Community Participation for Effective Dengue Management in Fort ThepsatriSrisunthon.(CPEDM)
Fort ThepsatriSrisunthon hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Dengue was considered a sporadic disease that caused epidemics at long intervals. In the last 50 years, the incidence of dengue has increased 30-fold. Today, dengue ranks as the most important mosquito-borne viral disease in the world. About 2.5 billion people, or 40% of the world’s population, live in areas where there is a risk of dengue transmission. Dengue is endemic in at least 100 countries in Asia, the Pacific, the Americas, Africa, and the Caribbean. The World Health Organization (WHO) estimates that 50 to 100 million infections occur yearly and 500,000 cases are diagnosed with dengue haemorrhagic fever (DHF) and 22,000 deaths, mostly among children. Up to date, there is no specific treatment for dengue and innovative approaches are still needed in preventing the disease at the community level. In Thailand, dengue was first found in 1949, the first outbreak occurred in 1958 in Bangkok-Thonburi. Dengue is found throughout the year mostly occurring during the rainy season between May to August and has an outbreak every two years, mostly among children. In 2010 there are 115,845 dengue infection cases (182.38 per 100000) and 141 deaths. Fort ThepsatriSrisunthon is located in Thungsong District, Nakhon SI Thammarat province. Geographic characteristic has degraded forests scattered around. The population is approximately 15,000 residents (1,402 families) mostly soldiers and their families. Dengue fever is a community health problem. In 2007-2008, the infection rate was over the target (266.67 and 466.67 per 100000). When considering the social factors, it was found that the military lived in consecutive row houses which easily spread diseases by mosquitoes. Considering behavioural factors, waste and waste management caused dengue outbreaks. Environmental factors from community surveys found that there are breeding site containers in houses and around the houses. In public areas, waste was retained from households without waste separation. Collection, disposal or recycling waste utilization is inefficient. Furthermore, Thungsong District located in the south of Thailand, has two seasons: summer and rainy seasons. Warmer temperatures in summer season are likely to increase dengue incidence by lengthening the life span of mosquitoes. Indeed, in the rainy season, conditions are perfect for mosquito breeding and cause wide spread outbreaks which are difficult to control. In conclusion, the condition caused dengue outbreaks in the Fort ThepsatriSrisunthon are due to the environment and the behaviour of the community that is conductive to mosquito breeding. Regarding epidemiology showing a link between host agents and environment, it is important for Fort ThepsatriSrisunthon hospital to create a best practice for protection the dengue incidence by encouraging people in their community to be highly considered in this problem as well as facilitate them to produce an effective approach for management of Dengue incidence.

B. Strategic Approach

 2. What was the solution?
Phase I, from 2009 – 2010, Fort ThepsatriSrisunthon hospital and women community volunteers launched a dengue prevention and control program in May, after that women community volunteers continuously monitored the breeding site every month. Hospital staffs audit their work every 3 months, paralleling to the infection rate from patient’s access. Phase II, from 2011 – 2014, women community volunteers reflect their concern about the dengue fever outbreak in the surveillance area and dengue infection in children was found. Fort ThepsatriSrisunthon hospital and women community volunteers were data analysed found infected rate in 2009 – 2010 were 113.33, 106.66 per 100000and developing Community Participation for Effective Management Dengue in Fort ThepsatriSrisunthon (CPEDM) project with two purposes which are 1) continuous destruction of breeding sites 2) sustainable environmental management as follows: Proactive implementation of environmental management in the short term to reduce breeding sites. Fort ThepsatriSrisunthon hospital along with a women community volunteers campaign to prevent dengue. Fort ThepsatriSrisunthon hospital and military leaders improving physical aspects at offices every Wednesday. When The Environmental Working committee found reduction of breeding sites, this project was extend to the community. Therefore, the community was united in action and had spirit to destroy the breeding sites weekly. Woman community volunteers monitor container index(CI) and house index(HI) monthly, hospital staff audit every three months, and publicize the data to the community throughout by public dissemination such as cable television, radio stations, and advertising cars. Create a network of environmental management by all sectors to the environmental sustainability. Fort ThepsatriSrisunthon hospital, District Public Health Network and local government organizations targeted to control the disease, district level campaign. Fort ThepsatriSrisunthon hospital, military leaders, army wives clubs and the community coordinate to waste management from offices was expanded to the community by waste separation in households to reduce waste and recycle waste by establishing a recycling bank. Waste management, landfill disposal waste, fermented garbage waste, fertilizer residues to organic soil. Modified degraded forest to growing economy palm trees. Management of basins to vegetable gardens and condo salad by army forces and army wives clubs.

 3. How did the initiative solve the problem and improve people’s lives?
The violent situation among three provinces of Southern Thailand caused soldiers to maintain peace in those areas at least 6 months per year. This situation is affect to women regarding the burden of care homes and family members in all aspects. Therefore, it is found that women who are army wives gather in to a group and clubs in order to support each other. Women community's volunteer groups are primarily have an idea to ally themselves with the Fort ThepsatriSrisunthon hospital for prevention and control dengue under the context of areas. All strategies using for prevention and control of the CPEDM project were planned by the team which comprised of the leaders of the military camps and housewife clubs. In addition, a district-level committee and sub-committees were set to solve environmental problems in both formal and informal occasions. Improvement of public space by troops and residential community and surrounding areas by households, monitoring results by community committees monthly and feedback to adjust the strategies.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Prevention and control of dengue project was conducted in 2 phases as follows; Phase I in 2009, Fort ThepsatriSrisunthon hospital collected morbidity data dengue found an infection rate of 113.33 per 100000, which is expected to outbreak in 2010. The hospital with women community volunteers started the campaign to prevention and control disease during the rainy season in May and reactive monitor infected rate, container index, house index. As a result in 2010, the team found an infection rate was 106.66 per 100000 and did not achieve project goals. Phase II in 2011, Fort ThepsatriSrisunthon hospital with women community volunteers analysed community context and culture from environmental community survey. They found that there are breeding site indoors and outdoors with a basin and forest degradation. Housing is a consecutive row surrounding with basin .Children need to study in schools 20km away from the city which has a chance to bring dengue fever to the community. The population education level was mostly lower secondary schools, so they usually lack of access to information and health awareness. Behavioural aspects, there is waste management, but it does not cover the area and is not discrete. The disposal method piled together in a particular area, makes it conducive to mosquito breeding sources. Elimination of breeding sites was not performed consistently during the campaign of health agencies only. Therefore proactive action by Fort ThepsatriSrisunthon hospital along with other networks occurred. The team decided to start the Awareness Campaign since February 2011onwards with the support of local government budget. Waste management activities in the office are organized every Wednesday by Fort ThepsatriSrisunthon hospital and military leaders. At first, waste recycling units are established which are open every Wednesday but there are the amount of waste at pool areas which do not have waste separation. In 2012, collaborated with agencies in the community and proactive monitoring monthly. Fort ThepsatriSrisunthon, military leaders and army wives community volunteer expand the environmental management from office to the community. There is a commitment to environmental management, waste separation, recycle waste to household income, wet waste was fertilized to be used in vegetable demonstration of bio-based units, applied effective microorganism (EM) to be a general purpose cleaner such as dish washing, liquid bathroom used in hospitals and offices for reduced rates of using chemicals. Waste from composting bio to build a fertilizer, residues of fermented mixed with other organic materials such as rice husk, grass, leaves, coir, soil to make soil organic and used in households, economic forests or bags to sell. Improve the basin to crops and vegetables. Divide the space of military units of arable areas to take advantage of space for those who earn less as sufficiency farmers. In 2013, nontoxic vegetable consumption culture occurs in the community. A learning centre was established to provide an environmental management model for young people. As a result of local administrative organization, high school and graduate students visited to study environmental management.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The Thai military is responsibility for the Fort ThepsatriSrisunthon area, which has Fort ThepsatriSrisunthon hospital as the health care agency responsible for soldiers, their families, and the public in the area according to the ministry of defence and ministry of public health policy. In this area, local government supports policies and budgets. The implementation of the initiatives main goal is holistic health care of the military community at Fort ThepsatriSrisunthon to meet the community requirements of health promotion and treatment is the final stage of health care caused the cooperation of all sectors. First, Fort ThepsatriSrisunthon hospital launched an initiative in a meeting of the camp. Educated women community volunteers, heads of household, troops and practices in destroy breeding sites, self-care prevention. Fort ThepsatriSrisunthon hospital, military leaders and army wives club called “Three-Team Coordination”collaborated to complete environmental management to establish a recycling bank, waste separation from households. Furthermore, hospitals collaborated with a network of public health and local government targets in disease control at the district level, the district level campaign plan, community leaders monitored community disease surveillance, women community volunteers proactive monitoring breeding sites, house index and container index monthly and reflected data back to the community to adjust their operations.
 6. How was the strategy implemented and what resources were mobilized?
To complete the initiative we asked for collaborative in the area both inside and outside the army, in terms of budget and personnel, with the goal to reduce dengue infection and community well-being. In the budget, local administration support for mosquito pesticide (1%Temephos sand granule). Fort ThepsatriSrisunthon hospital distributed to the community. The Army Medical Department supports oil and smog spraying chemicals, Fort ThepsatriSrisunthon hospital fogging the infected reported area with a radius of 100 meters. The campaign activity is supported by the National Health Security Office (NHSO). Media support is provided by the provincial public health Office in Nakhon Sithammarat. Fort ThepsatriSrisunthon hospital supports surveillance teams, patient care teams, health promoting teams in the area. Military leaders support environmental committees and troops to develop degraded forest and basin areas. Woman community volunteers monitor indicators. The network public health disease control targeting at level district and SRRT team support if necessary. Local governments plan to campaign at local level.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Phase I, The result of prevention and control of dengue in 2009 - 2010are infected rate 113.33 and 106.66 per 100000 which exceed the target of not more than 50 per 100000. Phase II, Change reactive to proactive operation by the networks, in cooperation with the hospital officers result to indicator decreased. Fort ThepsatriSrisunthon meets the community health management criteria by health agencies from HI, CI and infected rate not exceed the target. In 2011-2013, hospital data query satisfaction rates of soldiers and their families are increased by 80.05%, 83.33% and 83.89%, respectively. There is the cooperation of three units in the network; Fort ThepsatriSrisunthon hospital, military units and army wives called "Three-Team Coordination".The output from the activity in this phase is reducing the cost of the treatment, reducing the cost of oil and chemicals from the Army Medical Department to 183,134 baht per year, a good environmental management model of the organization so as to reduce the burden of waste disposal. In 2014, the hospital along with woman community volunteers monitor the infected rate of 6.67 per 100000, not exceed goals (50 per 100000) larvae index (HI 18.6, CI 7.1) does not exceed goals ( HI <50, CI <10).Dengue infection rate less when compared with adjacent area infection rate are 6.67, 145, 76 and 77 per 100000 in Fort ThepsatriSrisunthon, Kangpla district, Kapang district and Klongtook district respectively. Not secondary infections were found, no dengue related deaths were noted in the area.

 8. What were the most successful outputs and why was the initiative effective?
Phase I, in 2009-2010 Fort ThepsatriSrisunthon hospital reactive monitoring infected rates from patient access and women community volunteers monitored larvae indices monthly but cannot control the epidemic of Dengue because of inaccurate time of control. Phase II, in 2011, monitor areas at risk. Women community volunteers proactive monitored larvae indices monthly. Hospital officer was data analysed areas at risk of dengue monthly and audit every 3 months, monitoring infected rate, number of fogging and monitor compliance with the principles of prevention found that principles were not continuous. Military leaders established a recycling bank for waste management which opened weekly and monitored the deposit of recycled waste by an environmental committee but still has waste retention in the house to solve it by collecting recycled waste at home. In 2012, monitor progress of waste management. Environmental committee monitored the points and the progress of economic vegetable beds weekly. In 2013, monitor the knowledge and practice of DHF. Fort ThepsatriSrisunthon hospital with women community volunteers educated and monitored the knowledge and practice of the community. The score of knowledge and practice in DHF protection were high, as detail: The knowledge about symptoms of dengue is high fever, headache, bored with food and red spots on the arms, legs and torso, which is 98.5% correct answered. Operating on dengue, 100%sleeping under mosquito nets or bed in a room every day, practice the principle of prevention is 83.33%. The suggestions are environmental management in basin and degraded forest. Fort ThepsatriSrisunthon hospital with women community volunteers monitored infective rates, larvae indices compared to the standard of the Ministry of Health and reported back in network meetings formally and informally monthly. Random checking of breeding sites every three months in working units. Report data to public health district, The Army Medical Department, and medical commander of the 4th army area to use as a comparison, in the district and national levels. Hospital officer monitored the use of resources supported by other agencies, including personnel, budget, chemical and fogging and sent a summary report to the army medical department to investigate the results. The system records the data using computer networks in the hospital. Sent patient information by documents, phone, and email through the district health office daily and the information were forwarded to the Office of Public Health and Center for Disease Control to analyse patient data reported in different areas.

 9. What were the main obstacles encountered and how were they overcome?
Firstly, the implementation of prevention and control dengue in Phase I failed to achieve its goals because reactive management, communities do not have participation in planning and implementation and agencies work split. Secondly, there are not have a person mainly taking care of space and residential areas between consecutive rows of houses. Indeed, army wives whose husband works outside not have knowledge of environmental management. This may result from the Fort ThepsatriSrisunthon hospital requested cooperation of military leaders to manage that area instead of the householders. Thirdly, inaccessibility of surrounding area of Fort ThepsatriSrisunthon where are an area of deep degraded forest and basins. To overcome this problem, we just only educated communities how to prevent mosquito bites during the pandemic and sleep in closed rooms or under mosquito nets via cable TV and broadcasting cars. Fourthly, some groups did not cooperate with the project implementation. The solution to improve environmental management gradually persuaded by neighbours, divided into zones setting committees from the residents of the same row, residents in each row and the committee from area outside the camp to participate in a contest rating of environmental scores compared to the different area before and after the development and continuous improvement results. Finally, the physical structure of incorrect slope drainage behind houses is a source basin, an inactive large water tank waiting for approved destruction.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The implementation of CPEDM to continuous destruction of breeding sites and sustainable environmental management in driving proactive by the networks caused the following results. Health aspect, infected rated decreased (in 2013-2014 are 98 and 6.67 per 100000), house index decreased(in 2013-2014 are 20.42 and 18), container index decreased (in 2013-2014 are 7.3 and 7.1)In 2014, infected rate6.67 per 100000 declined compared to implementing the project in Phase I and less than adjacent areas which are Kangpla district, Kapang district, BanKlongtook (In 2014 infected rate are 145, 76 and 77 per 100000. Not found mortality rate, not found secondary patients group. A learning centre was established in the community for sustainable environmental management through community participation. As they change and develop the area which reduce of breeding site. There are non-toxic vegetable garden demonstrations of military units. For example condo salad, vegetable gardens of the household. There are also soil organic plant managed by community and supported by military leaders. Nowadays, the community can growth their income by selling their product such as multi-purpose liquid products, soil organic fertilizer of army wives group amount 144,000 baht/year and non-toxic vegetables amount 4,500 baht/month and the last is reduction of breeding sites. The integrated network of health promoting agencies in the community was occurred. There are consist of health agencies, military units, and local authorities including women’s community volunteers whose have a different duties for continue the project. Fort ThepsatriSrisunthon hospital feedbacks promotion, coordination and consulting projects, military leaders and subordinates are responsible for managing people, and area of responsibility and army wives, woman community volunteer take care of household families and the area around the house. The Tree Team coordinated run by Fort ThepsatriSrisunthon hospital was initiated, military leaders continue to practice and personnel support. Army wives/woman community volunteers monitor and report data in the community. Three networks work together, coordinate and support each other. They can spin the wheel of development dynamically. The activities include helping children with disabilities in the community, helping army wives and their families who are affected. In summary, the most important result of the CPEDM project is appearing holistic health care in the community. Furthermore, this project can generate the positive effect on good environment and health aspects.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
CPEDM is a health promoting project by collaboration between local community agencies for the same purpose is the prevention and control of dengue fever can be as sustainable by; A learning centre was established as a community environmental management model calling “ThepsatriSrisunthon Model”. The excellent model was sharing and encouraging others organizations to develop their work. In addition, this model becomes a learning centre for academic institutions of all levels, Network working at district-level, committee carried out and pushed a public policy on environmental management. Continuously created social responsibility awareness and ownership of health by destroying breeding sites. Disease surveillance, larvae index monitoring in the community by hospital and women community volunteers monthly. Environmental Management in CPEDM Project can be applied in tropical and subtropical areas where dengue is a problem. This fits with a small community which have a strong leader and sufficient human resources groups in term of health leaders, community leaders and community volunteers.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Lessons learned from the project in Phase I can be reduced the duration of action in 2009-2010 if all agencies work together. In Phase II: Regarding the project, it could be emphasised that in Phase II of the project, we can learn that the health care teams are not necessary to be a leaders all the time when we need to do this project. The leaders both community and woman community volunteers can manage the problem of dengue by themselves since initial phases. As a result, an effective government–community partnerships can be occurred and being sustainable. The lessons learned from the program operation are the most significant change resulting from this project. There was three team coordinate approached which were working together with communities and other key agencies in order to resolve the problems coming from their mutual concern. There was a shift away from an exclusively ‘government’ approach to one of dialogue, negotiation and partnership to resolve environmental sanitation and vector control problems. One consequence of this change was that dengue control programs should broadened their responsibility beyond mosquito control, and adopted a more flexible, relied on local context approach. Furthermore, shifting from reactive to proactive approach resulting in prevention and control of dengue in a suitable time so that it can make a positive effect to health, social and economic aspects.

Contact Information

Institution Name:   Fort ThepsatriSrisunthon hospital
Institution Type:   Government Agency  
Contact Person:   Suppaluk Wongwisansri
Title:   Facilitator of Quality Center, Fort ThepsatriSrisu  
Telephone/ Fax:   +(66)75495250, +(66)75495276-8 ext. 45065
Institution's / Project's Website:  
Address:   181 moo 11, tambon Kapang
Postal Code:   80310
City:   Thongsong
State/Province:   Nakhon si Thammarat

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