered the drug) but there appears to be a problem with compliance (3 people didn’t swallow the drug). Based on only 16 people swallowing the drug you cannot conclude that coverage is above the threshold, the reported coverage results support this. It should be recommended that follow-up activities take place to determine why coverage could be low

Scenario 3: You are using the SCT to classify coverage for schistosomiasis. Interpret the following results: Number who were offered the drug: 11 Number who swallowed the drug: Reported coverage for the implementation unit: 90% In this example based on the SCT results coverage in the SA is classified as inadequate (likely to be below the target threshold). Another problem is that the reported coverage does not reflect this, but rather suggests that coverage was high. This should be a warning bell triggering follow-up action. Discuss with the team what steps they might take immediately (i.e., should anything be done to reach those who weren’t covered – perhaps several schools were missed entirely) and what can be done to identify the problems with the reporting system.

Scenario 4: You are using the SCT to classify coverage for trachoma. Interpret the following results: Number who were offered the drug: 16 Number who swallowed the drug: Reported coverage for the implementation unit: 98% In this example the SCT results suggest that the coverage cannot be classified as good; however the reported coverage results suggest that it is much higher. Discuss how to investigate the discrepancy. This may be a good time to bring up that, though we would ideally like to see coverage results that fall in the “good coverage” zone all the time, just because they fall in the “cannot conclude coverage is good” doesn’t mean that the coverage is necessarily below the threshold, but it is better to error on the side that coverage could be bad and to take steps to improve coverage, rather than assuming it is good and taking no follow-up actions. Because the sample size is so small, we have very low power for correctly identifying when coverage is above the threshold (unless coverage is VERY high). Similarly we have low power for identifying when coverage is below the threshold, unless it is VERY low. Will discuss more on future slide.

Step 8: Develop an Action Plan

Step 8: Develop an Action Plan
Helps the district and provincial-level supervisors come up with an actionable plan to improve MDA performance. Action Plan must be developed immediately following the SCT to allow time for mop-up activities if necessary. Treatment mop-up is indicated in any SA classified as having ‘inadequate’ coverage District supervisor may choose to limit the mop-up to only those SA(s) where coverage was classified as ‘inadequate’ or he/she may choose to extend the mop-up activities to other parts of the district.

Once the survey results are tallied it is important to complete the SCT Action Plan document to help interpret the results and identify the next steps that need to be taken to improve the program. Examples of follow-up actions may include: Improve community sensitization prior to next round to ensure that more people are home Dispel myths about potential side effects Conduct mop-up campaign Retrain CDDs

Potential Actions Conduct treatment mop-up Provide refresher trainings to drug distributors and/or first-level supervisors Improve community registers Increase social mobilization efforts or try new strategy Adapt information/education materials before next round to target common reasons for non-compliance Congratulate and/or publicly acknowledge drug distributors and first-level supervisors doing well

Complete Exercise 7 (in the accompanying Participant’s Guide)

Implement the Action Plan
Step 9: Implement the Action Plan

Step 9: Implement the Action Plan
Some actions, like treatment mop-up, will require immediate mobilization to implement Improved coverage  effective MDA Other actions may take place during period between MDA rounds or immediately proceeding next MDA Up to national program how completed Action Plans are shared

Country Experiences

REVIEW

Summary of SCT Steps Step 1: Identify population to survey
Step 2: Identify supervisory areas (SA) Step 3: Obtain a list of all households using a) registers or b) household enumeration Step 4: Randomly select 20 households Step 5: Selection of Individuals Step 6: Interview Individuals Step 7: Interpretation of Results Step 8: Develop an Action Plan Step 9: Implement the Action Plan

Limitations of the SCT The SCT cannot be used to generate an estimate of coverage, but rather can only be used to classify coverage as likely good/poor The SCT is not an equal probability sample The SCT has poor power, meaning it will often classify SAs with coverage that is truly above or below the threshold as being “consistent with the threshold.”

Benefits of the SCT Inexpensive and can be easily implemented by sub-district supervisors Can be adapted for any of the PC NTDs, including integrated Internal self-assessment, not external audit Timing of tool provides opportunity for mop-up Can identify gaps in social mobilization or drug distribution Feedback we received was that by just telling drug distributors that you may supervise their supervision area they are likely to do a better job

THANK YOU

Review Quiz What is the name of the tool we have discussed today?
How soon after MDA should you implement the tool? What is a supervision area and how do you choose one? How many people are sampled per survey population in one supervision area? How do you determine if it is appropriate to use village registers to select the households? If an accurate register exists, how do we determine the maximum range for our random number? This should be a relaxed quiz with people raising their hands or shouting out answers. The trainer may want to have little candies or prizes to increase participation.

Review Quiz If there are 377 households in the register how many digits should our random number have? Should we include people who are ineligible for MDA in an LF SCT? What happens if the selected household is empty? What if the person selected is not present? What is meant by “target threshold”? What do you do after you have collected data on all 20 individuals?

Review Quiz Why do we ask if the drug was offered and if it was swallowed as separate questions? If 16 people swallowed the drugs for LF how should we classify coverage? What should you do if the reported coverage is 95% but using the SCT you find only 13 people who report having swallowed the drug? What actions might you take if the number of people who swallowed the drug is classified as “inadequate”? What is the last step of the SCT?

Rapid Monitoring of Treatment Coverage: The Supervisor's Coverage Tool

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Rapid Monitoring of Treatment Coverage: The Supervisor's Coverage Tool

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Presentation on theme: "Rapid Monitoring of Treatment Coverage: The Supervisor's Coverage Tool"— Presentation transcript:

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