Study participants’ socio demographic information
Two hundred and ninety-five health personnel were enrolled in the study with a response rate of 96%. Excluding those who did not give their consent (n=12), comprising community health workers (n=5) and health facility workers (n=7), the final sample size was 283. This comprised of community (50, 18%), health facility (192, 68%), sub-county (19, 7%) and county (10, 3%) level health personnel and other key informants (12, 4%). Overall, majority (89%, 251/283) of the study participants were aged over 30 years with a preponderance (58%, 165/283) of male participants. Forty-one percent (116/283) of study participants had more than five years working experience in their current designation with 93% (264/283) having at least attained a diploma or a higher level of education (Table 2, 3, 4, 5 & 6).
Study participants’ involvement in surveillance activities
The data showed that in their current cadre, up to 53% (101/192) of health facility respondents had been involved in health facility based disease surveillance for at least three years (Figure 4). On the other hand, 86% (43/50) of respondents at the community level reported to be involved in disease surveillance activities.
Eighty-four percent (161/192) of facility respondents reported having a functional health facility-based surveillance system with the capacity to detect, confirm, report, analyse and interpret surveillance data to inform response actions. Availability of a laboratory equipped to confirm PC-NTDs cases, provision for PC-NTDs in the reporting forms and training of personnel on disease surveillance were associated with higher odds of having a functional health facility-based surveillance system [AOR = 3.07, 95% CI: 1.36, 6.94, p = 0.007], [AOR = 3.20, 95% CI: 1.44, 7.10, p = 0.004] and [AOR = 4.15, 95% CI: 2.30, 7.48, p<0.001] respectively. Of the facilities with a functional health facility-based surveillance system, 64% (104/161) confirmed to report PC-NTDs through this system and up to 97% of respondents reported that it was important to have a PC-NTD surveillance system at the facility level. Majority (95%, 182/192) of facility respondents were well aware of PC-NTDs prevalent in the region. Twenty-three percent (45/192) of facility respondents identified Schistosomiasis and Soil Transmitted Helminths as the most common co-endemic conditions while 22% (42/192) reported Lymphatic Filariasis, Schistosomiasis and Soil Transmitted Helminths to commonly co-occur at any given time. At the community level, 88% (44/50) of respondents were aware of the PC-NTDs prevalent in the study regions and 80% of them had identified and reported at least one PC-NTD case at the community level in the previous year.
Case detection, registration and guidelines
All sub-national levels (sub-counties and counties) were provided with IDSR standard case definition guidelines. Fifty-three percent and 70% of respondents reported to use the available standard case definitions to detect at least one PC-NTD in the previous year in the sub-county and county levels respectively (Table 7). Fifty percent (25/50) of community level respondents indicated that the surveillance guidelines were useful for PC-NTDs case detection. At the health facility level, 83% (159/192) of the respondents reported that standard case definitions for all diseases were available for use. Up to 60% of health facility workers admitted that the available PC-NTDs case definitions were clear and easy to use. However, a health facility respondent remarked;
“There was a time we came across a suspected trachoma case at the onset and it was difficult to apply the provided case definition guidelines…symptoms of redness and teary eyes are at times as a result of other allergic reactions…we needed more clear case definitions to accurately identify a trachoma case especially at the acute stages before follicles are visible” – HFW#118 (Kitui County)
Sixty-eight percent (34/50) of community level respondents reported to register identified PC-NTD cases. At facility level, 19% of respondents reported that specific case registers for PC-NTDs were available. However, these facilities were mainly designated NTDs treatment centres. Further, facility respondents reported that most disease conditions were routinely recorded in a common outpatient register;
“We record all disease cases in a common register…so there is no separate register for certain specific diseases…may be such registers are present in the health facilities that mostly see and treat patients with diseases such as Trachoma” – HFW#009 (Baringo County)
Less than half (48%, 93/192) of the respondents reported that manuals for disease surveillance were available at the facility. Of this fraction, 75% reported that the manuals were up-to-date, 89% reported that the manuals were useful in guiding disease surveillance activities, and 61% reported that the available manuals specifically guided PC-NTDs surveillance activities at the health facility level. Health workers recommended the need for case registers specific for registering PC-NTDs cases to ensure there is a clear log of reported cases starting from the peripheral to county levels;
“By having specific case registers for NTDs that are being utilised right from the peripheral level...will help track disease occurrences…suspected cases can always be followed up if they are well registered and a proper record is kept” – CHEW#031 (Kwale County)
At the sub-national level, 84% of sub-counties had the capacity to collect and store PC-NTD specimens (Table 7). Thirty-two percent (16/50) of community level respondents reported to have referred collected samples of at least one PC-NTD to the health facility level in the previous year. An equivalent proportion (32%) of respondents reported to receive case confirmation reports on the referred specimens. Of this number, 88% of them indicated that they had referred urine samples for suspected cases of urinary schistosomiasis. On the other hand, 52% (100/192) of health facility respondents reported presence of a functional laboratory with 51% of them indicating that the laboratories were adequately equipped to confirm PC-NTD cases. However, direct observations revealed that only about 22% (43/192) of health facility laboratories were adequately equipped to confirm PC-NTDs. Up to 41% (79/192) of respondents reported that the health facilities were able to handle PC-NTD specimens, and 46% reported that the facilities had capacity to transport the specimens to higher-level laboratories. Further, 18% (35/192) of respondents reported that the facilities sent PC-NTD specimens to higher-level laboratories in the past year with 80% of this fraction reporting that the facilities received specimen feedback reports. Respondents recommended the need to strengthen laboratory capacity to confirm suspected PC-NTD cases. Further recommendations alluded to provision of adequate laboratory personnel, reagents, and equipment;
“We require fully equipped laboratories with trained laboratory personnel at the community level which mostly lack capacity to confirm suspected NTDs cases…we lack adequate resources to transport specimens…patients also lack money to cover for transport costs when referred to the facility” – HFW#161 (Tana River County)
Eighty-four percent and 80% of sub-national levels met deadlines for submission of PC-NTDs surveillance reports at the sub-county and county levels respectively (Table 7). Forty percent (20/50) of community level respondents reported lack of reporting forms at some point in the past six months with 78% having reported at least one PC-NTD case in the past year and 76% having referred the identified PC-NTD case to the health facility level. Slightly more than half (55%) of health facility respondents reported that the forms had provision for reporting PC-NTDs. Of this fraction, 61% indicated that the provision for reporting PC-NTDs was sufficient. Facility respondents (39%) who felt that the reporting form provision was insufficient, attributed their reasons to lack of PC-NTDs inclusion in the forms;
“NTDs are in extension still neglected even in the available IDSR reporting forms…seeing that NTDs are not included in summary forms clearly indicates lack of priority…these diseases need to be listed in the forms similar to other common conditions to ease reporting” – HFW#094 (Kilifi County)
Results showed that 84% (162/192) of respondents were aware of deadlines for submission of PC-NTDs surveillance reports at the facility level with 88% of them confirming compliance with the reporting deadlines. Health workers of the nursing cadre (48%) were solely responsible for preparing PC-NTDs surveillance reports at the facility level. Further, 81% of facility respondents confirmed, "zero” reporting was undertaken when there were no PC-NTD cases to report at any given month. Findings from a logistic regression model assessing the predictors of “zero” reporting of PC-NTDs showed that respondents with longer years of work experience had higher odds of undertaking “zero” reporting compared to those who had served fewer years (Table 8). In addition, availability of PC-NTDs case definitions and availability of reporting forms were associated with increased odds of undertaking “zero” reporting; [AOR = 2.52, 95% CI: 1.01, 6.28; p = 0.048] and [AOR = 3.18, 95% CI: 1.10, 9.23; p = 0.033] respectively.
The common channels for surveillance reports submission utilised by respondents at the facility level were through mobile phone short message services (SMSs) (81%) for weekly reporting and in person report submission (73%) for monthly summary reports. At the community level, 82% of respondents reported that the channel mostly used to transmit PC-NTDs monthly surveillance reports was in person submission of hardcopy forms to the health facilities. Respondents at the community level also reported using phone calls (64%) and mobile phone SMS (48%) to transmit surveillance data during weekly reporting. Respondents across the surveillance levels reported challenges using the available reporting channels;
“Submitting reports via the DHIS2 portal is at times challenging given the inconsistent internet connectivity in the area…most times we have to incur the expenses resulting from purchase of internet bundles so as to access the portal during report submission” – KII#003 (West Pokot County)
“Long distances between the health facility and the next reporting level…and poor terrain in the region pose a challenge to delivering hardcopy monthly summary reports within the required time” – SCDSRC#001 (Baringo County)
Health personnel mainly recommended improving PC-NTDs reporting within the IDSR system through provision of adequate resources to facilitate surveillance data reporting. Adopting electronic reporting tools through use of computers and mobile phone devices, and provision of financial incentives to cover for airtime, internet and transport costs;
"If we had an electronic reporting system right from the facility level it would ease reporting and eliminate the burden of having to physically submit monthly summary reports" – KII#001 (Baringo County)
Respondents further recommended provision of adequate reporting forms at any given time to ensure timely compilation of surveillance reports. In addition, providing improved monthly summary reporting forms with the inclusion of PC-NTDs to enhance their priority in surveillance reports;
"The current reporting forms hardly include most of the NTDs…this makes it difficult to report the cases especially in the monthly summary reports…it would be better if most of the NTDs common in the region would be included in the reporting forms" – HFW#112 (Kitui County)
Further recommendations alluded to enhanced training amongst health facility workers on the use of reporting tools and the need for health workers sensitisation on the benefits of effective surveillance reporting;
“We need periodical training and capacity building on NTDs surveillance activities...health workers sensitisation on NTDs will improve reporting of the cases through the surveillance system" – HFW#089 (Kilifi County)
Surveillance data analysis for PC-NTDs at the health facility level was mainly either based on age and locality of the individual (27%), age and gender of the individual (23%) or solely based on the individuals’ age (24%). Among health facilities that conducted data analysis, 44% (49/111) performed trend analysis based on PC-NTDs surveillance data collected in the previous year. Availability of PC-NTDs case definitions, presence of disease-specific case registers and receipt of feedback on surveillance reports were associated with higher odds of conducting analysis of surveillance data at the facility; [AOR = 2.76, 95% CI: 1.44, 5.31; p = 0.002], [AOR = 2.28, 95% CI: 1.08, 4.83; p = 0.030] and [AOR = 5.11, 95% CI: 2.13, 12.3; p<0.001] respectively (Table 9). Availability of computers as well as the availability of posters were also associated with higher odds of conducting data analysis at the facility; [AOR: 2.47, 95% CI: 1.18, 5.18; p = 0.017] and [AOR = 3.37, 95% CI: 1.52, 7.48; p = 0.003) respectively. On the contrary, supervision of surveillance activities was associated with 70% reduction in the odds of conducting data analysis at the facility level [AOR = 0.30, 95% CI: 0.11, 0.81; p = 0.017].
At the facility level, slightly less than one-third (29%) of respondents reported that their facilities had action thresholds for PC-NTDs. The action thresholds were based mostly (89%) on number of cases reported and to a lesser extent based on percentage increase in number of cases (4%) or rates based on specific variables (4%). Respondents reported initiating mass drug administration and deworming exercises, conducting health education at the community level and putting in place epidemic preparedness measures as the common actions that followed when the number of PC-NTD cases met the set thresholds.
Respondents attributed improved analysis of PC-NTDs surveillance data to provision of proper analytical tools and equipment such as computers with pre-loaded analysis software for effective surveillance data analysis and refining existing reporting tools to accommodate all PC-NTDs. Further recommendations suggested the need for enhanced training and capacity building on analytical skills by involving all health workers across the surveillance levels and conducting sensitisation on the importance of data analysis to inform follow up actions;
“More training and awareness among health workers on conducting analysis of NTDs surveillance data is needed…through frequent analysis of data we will be able to monitor trends of NTD cases in the region and plan well to control the diseases” – HFW#027 (West Pokot County)
Additionally, health personnel recommended prioritisation of PC-NTDs in the analysis process and adapting simplified analysis methods to ensure minimal time is spent to complete data analysis;
“More needs to be done in the region to capture enough NTDs data to warrant analysis…most of the NTDs are not well captured in the data analysis and this needs to be done” – CDSRC#002 (West Pokot County)
At the community level, 54% (27/50) of respondents reported to receive feedback relating to PC-NTDs from the facility level and 32% indicated that it took more than a week to receive the feedback reports. At the facility level, 37% (70/192) of facilities received feedback on PC-NTDs reports submitted to the next surveillance level in the previous one-year surveillance period. Of this fraction, 39% of the facilities received 1-2 feedback reports while 41% received at least three reports from the higher levels. The ability to meet reporting deadlines and to conduct data analysis at the facility level were associated with increased odds of receiving feedback on surveillance reports; [AOR = 1.80, 95% CI: 1.29, 2.52; p = 0.001] and [AOR = 4.55, 95% CI: 2.08, 9.97; p<0.001] respectively (Table 10). Sixty percent (115/192) of facilities did not hold feedback meetings with CHUs and some of the respondents (6%) were not aware of the number of meetings held with CHUs in the previous year;
“Feedback meetings with members of the community units were mostly based on the common health conditions such as malaria…those diseases affecting the community regularly…but the agenda was not specific to NTDs…I can hardly recall the number of meetings held with the community units in the past year” – HFW#071 (Kwale County)
Recommendations by respondents for improved feedback regarding PC-NTDs surveillance data suggested the need for regular and timely feedback on reports sent from one level to the other to inform actions at the point of surveillance report generation. In addition, ensuring feedback reports are relevant and applicable to surveillance activities undertaken by the concerned surveillance level;
“Feedback should be provided promptly and all health staff at the facility should have access to the feedback reports…feedback on submitted reports from our in-charges will enable us gauge our reporting performance and know what actions to take at a facility level” – HFW#037 (Narok County)
Additional recommendations required adoption of electronic mechanisms or hardcopy written feedback reports to ensure timely feedback is provided to the relevant surveillance levels as opposed to verbal feedback for effective PC-NTDs surveillance and response;
“We need to improve the feedback mechanisms by adapting electronic methods to ensure timely feedback is provided…using electronic media such as mobile SMSs and emails” – HFW#142 (Embu County)
Epidemic preparedness and response
Respondents at the sub county (63%) and county (100%) levels reported the presence of a rapid response team and having adequate outbreak response supplies. Respondents further reported challenges facing effective response to NTDs outbreaks at the sub-national level;
“At this sub county level we lack a team that has been put together to rapidly respond to outbreaks arising from NTDs…we mostly notify the county level in case of an increased number of reported cases and response is coordinated at that level” – HFW#127 (Embu County)
“We mostly rely on the county health management team to coordinate activities for outbreak response because we lack adequate personnel and supplies at the sub county level to efficiently respond to disease outbreaks” – HFW#065 (Kwale County)
Eighty-one percent (156/192) of facilities received regular supervisory visits from the sub-national levels (Table 11). Of this fraction, slightly more than half (53%) received supervisory visits more than twice in the previous one-year surveillance period. Eighty percent of facilities that received regular supervisory visits had disease surveillance activities reviewed. However, previous supervisory visits focused largely on other common conditions and hardly on PC-NTDs surveillance activities as reported by 53% (83/156) of facility respondents. Higher-level facilities (level 3, 4 and 5) were more likely to receive regular supervisory visits compared to lower level 2 facilities (93% vs. 77%, p = 0.008). Respondents at the sub-national level claimed that poor accessibility to remotely located health facilities, unavailability of reliable transport means and inadequate human resource hindered effective supervision of surveillance activities. Respondents (31%, 49/156) further reported that recommendations concerning PC-NTDs surveillance activities were provided during the last supervisory visits with 55% of this fraction reporting that follow-up on previous recommendations were undertaken in the last supervisory visit;
“During the previous supervisory visit the need for timely reporting of both weekly and monthly surveillance data was overly emphasised…the team followed up recently by reviewing timeliness of previous reports sent over the last couple of months” – HFW#047 (Kwale County)
Of the facilities (41%, 78/192) that had conducted supervision of surveillance activities at the community level, 41% reported to have conducted supervisory visits more than twice in the previous year. Up to 62% (48/78) of facility respondents reported that PC-NTDs surveillance activities at the community level were reviewed during the last supervisory visit. Of this fraction, 79% reported that written feedback reports were issued to the community levels. Respondents recommended that improved supervision required adequate resource provision in terms of financial and logistical support to facilitate supervisory activities at the community levels. Furthermore, ensuring supervisory teams are well constituted by including an NTD focal person as part of the team;
“Ensuring there is a designated surveillance focal person always accompanying the supervisory teams to review NTDs surveillance data among other diseases…we require specific staff to be assigned duties for supervision of disease surveillance activities at the lower levels” – KII#004 (Baringo County)
Further recommendations by respondents alluded to regular supervision of surveillance activities relating to PC-NTDs at the community levels and involvement of community health workers through strengthened and functional CHUs for effective supervision of active case search activities for PC-NTDs. In addition, reinstatement of inactive CHUs to functional status for effective community-based surveillance. Furthermore, respondents recommended the need to train supervisory teams on the conduct of supervisory activities and to put focus on monitoring PC-NTDs surveillance activities during supervision;
“Important to have on-job trainings and sensitisation of health workers on supervisory activities at the lower levels…this will encourage ownership and should motivate their involvement in surveillance activities” – HFW#016 (West Pokot County)
Most facility respondents (83%, 159/192) were trained on disease surveillance during their basic training (Table 11). Of this number, up to 40% admitted that their basic training was sufficient to adequately undertake disease surveillance activities with 67% confirming that the training was applicable to undertaking PC-NTDs surveillance activities at the facility level. Twenty percent (39/192) of facility respondents had received post-basic training on disease surveillance with 64% of this fraction reporting that all elements of disease surveillance and response were covered during the last post-basic training. Up to 44% (17/39) of the respondents reported that the post basic training covered aspects relating to PC-NTDs surveillance. Respondents also reported that surveillance updates were mostly provided through on-the job trainings;
“Training of health workers on issues regarding disease surveillance in most health facilities was mainly on the basis of on-job training…especially during supervisory visits…formally organised trainings are rarely done” – SCDSRC#012 (Kilifi County)
Fifty-one percent (20/39) of facility respondents reported that disease surveillance aspects specific to PC-NTDs were not covered in previous post-basic trainings and would be interested in a training focusing on PC-NTDs. Respondents recommended regular training and dissemination of up-to-date information on PC-NTDs for effective surveillance and response to common cases prevalent in the region. In addition, well-formulated training plans and schedules would ensure training covers important aspects relating to PC-NTDs surveillance activities;
“Need for the sub-county level to ensure on-job trainings and updates especially regarding surveillance of NTDs are frequently provided” – SCDSRC#007 (Kwale County)
Moreover, respondents identified the need for resource provision through financial incentives for organising training sessions and providing training tools and materials to facilitate training on surveillance activities. Health workers also suggested the need to prioritise training for PC-NTDs surveillance activities. Furthermore, respondents pinpointed the need to involve all the health cadres in training activities to ensure knowledge and awareness on PC-NTDs is cascaded to other health workers. Additionally, need to retain trained staff across surveillance levels for sustained performance of surveillance activities and conduct training needs assessment to determine specific areas of focus regarding PC-NTDs surveillance.
Assessment of surveillance resources regarding transport support showed that 13% (24/192) of facilities had motor vehicles available and were fully functional. Up to 67% (16/24) of respondents in these facilities reported that the motor vehicles facilitated PC-NTDs surveillance activities. On the other hand, motor cycles were available in 38% (72/192) of facilities with 92% (66/72) of these facilities having motor cycles that were functional and 92% (61/66) of respondents in these facilities reported that the motor cycles facilitated surveillance activities. Other respondents reported that bicycles were available in 6% (12/192) of the facilities, functional and supported surveillance activities in all the twelve facilities. Electricity supply was available in 85% (164/192) of health facilities. Of these fraction, 98% (161/164) of respondents in these facilities indicated that the electricity was functional with 91% (146/161) reporting that electricity facilitated PC-NTDs surveillance activities. Calculators, computers, printers and photocopiers were available in 69% (133/192), 40% (76/192), 25% (47/192) and 23% (45/192) of the facilities respectively. These equipment were functional in 99% (132/133), 83% (63/76), 87% (41/47) and 91% (41/45) of the facilities and facilitated surveillance activities in 96% (126/132), 83% (52/63), 85% (35/41) and 90% (37/41) of the health facilities respectively. Data analysis software were available in 12% (22/192) of the facilities, functional in 86% (19/22) and facilitated surveillance activities in 63% (12/19) of the facilities. Assessment of communication equipment, internet access and information, education and communication (IEC) materials showed that telephone or mobile phone services were available in 85% (164/192) of the facilities, functional in 98% (160/164) and facilitated surveillance activities in 96% (154/160) of the facilities. Posters, pamphlets and flipcharts for PC-NTDs were available in 61% (117/192), 27% (51/192) and 8% (15/192) of the facilities respectively.
Respondents recommended provision of electronic equipment such as calculators, mobile phones and computers to ease reporting and data analysis at the lower surveillance levels. Additionally, provision of financial incentives to cover for communication and transport costs during surveillance reports submission. Moreover, providing an adequate number of surveillance staff responsible for collection, collation and transmission of reports across the surveillance levels;
“I wish we had a health staff designated to this facility whose role will be handling of surveillance activities and reports submission…this will allow the rest of the health workers to concentrate on other tasks knowing there is someone responsible for compilation of all reports” – HFW#122 (Kitui County)
Satisfaction with PC-NTDs surveillance activities
Logistic regression analysis assessing the predictors of satisfaction with PC-NTDs surveillance and response activities indicated that the facility level, adequacy of forms for reporting PC-NTDs and feedback on submitted PC-NTDs surveillance reports were associated with increased odds of satisfaction with PC-NTDs surveillance and response activities in the endemic region; [AOR = 3.04, 95% CI: 1.77, 5.23; p<0.001], [AOR = 4.25, 95% CI: 2.23, 8.08; p<0.001] and [AOR = 4.55, 95% CI: 2.30, 9.02; p<0.001] respectively. Respondents reported that having in place alternative PC-NTDs surveillance strategies within the existing IDSR system would influence their satisfaction with the system;
“We require a behavioral surveillance system to better understand community dynamics for effective active case finding of neglected diseases…these are diseases (NTDs) associated with a lot of stigma, therefore, making it difficult to capture certain cases with a majority of those suffering from example elephantiasis shying away from the public eye” – KII#009 (Kwale County)
There were eleven a priori identified main themes with up to 62 emerging sub-themes, which were derived based on recommendations to improve PC-NTDs surveillance and response within the existing IDSR system according to health workers’ perspectives (Table 12 and 13). The numerical value of code groundedness was used to determine the degree of probable evidence for each code . A high degree of code groundedness was defined as those codes (recommendations) that were mentioned fifteen or more times (G ≥ 15) by the research participants under each main theme.