MOJ ISSN: 2379-6383 MOJPH

Public Health
Research Article
Volume 5 Issue 2 - 2017
Gaps in the Process of Case Detection, Reporting and Feedback of Severe Acute Malnutrition Program in Three Governorates in Yemen: A Quantitative Study
Abdulla Salem Bin Ghouth1* and Salem Yser Farag Meftah2
1Hadramout University College of Medicine, Yemen
2Ministry of public health and population, Hadramout, Yemen
Received: October 20, 2016 | Published: February 20, 2017
*Corresponding author: Abdulla Salem Bin Ghouth, Hadramout University College Of Medicine, Yemen, Tel: +967 774954505; Email:
Citation: Ghouth ASB, Meftah SYF (2017) Gaps in the Process of Case Detection, Reporting and Feedback of Severe Acute Malnutrition Program in Three Governorates in Yemen: A Quantitative Study. MOJ Public Health 5(2): 00125. DOI: 10.15406/mojph.2017.05.00125

Abstract

Background: Monitoring of the nutritional therapeutic program for management of Severe Acute Malnutrition (SAM) in Yemen are limited to the outcome indicators. A lot of information about monitoring and evaluation of the process of implementation of the program are not known especially in areas of case finding/reporting and feedback.

Objectives: To understand case detection, reporting and feedback processes of SAM in OTP clinics among GP/health care providers and managers Yemen 2015.

Methods: This is a quantitative study through cross sectional design of purposeful sample of 213 participants including program manager, physicians and health workers working in the selected 22 health facilities in 20 districts from three governorates (Lahj, Aden and Hadramout). Data collected through structured questionnaire.

Findings: Finding from quantitative data analysis focus on data obtained through questionnaires that returned from the three governorates (n=213). About 58% are females. The mean age of participants are 34.3 years (SD=7.6 years) about half of participants have previous training regarding SAM management guideline (51%) and 66% of them answer correctly about management of SAM children. About 51% of participants have SAM management guideline but only 43% of participants practice SAM management according to the guideline; this reflect on the ability of the system to detect and manage SAM children: about 49% of participants did not detect any SAM child during two weeks preceding the data collection and 69% did not teat any case of SAM and 59% of participants did not refer any SAM case to the TFC. Regarding reporting; the gap identified is the huge data and difficulty in understanding the reporting forms while feedback is mainly verbal by telephone and be not documented.

Conclusion: Different gaps were identified in the SAM program implementation through the quantitative study mainly low coverage of SAM training, more detailed and complicated report's contents, non-adherence of physician with the guideline and lack of coordination between physicians and health workers of the program.

Keywords: Malnutrition; SAM; OTP clinics; TFC; Pneumonia; Diarrheal; Malaria; Measles; Diarrhoeal Disease

Abbreviations

SAM; Acute Severe Malnutrition; MAM: Moderate Acute Malnutrition; TFC: Therapeutic Feeding Centre; OTP: Outpatient Therapeutic Feeding Program; YNP: Yemen Nutrition Program; HUCOM: Hadramout University College of Medicine

Introduction

Every year 10.6 million children die worldwide due to preventable conditions such as pneumonia, diarrheal, malnutrition, malaria and measles. Of these deaths, malnutrition accounts for about 2.2 million deaths annually in children under the age of 5 [1]. Acute Malnutrition is classified according to the degree of wasting and the presence of oedema. It is acute severe malnutrition (SAM) if the wasting is severe (W/H < -3 Z score WHO standards or a low MUAC) or there is oedema. These guidelines address the treatment of SAM. Malnutrition is defined as moderate acute malnutrition (MAM) if the wasting is less severe (W/H between -2 and -3 Z-score WHO standards); oedematous cases are always classified as severe [2].

Level of child malnutrition in Yemen

The demographic and health survey (2013) reported that the overall 16 percent of children under age 5 are wasted, and 5 percent are severely wasted. The prevalence of wasting is highest among children age 6-8 months (28 percent) [3]. The same findings were reported from the family health survey (2003) prevalence of stunting is 53.1%, wasting 12.4% and underweight is 45.6% [4]. Comparing the results of these surveys shows that the prevalence of stunting has greatly decreased in the past 10 years, from 53 percent in 2003 to 41 percent in 2013. However, the percentage of children who are underweight (which decreased from 46 percent to 44 percent) and the prevalence of wasting (which increased from 13 percent to 14 percent) have not significantly changed since 1997 [3].

Impact of the complex emergency on the health system in Yemen

Since March 2015 till now, Yemen living bloody conflicts; the humanitarian impact of the conflict has been catastrophic. The capacity of an already weak health system to respond to growing need has been crippled by extensive damage to medical facilities, supply shortages and safety concerns for health workers. The World Health Organisation (WHO) now considers that the Yemeni health system has collapsed. Future expectation for the health situation in Yemen is worse; the burden of malnutrition will increase especially in the areas worst affected by conflict. Damage to infrastructure will likely mean wider spread of diarrhoeal disease, already a major cause of mortality in Yemen especially among children [5]. More over a recent report of the world food program about Yemen conclude that:  half of the country's children are chronically malnourished and less than 1 in 10 children live to reach the age of 5. Such emergency levels of chronic malnutrition-or stunting - are second globally only to Afghanistan. Yemen has the third highest rates of underweight children in the world after India and Bangladesh; affecting more than half of all children under 5 are underweight [6].

The severe  acute malnutrition program in Yemen (SAM)

In 2008, Yemen had launched a national programme for the management of severe acute malnutrition with an aim of decreasing childhood mortality and illnesses, meeting the MDG by 2015 [2]. The Yemen nutrition program YNP on management of severe acute malnutrition is composed of two arms; Outpatient Therapeutic feeding Program (OTP) and Inpatient Therapeutic feeding centre (TFC). The inpatient TFC program is a hospital level program and  has been known to provide better health care for severely malnourished children while, the OTP is a community level program and successfully examined in many low resource settings with organization and follow up from primary health units, health centres and/or hospitals [7-9]. Studies about the performance of the SAM program were scarce, and the available studies focused of description of SAM children or outcome indicators. A descriptive cross-sectional hospital based study was conducted on 622 hospitalized children (336 males and 286 females) below 6 years of age during 2012-2013 in aden. SAM was diagnosed in 622 children with prevalence rate of 5.2% from total 11,941 admissions during 24 months period [10]. The outcome indicators of 303 hospitalized children at age group 6-59 months in Mukalla hospital in Hadramout were studied in 2013; the study show recovered 31 (10.2%), died 10 (3.3%), transferred 19 (6.3%), defaulted 243 (80.2%) and median stay of children in program were 40 days [11]. Death rate among children with SAM reported from Al-Sadaqa hospital in Aden was 5% in 2011 [12]. A lot of information about monitoring and evaluation of the process of implementation of the program are not known especially in areas of case finding/reporting and feedback.

Methodology

This is a quantitative study through cross sectional design of purposeful sample of 213 participants including program manager, physicians and health workers working in the selected 22 health facilities in 20 districts from three governorates (Lahj, Aden and Hadramout). Data collected through a structured questionnaire by trained health workers during the period from October to December 2015. Data were cleaned, coded and fed in personal computer of the first author using the SPSS version 20 program. Data were analyzed for the three participant's categories: program managers (n=14), physician (pediatricians or GP, n=63) and health workers engaged in SAM program (n=136). Missing values are not included in analysis so the denominator include only participants responses without those did not respond. So all the percentages calculated as valid percentages. Ethical approvals were obtained from Hadramout University College of Medicine (HUCOM) and WHO/EMRO. Institutional approval was obtained from health offices of Aden, Lahj and Hadramout governorates. Purpose of the study was clarified to participants in informed consent and those are agree to participate were included in the study.

Results

The data collected through three methods: questionnaire, review of program reports for quantitative data and interview for qualitative data. This part is present the finding obtained from data analysis of questionnaires that returned from three governorates (n=213). Data was collected by trained health workers through the period from November to February 2016. Data management and analysis of the completed questionnaires were done in March 2016. The proposed participants were 220 persons, the returned questionnaires are 215 copies (98%), and two questionnaires were canceled due to incomplete data, so the eligible questionnaires for analysis are 213 questionnaires. About 49% of the participants from hadramout governorate, 32% from Aden governorate and 18.8% from Lahj governorate. Most of participants were females (58%), 49% have post secondary diploma and 35% are nurses. The mean age of participants are 34.3 years (SD=7.6 years) and within the age range of 19-55 years. About half of participants have previous training regarding SAM management guideline (51%), but physician have low chance for training (32/62, 40%) (Table 1). The gap identified here is low coverage of SAM training.

Characteristics

Participant's Category

No. (%)

Program manager

Physician

Health Workers

Governorate

 

 

 

 

        Lahj

3

10

27

40(18.8%)

         Hadramout

10

41

54

105(49.2%)

         Aden

1

12

55

68(32%)

         Total

14

63

136

213(100%)

Sex

 

 

 

 

         Male

5

27

54

86(42%)

         Female

7

24

29

119(58%)

         Total

1

1

1

205(100%)

Age (in years)

 

 

 

 

         Mean

42

35

33.4

34.3

         SD

6.3

7

7.5

7.6

         Minimum

35

21

19

19

         Maximum

54

50

55

55

         Range

19

29

36

36

Qualification

 

 

 

 

         Post-secondary diploma

7

0

96

103(49%)

         Bachelor

3

36

16

55(26%)

         Master

3

18

0

21(10%)

         PhD

1

9

0

10(5%)

         Others

0

0

1

21(10%)

         Total

14

63

133

210 (100%)

Professional title

 

 

 

 

         Specialist

4

25

0

29(13.5%)

         GP

1

39

0

40(19%)

         Medical assistant

1

0

32

33(15.5%)

         Nurse

6

0

68

74(35%)

         Midwife

1

0

22

23(11%)

         Public health worker

1

0

4

5(2%)

         Others

0

0

8

8(4%)

         Total

14

64

134

212 (100%)

Training about SAM management guideline

 

 

 

 

         Yes

 

 

 

 

         No

12

32

62

106 (51%)

         Total

2

30

71

103 (49%)

 

14

62

133

209 (100%)

Table 1: Socio-demographic characteristics of 213 participants.

Knowledge about SAM management

In the four questions regarding SAM management, the range of proportion of participants given of correct answer is from 55% to 67% (the mean is 66.3%). The highest mean proportion  of the correct answers were reported by program managers (74.8%) followed by physicians (66.3%) while lowest mean proportion of correct answers were reported by health workers (57.8%) (Table 2). The gap identified here is the poor knowledge of participants regarding SAM management.

Question

Answers

Participant's Category

Total No. (%)

Comments

Program manager
No( %)

Physician
No( %)

Health workers No(%)

In phase one of SAM management

Rapid weight gain at this stage is dangerous

11 (78.6%)

42(71%)

71 (61%)

124 (65.6%)

Correct answer

Rapid weight gain at this stage is preferable

1

9

20

30 (15.9%)

Rapid weight gain at this stage is necessary for cure

2

8

25

35 (18.5%)

Total

14

59

116

189 (100%)

F75 used in

Phase 1

11
(84.6%)

41
(72%)

67
(61.5%)

119 (66.5%)

Correct answer

Transition phase

2

8

13

45(25%)

Phase 2

0

5

5

15(8%)

Total

13

57

109

179 (100%)

In transition phase, child should treated in

At home

0

2

11

13 (7%)

Out-patient

2

20

46

68 (38%)

In-patient

12(86%)

33 (60%)

54 (48.6%)

99 (55%)

Correct answer

Total

14

55

111

180
(100%)

Whenever patient have good appetite and no acute major medical complication they enter

Phase 1

2

2

12

16 (9%)

Transitional phase

4

21

30

55 (31%)

Phase 2

6(50%)

38 (62%)

64 (60%)

108 (60%)

Correct answer

Total

12

61

106

179
(100%)

Mean proportion of the correct answers

74.80%

66.30%

57.80%

66.30%

Table 2: Knowledge about SAM management.

Participant's practice regarding SAM case detection and management

About 54% of participants reported that the targeted discharge Wg and Wg/Hg in comparing with admission Wg and Wg/Hg is available in his/her clinic and 51% have a copy of SAM management guideline. Only 43% of participants practice SAM management according to the guideline while 25% of them feel always difficulty in using the guideline. Regarding case detection, 51% reported they detect SAM children under 5 years of age during the last two weeks preceding the day of data collection, while only 31% of the reported that they treat SAM cases during the last two weeks. Refer of SAM children to TFC was reported by 41% of participants and only 24% of them reported that they treat SAM children in phase 2 in the outpatients during the last two weeks preceding the study. Only 24% of participants reported that they are not satisfied at all with the SAM management guideline (Table 3). The gap identified here is unavailability and difficulty of using the guideline in detecting and treating SAM children especially among Physician.

Question/Options

Participant's Category

Total
No. (%)

Program manager

Physician

Health workers

Does the targeted discharge Wg and Wg/Hg in comparing

with admission Wg and Wg/Hg is available in your clinic

 

 

 

 

Yes

 

 

 

 

No

 

 

 

 

Total

10

27

69

106(54%)

 

3

36

51

90 (46%)

 

13

63

120

196(100%)

Did you have a copy of guideline of SAM management

 

 

 

 

Yes

 

 

 

 

No

11

25

60

96 (51%)

Total

2

33

56

91 (49%)

 

13

58

116

 187(100%)

Did you practice for SAM management according to this guideline

 

 

 

 

Always

 

 

 

 

Sometimes

9

23

53

85(43%)

Never

2

12

21

35 (18%)

Total

2

24

52

78 (39%)

 

13

59

126

198 (100%)

Did you feel difficulty in using this guideline

 

 

 

 

Always

1

12

33

46 (25%)

Sometimes

5

18

34

57 (31%)

Never

7

25

49

81 (44%)

Total

13

55

116

184(100%)

Did you discover a child less than 5 years with SAM during the last two weeks

 

 

 

 

Yes

 

 

 

 

No

10

34

59

103(51%)

Total

4

29

66

99(49%)

 

14

63

125

202 (100%)

Did you treat any SAM vase in out-patient in the last two weeks

 

 

 

 

Yes

 

 

 

 

No

8

16

34

58 (31%)

Total

6

45

77

128(69%)

 

14

61

111

186(100%)

Did you refer any case to TFC in the last two weeks

 

 

 

 

Yes

9

33

33

75(41%)

No

3

29

77

109 (59%)

Total

12

62

110

184 (100%)

Did you treat any SAM case in the last two weeks as phase 2 in outpatient

 

 

 

 

Yes

 

 

 

 

No

7

9

28

44(24%)

Total

6

51

81

138(72.7%)

 

13

60

109

182(100%)

Did you satisfied with SAM guideline

 

 

 

 

Satisfied

8

24

41

73 (43%)

to some extent

2

21

34

57 (33%)

Not at all

3

12

28

43 (24%)

Total

11

56

103

173 (100%)

Table 3: Practice of participants toward SAM management.
*Significant at 0.05 level

The ability of SAM program to detect and manage SAM children

About 54% of participants did not detect any SAM child during two weeks preceding the data collection and 69% did not treat any case of SAM and 65% of participants did not refer any SAM case to the TFC. Physician who is the qualified person for case detection and management and expected to play a cornerstone in case detection and management, they reported 0case regarding case detection (27/54, 50%), case treated (45/57, 79%) and referral (27/48, 56%)  (Table 4). The gap identified here is poor physician adherence with SAM management guideline.

Question/Options

No Of SAM Children Detected

Participant's Category

Total

No. (%)

Program Manager

Physician

Health Workers

SAM cases detected during the last two weeks

0 cases

4

27

64

95 (54%)

1-10 cases

7

22

39

68 (39%)

11-22 cases

2

5

6

13 (7%)

Total

13

54

109

176 (100%)

SAM cases treated during the last two weeks

0 cases

5

45

73

123 (69%)

1-10 cases

7

8

28

43 (24%)

11-66 cases

1

4

7

12 (7%)

Total

13

57

108

178 (100%)

SAM cases referred to TFC

0 cases

3

27

74

104 (65%)

1-10 cases

8

19

26

53 (33%)

11-15 cases

0

2

1

3 (2%)

Total

11

48

101

160 (100%)

SAM cases treated in the last two weeks as phase 2 un outpatient

0 cases

6

50

80

136 (82%)

1-10 cases

4

6

14

24 (15%)

11-30 cases

0

2

4

6 (3%)

Total

10

58

98

166 (100%)

Table 4: The ability of the system to detect and manage SAM children.

Reporting practice

Less than half of participants fill the different reporting forms: filling the OTP chart (45%), the transfer form (38%), the referral form (33%), the registration book (47%) and the monthly report (40%). Although 51% of participants reported that the reporting forms were regularly and always available but only 30% of them reported that data in the forms were clear and understandable (Table 5). The gap identified here is the huge data and difficulty in understanding the reporting forms.

Question/Options

Participant's Category

Total

No. (%)

P-Value

Program Manager

Physician

Health Workers

Did you fill OTP chart

Yes

12

17

61

90 (45%)

0.001*

No

2

44

62

108 (55%)

Total

14

61

123

198 (100%)

Did you fill the transfer form

Yes

8

19

48

75 (38%)

0.4

No

6

41

75

122 (62%)

Total

14

60

123

197 (100%)

Did you fill referral form to TFC

Yes

10

20

35

65 (63%)

0.04*

No

4

41

87

132 (67%)

Total

14

61

122

197 (100%)

Did you fill registration book in outpatient

Yes

11

15

65

91 (47%)

0.001*

No

3

45

57

105 (53%)

Total

14

60

122

196 (100%)

Did you fill the monthly report

Yes

11

9

57

77 (40%)

0.001*

No

3

49

63

115 (60%)

Total

14

58

120

192 (100%)

Does the reporting forms are regularly available

Always

11

15

62

88 (51%)

0.001*

Sometimes

2

7

14

23 (13%)

Never

1

31

30

62 (36%)

Total

14

53

106

173 (100%)

Did data in the reporting forms are clearly stated and understandable

Very clear

0.04*

With some difficulty

9

8

28

45 (30%)

Very difficult

3

15

39

57 (38%)

Total

2

15

32

49 (32%)

14

38

99

151 (100%)

Table 5: Reporting practice of participants.

*Significant at 0.05 level

Reasons behind no reporting

The most frequent reason of no reporting mentioned by those did not report (n=42) is that the reporting forms were not available in the clinic (26% for OTP chart, 51% for referral form), the second reason is that the participant being not the responsible person of reporting (92% for monthly reporting) (Table 6). The gap identified here is lack of coordination between physicians and health workers lead to missing SAM cases due to no reporting.

Item

Reasons of No Reporting

No

%

No filling of the OTP chart

the form is not available in the clinic

11

26%

no OTP in the canter

6

14%

it is not my responsibility

12

29%

the form available only in the TFC clinic in hospital but not in paediatric or GP clinic

5

12%

i refer the cases to TFC in hospital so i did not fill the OTP form

2

5%

I am not trained about the guideline

6

14%

Total

42

100%

No filling of the transfer from

the referral form is not available in the clinic

10

34%

i am working in referral hospital where admission unit is available so we didn't refer to any hospital

8

28%

No TFC in our facility

2

7%

it is not my responsibility

9

31%

Total

29

100%

No filling the referral form

the form is not available in the clinic

11

51%

There is no admission unit in the facility

4

19%

the SAM children seen by nutrition specialist in the TFC in Mukalla hospital " this may be verbal refer

2

10%

my hospital is the referral hospital in the government so i am working in this hospital

4

20%

Total

21

100%

No filling of the registration form

no registry in the clinic

7

25%

no cases

1

4%

it s not my responsibility

19

67%

I am not working now in nutrition clinic because there is no treatment diet (Plumping nuts)

1

4%

Total

28

100%

No monthly report

i am not the responsible person for monthly report preparation

92%

36

no follow up

2

5%

No OTP in the centre

1

3%

Total

39

100%

Table 6: Reasons behind no reporting.

Feedback

Feedback indicators were also low. Health workers or clinic officers reported that they received feedback from program managers about the different performance of reporting: 55% about completeness, 51% about timeliness, 53% about comments and 53% about data analysis. Only 17% of participants mentioned they received newsletter from the program managers (Table 7). Regarding feedback from program managers to the lower level: similar findings were reported by program mangers (Table 8). The most communication tools used by program managers for communicating feedback to the lower level were telephone (57%) followed by the social media (14%) (Table 9). The gap identified here is the feedback is mainly verbal by telephone and be not documented.

Question

Answer

No

%

Did you receive feedback from the upper level to you about completeness of reports (n=74)

Yes

41

55%

No

33

44%

Did you receive feedback from the upper level to you about timeliness of reports (n=73)

Yes

37

51%

No

36

49%

Did you receive feedback from the upper level to you about comments on report content (n=73)

Yes

39

53%

No

34

47%

Did you receive feedback from the upper level to you about analysing the findings (n=71)

Yes

34

47%

No

37

53%

Did you receive from the upper level regular newsletter (n=71)

Yes

12

17%

Table 7: Feedback from the upper level to the lower level.

Question

Answer

No

%

Did you sent feedback to the lower level about completeness of reports (n=17)

Yes

8

47%

No

9

53%

Did you sent feedback to the lower level about timeliness of reports (n=16)

Yes

9

56%

No

7

44%

Did you sent to the lower level about comments on report content (n=16)

Yes

8

50%

No

8

50%

Did you sent feedback to the lower level about analysing the findings (n=16)

Yes

6

38%

No

9

62%

Did you sent to the lower level regular newsletter (n=16)

Yes

2

13%

No

14

87%

Table 8: Feedback from program managers to the lower level.

Tools Used

No

%*

Telephone

8

57%

Social media

2

14%

Nothing

6

42%

Others

2

14%

Table 9: Tools used for feedback communication by 14 program managers.
* proportion%.

Discussion

This study is a part of a big study about SAM program performance in Yemen focusing on monitoring and evaluation. It is the quantitative part, collecting information through questionnaires about process of case detection, reporting and feedback among program managers, physicians and health workers working in SAM program and its service delivery points. A total of 213 subjects enrolled in the study from different categories.  Building the capacity of health workers is important to best performance of any health program or intervention, not only the formal training but also the continuous education and in-service training. In-service training changes attitudes to malnutrition and treatment practices [13,14]. In this study; only about half of participants have previous training regarding SAM management guideline (51%) and this was reflected on the knowledge and practice f participants where 66% of them answer correctly about management of SAM children and 51% of participants have SAM management guideline but only 43% of participants practice SAM management according to the guideline; emphasizing on training about guideline to improve practice toward SAM management was reported elsewhere [15,16]. Wuehler SE et al. [17] reported in their study in Mauritania the need for support activities to adapt training materials and programme protocols to fit local needs [17]. This poor knowledge and practice reflected on the ability of the system to detect and manage SAM children: only 49% of participants did not detect any SAM child during two weeks preceding the data collection and 69% did not treat any case of SAM while 59% of participants did not refer any SAM case to the TFC. Lack of training and therefore lack of knowledge on the dangers of poor monitoring of patients as well as shortage of nurses, may have contributed to the inadequate adherence with the guideline; Warfa et al.  [18] recommended that training of health care workers on the implementation of WHO guideline can improve quality of care for SAM children [18]. Within the SAM program; the nutritional surveillance depends on the routine reporting from the health facilities; and it is important if the data collected in a regular time, accurate and be completed and on time in order to be able to extract indicators for monitoring and evaluation. The implementation of programs can be monitored as long as data are collected on process indicators such as access to, and use of, services. The disadvantages of data collected from health facilities are that the data are rarely complete and data are often of poor quality due to factors including poor motivation, lack of supervision, inadequate feed-back, and overburdening of staff by multiple reporting requests [19]. This picture is the same in the reality of reporting process in SAM program in Yemen; in this study were only 45% of respondents filled the monthly reports and 92% of those not report at all given the reason of no reporting that it is not their responsibilities. Other factors contributing in poor reporting is that the huge data and difficulty in understanding the reporting forms. Feedback is important element of any surveillance system; ongoing feedback enabled the nutritional program to improve targeting and supply of supplements [20]. In This study Feedback is mainly verbal by telephone and be not documented and in best situation 54% of participants received feedback from their top managers by telephone or through social media indicate the need for innovative methods for reporting and feedback.

Conclusion

In this study, gaps are identified regarding case detection/management, reporting and feedback among program managers, physicians and health workers of the SAM program in three governorates in Yemen. These gaps are:

  1. Low coverage of SAM training.
  2. Poor knowledge of participants regarding SAM management.
  3. Unavailability and difficulty of using the guideline in detecting and treating SAM children especially among Physicians.
  4. Poor physician adherence with SAM management guideline.
  5. Huge data and difficulty in understanding the reporting forms.
  6. Lack of coordination between physicians and health workers lead to missing SAM cases due to no reporting.
  7. Feedback is mainly verbal by telephone and be not documented.

Acknowledgement

This is work is the final report of two of projects of WHO reference numbers of 2015/573680-0 and 2016/611659-0 with unit reference iPIER 14-6 that received technical and financial support from the WHO/ EM RGO/IER/RPD and AHPSR and technical assistance from ICPH/Berziet University. Here we express my great appreciation for this support.

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