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Preventing Zika Infection in Pregnant Women

NEEDS ASSESSMENT
A. Introduction to the request and Overall Program Goal
Project HOPE, which stands for Health Opportunities for People Everywhere, reflects the goal of the organization clearly in its name. Project HOPE was founded in 1958, and within those past five decades of service, it supports the idea of providing long-term and sustainable health solutions to people, and communities, in need. The mission of Project HOPE is to “enable health workers to have the greatest positive impact on the health of the people they serve”, which encompasses our vision of having “a world where everyone has the health care needed to reach life’s full potential”.31 This strong foundation the organization is based on is supported by their specialized services and programs, to include medical training, health education, and humanitarian assistance programs, which helps in addressing new health threats around the world, as well as in developing solutions alongside the health care professional of the community in need.31 We are requesting $50,000 to address the Zika epidemic in Rio de Janeiro, Brazil. Our health objective for the program is to reduce the incidence of Zika among pregnant women age 15-45, living in Rio de Janeiro, by 10% within one year.
B. Background of the Health Problem
Zika is primiarly known as being a vector-borne disease, spread by mosquito bites from infected mosquitos (Aedes aegypti and Aedes albopictus), however it is also transmitted through sex and from a pregnant woman to her fetus.44 The first reported cases of the Zika virus in Brazil was in 2014, from then the number of cases increased exponentially through 2015 and 2016. The magnitude of the outbreak in the country led to a cease in the case count of Zika virus, however it is estimated that from the start of the outbreak between 497,593 – 1,482,701 cases have occurred according to the Brazilian national authorities.41 There has been a 14-fold decrease in the number of weekly cases between EW 1 and 22 of 2017 compared to the same period in 2016, regardless, the number of cases are still the highest in the world with an average of 776 weekly reported cases in 2017.29 In 2017, states located in the North and Central-West region of Brazil showed the highest Zika virus incidence rates in the country. The state of Rio de Janeiro had the second highest cumulative incidence rate in the country with 419 cases per 100,000 population.29
Zika virus is specifically a major threat for pregnant women living in high-risk Zika regions because of the fetus complications associated with the infection. From 2016 through 2017, there were a reported total of 26,066 suspected Zika virus cases in pregnant women in Brazil.29 Of those suspected cases, 11,546 were confirmed by the Brazil Ministry of Health. The Ministry also reported a total of 14,558 suspected cases of microcephaly, along with other central nervous system congenital malformation associated with Zika virus infection between 2015 and 2017. In 2017 there were 2,952 confirmed cases of Zika virus-related microcephaly, a huge negative impact of Zika virus.29
C. Social Assessment of the Problem
Rio de Janeiro is one of the largest cities in Brazil, second largest to be exact, with a population size of 6.45 million in 2016. It is also the third largest metropolis on the continent of South America. It is the capital city of the state Rio de Janeiro, which is located in the southeastern part of the country along the Atlantic Ocean.34 The population of the city is made up of people of African, European (Portuguese, Spanish, and Italian), and Asian descent.30 Of the total population in Rio de Janeiro, as mentioned before, there are 26,066 suspected Zika virus infected pregnant women cases and of those nearly half, 11,546, were confirmed.29
Poverty is a huge concern in Rio de Janeiro, and all over Brazil. The Brazilian Institute of Geography and Statistics reported in December of 2017 that 25% of the population in Brazil live below the poverty line.12 According to the 2010 Brazilian census, 22.03% of the population of Rio de Janeiro live in favelas, which are poor communities, or slums, within the city.20 Favelas are associated with inequalities in health, education, and housing infrastructure forming a huge disadvantage for the people living there.  A study done in 2006 in Rio de Janeiro on the health inequalities in socioeconomically disadvantaged areas, especially favelas, discusses the relationship between individuals with socioeconomic instability and stress, which leads to increased risk of health condition, which include “depression and anxiety, heart disease, obesity, drug addiction, violence, and premature morality”.37
Individuals who has contracted Zika virus infection experience symptoms such as, fever, skin rash, muscle and/or joint pain, headache, and red eyes. The virus’s most serious threat comes to pregnant women who have contracted Zika and transmitted the infection to their fetus.44 Zika virus is associated with congenital microcephaly, a condition where the infant’s head is unusually smaller than an expected infant, contributing to an insufficient development in their brain. Due to this, this condition is linked to developmental delays and issues as they child grows older.11 This complication creates high-levels of psychological stress among pregnant women because of the chances of having a child with a malformation. Not only that, but the fear in those women of abandonment by their partners with the birth of a child with disabilities. This leaves the women to face the costly burden, both financially and emotionally, of raising a child with disabilities associated with Zika virus-related microcephaly.22,33 The infant with disabilities are linked to poverty, poor health, and school exclusion throughout their lifetime. The stresses and difficulties associated with Zika virus-related microcephaly decreases the quality of life for both mother and child.22
D. Epidemiologic Assessment of the Problem
Death by Zika virus infection is uncommon, but the complications from spreading the infection from a pregnant woman to her fetus lead to negative effects. There are many health factors that contribute to the transmission of Zika virus from one individual to another. Addressing those issues, and forming solutions to tackle the problem, helps reduce the number of infected pregnant women. There is no genetic, biological, or physiological risk factors associated with Zika virus. Prenatal risk factors are only linked to the fetus of the pregnant women infected, there are no other prenatal risk factors for the target population of pregnant women.44 There are however many environmental and behavioral risk factors associated with Zika virus. Environmental risk factors are characteristics in pregnant women living in Rio de Janeiro life that increases their likelihood of contracting Zika virus. The first risk factor is living in areas where the Zika virus is endemic. Brazil is the most infested country in South America with both Ae. aeypti and Ae. albopictus inhabiting all states in the country due to its favorable temperature and diurnal temperature range throughout the country.22
Another environmental risk factor is traditional water storage practices and standing water. Collecting rain water is a common practice, especially in lower socioeconomic communities because of the lack of access to running water. Studies done in Rio de Janiero have shown those households with lack of access hoard water in large containers that provide ideal mosquito-breeding sites, increasing the risk of contracting Zika virus.14
Rio de Janiero has experienced rapid urbanization within the last few years, however the city does not have the resources to support the growing population; as a result, many live in favelas and communities of low socioeconomic status. There are nearly 2 million people living in favelas in Rio de Janiero. These communities have poor infrastructure, overcrowding, lack of access to piped water, and poor sanitary conditions.22,24 These factors are favorable conditions for mosquitos and for the proliferation of mosquito-breeding sites, which can lead to the rapid spread of diseases throughout the community.22 Pregnant women faced with any of these environmental risk factors have an increased risk of contracting Zika virus infection.
There are two main behavioral factors that should be addressed when tackling the transmission of Zika virus: unprotected sex and the use of personal protective measures. Zika virus is spread through sexual contact, so it important to be responsible and wear condoms or refrain from sex to avoid transmission. Zika infected individuals can sometimes be asymptomatic but are still capable of spreading the virus to their sex partners. It is important to be mindful of sexual partners who visit or live in high risk Zika areas, especially in the case of pregnant women because of the high chances of the contraction of Zika virus.6
Personal protective measures such as wearing long-sleeved tops and long pants and using specialized insect repellents. Wearing protective clothing that covers large surface areas of the body helps reduce skin exposure for mosquitos to bite. Also, treating clothing with permethrin, a synthetic insecticide, helps reduce the risk of being bit by Zika-infected mosquitos. Insect repellents are crucial as well to help avoid disease-carrying mosquitos. It is important for insect repellents to include at least one active ingredient, of which could include DEET, picaridin, IR3535, oil of lemon eucalyptus or para-menthane-diol, or 2-undecanone. These repellents are both safe and effective for pregnant women as well.44
 
E. Educational and Ecological Assessment
There are several underlying factors affecting this population that contribute to their behavioral risks described above and ultimately the health problem of Zika infections. These factors may be divided into three categories including, predisposing, reinforcing, and enabling factors. Predisposing factors are a person’s knowledge, attitude, values, beliefs, or perceptions that contribute to his/her motivation to change. These factors for our target population include lack of knowledge of the benefits of condoms, lack of self-efficacy/confidence to use condoms, lack of knowledge of protective and preventive measures against mosquitos, belief that violence and poverty are a more imminent threat to their well-being, and communal belief system that associates condom use with prostitution and disease. Consider for example that feminists have attempted for many years to disassociate use of condoms with disease or prostitution; this stigma is decades old yet there remains advancement to be made in order to bring down barriers to sound and appropriate teaching on the benefits of safe sex practices in preventing sexually transmitted diseases. These types of long standing beliefs contribute to more women in our target population being at risk for infection with the Zika virus through sexual intercourse. It’s evident in the fact that although more than seventy percent of Brazilian women ages 15 to 54 who are sexually active with a male partner use contraception, less than two percent of them actually use condoms.
Enabling factors may facilitate or impede performance of health behaviors; they can be described as the skills that individuals in the population have and the resources available to them. For our target population, these factors include paucity of health education programs within schools and community centers, limited access to condoms, and limited access to protective and preventive measures against mosquitos (i.e repellents and nets). One study conducted by Calazans et al found that females who receive less education, who are not working, or are associated with a low economic status were less likely to use condoms. These women have little to no access to basic education and that, unfortunately, becomes a systemic norm; they remain uneducated, untrained, and with little confidence to practice for themselves behaviors that may have a positive impact their health.
Reinforcing factors may be anything that strengthen or weaken an individual’s continuation of the health behaviors. Examples of this in our target population include the community’s culture and beliefs about condoms, the social norms of collecting rainwater, and peers using mosquito nets improperly. Several studies have shown the positive effects that structured teaching through seminars and discussions among peers can have on their practice of safe sex. This also informs our understanding of the reality that the norms that exist among the peers does influence the behaviors of that population. Unfortunately, that means the norms may encourage a behavior that is detrimental to their health. However, this also means that it leaves a window within which we can make significant impact by promoting behavioral changes that will ultimately contribute to decrease in Zika infections within our target population.
F. Summary and Synthesis of Need
According to the CDC Foundation, preventing and responding to infectious diseases are essential parts in public health work.5 Fortunately, in our world today, we have the ability to do exactly that. It is therefore, with this ethical obligation in mind and in keeping with the Millennium Developmental Goals four (i.e. reduce childhood mortality rates) and five (i.e. improve maternal health) that we make this call to arms to prevent the spread of the Zika infection in pregnant women, living in Rio de Janeiro—the second largest city in a country where a quarter of the population lives below the poverty line.35 The severity of the consequences of Zika infection outlined above are undeniable. Hundreds of thousands of cases of Zika were being reported in just the span of a year. The outbreak of Zika in Brazil was identified in late 2014, but by the start of 2016, there had already been over 3500 suspected cases of Zika-related microcephaly. Also, in that time, there was increasing prevalence of suspected microcephaly-related deaths caused by Zika. For example, states with confirmed Zika virus transmission had 2.8 cases per 10,000 live births versus 0.6 cases per 10,000 live births in states without confirmed Zika virus transmission.7 Additionally, there have been evidence of serious neurologic sequelae such as Guillain-Barre Syndrome.13,25 The people in Rio de Janeiro will face grave outcomes from this disease if this pattern persists. Therefore, there is a need for action.
While there is a growing number of information on Zika available, there are no programs aimed at reaching our specific target population and with the same approach to empower through use of the behavioral theory to be discussed later. There is especially a need to reach those who are from the economically disadvantaged neighborhoods as they are less likely to have received knowledge that can enable them to feel confident in practicing behaviors that are beneficial to their health. The current state of the healthcare system leaves the community wanting for essential resources to take action toward preventive health behaviors. We have the power to intervene, to invest in establishing infrastructure in terms of personnel and places, and transportation to create an atmosphere that encourages learning and empowerment to act.
G. Administrative and Policy Assessment
For over 20 years, Project HOPE has carried out programs to prevent, manage, and control infectious diseases. Their capacity to address the Zika health problem is strong as they have many assets that have been used in previous projects. Some resources already in place include partnership with Ministries of Health, community-wide education programs on infectious diseases and sexually transmitted diseases.32 As such, there is no shortage of trained staff, however funding is needed to support the staff financially and to assure that the educational materials needed are readily available.
The healthcare system in Rio de Janeiro is in dire conditions and has chronic problems of resource shortages including funding, medications, and adequate pay for staff, among other things. Compounded onto this grave reality is the health inequalities that exist among the socially and economically disadvantaged individuals in the population. Although Brazil has universal health care, access to these medical services are limited due largely in part to the under-funding of these services and institutions. A system like this cannot sustain the impact of a health problem like the Zika outbreak and its aftermath without outside assistance. Through our community inventory (found in appendix), we identified an organization in Brazil known as the Center for Health Promotion (CEDAPS). Since 2004, CEDAPS coordinates the Network of Healthy Communities in Rio de Janeiro and includes more than 100 community groups and organizations. Given its existing role in the community, this organization can help us identify other potential partnerships we can form and whether there are any duplications in our proposed work. Moreover, there is network of community health educators made up of women who live in favelas; this is a pool from which we can potentially
H. Proposed Solution to Address Need
Our proposed solution to address the Zika health problem is to communicate the seriousness of this disease and its complications to the target population and to promote personal protective measures through community education programs. As outlined in the priority-scoring matrix and the decision matrix that are in the appendix, we found that lack of knowledge of the benefits of condom usage and self-efficacy to use condoms as well as the lack of available educational community programs are very important underlying factors that we could realistically improve upon and that our organization has the capacity to address. There are also systemic problems (e.g. poor health care system, community’s culture and beliefs about condoms) that contribute to the issue at hand, however, any attempt to fix these problems in our one-year program would be futile as they require an approach with more breadth and depth. Given the body of evidence that strongly supports the need for increased knowledge on condom usage and benefits and the known facts on vector and mode of transmission of this disease, our decision is to prioritize those underlying factors that will be most impactful towards behavioral changes to reduce incidence of Zika infections in pregnant women.
PROGRAM DESIGN
A. Program Objectives and Description
Based on the needs assessment for our program, we have identified some priority factors in which will be targeted in the intervention. To address these factors, we will focus on reaching the target population in a community-based setting, such as a clinic, where we will implement methods to reach the goal of the Zika virus health program.

  1. Overarching Program Goal
  • The program goal is to raise awareness of Zika infection in high-risk communities by providing education and resources for prevention and protection to reduce the number of Zika cases amongst pregnant women
  1. Long-Range Health Objective
  • To reduce the incidence of Zika among pregnant women age 15-45, living in Rio de Janeiro Brazil, by 10 percent within one year.

3. Intermediate Objective:

  • Increase adherence to safe sex practices (condom usage) among pregnant women age 15-45, living in Rio de Janeiro Brazil, by 20 percent within six months.
  • Increase use of personal protective measures against mosquito bites among women ages 15-45, living in Rio de Janeiro Brazil by 20 percent within six months.
  1. Process Objectives:
  • To conduct two, two-hour educational sessions per week for pregnant women ages 15-45, living in Rio de Janeiro within 3 months.

The educational sessions will be broken up in two parts; 1) Educational background and prevention strategies to avoid contracting the Zika virus, 2) Application and Review. These two sessions will be conducted on Tuesdays (Part 1) and Thursdays (Part 2), every week for 3 months. The sessions will take place in different community centers, schools, and/or clinics each week across Rio de Janeiro in order to reach and educate pregnant women across the whole city. The sessions will be delivered by trained nurses, who will educate the women on the importance of condom usage and personal protective measures, like insect repellents and long selves, and create awareness of the consequences associated with Zika infection, such as microcephaly in fetus. In the second session the women will practice proper condom usage to increase their self-efficacy and use of condoms during sex, consistently and correctly.26 Dr. Artur Timerman, an Brazilian epidemiologist working on the Zika outbreak since 2015, has been researching the similarity of Zika Virus to HIV in regard to sexual transmission. Community mobilization, such as educational campaigns and community outreach for HIV have been effective is reducing legal barriers, misinformation, and stigma associated with HIV, this type of community mobilization he says is needed to overthrow the Zika virus as well.38
Output Objective: 18 educational sessions will be conducted over the course of 3 months.

  • To distribute 4,000 condoms to pregnant women ages 15-45, living in Rio de Janeiro within 3 months.

Condoms are crucial to preventing Zika spread among sexual partners, especially to pregnant women because it is transmissible through.15 The CDC’s issued Zika Virus outbreak guidelines, focusing on the sexual transmission of the virus to encourage abstinence or condom usage to prevent the spread.26 The nurses will distribute 160 condoms after the completion of each educational session. This will encourage the 1,500 women attendees to immediately practice what they’ve learned during the sessions.
Output Objective: 4,000 condoms will be distributed to pregnant women at the end of 3 months.

  • To distribute 2,000 Zika infection prevention educational brochures in clinics and physician offices to pregnant women ages 15-45 living in Rio de Janeiro within 3 months.

Trained volunteers will distribute Zika infection prevention educational brochures for two purposes; First, to provide educational material to pregnant women in order to create awareness of the importance of protecting themselves against Zika virus, and second, to inform them about the educational sessions available to them, where they can receive free condoms and mosquito repellent with DEET after each session to protect themselves. Volunteers will distribute brochures in clinics and physician offices, mostly OB/GYN offices in order to reach the most pregnant women possible. A Zika virus communication preference study in Atlanta, Georgia, showed that pregnant women preferred educational information in the form of brochures second to direct obstetric provider advice. Unfortunately, many providers don’t have sufficient time to inform and discuss every concern with every patient, so educational brochures can fill that gap of patient knowledge.10
Output Objective: 2,000 brochures to pregnant women

  • To distribute 3,000 bottles of mosquito repellents with DEET to pregnant women ages 15-45, living in Rio de Janeiro within 3 months.

Repellents help prevent Zika virus and other mosquito-borne diseases. Studies have been done comparing the efficacy of mosquito repellents. Among 11 different mosquito repellents, the repellents which contained DEET were more effective in repelling mosquitos. Mosquito repellents containing DEET, are also safe for the use among pregnant women, which is extremely important in regard to our target population.36 After the completion of the educational sessions, the nurses holding the session will distribute 120 mosquito repellents with DEET to encourage and promote its usage among the attendees
Output Objective: 3,000 bottles of mosquito repellents to pregnant women
Immediate Objective:

  • Increase awareness and perceived susceptibility of Zika infection among pregnant women age 15-45, living in Rio de Janeiro Brazil by 40% within 3 months.
  • Increase self-efficacy of condom usage to prevent Zika infection among women ages 15-45, living in Rio de Janeiro Brazil by 40% within 3 months.
  • Increase knowledge of the benefits of personal protective measures against mosquito bites among women ages 15-45, living in Rio de Janeiro by 40% within 3 months.
  • Increase number of available personal protective equipment to prevent mosquito bites among women ages 15-45, living in Rio de Janeiro by 40% with 3 months.

B. Grounding in Behavioral Theory
The Health Belief Model (HBM) has been around since the 1950’s, and since then has been the most widely used psychological model to explain and predict health behaviors.  The rationale of using this model for this program is that it often used as a framework for mosquito-borne disease interventions and sexually transmitted diseases to understand and help modify behaviors. Many Dengue, another mosquito-borne vector disease, interventions in South America and other tropical areas of the world, with similar climates as Brazil, have used this model to support their program.40 The HBM is made up of six constructs: 1) perceived susceptibility, 2) perceived severity, 3) perceived benefits, 4) perceived barriers, 5) cues to action, and 6) self-efficacy.18 The original model only contains the first four constructs, which affirms the individual’s perceptions on the targeted disease. The latter two constructs were added later to establish an individual’s readiness and confidence to modify their behaviors.18 The Theory Operationalization Table located in the appendix expands on the reasoning and support behind each construct in the HBM for this program.
Perceived susceptibility is the individual’s opinion of their chances of contracting the disease, in our case the Zika virus.18 In Brazil, the state of Rio de Janeiro had the second highest cumulative incidence rate in the country with 419 cases per 100,000 population in 2017.43 These high numbers increase an individual’s susceptibility. In a Dengue study done in Malaysia, participants mentioned that their perceived susceptibility increased when someone they knew contracted the disease.40 Dengue is another mosquito-borne disease that comes from the same species of mosquito as Zika. Interventions for one mosquito-borne disease can be used for another because of the same preventive measures and control strategies. In the same study, the participants also claimed that because Aedes mosquitos are the only mosquitos that transmit dengue, even if one is bitten, it doesn’t guarantee disease contraction. Lastly, the misconception that a strong body defense system will protect against contracting mosquito-borne diseases decreases an individual’s perception of susceptibility to the disease.40 In regard to sexual transmission, married women believe they have a low susceptibility of contracting Zika through sex because they trust their husbands. However, infidelity is possible, and risky behaviors with other women can bring home infection.1 Nurses will be trained on these perceptions and address them in the educational sessions, as well as educate the women on prevention strategies.
Perceived severity is defined as an individual’s belief of the seriousness of the condition and what its consequences are to them.18 Zika Virus is linked with congenital malformation in the fetuses of pregnant women who have contracted Zika, such as microcephaly.15This is a huge consequence that increases perceived severity among pregnant women. Microcephaly is associated with developmental delays and issues as the child grows older, which creates high-levels of psychological stress among pregnant women who bear a child with a malformation, but the social stress put on them by their partners and friends.43Trained nurses will address these issues during the educational sessions in order to well inform the women attendees.
Perceived benefits is the next construct of the model. This construct refers to an individual’s belief in the effectiveness of the advised behavioral change action is in reducing the risk and/or seriousness of the disease impact.18 Trained nurses in the program’s educational sessions will discuss the benefits of condoms usage to avoid contracting Zika virus through sex, and the use of personal protective measures, like using mosquito repellent with DEET and wearing long selves shirts and pants in reducing the risk of Zika infection through mosquito bites. This is especially important for our target population, pregnant women, because in turn it minimizes the chance of fetal malformations, i.e. microcephaly.44
The perceived barriers construct suggests that although people may be willing to make health behavior changes, they are less likely to act if they believe that there are factors impeding their ability to move forward with those changes.10,13 In the case of our target population, location of our education sessions may pose an inconvenience for the women due to transportation. Moreover, this population is predominantly of a conservative background in terms of religious preferences. This may present a barrier for them to have open dialog regarding sexual activities and/or to accept the types of interventions we are proposing to reduce transmission of the Zika virus (i.e. condom usage), as it may be perceived as promoting sex outside of marriage. Given that our educational sessions will be at locations that may not necessarily be readily accessible for all individuals in the target population, the program will include transportation in the form of a bus from a common pickup location to the site of our sessions. We will enlist the help of person of faith with influence in the community to make every effort possible to assure that our methods of transmission prevention are addressed with the appropriate cultural sensitivity.
The construct cues to action refers to indicators that prompt individuals to act; they may be internal or external.15,27 In the case of our target population, external cues may include declarations of public health emergency by the ministry of health, news of infection incidences, and accounts of the sequelae that follow including microcephaly, Guillain-Barre syndrome, and eye infections.1,7 Internal cues may include symptoms like fever, headache, and rash concerning for Zika infection.45 Our program will have a component that focuses on campaign efforts like public service announcements through the television, radio, and places of worship within the community. This form of campaigning will be instrumental in establishing and actively promoting cues to action essential in our efforts to reduce incidence of Zika infection in pregnant women.
Self-efficacy, being one of the more recent adopted constructs is a bit less developed, but essentially it refers to a person’s perception of his/her ability to confidently and successfully perform the health behavior.15,27 Given our understanding of the Zika virus and how it is spread, we recognize the importance of training individuals in our target population to be confident in using the recommended methods of prevention. Our program aims to increase their confidence level to perform the interventions that are key to preventing the spread of the Zika virus through didactic and experiential learning, thus decreasing its incidence in pregnant women.
C. Theory of Action and Logic Model
The following theories of action, illustrated by the logic model in the appendix, borrow from the health belief model and shows how our program will be effective at addressing the problem of Zika virus infections in the target population through the inputs and activities and result in our predicted outcomes.

  1. If we train nurses to teach using a CDC-approved curriculum on prevention of Zika virus infections, then we can develop a program of didactic and hands-on teaching sessions for pregnant women living in Rio de Janeiro.
  2. If community health workers are trained to do one-on-one outreach in clinics using brochures about Zika virus, then we can increase awareness about Zika and generate more interest in our teaching sessions.
  3. If through didactic and experiential teaching sessions, and one-on-one clinic outreach we increase knowledge and awareness about Zika infection, then we will increase the target population’s perceived susceptibility to and perceived severity of Zika virus infection.
  4. If we can demonstrate the importance of using condoms during sexual intercourse, then we can increase the target population’s perceived benefits of practicing safe sex.
  5. If we can demonstrate the importance of using personal protective equipment against mosquito bites, then we can increase the target population’s perceived benefits of using personal protective measures against mosquitos.
  6. If we increase women’s awareness of their perceived threat of Zika virus infection and their perceived severity of the disease, remove perceived barriers to engaging in preventive measures, and increase awareness of the perceived benefits of using condoms and protecting against mosquito bites, then women will have a cue to action to and be more likely to engage in safe sex practices and use personal protective measures against mosquitos.
  7. If women are more likely to engage in safe sex practices and use personal protective measures against mosquitos, then it will decrease the incidence of Zika among pregnant women age 15-45, living in Rio de Janeiro Brazil.

 
IMPLEMENTATION PLAN
Phase 1: Staff Recruitment and Training, Program Development
The Zika Virus Program is a one-year health promotion program in Rio de Janeiro, Brazil, starting in May and ending in May of the following year. The program will begin with hiring the staff needed to run the program successfully. First, the Program Director (PD) will be chosen, this individual is crucial for the success of the program. The PD will be required to be bilingual, English/Portuguese, in order to bridge information to the English-speaking supporting organizations (Project Hope and The Rotary) and the Portuguese-speaking staff working on the program. The PD will also help hire the Nurses, Outreach Coordinator, Community Health Workers (CHW), Evaluator, and the Bus Driver to ensure a strong staff is selected that coincides with the mission and goals of the program. After the desired staff is hired, they will be trained in Zika Virus background and prevention strategies, as well as counseling, outreach, and teaching skills to help the target population better receive and retain important information regarding their health, their child’s health, and Zika Virus. Proper training is an important foundational step to a successful health promotion program. Hiring and training staff will be covered in the first two months of the program.
In the first month of the program, following staff selection and training, the development of the evaluation plan and instruments will commence. A pre- and post-test will be created using a scale of 1-5 to rate the women’s opinion of the program and what they’ve learned. The pre/post-test will be exactly the same and will be administered before the educational session starts and at the very end as well. There will also be some multiple-choice questions in order to truly test their knowledge to see if there is improvement following the session.
In the second month of the program, will be the development of outreach brochures and organizing all the materials needed for the Zika Virus educational sessions. The Centers for Disease Control and Prevention (CDC) is a great resource for both the brochures and session materials because there are available printable fact sheets and educational posters with Zika basic information, transmission, prevention and control strategies, and pregnancy risks.45 The State of New Jersey Department of Health also has printable educational material available on their website in Portuguese.42 This array of available material holds all the information needed for the program in regard to paper material. This material will also be used to develop material that will be projected on a screen during the educational sessions. This allows the women attendees to collectively follow along, while also having a physical copy for hands on learners and for everyone to take home with them.
Phase 2: Community Outreach
From July to September, the volunteer CHWs will distribute the educational brochures to OB/GYN offices and maternity clinics in Rio de Janeiro to reach out and inform pregnant women one-on-one on the risks associated with Zika infection, and to get them interested in the educational sessions available to them. The two CWHs will each cover four clinics and work two days a week in order to reach different women each time.
Phase 3: Participant Education
During the same period, July through September (nine weeks) there will be Zika educational sessions twice a week for the pregnant women to learn and ideally implement new behaviors to reduce their risk of Zika infection. The Nurses will be leading the sessions. Snack food and beverages will be provided as an incentive to come and participate in the sessions, free condoms and mosquito repellents will also be incentives to stay until the very end. The Nurses will hand out and keep record on the number of attendees and products handed out at each session. A bus driver will also be available to get women to and from the sessions.
The budget for the program, as provided by the Rotary Foundation through their global grants, is $200,000.17 The personnel needed for the program accounts for $106,790. The fringe benefits for the personnel are 18%.  Other costs, which includes consultants, local travel, equipment, rent, supplies, printing and reproduction, and participant refreshments, comes out to $59,300. Combining all the costs, the total funding requested is $182,699. The supplies, which includes condoms and mosquito repellents with DEET, and refreshments are necessary to incentivize the women to come to the sessions and stay to the end. The equipment is crucial for the learning experience for the women. Having a projector to project the educational images and information from the laptop works as a visual aid of the information the Nurses are discussing. The Budget Justification located in the Appendix elaborates more on the reasoning behind the costs.
Phase 4: Evaluation
The purpose of the evaluation is to determine whether the Zika Virus health promotion program will reduce the number of pregnant women with Zika infection. We are interested in determining if adherence to safe sex practices, such as condom use and if the use of personal protective measures against mosquito bites will reduce the number of pregnant women with Zika. The data collection process requires IRB review because the information comes from human subjects, in this case pregnant women ages 15-45 living in Rio de Janeiro, Brazil that attend the educational sessions.8 This information will then be distributed as reports to the supporting organization, Project HOPE, and the funder, the Rotary Foundation to help contribute to generalizable knowledge for future programs.8
Each woman participating in the educational sessions will take a survey as the arrive before the session begins, and after the session before they leave. This pre/post-test will determine the women’s opinion of the session and their perceived knowledge by asking them to rank themselves on a scale of 1-5 (5 being the best) on questions related to Zika Virus, such as their knowledge, perceived susceptibility/severity, and self-efficacy on condom usage. There will also be a multiple-choice question section that will determine what they learned from the session, ideally improving in their results in the post-test. The Nurses with gather the surveys at each session over the course of the nine weeks dedicated to educational sessions.
There will also be a follow-up post-test 6 months after the last week of education sessions (month 9 of the program) administered by the Nurses. This will be the exact same survey used as the pre/post-test during each educational session. The purpose of this to measure their education retention and continued adherence to the Zika protective and preventive measures discussed in the sessions.
The evaluator selected for the program with interpret the data collected from the surveys after the completion of the all educational sessions. This analysis will help determine the strength of the program and how well the educational information influenced the women attending the sessions. During the last month of the program, the evaluator will interpret the data collected during the follow-up post-test to analyze the educational retention of the women and the adherence to the suggested Zika protective and preventative measures, such as correct and consistent use of condoms and use of mosquito repellent with DEET. Reports will be generated after the initial data collection analysis and for the follow-up post-test done at the end as well. The evaluator will then process and combine these reports to be analyzed together in order to determine the effect of the program as a whole. Analysis and generated reports will be computed through SPSS.
After the generation of each of the reports, the evaluator will pass the information on to the Program Director, who will then inform the supporting organization, Project HOPE, and the funder, the Rotary Foundation, on the progress and effects of the program. The final report will be reported to both organizations also in order to determine the success of the program in addressing the program objectives. The organizations can also use the program reports to contribute in determining adjustments where necessary in the program to help future Zika Virus health promotion programs in regions needing to address the ongoing battle of Zika Virus.
Management Plan
Staffing Plan
The program staff will include the Program Director, the Outreach Coordinator, evaluator, nurses, CHW, and bus driver. The work plan for the staff may be found in the appendix. The director will oversee the whole program, perform all administrative duties, and supervise the staff; all staff will report to this person. (S)he will report directly to the organization and the funder. This person will be someone with a master’s (preferably) and at least 5 years of managerial experience. This person will also demonstrate competency in project management software and Microsoft Office Suite, and be bilingual in Portuguese.
The Outreach Coordinator will be someone who has at least 3 years of experience in health-related programming, community outreach and other related areas as well as be competent in Microsoft Office Suite. (S)he will be responsible for securing the sites for program activities and in charge of all promotional materials and teaching supplies for program activities including brochures, teaching equipment, incentive items, and printed materials for promoting the program’s activities. (S)he will assist the Program Director as needed with staffing arrangements for clinic outreach efforts and teaching sessions.
The personnel who will teach at the teaching sessions must be registered nurses with two or more years of experience and preferably with previous experience in community health or related field. These individuals must possess excellent verbal communication skills and interpersonal skills as well as be bilingual in Portuguese. They will be responsible for implementing the Zika prevention curriculum at the teaching sessions through didactic and experiential instruction. Furthermore, they will be responsible for collecting data on the number of attendees and the number of post-session incentives handed out. They will support the coordinator as needed with preparation of materials for the teaching sessions.
Community Health workers must have at least two years of experience conducting community outreach or providing health-related education or promotion services and excellent interpersonal skills. They will be responsible for visiting their assigned clinics each week with pamphlets to hand out to prenatal patients in the waiting areas and for encouraging the women to attend the teaching sessions and/or stop by the office if they require more assistance.
The Program Evaluator must possess a Master’s in Public Health with at least four years of experience in program evaluation. This person will be responsible for the complete process of evaluation including, design, data collection instruments, analysis of data, and reporting of findings. The bus driver must have a valid license and be in good standing. (S)he will be responsible for driving program participants in the target population to and from teaching sites and a common pick up location.



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