Community participation in malaria control in Tigray region Ethiopia

Primary healthcare delivery models in African conflict-affected settings: a systematic review

BACKGROUND

In conflict-affected settings, access to primary healthcare for displaced populations is constrained by multiple challenges. These include geographical, cultural, communication, logistical and financial barriers, as well as risks posed to health workers and the population by insecurity. Different models of care are used to provide primary healthcare to affected communities. However, there is a paucity of evidence on how these models are selected and implemented by organisations working in conflict and displacement-affected settings. Our aim was to explore the different primary healthcare delivery models used in conflict-affected settings to understand gaps in existing healthcare delivery models.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The review protocol was registered with the International Prospective Register of Systematic Reviews. We searched six databases for manuscripts published from January 1992 to December 2020. Publications were included if they reported primary healthcare models of care in conflict-affected settings of Africa. Data was analyzed descriptively and thematically using tables, charts and text.

RESULTS

Forty-eight primary research articles were included for analysis from which thirty-three were rated as "high" quality. The results showed that the models of care in place in these conflict-affected settings include health facility-based, community-based, mobile clinics, outreach and home visits. Primary healthcare for internally displaced persons and refugees is provided by a wide range of actors including national and international organisations. A range of services is offered, most commonly nutrition, mental health and sexual/reproductive health. Some organisations offer vertical (stand-alone) services, while others use an integrated service delivery model. Multiple cadres of healthcare workers provide services, frequently lay healthcare workers such as Community Health Workers.

CONCLUSION

Understanding the different modalities of primary healthcare delivery in conflict-affected settings is important to identify existing practices and gaps in service delivery. Service delivery using community health workers in conflict-affected settings is a low-cost primary care delivery strategy that may help optimize contributions of existing personnel through task shifting.

Epidemic malaria dynamics in Ethiopia: the role of self-limiting, poverty, HIV, climate change and human population growth

Background

During the last two decades, researchers have suggested that the changes of malaria cases in African highlands were driven by climate change. Recently, a study claimed that the malaria cases (Plasmodium falciparum) in Oromia (Ethiopia) were related to minimum temperature. Critics highlighted that other variables could be involved in the dynamics of the malaria. The literature mentions that beyond climate change, trends in malaria cases could be involved with HIV, human population size, poverty, investments in health control programmes, among others.

Methods

Population ecologists have developed a simple framework, which helps to explore the contributions of endogenous (density-dependent) and exogenous processes on population dynamics. Both processes may operate to determine the dynamic behaviour of a particular population through time. Briefly, density-dependent (endogenous process) occurs when the per capita population growth rate (R) is determined by the previous population size. An exogenous process occurs when some variable affects another but is not affected by the changes it causes. This study explores the dynamics of malaria cases (Plasmodium falciparum and Plasmodium vivax) in Oromia region in Ethiopia and explores the interaction between minimum temperature, HIV, poverty, human population size and social instability.

Results

The results support that malaria dynamics showed signs of a negative endogenous process between R and malaria infectious class, and a weak evidence to support the climate change hypothesis.

Conclusion

Poverty, HIV, population size could interact to force malaria models parameters explaining the dynamics malaria observed at Ethiopia from 1985 to 2007.

Participation by conflict-affected and forcibly displaced communities in humanitarian healthcare responses: A systematic review

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The moderate quantity and quality of evidence indicate benefits from community participation.

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There was limited evidence on involvement of communities in framing problems or designing solutions.

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There was inadequate engagement with the construct of community participation and power relations.

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There was extremely weak evidence on participation by forcibly displaced communities.

Background

Community participation in health responses in humanitarian crises is increasingly promoted by humanitarian actors to support adoption of measures that are relevant and effective to local needs. Our aim was to understand the role of community participation in humanitarian health responses for conflict-affected populations (including forcibly displaced populations) in low- and middle-income countries and the barriers and facilitators to community participation in healthcare responses.

Methods

Using a systematic review methodology, following the PRISMA protocol, we searched four bibliographic databases for publications reporting peer-reviewed primary research. Studies were selected if they reported how conflict-affected populations were involved in healthcare responses in low- and middle-income settings, and associated changes in healthcare responses or health outcomes. We applied descriptive thematic synthesis and assessed study quality using study design-specific appraisal tools.

Results

Of 18,247 records identified through the database searching, 18 studies met our inclusion criteria. Various types of community participation were observed, with participation mostly involved in implementing interventions rather than framing problems or designing solutions. Most studies on community participation focused on changes in health services (access, utilisation, quality), community acceptability and awareness, and ownership and sustainability. Key barriers and facilitators to community participation included political will at national and local level, ongoing armed conflict, financial and economic factors, socio-cultural dynamics of communities, design of humanitarian responses, health system factors, and health knowledge and beliefs. Included studies were of mixed quality and the overall strength of evidence was weak. More generally there was limited critical engagement with concepts of participation.

Conclusion

This review highlights the need for more research on more meaningful community participation in healthcare responses in conflict-affected communities, particularly in framing problems and creating solutions. More robust research is also required linking community participation with longer-term individual and health system outcomes, and that critically engages in constructs of community participation.

Community health workers in humanitarian settings: Scoping review

Background

There is a need for greater understanding of experiences implementing community-based primary health care in humanitarian settings and of the adjustments needed to ensure continuation of essential services and utilization of services by the population, and to contribute to effective emergency response. We reviewed the evidence base on community health workers (CHWs) in humanitarian settings, with the goal of improving delivery of essential services to the most vulnerable populations.

Methods

We conducted a scoping review of published and grey literature related to health and nutrition services provided by CHWs in humanitarian settings. Extracted data from retained documents were analyzed inductively for key themes.

Results

Of 3709 documents screened, 219 were included in the review. Key findings from the literature include: 1) CHWs were often able to continue providing services during acute and protracted crises, including prolonged periods of conflict and insecurity and during population displacement. 2) CHWs carried out critical emergency response activities during acute crises. 3) Flexible funding facilitated transitions between development and humanitarian programming. 4) Communities that did not have a locally-resident CHW experienced reduced access to services when travel was limited. 5) Community selection of CHWs and engagement of respected local leaders were crucial for community trust and acceptance and high utilization of services. 6) Selection of local supervisors and use of mobile phones facilitated continued supervision. 7) Actions taken to maintain supplies included creating parallel supply chains, providing buffer stocks to CHWs, and storing commodities in decentralized locations. 8) When travel was restricted, reporting and data collection were continued using mobile phones and use of local data collectors. 9) CHWs and supervisors faced security threats and psychological trauma as a result of their work.

Conclusions

To achieve impact, policy makers and program implementers will have to address the bottlenecks to CHW service delivery common in stable low-income settings as well as the additional challenges unique to humanitarian settings. Future interventions should take into account the lessons learned from years of experience with implementation of community-based primary health care in humanitarian settings. There is also a need for rigorous assessments of community-based primary health care interventions in humanitarian settings.

Delivering maternal and neonatal health interventions in conflict settings: a systematic review

BACKGROUND

While much progress was made throughout the Millennium Development Goals era in reducing maternal and neonatal mortality, both remain unacceptably high, especially in areas affected by humanitarian crises. While valuable guidance on interventions to improve maternal and neonatal health in both non-crisis and crisis settings exists, guidance on how best to deliver these interventions in crisis settings, and especially in conflict settings, is still limited. This systematic review aimed to synthesise the available literature on the delivery on maternal and neonatal health interventions in conflict settings.

METHODS

We searched MEDLINE, Embase, CINAHL and PsycINFO databases using terms related to conflict, women and children, and maternal and neonatal health. We searched websites of 10 humanitarian organisations for relevant grey literature. Publications reporting on conflict-affected populations in low-income and middle-income countries and describing a maternal or neonatal health intervention delivered during or within 5 years after the end of a conflict were included. Information on population, intervention, and delivery characteristics were extracted and narratively synthesised. Quantitative data on intervention coverage and effectiveness were tabulated but no meta-analysis was undertaken.

RESULTS

115 publications met our eligibility criteria. Intervention delivery was most frequently reported in the sub-Saharan Africa region, and most publications focused on displaced populations based in camps. Reported maternal interventions targeted antenatal, obstetric and postnatal care; neonatal interventions focused mostly on essential newborn care. Most interventions were delivered in hospitals and clinics, by doctors and nurses, and were mostly delivered through non-governmental organisations or the existing healthcare system. Delivery barriers included insecurity, lack of resources and lack of skilled health staff. Multi-stakeholder collaboration, the introduction of new technology or systems innovations, and staff training were delivery facilitators. Reporting of intervention coverage or effectiveness data was limited.

DISCUSSION

The relevant existing literature focuses mostly on maternal health especially around the antenatal period. There is still limited literature on postnatal care in conflict settings and even less on newborn care. In crisis settings, as much as in non-crisis settings, there is a need to focus on the first day of birth for both maternal and neonatal health. There is also a need to do more research on how best to involve community members in the delivery of maternal and neonatal health interventions.

PROSPERO REGISTRATION NUMBER

CRD42019125221.

Knowledge and practice of health extension workers on drug provision for childhood illness in west Gojjam, Amhara, Northwest Ethiopia

Background

The HEP was established decades ago to address preventive, promotive and selective curative services through Health Extension Workers (HEWs). However, knowledge and practice of HEWs on drug provision for childhood illnesses such as diarrhea, fever, and/or acute respiratory infection have not been well studied. This study aimed to assess the knowledge and practice of HEWs on drug provision for childhood illnesses.

Methods

An institutional-based cross-sectional study was conducted among 389 rural HEWs. The districts were selected by using simple random sampling technique, and all the HEWs in the districts were included in the study. Bivariable and multivariable logistic regressions were performed to see the association between knowledge and practice of HEWs on drug provision with the response variables.

Results

The study revealed that 57.5 and 66.8% of HEWs had good knowledge and practice on drug provision for childhood illnesses, respectively. Having college diploma (AOR = 5.59; 95% CI: 1.94, 16.11), 7–9 years (AOR = 2.7; 95% CI: 1.3, 5.5) and 10–12 years (AOR = 2.7; 95% CI: 1.4, 5.4) of experiences, being supervised quarterly (AOR = 0.24; 95% CI: 0.13, 0.47) and biannually (AOR = 0.11; 95% CI: 0.04, 0.30), and having national guideline (AOR = 0.22; 95% CI: 0.06, 0.90) were factors significantly associated with good knowledge. In addition, having college diploma (AOR =3.1; 95% CI: 1.1, 8.8), not receiving refreshment training (AOR = 0.31; 95% CI: 0.11, 0.91), being supervised biannually (AOR = 0.32, 95% CI: 0.13, 0.80), and not having national guideline (AOR = 0.16, 95% CI: 0.04, 0.60) were factors significantly associated with good practice.

Conclusion

The study indicated that a considerable number of HEWs had poor knowledge and practice on drug provision. Socio-demographic factors such as educational status, and work experience; and health systems and support related factors such as training, supervision, and availability of national guidelines, and training had a significant association with HEWs’ knowledge and practice on drug provision. Therefore, designing appropriate strategy and providing refreshment training, and improving supervision and availability of national guidelines for HEWs might improve the knowledge and practice of HEWs on drug provision.

Delivering infectious disease interventions to women and children in conflict settings: a systematic reviefw

BACKGROUND

Conflict has played a role in the large-scale deterioration of health systems in low-income and middle-income countries (LMICs) and increased risk of infections and outbreaks. This systematic review aimed to synthesise the literature on mechanisms of delivery for a range of infectious disease-related interventions provided to conflict-affected women, children and adolescents.

METHODS

We searched Medline, Embase, CINAHL and PsychINFO databases for literature published in English from January 1990 to March 2018. Eligible publications reported on conflict-affected neonates, children, adolescents or women in LMICs who received an infectious disease intervention. We extracted and synthesised information on delivery characteristics, including delivery site and personnel involved, as well as barriers and facilitators, and we tabulated reported intervention coverage and effectiveness data.

RESULTS

A majority of the 194 eligible publications reported on intervention delivery in sub-Saharan Africa. Vaccines for measles and polio were the most commonly reported interventions, followed by malaria treatment. Over two-thirds of reported interventions were delivered in camp settings for displaced families. The use of clinics as a delivery site was reported across all intervention types, but outreach and community-based delivery were also reported for many interventions. Key barriers to service delivery included restricted access to target populations; conversely, adopting social mobilisation strategies and collaborating with community figures were reported as facilitating intervention delivery. Few publications reported on intervention coverage, mostly reporting variable coverage for vaccines, and fewer reported on intervention effectiveness, mostly for malaria treatment regimens.

CONCLUSIONS

Despite an increased focus on health outcomes in humanitarian crises, our review highlights important gaps in the literature on intervention delivery among specific subpopulations and geographies. This indicates a need for more rigorous research and reporting on effective strategies for delivering infectious disease interventions in different conflict contexts.

PROSPERO REGISTRATION NUMBER

CRD42019125221.

Community based integrated vector management for malaria control: lessons from three years' experience (2016-2018) in Botor-Tolay district, southwestern Ethiopia

BACKGROUND

Integrated vector management (IVM) remains a key strategy in the fight against vector-borne diseases including malaria. However, impacts of the strategy should be regularly monitored based on feedback obtained through research. The objective of this study was to assess the impact of IVM for malaria control in Botor-Tolay district, southwestern Ethiopia after three years (2016-2018) of IVM implementation.

METHOD

Prior to the implementation of IVM, a survey of socio-demographic, malaria burden, and communities' perception towards malaria control was conducted in 200 households selected at random from 12 villages using standard questionnaire. Households were revisited after three years of project implementation for impact assessment. Compiled malaria case data was obtained from district health bureau for the three years period of the study while adult mosquito collection was conducted during each year using CDC light traps. Monthly larval mosquito collections were made each year using standard dipping method. Community education and mobilization (CEM) was made through different community-based structures.

RESULTS

The proportion of respondents who sought treatment in health facilities showed a significant increase from 76% in 2015 to 90% in 2018(P < 0.001). An average of 6.3 working and 2.3 school days were lost per year in a household due to parents and children falling sick with malaria. Malaria costs in a household in Botor-Tolay averaged 13.3 and 4.5 USD per episode for medical treatment and transportation respectively. Significantly fewer adult mosquitoes were collected in 2018 (0.37/house/trap-night) as compared to 2015 (0.73/house/trap-night) (P < .001). Malaria cases significantly declined in 2018 (262) when compared to the record in 2015 (1162) (P < 0.001). Despite improved human behavioral changes towards mosquito and malaria control, there were many setbacks too. These include reluctance to seek treatment in a timely manner, low user compliance of LLINs and low net repairing habit.

CONCLUSION

The coordinated implementation of community-based education, environmental management, larviciding together with main core vector control interventions in Botor-Tolay district in Southwestern Ethiopia have contributed to significant decline in malaria cases reported from health facilities. However, commitment to seeking treatment by people with clinical symptoms of malaria and to repair of damaged mosquito nets remained low.

Strengthening primary health care at district-level in Malawi - determining the coverage, costs and benefits of community-directed interventions

Background

Community-Directed Interventions (CDI) is a participatory approach for delivery of essential healthcare services at community level. It is based on the values and principles of Primary Health Care (PHC). The CDI approach has been used to improve the delivery of services in areas that have previously applied Community-Directed Treatment with ivermectin (CDTi). Limited knowledge is available about its added value for strengthening PHC services in areas without experience in CDTi. This study aimed to assess how best to use the CDI approach to strengthen locally identified PHC services at district level.

Methods

This was a comparative intervention study carried out over a period of 12 months and involving four health centres and 16 villages assigned to 1) a conventional Essential Health Package (EHP)/PHC approach at health centre level or 2) an EHP/PHC/CDI approach at community level in addition to EHP/PHC at health centre level. Communities decided which intervention components to be included in the intervention. These were home management of malaria (HMM), long lasting insecticide treated nets (LLIN), vitamin A and treatment against schistosomiasis. The outcomes of the two strategies were compared quantitatively after the intervention was completed with regard to intervention component coverage and costs. Qualitative in-depth interviews with involved health professionals, implementers and beneficiaries were carried out to determine the benefits and challenges of applied intervention components.

Results

Implementation of the EHP/PHC/CDI approach at community level as an add-on to EHP/PHC services is feasible and acceptable to health professionals, implementers and beneficiaries. Statistically significant increases were observed in intervention components coverage for LLIN among children under 5 years of age and pregnant women. Increases were also observed for HMM, vitamin A among children under 5 years of age and treatment against schistosomiasis but these increases were not statistically significant. Implementation was more costly in EHP/PHC/CDI areas than in EHP/PHC areas. Highest costs were accrued at health centre level while transport was the most expensive cost driver. The study identified certain critical factors that need to be considered and adapted to local contexts for successful implementation.

Conclusion

The CDI approach is an effective means to increase accessibility of certain vital services at community level thereby strengthening delivery of EHP/PHC services. The approach can therefore complement regular EHP/PHC efforts.

Trial registration

The study was retrospectively registered with the Pan African Clinical Trial Registry TRN: PACTR201903883154921.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4341-5) contains supplementary material, which is available to authorized users.

Community-based surveillance: A scoping review

Background

Involving community members in identifying and reporting health events for public health surveillance purposes, an approach commonly described as community-based surveillance (CBS), is increasingly gaining interest. We conducted a scoping review to list terms and definitions used to characterize CBS, to identify and summarize available guidance and recommendations, and to map information on past and existing in-country CBS systems.

Methods

We searched eight bibliographic databases and screened the worldwide web for any document mentioning an approach in which community members both collected and reported information on health events from their community for public health surveillance. Two independent reviewers performed double blind screening and data collection, any discrepancy was solved through discussion and consensus.

Findings

From the 134 included documents, several terms and definitions for CBS were retrieved. Guidance and recommendations for CBS were scattered through seven major guides and sixteen additional documents. Seventy-nine unique CBS systems implemented since 1958 in 42 countries were identified, mostly implemented in low and lower-middle income countries (79%). The systems appeared as fragmented (81% covering a limited geographical area and 70% solely implemented in a rural setting), vertical (67% with a single scope of interest), and of limited duration (median of 6 years for ongoing systems and 2 years for ended systems). Collection of information was mostly performed by recruited community members (80%).

Interpretation

While CBS has already been implemented in many countries, standardization is still required on the term and processes to be used. Further research is needed to ensure CBS integrates effectively into the overall public health surveillance system.

Housing gaps, mosquitoes and public viewpoints: a mixed methods assessment of relationships between house characteristics, malaria vector biting risk and community perspectives in rural Tanzania

BACKGROUND

House improvement and environmental management can significantly improve malaria transmission control in endemic communities. This study assessed the influence of physical characteristics of houses and surrounding environments on mosquito biting risk in rural Tanzanian villages, and examined knowledge and perceptions of residents on relationships between these factors and malaria transmission. The study further assessed whether people worried about these risks and how they coped.

METHODS

Entomological surveys of indoor mosquito densities were conducted across four villages in Ulanga district, south-eastern Tanzania. The survey involved 48 sentinel houses sampled monthly and other sets of 48 houses randomly recruited each month for one-off sampling over 12 months. Physical characteristics of the houses and surrounding environments were recorded. Questionnaire surveys were administered to 200 household heads to assess their knowledge and concerns regarding the observed housing and environmental features, and whether they considered these features when constructing houses. Focus group discussions, were conducted to clarify emergent themes on people's perceptions on relationships between housing or environmental factors and malaria transmission.

RESULTS

The entomological surveys showed statistically higher indoor densities of the malaria vectors (Anopheles arabiensis and Anopheles funestus) in houses with mud walls compared to plastered or brick walls, open eaves compared to closed eaves and unscreened windows compared to screened windows. Most respondents reported that their houses allowed mosquito entry, at least partially. Participants were aware that house structure and environmental characteristics influenced indoor mosquito densities and consequently malaria transmission. They were concerned about living in poorly-constructed houses with gaps on eaves, walls, windows and doors but were constrained by low income.

CONCLUSION

In rural south-eastern Tanzania, significant proportions of people still live in houses with open eaves, unscreened windows and gaps on doors. Though they are fully aware of associated mosquito biting and pathogen transmission risks, they are constrained by low-income levels. The study proposes that community-based house improvement initiatives combined with targeted subsidies could lower the financial barriers, improve access to essential construction materials or designs, and significantly accelerate malaria transmission control in these communities.

Impact of Irrigation Extension on Malaria Transmission in Simret, Tigray, Ethiopia

Poor subsistence farmers who live in a semi-arid area of northern Ethiopia build irrigation systems to overcome water shortages. However, there is a high risk of malaria transmission when increased standing water provides more favorable habitats for mosquito breeding. This is a serious problem because there are many barriers to malaria control measures and health care systems in the area. Using a causal loop diagram and computer simulations, the author attempted to visually illustrate positive and negative feedbacks between mosquito and human populations in the context of Simret, which is a small village located in northern Ethiopia and is generally considered a malaria-free area. The simulation results show that the number of infectious mosquitos increases to 17,215 at its peak, accounting for 3.5% of potentially dangerous mosquitos. At the same time, the number of sick people increases to 574 at its peak, accounting for 15% of local population. The malaria outbreak is controlled largely because of a fixed number of vulnerable people or local population that acts as an intermediate host.

A review of generalist and specialist community health workers for delivering adolescent health services in sub-Saharan Africa

BACKGROUND

The health of adolescents is increasingly seen as an important international priority because the world's one point eight billion young people (aged 10 to 24 years) accounts for 15.5% of the global burden of disease and are disproportionately located in low- and middle-income countries (LMICs). Furthermore, an estimated 70% of premature adult deaths are attributable to unhealthy behaviors often initiated in adolescence (such as smoking, obesity, and physical inactivity). In order for health services to reach adolescents in LMICs, innovative service delivery models need to be explored and tested. This paper reviews the literature on generalist and specialist community health workers (CHWs) to assess their potential for strengthening the delivery of adolescent health services.

METHODS

We reviewed the literature on CHWs using Medline (PubMed), EBSCO Global Health, and Global Health Archive. Search terms (n = 19) were sourced from various review articles and combined with subject heading 'sub-Saharan Africa' to identify English language abstracts of original research articles on generalist and specialist CHWs.

RESULTS

A total of 106 articles, from 1985 to 2012, and representing 24 African countries, matched our search criteria. A single study in sub-Saharan Africa used CHWs to deliver adolescent health services with promising results. Though few comprehensive evaluations of large-scale CHW programs exist, we found mixed evidence to support the use of either generalist or specialist CHW models for delivering adolescent health services.

CONCLUSIONS

This review found that innovative service delivery approaches, such as those potentially offered by CHWs, for adolescents in sub-Saharan Africa are lacking, CHW programs have proliferated despite the absence of high quality evaluations, rigorous studies to establish the comparative effectiveness of generalist versus specialist CHW programs are needed, and further investigation of the role of CHWs in providing adolescent health services in sub-Saharan Africa is warranted.

A community-based education trial to improve backyard poultry biosecurity in rural Cambodia

The emergence and spread of Highly Pathogenic Avian Influenza H5N1 has caused substantial poultry-related economic losses and public health concerns in relation to a potential pandemic. While biosecurity measures for commercial poultry industry are of the highest standards, these measures are difficult to implement and often unaffordable for backyard poultry farming, particularly in tropical and low-income settings. We designed a feasible biosecurity intervention to improve flock hygiene in Cambodia, - based on community hygiene, cleaning of poultry flock areas and human and poultry movement control. We conducted a cluster randomized and controlled intervention trial in 18 villages in Takeo province to evaluate improvements in biosecurity-related knowledge and practices. The intervention relied on community involvement and community education using special information dissemination tools. We trained village teams (VT) to assist villagers in implementing the intervention using a cascade training approach, in which a few individuals were trained, who in turn trained a larger group of people. During the 14 month follow up, we conducted observational and interview-based surveys (baseline vs. final surveys, VT supervision visits, monitoring surveys) to assess VTs' motivation, intervention messages dissemination and the implementation of recommended measures. Most of villagers (95%, confidence interval: 87.8-100.0%) in intervention villages received general information about how to raise poultry. Farmers in intervention villages reported to have made more changes (≥1 biosecurity related practice during the study period) compared with that of control villages (70.0% (260/372) vs. 22.6% (85/377), p value<0.01). When observing biosecurity-related practices in intervention villages, overall scores increased significantly (p<0.05). Practices such as use of quarantine cages for new and sick birds, limitation of people movement in backyards and waste management reached high scores during the 15-months period within five of the nine intervention villages. Cascade training managed to reach out to almost all villagers and significantly influence changes in biosecurity practices in the community. However, further follow-ups are needed to assess whether practices-related changes persist over a longer period of time.

Community perceptions on malaria and care-seeking practices in endemic Indian settings: policy implications for the malaria control programme

BACKGROUND

The focus of India's National Malaria Programme witnessed a paradigm shift recently from health facility to community-based approaches. The current thrust is on diagnosing and treating malaria by community health workers and prevention through free provision of long-lasting insecticidal nets. However, appropriate community awareness and practice are inevitable for the effectiveness of such efforts. In this context, the study assessed community perceptions and practice on malaria and similar febrile illnesses. This evidence base is intended to direct the roll-out of the new strategies and improve community acceptance and utilization of services.

METHODS

A qualitative study involving 26 focus group discussions and 40 key informant interviews was conducted in two districts of Odisha State in India. The key points of discussion were centred on community perceptions and practice regarding malaria prevention and treatment. Thematic analysis of data was performed.

RESULTS

The 272 respondents consisted of 50% females, three-quarter scheduled tribe community and 30% students. A half of them were literates. Malaria was reported to be the most common disease in their settings with multiple modes of transmission by the FGD participants. Adoption of prevention methods was seasonal with perceived mosquito density. The reported use of bed nets was low and the utilization was determined by seasonality, affordability, intoxication and alternate uses of nets. Although respondents were aware of malaria-related symptoms, care-seeking from traditional healers and unqualified providers was prevalent. The respondents expressed lack of trust in the community health workers due to frequent drug stock-outs. The major determinants of health care seeking were socio-cultural beliefs, age, gender, faith in the service provider, proximity, poverty, and perceived effectiveness of available services.

CONCLUSION

Apart from the socio-cultural and behavioural factors, the availability of acceptable care can modulate the community perceptions and practices on malaria management. The current community awareness on symptoms of malaria and prevention is fair, yet the prevention and treatment practices are not optimal. Promoting active community involvement and ownership in malaria control and management through strengthening community based organizations would be relevant. Further, timely availability of drugs and commodities at the community level can improve their confidence in the public health system.

Primary Health Care in rural Malawi - a qualitative assessment exploring the relevance of the community-directed interventions approach

Background

Primary Health Care (PHC) is a strategy endorsed for attaining equitable access to basic health care including treatment and prevention of endemic diseases. Thirty four years later, its implementation remains sub-optimal in most Sub-Saharan African countries that access to health interventions is still a major challenge for a large proportion of the rural population. Community-directed treatment with ivermectin (CDTi) and community-directed interventions (CDI) are participatory approaches to strengthen health care at community level. Both approaches are based on values and principles associated with PHC. The CDI approach has successfully been used to improve the delivery of interventions in areas that have previously used CDTi. However, little is known about the added value of community participation in areas without prior experience with CDTi. This study aimed at assessing PHC in two rural Malawian districts without CDTi experience with a view to explore the relevance of the CDI approach. We examined health service providers’ and beneficiaries’ perceptions on existing PHC practices, and their perspectives on official priorities and strategies to strengthen PHC.

Methods

We conducted 27 key informant interviews with health officials and partners at national, district and health centre levels; 32 focus group discussions with community members and in-depth interviews with 32 community members and 32 community leaders. Additionally, official PHC related documents were reviewed.

Results

The findings show that there is a functional PHC system in place in the two study districts, though its implementation is faced with various challenges related to accessibility of services and shortage of resources. Health service providers and consumers shared perceptions on the importance of intensifying community participation to strengthen PHC, particularly within the areas of provision of insecticide treated bed nets, home case management for malaria, management of diarrhoeal diseases, treatment of schistosomiasis and provision of food supplements against malnutrition.

Conclusion

Our study indicates that intensified community participation based on the CDI approach can be considered as a realistic means to increase accessibility of certain vital interventions at community level.

The architecture and effect of participation: a systematic review of community participation for communicable disease control and elimination. Implications for malaria elimination

BACKGROUND

Community engagement and participation has played a critical role in successful disease control and elimination campaigns in many countries. Despite this, its benefits for malaria control and elimination are yet to be fully realized. This may be due to a limited understanding of the influences on participation in developing countries as well as inadequate investment in infrastructure and resources to support sustainable community participation. This paper reports the findings of an atypical systematic review of 60 years of literature in order to arrive at a more comprehensive awareness of the constructs of participation for communicable disease control and elimination and provide guidance for the current malaria elimination campaign.

METHODS

Evidence derived from quantitative research was considered both independently and collectively with qualitative research papers and case reports. All papers included in the review were systematically coded using a pre-determined qualitative coding matrix that identified influences on community participation at the individual, household, community and government/civil society levels. Colour coding was also carried out to reflect the key primary health care period in which community participation programmes originated. These processes allowed exhaustive content analysis and synthesis of data in an attempt to realize conceptual development beyond that able to be achieved by individual empirical studies or case reports.

RESULTS

Of the 60 papers meeting the selection criteria, only four studies attempted to determine the effect of community participation on disease transmission. Due to inherent differences in their design, interventions and outcome measures, results could not be compared. However, these studies showed statistically significant reductions in disease incidence or prevalence using various forms of community participation. The use of locally selected volunteers provided with adequate training, supervision and resources are common and important elements of the success of the interventions in these studies. In addition, qualitative synthesis of all 60 papers elucidates the complex architecture of community participation for communicable disease control and elimination which is presented herein.

CONCLUSIONS

The current global malaria elimination campaign calls for a health systems strengthening approach to provide an enabling environment for programmes in developing countries. In order to realize the benefits of this approach it is vital to provide adequate investment in the 'people' component of health systems and understand the multi-level factors that influence their participation. The challenges of strengthening this component of health systems are discussed, as is the importance of ensuring that current global malaria elimination efforts do not derail renewed momentum towards the comprehensive primary health care approach. It is recommended that the application of the results of this systematic review be considered for other diseases of poverty in order to harmonize efforts at building 'competent communities' for communicable disease control and optimising health system effectiveness.

Social and cultural factors affecting uptake of interventions for malaria in pregnancy in Africa: a systematic review of the qualitative research

Background

Malaria during pregnancy (MiP) results in adverse birth outcomes and poor maternal health. MiP-related morbidity and mortality is most pronounced in sub-Saharan Africa, where recommended MiP interventions include intermittent preventive treatment, insecticide-treated bednets and appropriate case management. Besides their clinical efficacy, the effectiveness of these interventions depends on the attitudes and behaviours of pregnant women and the wider community, which are shaped by social and cultural factors. Although these factors have been studied largely using quantitative methods, qualitative research also offers important insights. This article provides a comprehensive overview of qualitative research on social and cultural factors relevant to uptake of MiP interventions in sub-Saharan Africa.

Methods and Findings

A systematic search strategy was employed: literature searches were undertaken in several databases (OVID SP, IS Web of Knowledge, MiP Consortium library). MiP-related original research, on social/cultural factors relevant to MiP interventions, in Africa, with findings derived from qualitative methods was included. Non-English language articles were excluded. A meta-ethnographic approach was taken to analysing and synthesizing findings. Thirty-seven studies were identified. Fourteen concentrated on MiP. Others focused on malaria treatment and prevention, antenatal care (ANC), anaemia during pregnancy or reproductive loss. Themes identified included concepts of malaria and risk in pregnancy, attitudes towards interventions, structural factors affecting delivery and uptake, and perceptions of ANC.

Conclusions

Although malaria risk is associated with pregnancy, women's vulnerability is often considered less disease-specific and MiP interpreted in locally defined categories. Furthermore, local discourses and health workers' ideas and comments influence concerns about MiP interventions. Understandings of ANC, health worker-client interactions, household decision-making, gender relations, cost and distance to health facilities affect pregnant women's access to MiP interventions and lack of healthcare infrastructure limits provision of interventions. Further qualitative research is however required: many studies were principally descriptive and an in-depth comparative approach is recommended.

Factors affecting treatment-seeking for febrile illness in a malaria endemic block in Boudh district, Orissa, India: policy implications for malaria control

Background

Orissa state in eastern India accounts for the highest malaria burden to the nation. However, evidences are limited on its treatment-seeking behaviour in the state. We assessed the treatment-seeking behaviour towards febrile illness in a malaria endemic district in Orissa.

Methods

A cross-sectional community-based survey was carried out during the high malaria transmission season of 2006 in Boudh district. Respondents (n = 300) who had fever with chills within two weeks prior to the day of data collection were selected through a multi-stage sampling and interviewed with a pre-tested and structured interview schedule. Malaria treatment providers (n = 23) were interviewed in the district to gather their insights on factors associated with prompt and effective treatment through a semi-structured and open-ended interview guideline.

Results

Majority of respondents (n = 281) sought some sort of treatment e.g. government health facility (35.7%), less qualified providers (31.3%), and community level health workers and volunteers (24.3%). The single most common reason (66.9%) for choosing a provider was proximity. Over a half (55.7%) sought treatment from appropriate providers within 48 hours of onset of symptoms. Respondents under five years (OR 2.00, 95% CI 0.84-4.80, P = 0.012), belonging to scheduled tribe community (OR 2.13, 95% CI 1.11-4.07, P = 0.022) and visiting a provider more than five kilometers (OR 2.04, 95% CI 1.09-3.83, P = 0.026) were more likely to have delayed or inappropriate treatment. Interviews with the providers indicated that patients' lack of trust in community volunteers providing treatment led to inappropriate treatment-seeking from the less qualified providers. The reasons for the lack of trust included drug side effects, suspicions about drug quality, stock-outs of drugs and inappropriate attitude of the provider.

Conclusion

Large-scale involvement of less qualified providers is suggested in the malaria control programme as volunteers after appropriate capacity development since the community has more trust in them. This should be supported by uninterrupted supply of drugs to the community volunteers, and involvement of the community-based organizations and volunteers in the planning, implementation, and monitoring of malaria control services. There is also a need for continuous and rigorous impact evaluations of the program to make necessary modifications, scale up and to prevent drug resistance.

An exploratory survey of malaria prevalence and people's knowledge, attitudes and practices of mosquito larval source management for malaria control in western Kenya

A large proportion of mosquito larval habitats in urban and rural communities in sub-Saharan Africa are man-made. Therefore, community-based larval source management (LSM) could make a significant contribution to malaria control in an integrated vector management approach. Here we implemented an exploratory study to assess malaria prevalence and people's knowledge, attitudes and practices on malaria transmission, its control and the importance of man-made aquatic habitats for the development of disease vectors in one peri-urban lowland and two rural highland communities in western Kenya. We implemented monthly cross-sectional malaria surveys and administered a semi-structured questionnaire in 90 households, i.e. 30 households in each locality. Malaria prevalence was moderate (3.2-6.5%) in all sites. Nevertheless, residents perceived malaria as their major health risk. Thirty-two percent (29/90) of all respondents did not know that mosquitoes are responsible for the transmission of malaria. Over two-thirds (69/90) of the respondents said that mosquito breeding site could be found close to their homes but correct knowledge of habitat characteristics was poor. Over one-third (26/67) believed that immature mosquitoes develop in vegetation. Man-made pools, drainage channels and burrow pits were rarely mentioned. After explaining where mosquito larvae develop, 56% (50/90) felt that these sites were important for their livelihood. Peri-urban residents knew more about mosquitoes' role in malaria transmission, could more frequently describe the larval stages and their breeding habitats, and were more likely to use bed nets even though malaria prevalence was only half of what was found in the rural highland sites (p<0.05). This was independent of their education level or socio-economic status. Hence rural communities are more vulnerable to malaria infection, thus calling for additional methods to complement personal protection measures for vector control. Larval source management was the most frequently mentioned (30%) tool for malaria control but was only practiced by 2 out of 90 respondents. Targeting the larval stages of malaria vectors is an underutilized malaria prevention measure. Sustainable elimination or rendering of such habitats unsuitable for larval development needs horizontally organized, community-based programs that take people's needs into account. Innovative, community-based training programs need to be developed to increase people's awareness of man-made vector breeding sites and acceptable control methods need to be designed in collaboration with the communities.

Evaluation of the performance of CareStart Malaria Pf/Pv Combo rapid diagnostic test for the diagnosis of malaria in Jimma, southwestern Ethiopia

OBJECTIVE

To evaluate the diagnostic performance of CareStart Malaria Pf/Pv Combo test relative to microscopy, for the diagnosis of falciparum and vivax malaria in Ethiopia.

METHODS

Two hundred and forty febrile patients visiting the Serbo health center in Jimma zone, southwestern Ethiopia, were involved in this study in 2008. Giemsa-stained thin and thick blood smears were prepared and microscopically examined under a 100x oil immersion microscope objective for Plasmodium species identification and determination of parasitemia respectively. CareStart Malaria Pf/Pv Combo test was performed as per the manufacturers' instruction.

FINDINGS

The validity of CareStart Malaria Pf/Pv Combo test for the diagnosis of Plasmodium was very good with a sensitivity of 95.8%, specificity of 100%, positive predictive value of 100% and negative predictive value of 96%. The test performed equally well for the identification of Plasmodium falciparum and P. vivax. The diagnostic performance of this CareStart test is comparable to light microscopy of thin and thick blood smears.

CONCLUSION

Although CareStart Malaria Pf/Pv Combo test and blood microscopy have comparable diagnostic performance for Plasmodium detection, the CareStart test has the added advantage of being simple to interpret, cost-efficient, and hence it is preferable to use this rapid diagnostic test for malaria diagnosis in areas where microscopy is not accessible and during times of malaria epidemics that are observed approximately every 4-5 years in Ethiopia.

Evaluation of the performance of CareStart Malaria Pf/Pv Combo and Paracheck Pf tests for the diagnosis of malaria in Wondo Genet, southern Ethiopia

OBJECTIVE

To evaluate the diagnostic performance of CareStart Malaria Pf/Pv Combo test relative to microscopy for the diagnosis of falciparum and vivax malaria in Ethiopia.

METHODS

668 febrile patients visiting two health centers in Wondo Genet, southern Ethiopia, involved in this study in 2008. Giemsa-stained thin and thick blood smears were prepared and microscopically examined under a 100x oil immersion microscope objective for Plasmodium species identification and determination of parasitaemia, respectively. CareStart Malaria Pf/Pv Combo test and Paracheck Pf test were performed as per the manufacturers' instruction.

FINDINGS

The diagnostic validity of CareStart Malaria Pf/Pv Combo test for the diagnosis of Plasmodium falciparum were very good with sensitivity of 99.4%, specificity of 98%, positive predictive value of 94.4% and negative predictive value of 99.8%. Sensitivity, specificity, positive predictive value and negative predictive value of the test for the diagnosis of P. vivax were 99.4%, 98.2%, 94.5% and 99.8%, respectively. The diagnostic performance of CareStart Malaria Pf/Pv Combo test is comparable to that of Paracheck Pf test for the diagnosis of P. falciparum (sensitivity 99.4%, specificity 98.2%).

CONCLUSION

Although CareStart Malaria Pf/Pv Combo test and Paracheck Pf test have comparable diagnostic performance for the diagnosis of P. falciparum, CareStart Malaria Pf/Pv Combo test has the added advantage of diagnosing P. vivax. Hence, it is preferable to use CareStart Malaria Pf/Pv Combo test for the diagnosis of malaria in areas where microscopy is not accessible and where malaria due to P. falciparum and P. vivax are co-endemic as in Ethiopia.

Rapid decrease of malaria morbidity following the introduction of community-based monitoring in a rural area of central Vietnam

BACKGROUND

Despite a successful control programme, malaria has not completely disappeared in Vietnam; it remains endemic in remote areas of central Vietnam, where standard control activities seem to be less effective. The evolution of malaria prevalence and incidence over two and half years in a rural area of central Vietnam, after the introduction of community-based monitoring of malaria cases, is presented.

METHODS

After a complete census, six cross-sectional surveys and passive detection of malaria cases (by village and commune health workers using rapid diagnostic tests) were carried out between March 2004 and December 2006 in Ninh-Thuan province, in a population of about 10,000 individuals. The prevalence of malaria infection and the incidence of clinical cases were estimated.

RESULTS

Malaria prevalence significantly decreased from 13.6% (281/2,068) in December 2004 to 4.0% (80/2,019) in December 2006. Plasmodium falciparum and Plasmodium vivax were the most common infections with few Plasmodium malariae mono-infections and some mixed infections. During the study period, malaria incidence decreased by more than 50%, from 25.7/1,000 population at risk in the second half of 2004 to 12.3/1,000 in the second half of 2006. The incidence showed seasonal variations, with a yearly peak between June and December, except in 2006 when the peak observed in the previous years did not occur.

CONCLUSION

Over a 2.5-year follow-up period, malaria prevalence and incidence decreased by more than 70% and 50%, respectively. Possibly, this could be attributed to the setting up of a passive case detection system based on village health workers, indicating that a major impact on the malaria burden can be obtained whenever prompt diagnosis and adequate treatment are available.

Evaluation of light microscopy and rapid diagnostic test for the detection of malaria under operational field conditions: a household survey in Ethiopia

BACKGROUND

In most resource-poor settings, malaria is usually diagnosed based on clinical signs and symptoms and not by detection of parasites in the blood using microscopy or rapid diagnostic tests (RDT). In population-based malaria surveys, accurate diagnosis is important: microscopy provides the gold standard, whilst RDTs allow immediate findings and treatment. The concordance between RDTs and microscopy in low or unstable transmission areas has not been evaluated.

OBJECTIVES

This study aimed to estimate the prevalence of malaria parasites in randomly selected malarious areas of Amhara, Oromia, and Southern Nations, Nationalities and Peoples' (SNNP) regions of Ethiopia, using microscopy and RDT, and to investigate the agreement between microscopy and RDT under field conditions.

METHODS

A population-based survey was conducted in 224 randomly selected clusters of 25 households each in Amhara, Oromia and SNNP regions, between December 2006 and February 2007. Fingerpick blood samples from all persons living in even-numbered households were tested using two methods: light microscopy of Giemsa-stained blood slides; and RDT (ParaScreen device for Pan/Pf).

RESULTS

A total of 13,960 people were eligible for malaria parasite testing of whom 11,504 (82%) were included in the analysis. Overall slide positivity rate was 4.1% (95% confidence interval [CI] 3.4-5.0%) while ParaScreen RDT was positive in 3.3% (95% CI 2.6-4.1%) of those tested. Considering microscopy as the gold standard, ParaScreen RDT exhibited high specificity (98.5%; 95% CI 98.3-98.7) and moderate sensitivity (47.5%; 95% CI 42.8-52.2) with a positive predictive value of 56.8% (95% CI 51.7-61.9) and negative predictive value of 97.6% (95% CI 97.6-98.1%) under field conditions.

CONCLUSION

Blood slide microscopy remains the preferred option for population-based prevalence surveys of malaria parasitaemia. The level of agreement between microscopy and RDT warrants further investigation in different transmission settings and in the clinical situation.

Impact of community-based presumptive chloroquine treatment of fever cases on malaria morbidity and mortality in a tribal area in Orissa State, India

Background

In the Global Strategy for Malaria Control, one of the basic elements is early detection and prompt treatment of malaria cases, especially in areas where health care facilities are inadequate. Establishing or reviving the existing drug distribution centers (DDC) at the peripheral levels of health care can achieve this. The DDCs should be operationally feasible, acceptable by community and technical efficient, particularly in remote hard-core malaria endemic areas.

Methods

Volunteers from villages were selected for distribution of chloroquine and the selection was made either by villagers or head of the village. The services of the volunteers were absolutely free and voluntary in nature. Chloroquine was provided free of charge to all fever cases. The impact was evaluated based on the changes observed in fever days, fever incidence, parasite incidence and parasite prevalence (proportion of persons harbouring malaria parasite) in the community. Comparisons were made between 1st, 2nd and 3rd year of operation in the experimental villages and between the experimental and check areas.

Results

A total of 411 village volunteers in 378 villages in the experimental community health center with a population of 125,439 treated 88,575 fever cases with a mean annual incidence of 331.8 cases per 1,000 population during the three-year study period. The average morbid days due to fever (AFD) was reduced to 1.6 ± 0.1 from 5.9 ± 2.1 in the experimental villages while it remained at 5.0 ± 1.0 in the check villages. There was a significant reduction, (p < 0.05) in Annual Fever Incidence (AFI) in the experimental hilltop and foothill villages in comparison to check villages. The change in Annual Parasite Incidence (API) was, however, not statistically significant (p > 0.05). In plain villages that were low endemic, the reductions in AFI and API in experimental villages were statistically significant (p < 0.05). There was significant reduction in the parasite prevalence in high endemic villages of the experimental area both during 2^nd and 3^rd year when compared with the check area (p < 0.05) but no such reduction was observed in low endemic areas (p > 0.0.5). Mortality due to malaria declined by 75% in the experimental villages in the adult age group whereas there was an increasing trend in check villages.

Conclusion

The study demonstrated that a passive chloroquine distribution system operated by village volunteers in tribal areas is feasible and effective in reducing malaria-related morbidity and mortality.

An exploratory study of community factors relevant for participatory malaria control on Rusinga Island, western Kenya

Background

Capacity strengthening of rural communities, and the various actors that support them, is needed to enable them to lead their own malaria control programmes. Here the existing capacity of a rural community in western Kenya was evaluated in preparation for a larger intervention.

Methods

Focus group discussions and semi-structured individual interviews were carried out in 1,451 households to determine (1) demographics of respondent and household; (2) socio-economic status of the household; (3) knowledge and beliefs about malaria (symptoms, prevention methods, mosquito life cycle); (4) typical practices used for malaria prevention; (5) the treatment-seeking behaviour and household expenditure for malaria treatment; and (6) the willingness to prepare and implement community-based vector control.

Results

Malaria was considered a major threat to life but relevant knowledge was a chimera of scientific knowledge and traditional beliefs, which combined with socio-economic circumstances, leads to ineffective malaria prevention. The actual malaria prevention behaviour practiced by community members differed significantly from methods known to the respondents. Beside bednet use, the major interventions implemented were bush clearing and various hygienic measures, even though these are ineffective for malaria prevention. Encouragingly, most respondents believed malaria could be controlled and were willing to contribute to a community-based malaria control program but felt they needed outside assistance.

Conclusion

Culturally sensitive but evidence-based education interventions, utilizing participatory tools, are urgently required which consider traditional beliefs and enable understanding of causal connections between mosquito ecology, parasite transmission and the diagnosis, treatment and prevention of disease. Community-based organizations and schools need to be equipped with knowledge through partnerships with national and international research and tertiary education institutions so that evidence-based research can be applied at the grassroots level.

Maternal responses to childhood febrile illnesses in an area of seasonal malaria transmission in rural Ethiopia

Although malaria is the leading cause of illness and death among children less than 5 years of age, there is limited information on mother's response and experience about diagnosis and treatment of the disease in children in rural areas of Ethiopia. The objective of this study was to assess maternal responses and treatment seeking behaviour for children reported to have malaria. A community-based cross-sectional study was conducted between October and November 2003 in Adami Tulu District, south-central Ethiopia. Mothers/caretakers of children less than 5 years of age were interviewed about history of febrile illness suspected to be malaria for all under-five children and the actions taken in the 2 weeks prior to the survey. Of 3872 children identified in 2372 households, 817 (21.1%) had febrile illness reported to be malaria according to the mothers/caretakers. The main symptoms included fever (99%), shivering/chills (92.2%), vomiting (55.1%), sleeplessness/restlessness (12.9%) and refusal to feed (21.3%). Of the total febrile children, 27.3% sought the first care from a public health facility, 27% visited community health workers (CHWs), 25.7% taken to private clinics, 6.4% received home treatment, and 13.3% did not get any care. Among 710 children who reported to receive any type of anti-malarial treatment, 78.8% got it from one source, 19.4% visited two sources and 1.8% sought three sources. Only 28% of the children received any form of treatment within 24h of the onset of illness. Public facilities, private clinics and CHWs were the main sources of care sought by febrile children. Strengthening peripheral health services and community-based interventions using CHWs at village levels would improve the early diagnosis and treatment of malaria among children.

Decentralizing EPI services and prospects for increasing coverage: the case of Tanzania

Primary health Care (PHC) strategies were adopted widely in 1978 after the Alma Ata declaration to improve accessibility to health services and the health of the people. Of the strategies of PHC was the decentralization of health services to lower levels in order to enhance participation and responsiveness of the health system to local problems. While PHC was being promoted vertical programmes such as the expanded programme on immunization (EPI) were also being promoted and achieved substantial benefits. However, almost 25 years later many countries have not been able to achieve these health goals. This study addressed the question: Can we make the process of health care decentralization more likely to support health system and EPI goals? This study analysed the experience of EPI decentralization at national, regional and district levels. Several stakeholders were identified who were supportive and others who were non-supportive of the process. Community support to EPI measured by using willingness to pay (WTP) for kerosene (to keep vaccines cool) was low. It was significantly (p < 0.05) associated with whether providers in the nearest health facility properly attended the target population and whether the providers in the facility were available when needed. There was a substantial stakeholder support and opposition to the process of decentralization at the district level. Community support was not high possibly due to the perceived non-availability of the service providers and their lack of awareness of the population they serve. It was proposed that reforms should give priority to the involvement of communities and peripheral health facility providers in the process.

Participation of African social scientists in malaria control: identifying enabling and constraining factors

Objective

To examine the enabling and constraining factors that influence African social scientists involvement in malaria control.

Methods

Convenience and snowball sampling was used to identify participants. Data collection was conducted in two phases: a mailed survey was followed by in-depth phone interviews with selected individuals chosen from the survey.

Findings

Most participants did not necessarily seek malaria as a career path. Having a mentor who provided research and training opportunities, and developing strong technical skills in malaria control and grant or proposal writing facilitated career opportunities in malaria. A paucity of jobs and funding and inadequate technical skills in malaria limited the type and number of opportunities available to social scientists in malaria control.

Conclusion

Understanding the factors that influence job satisfaction, recruitment and retention in malaria control is necessary for better integration of social scientists into malaria control. However, given the wide array of skills that social scientists have and the variety of deadly diseases competing for attention in Sub Saharan Africa, it might be more cost effective to employ social scientists to work broadly on issues common to communicable diseases in general rather than solely on malaria.

Increases in correct administration of chloroquine in the home and referral of sick children to health facilities through a community-based intervention in Bougouni District, Mali

Save the Children/USA in collaboration with the Ministry of Health of Mali has established over 300 village drug kits in southern Mali since 1996. A cluster-randomized trial was conducted between November 2001 and February 2002 in 10 health zones of Bougouni District to evaluate an intervention to (i) improve the skills of the village drug kit managers to counsel parents on correct home administration of chloroquine (CQ), and (ii) increase the referral of sick children to community health centres (CHC). Children's carers were interviewed 5 d after the sale of CQ about knowledge of danger signs requiring referral, quality of counselling, administration of CQ, and referral. The intervention was associated with significant increases in knowledge of danger signs requiring referral, reported quality of counselling by the manger of the drug kit, and correct administration of CQ in the home. Parents reported that 42.1% of children in the intervention group were referred to the CHC by the drug kit manager compared with 11.2% in the comparison group (odds ratio = 7.12, 95% CI 2.62-19.38). CHC registers indicated that 87.0% of referrals recorded in drug kit referral notebooks arrived at the health centre. Further research is needed to increase the effectiveness of the counselling and the community referral mechanism tested in this study.

A critical review of behavioral issues related to malaria control in sub-Saharan Africa:

In 1996, Social Science & Medicine published a review of treatment seeking for malaria (McCombie, 1996). Since that time, a significant amount of socio-behavioral research on the home management of malaria has been undertaken. In addition, recent initiatives such as Roll Back Malaria have emphasized the importance of social science inputs to malaria research and control. However, there has been a growing feeling that the potential contributions that social science could and should be making to malaria research and control have yet to be fully realized. To address these issues, this paper critically reviews and synthesizes the literature (published, unpublished and technical reports) pertaining to the home management of illness episodes of malaria in sub-Saharan Africa from 1996 to the end of 2000, and draws conclusions about the use of social science in malaria research and control. The results suggest that while we have amassed increasing quantities of descriptive data on treatment seeking behavior, we still have little understanding of the rationale of drug use from the patient perspective and, perhaps more importantly, barely any information on the rationale of provider behaviors. However, the results underline the dynamic and iterative nature of treatment seeking with multiple sources of care frequently being employed during a single illness episode; and highlight the importance in decision making of gender, socio-economic and cultural position of individuals within households and communities. Furthermore, the impact of political, structural and environmental factors on treatment seeking behaviors is starting to be recognised. Programs to address these issues may be beyond single sector (malaria control programme) interventions, but social science practice in malaria control needs to reflect a realistic appraisal of the complexities that govern human behavior and include critical appraisal and proposals for practical action. Major concerns arising from the review were the lack of evidence of 'social scientist' involvement (particularly few from endemic countries) in much of the published research; and concerns with methodological rigor. To increase the effective use of social science, we should focus on a new orientation for field research (including increased methodological rigor), address the gaps in research knowledge, strengthen the relationship between research, policy and practice; and concentrate on capacity strengthening and advocacy.

Promoting the Use of Insecticide Treated Materials at the Community Level: Experience from the ITN-Oriade Initiative

A survey of 4,309 respondents from the local community was conducted. There was a high level of poor access to sanitary methods of refuse disposal with 63.1 percent disposing their refuse in open dumps and 35.3 percent obtained their water from streams, rivers, and rain. More than two-thirds of respondents accepted environmental control methods as a feasible strategy for organized community participation in malaria control. Insecticide treated bed nets (ITN) were introduced for personal protection. Although the nets were accepted, the high cost of initial purchase limits its use. local strategies for participatory control of malaria include environmental methods, home based management of simple malaria, with referral capacity for the management of complicated and severe malaria built and/or strengthened at facility level. Furthermore, personal protection using ITN may be enhanced with higher subsidy for the initial purchase of the nets and the establishment of community-managed treatment centers.

Earth observation, geographic information systems and Plasmodium falciparum malaria in sub-Saharan Africa

This review highlights the progress and current status of remote sensing (RS) and geographical information systems (GIS) as currently applied to the problem of Plasmodium falciparum malaria in sub-Saharan Africa (SSA). The burden of P. falciparum malaria in SSA is first summarized and then contrasted with the paucity of accurate and recent information on the nature and extent of the disease. This provides perspective on both the global importance of the pathogen and the potential for contribution of RS and GIS techniques. The ecology of P. falciparum malaria and its major anopheline vectors in SSA in then outlined, to provide the epidemiological background for considering disease transmission processes and their environmental correlates. Because RS and GIS are recent techniques in epidemiology, all mosquito-borne diseases are considered in this review in order to convey the range of ideas, insights and innovation provided. To conclude, the impact of these initial studies is assessed and suggestions provided on how these advances could be best used for malaria control in an appropriate and sustainable manner, with key areas for future research highlighted.

Household risk factors for malaria among children in the Ethiopian highlands

Malaria transmission varies from village to village and even from family to family in the same village. The current study was conducted in northern Ethiopia to identify risk factors responsible for such variations in a hypoendemic highland malaria setting: 2114 children aged < 10 years living in 6 villages situated close to small dams at altitudes from 1775 to 2175 m were monitored. Monthly malaria incidence was determined 4 times over a 1-year period during 1997. Incidence results were then analysed by 14 individual and household factors using Poisson multivariate regression. Among 14 factors analysed, use of irrigated land (rate ratio[RR] = 2.68, 95% CI 1.64-4.38), earth roof (RR = 2.15, 95% CI 1.31-3.52), animals sleeping in the house (RR = 1.92, 95% CI 1.29-2.85), windows (RR = 1.84, 95% CI 1.30-2.63), open eaves (RR = 1.85, 95% CI 1.19-2.88), no separate kitchen (RR = 1.57, 95% CI 1.10-2.23), and 1 sleeping room (RR = 1.52, 95% CI 1.05-2.20), were significantly associated with malaria. The proportion of infection among children exposed to one or no risk factor was 2.1%, increasing with the number of risk factors and reaching 29.4% with 5 or more. Further studies are needed to confirm the importance of particular risk factors, possibly leading to simple health education and control measures that could become part of routine control programmes, implemented with inter-sectoral collaboration.

Characteristics of effective village treatment assistants: the Kongwa Trachoma Project

PURPOSE

Mass treatment of entire communities with tetracycline eye ointment is one method for treatment of hyperendemic trachoma. Village Treatment Assistants (VTAs) are often recruited to implement mass treatment in their neighborhoods. We determined characteristics of these volunteers that were associated with effective treatment outcomes.

METHODS

Three villages received mass treatment with tetracycline ointment daily for four weeks as part of a clinical trial. Community members selected VTAs to administer the ointment. Trachoma status was assessed by grading photographs of the tarsal conjunctiva in a sample of children randomly selected from households in each village. Change in trachoma status was determined from baseline to one month post treatment. VTA performance outcome was "good" if there was improvement in the majority of the children treated by the VTA, "poor" if the majority worsened, and "neutral" if there was neither improvement nor worsening on average. Trained interviewers administered a questionnaire measuring socioeconomic and demographic variables to 82% of all VTAs.

RESULTS

A total of 280 VTAs (229 with questionnaire) were evaluated: 36.8% had good outcomes and 12.5% had poor outcomes. Those VTAs with poor outcomes tended to be unmarried females (OR = 11.73) and those who used a bicycle to carry out treatment activities (OR = 4.16). Formal education or prior experience as a health worker were not predictors of performance.

CONCLUSION

Community selection and effective, non-formal, training are key components for the use of VTAs in mass treatment campaigns. Prior education or health training does not play a major role in effectiveness. The possible effects of gender roles in the community need to be considered in program design.

Incidence of malaria among children living near dams in northern Ethiopia: community based incidence survey

OBJECTIVE

To assess the impact of construction of microdams on the incidence of malaria in nearby communities in terms of possibly increasing peak incidence and prolonging transmission.

DESIGN

Four quarterly cycles of malaria incidence surveys, each taking 30 days, undertaken in eight at risk communities close to dams paired with eight control villages at similar altitudes but beyond flight range of mosquitoes.

SETTING

Tigray region in northern Ethiopia at altitudes of 1800 to 2225 m.

SUBJECTS

About 7000 children under 10 years living in villages within 3 km of microdams and in control villages 8-10 km distant.

MAIN OUTCOME MEASURES

Incidence of malaria in both communities.

RESULTS

Overall incidence of malaria for the villages close to dams was 14.0 episodes/1000 child months at risk compared with 1.9 in the control villages-a sevenfold ratio. Incidence was significantly higher in both communities at altitudes below 1900 m.

CONCLUSIONS

There is a need for attention to be given to health issues in the implementation of ecological and environmental development programmes, specifically for appropriate malaria control measures to counteract the increased risks near these dams.