Terms Of References for the evaluation of Knowlegde, Attitude and Practices (KAP) on Tuberculosis (TB) disease in refugees camp.
I. Background and rational
For the past half century, the military Junta in Burma has continuously denied basic human rights to minorities living in the peripheral states of Burma. This led to a dramatic humanitarian crisis: lack of access to minimum health services and education, reduced livelihoods opportunities and active oppressive measures, such as forced displacement, forced labour, land confiscation, etc. Since 1984, the flow of refugees has fed the 9 Temporary Shelters along the Thailand/Burma border. The situation of refugees in Thailand is one of the most protracted in the world. These refugees have been confined to closed camps since their arrival in the 1980s. Long term confinement has had a negative impact on both physical and psychological health while wearing down coping mechanisms and increasing health risk behaviors.
Maela camp is the biggest camp along the Thai-Burmese Border, accounting for 46,293 refugees. Several socio-economic factors make this particular setting particularly challenging in terms of public health, i.e. (i) high population density in the camp; (ii) limited access to healthcare for cross-border and migrant’s communities; (iii) mobility of population, with an estimate 30% of the adult population working regularly or with a travel history outside the camps; (iv) ongoing new arrivals inside and outside the camp. In this environment, outbreaks, diseases with pandemic potential, endemic diseases and drugs resistance (i.e. MDR-TB), are growing concerns and are recognized as serious and direct health security threat to Thailand and regionally.
TB epidemiology in the region: The Southeast Asian region accounts for 35% of the TB cases, with both Thailand and Myanmar appearing in the list of the 22 countries with the highest TB burden . The national prevalence survey conducted in Myanmar in 2009 even showed that the prevalence of TB was more than triple the estimates used by the National TB program. Based on the outcomes of the survey, WHO estimates that the prevalence of TB in Myanmar is 597/100,000. The survey also confirms that the vast majority of TB cases remains undetected. In Tak province, TB prevalence estimates in the area are also alarming. IOM reported 464/100,000 prevalence in candidates selected for resettlement in 2011. In 18 months, PU-AMI TB program in ML detected 185 cases through passive case finding, thus representing an incidence of 165/100000 population (107 camp residents) whereas higher number of cases are expected with enhanced case finding.
Première Urgence-Aide Médicale Internationale (PU-AMI) programs in Thailand: PU-AMI is an international non-governmental organization whose mandate is to bring a comprehensive response to the essential needs of populations suffering from humanitarian crises in emergencies until autonomy and dignity can be obtained. PU-AMI is the result of the 2011 merger between two French NGOs: Première Urgence and Aide Médicale Internationale. The Thailand mission is a former AMI mission. AMI was founded in 1979. In Thailand, PU-AMI Thailand offers: • clinical services and communicable disease surveillance/control in the Maela, Umpiem and Nupo temporary shelters (3 IPD’s and 5 OPD’s); • health promotion and disease prevention (in Maela camp); • services for HIV/AIDS, Tuberculosis (TB), and Mental Health; • capacity building through initial and refresher trainings.
Until the end of 2009, the TB program in Maela Temporary Shelter was managed by MSF-France. As PU-AMI was already in charge of the primary healthcare services in the camp, PU-AMI accepted to take the 1st line patients and solution to address MDR-TB are discussed in collaboration with local health authorities. Since 2010, PU-AMI TB program addresses: • TB awareness raising, stigma reduction and social mobilization; • case finding and diagnosis; • treatment and care: community-based or residential DOT and patient support; • capacity building for TB.
Challenges for TB control: The mobility of the camp population, the high population density in Maela camp, the stigma or lack of awareness leading to delayed health seeking behavior, are factors that further increase the vulnerability of the camp populations to TB. TB is best controlled through early case detection and treatment. Therefore increased efforts to raise TB awareness, and to reinforce enhanced case finding strategies are essential. The long treatments, with their negative physical and mental side effects, add to the risks of decreased treatment adherence, which could possibly lead to a much greater evil: the development of drug resistant bacteria. Addressing the needs of cross-border or migrant populations has been reported as more challenging, as they tend to reach the health services at a more advanced stage of the disease and, generally, present a higher risk of defaulting . In that context, the mobility of undetected TB cases along and across the border presents a major public health risk. Also, the diagnosis and treatment capacity of MDR-TB (Multi Drug Resistant-TB) cases remains a major challenge in the province.
Rational for a TB KAP survey In that context, it is of utmost importance that culturally adapted and acceptable TB control strategies are well identified and implemented. For that, in depth understanding of what the population knows about TB, what they think about people with TB, and what they actually do with regard to seeking care or taking other action related to TB are needed. A KAP surveys can identify knowledge gaps, cultural beliefs, or behavioural patterns that may facilitate action, as well as pose problems or create barriers for TB control efforts. It can also also help understanding communication processes that are key to defining effective activities and messages in TB prevention and control, dispelling myth and encouraging people with TB and their family members to be more actively involved in care and to support community approach. It can also help identifying problems and barriers in programme delivery, as well as solutions for improving quality and accessibility of services.
II. Survey objectives
The KAP survey will be an exploratory survey with the aim to gather information on knowledge and behaviors as well as stigma and discrimination perception related to TB in Maela camp, in order to develop an effective behavior change communication and program strategy.
The specific objectives are:
• to gather baseline information on the knowledge, attitudes and practices of Mae La population, including recently-diagnosed TB patients and health care workers.
• to determine the individual, social and environmental barriers and enabling factors in the community that contribute to TB case detection and TB treatment compliance.
• to provide recommendations for communications and program strategies related to TB control (including intensified case finding and community DOTS), adapted to the camp refugee context in order to maximize the impact and ensure gender and cultural sensitivity.
III. Methodology
The methodology will be defined by the Consultant, in close collaboration with PU-AMI epidemiologist and Medical Coordinator. The Consultant is expected to propose a detailed protocol for the KAP survey, including the following components: • title of the survey • problem statement or background • survey goal and key research questions • survey population and sampling plan • survey area (geographic) • data collection and management • methods • data analysis plan • plan for ethics review - plan for protecting confidentiality and observing informed consent - risks and benefits for participants • budget (maximum 20000 USD all inclusive) • timeline (workplan) • plan for utilization and dissemination of findings.
The pre-tested survey questionnaire and the template for the consent form (both translated in Karen and Burmese) will be enclosed with the protocol.
IV. Expected outputs
The Consultant is expected to achieve the following results: • Comprehensive KAP survey protocol developed • Surveyors’ training curriculum, methodology and supervision plan developed and implemented • KAP survey implemented, strictly following the protocol as validated by PU-AMI coordination team • Written and oral presentation provided including: - the quantitative and qualitative results of the KAP survey - the discussion on the result, taking into account the bias of the survey methodology and the constraints of the setting as well as PU-AMI mandate - the recommendations to develop communication and social mobilization around TB in the camp and to correct any perceived weaknesses in the current program strategy Deliverables • 1 draft and finalized KAP survey protocol, to be discussed with PU-AMI coordination team • 1 training curriculum, methodology and supervision plan for the surveyors • 1 draft and finalized KAP survey report • 2 presentations, (i) to PU-AMI health workers in Maela camp and (ii) to PU-AMI management staff in Mae Sot
Time frame: the consultancy is expected to start in May. The time limit for achieving all results and deliverables is the end of June 2013.
V. Consultant Profile
Education and Experience - 1 specialist in Public Health, or in social science/anthropology - Experience in KAP survey implementation
Knowledge and Skills • Proven analytical skills • Able to respect policies, procedures and other requirements • Excellent communication skills, both verbal and written • Patience, diplomacy, flexibility, cultural sensitivity, and autonomy • Fluent in English (written/oral); Burmese/ Karen an asset • 100% computer literate, including statistical software (SPSS, STATA)
Applications should contain:
- Curriculum Vitae up to date
- Technical and methodological proposal incorporating an action chronogram, following to the TOR
- Financial proposal with overall budget and detailed prices ( fees, daily perdiem, transportation ..)
How to apply:
Applications must be sent to tha.programco@pu-ami.org or PU-AMI 21/22-26 Mae Sot Mae Tao road, MAE SOT, Tak 63110
Deadline of submission: Friday, March 29th 2013. Starting date : May 2013
Applications should contain: 1. Curriculum Vitae up to date 2. Technical and methodological proposal incorporating an action chronogram, following to the TOR 3. Financial proposal with overall budget and detailed prices ( fees, daily perdiem, transportation ...)
