Collaborative Course on Infectious Diseases 18 January 2008

1. Socio-Economic Status and Uptake of Visceral Leishmaniasis Prevention Measures in Araçatuba, São Paulo, Brasil Collaborative Course on Infectious Diseases 18 January 2008 Otibho Obianwu, Renata Bortoleto, Amelia Rock

2. Measures for controlling VL: Population/Individual Level • Report the presence of insects • Keep backyards clear of organic material • Use screens in windows (especially at night) • Register and care for dogs (clean & feed) • Report dogs with symptoms • Give up dogs for euthanasia if they are infected (SUCEN, 2006)

3. Taking preventive measures may be an important mediating factor in the relationship between SES and VL incidence in Araçatuba. Uptake of disease control measures SES Incidence of VL

4. Proposal • Conduct a study to describe socio-economic characteristics of Araçatuba and each of its sectors, and test the hypothesis that socio-economic status (SES) is positively correlated with the odds that residents take the measures to prevent human VL included in the VL control public education program of SUCEN.

5. Other possible determinants of taking measures to prevent VL We will also examine the following : • Demographic and social network characteristics • Perceived risk of infection • Knowledge of the disease, its risk factors, and prevention methods • Contact with the VL control public education program • Contact with the healthcare system

6. Ultimate Aims • To provide SUCEN with information that will enable it to tailor public VL education to the needs of particular communities in Araçatuba, and to increase the effectiveness of the VL control program. • To empower communities most greatly affected by VL and to reduce health disparities in Araçatuba.

7. Methods • Population-based household survey • Qualitative research

8. Survey • Demographic, Socio-Economic, and Social Network Characteristics • Personal Data/Moradia • Education • Income/Work • Neighborhood Indicators • Knowledge of Leishmaniasis • Perceived Risk of Infection • Contact with Control Program • Contact with Health Care System

9. Qualitative research/community input • Solicit input of community members in analyzing survey results • Hold meetings, show and explain the results, ask for opinions on the reasons for these findings.

10. Aims of community meetings/qualitative research • Enhance the information provided by survey findings • Engage the community in the research process • Increase community involvement in and awareness of VL control • Align this study with SUCEN’s goals of including active participation of the population in VL control and increasing public sense of responsibility for control and risk of infection, and work toward meeting these goals (SUCEN, 2006) • Serve as a forum in which community members can interact with one another and facilitate community organization to control VL and promote health in other ways.

11. Observations:Community 1 – Jardim Amizade • Near the city center; streets and homes were well-kept, clean; adequately paved roads • Universal knowledge of disease, purpose and need for the canine serological survey, and preventive measures • Sources of information: T.V., flyers, health care agents and professionals

12. Community 1 – Jardim Amizade cont’d • Experienced adequate disease control efforts by the government • Previous experience with C.C.Z. efforts, highly receptive to C.C.Z. team, reported no challenges in taking preventive measures • C.C.Z. team: with only dog cases public less cooperative, with human cases public more receptive and aware; higher SES less cooperative; co-morbidities increases vulnerability to disease

14. Observations:Community 2 – Jardim Umuarama • Eastern periphery, poorly maintained roads, many dogs and fowl, more vegetation (trees, grass) in backyards. • Less well-kempt backyards • Empty lots with overgrown vegetation, other organic matter, garbage, frequently targeted for sandfly capture • Heterogeneity in level of contact with health workers and level of knowledge about leishmaniasis

15. Community 2 – Jardim Umuarama cont’d • Residents believe public primarily responsible for performing disease prevention efforts; some did not understand question regarding those who are most vulnerable; reported no challenges in regard to performing preventive activities • Sources of information: TV, SUCEN worker visits, health workers, children’s school curriculum • SUCEN employee: over 20 years, environment improved but socio-economic conditions still primary challenges to control effort

18. Observations:Community 3 –Jardim Vista Verde • Border of Araçatuba and Birigui; some roads unpaved; larger areas of spaces filled with unkempt vegetation and garbage; usage of spaces for cow grazing and burning garbage; sanitation problems • Heterogeneity in backyard cleanliness, knowledge of disease, population primarily responsible for control efforts; some reported difficulties in performing prevention activities (e.g. working hours)

20. Examples of application of research

21. Potential challenges, logistics of survey administration & qualitative research • Cost • Personnel for survey administration and processing completed surveys • Idea: train C.C.Z. canine survey workers who already know and have a good relationship with community • Safety in some neighborhoods – i.e. the factors currently hindering canine survey in certain areas • People may not have time or interest in coming to community meetings/participating in qualitative research • Solicit the support of community leaders (whom we will identify by talking to people in communities) and active community members (e.g. couple in Community 3 who called the municipality and TV station re sewage problem) • Organize fun event (e.g. with food, music, activities for children), ideally connected to another, already established community event • Space for holding meetings

22. Thank you!!