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Masunaga Y, Muela Ribera J, Jaiteh F, de Vries DH, Peeters Grietens K. Village health workers as health diplomats: negotiating health and study participation in a malaria elimination trial in The Gambia. BMC Health Serv Res 2022; 22:54. [PMID: 35016656 PMCID: PMC8753917 DOI: 10.1186/s12913-021-07431-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/16/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Although many success stories exist of Village Health Workers (VHWs) improving primary health care, critiques remain about the medicalisation of their roles in disease-specific interventions. VHWs are placed at the bottom of the health system hierarchy as cheap and low-skilled volunteers, irrespective of their highly valued social and political status within communities. In this paper, we shed light on the political role VHWs play and investigate how this shapes their social and medical roles, including their influence on community participation.
Method
The study was carried out within the context of a malaria elimination trial implemented in rural villages in the North Bank of The Gambia between 2016 and 2018. The trial aimed to reduce malaria prevalence by treating malaria index cases and their potentially asymptomatic compound members, in which VHWs took an active role advocating their community and the intervention, mobilising the population, and distributing antimalarial drugs. Mixed-methods research was used to collect and analyse data through qualitative interviews, group discussions, observations, and quantitative surveys.
Results and discussion
We explored the emic logic of participation in a malaria elimination trial and found that VHWs played a pivotal role in representing their community and negotiating with the Medical Research Council to bring benefits (e.g. biomedical care service) to the community. We highlight this representative role of VHWs as ‘health diplomats’, valued and appreciated by community members, and potentially increasing community participation in the trial. We argue that VHWs aspire to be politically present and be part of the key decision-makers in the community through their health diplomat role.
Conclusion
It is thus likely that in the context of rural Gambia, supporting VHWs beyond medical roles, in their social and political roles, would contribute to the improved performance of VHWs and to enhanced community participation in activities the community perceive as beneficial.
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Masunaga Y, Jaiteh F, Manneh E, Balen J, Okebe J, D'Alessandro U, Nieto-Sanchez C, de Vries DH, Gerrets R, Peeters Grietens K, Muela Ribera J. The Community Lab of Ideas for Health: Community-Based Transdisciplinary Solutions in a Malaria Elimination Trial in The Gambia. Front Public Health 2021; 9:637714. [PMID: 34354972 PMCID: PMC8329351 DOI: 10.3389/fpubh.2021.637714] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/28/2021] [Indexed: 01/26/2023] Open
Abstract
Background: Community participation in global health interventions may improve outcomes and solve complex health issues. Although numerous community participatory approaches have been developed and introduced, there has been little focus on "how" and "who" to involve in the implementation of community-based clinical trials where unequal distribution of power between implementers and communities pre-exists. Addressing how to achieve community-based solutions in a malaria elimination trial in The Gambia, we developed the Community Lab of Ideas for Health (CLIH): a participatory approach that enabled communities to shape trial implementation. Methods: As part of transdisciplinary research, we conducted qualitative research with in-depth interviews, discussions, and observations in 17 villages in the North Bank Region of The Gambia between March 2016 and December 2017. We designed an iterative research process involving ethnography, stakeholder-analysis, participatory-discussions, and qualitative monitoring and evaluation, whereby each step guided the next. We drew upon ethnographic results and stakeholder-analysis to identify key-informants who became participants in study design and implementation. The participatory-discussions provided a co-creative space for sharing community-centric ideas to tackle trial implementation challenges. The proposed strategies for trial implementation were continuously refined and improved through our monitoring and evaluation. Results: The CLIH incorporated communities' insights, to co-create tailored trial implementation strategies including: village health workers prescribing and distributing antimalarial treatments; "compounds" as community-accepted treatment units; medicine distribution following compound micro-politics; and appropriate modes of health message delivery. Throughout the iterative research process, the researchers and communities set the common goal, namely to curtail the medical poverty trap by reducing malaria transmission and the burden thereof. This innovative collaborative process built trust among stakeholders and fully engaged researchers and communities in co-creation and co-implementation of the trial. Discussion: The CLIH approach succeeded in touching the local realities by incorporating a spectrum of perspectives from community-members and discerning project-derived knowledge from local-knowledge. This process allowed us to co-develop locally-oriented solutions and ultimately to co-establish an intervention structure that community-members were ready and willing to use, which resulted in high uptake of the intervention (92% adherence to treatment). Successfully, the CLIH contributed in bridging research and implementation.
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Affiliation(s)
- Yoriko Masunaga
- Department of Public Health, Unit of Socio-Ecological Health Research, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Sociology and Anthropology, Faculty of Social and Behavioural Science, University of Amsterdam, Amsterdam, Netherlands
| | - Fatou Jaiteh
- Department of Public Health, Unit of Socio-Ecological Health Research, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Sociology and Anthropology, Faculty of Social and Behavioural Science, University of Amsterdam, Amsterdam, Netherlands
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, Gambia
| | - Ebrima Manneh
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, Gambia
| | - Julie Balen
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Joseph Okebe
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, Gambia
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Umberto D'Alessandro
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, Gambia
| | - Claudia Nieto-Sanchez
- Department of Public Health, Unit of Socio-Ecological Health Research, Institute of Tropical Medicine, Antwerp, Belgium
| | - Daniel H. de Vries
- Department of Sociology and Anthropology, Faculty of Social and Behavioural Science, University of Amsterdam, Amsterdam, Netherlands
| | - René Gerrets
- Department of Sociology and Anthropology, Faculty of Social and Behavioural Science, University of Amsterdam, Amsterdam, Netherlands
| | - Koen Peeters Grietens
- Department of Public Health, Unit of Socio-Ecological Health Research, Institute of Tropical Medicine, Antwerp, Belgium
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Joan Muela Ribera
- PASS Suisse, Neuchâtel, Switzerland
- Medical Anthropology Research Centre (MARC) at Departament d'Antropologia, Filosofia i Treball Social, Universitat Rovira i Virgili, Tarragona, Spain
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Okebe J, Dabira E, Jaiteh F, Mohammed N, Bradley J, Drammeh NF, Bah A, Masunaga Y, Achan J, Muela Ribera J, Yeung S, Balen J, Peeters Grietens K, D'Alessandro U. Reactive, self-administered malaria treatment against asymptomatic malaria infection: results of a cluster randomized controlled trial in The Gambia. Malar J 2021; 20:253. [PMID: 34098984 PMCID: PMC8186162 DOI: 10.1186/s12936-021-03761-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/11/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Selectively targeting and treating malaria-infected individuals may further decrease parasite carriage in low-burden settings. Using a trans-disciplinary approach, a reactive treatment strategy to reduce Plasmodium falciparum prevalence in participating communities was co-developed and tested. METHODS This is a 2-arm, open-label, cluster-randomized trial involving villages in Central Gambia during the 2017 and 2018 malaria transmission season. Villages were randomized in a 1:1 ratio using a minimizing algorithm. In the intervention arm, trained village health workers delivered a full course of pre-packed dihydroartemisinin-piperaquine to all residents of compounds where clinical cases were reported while in the control arm, compound residents were screened for infection at the time of the index case reporting. All index cases were treated following national guidelines. The primary endpoint was malaria prevalence, determined by molecular methods, at the end of the intervention period. RESULTS The trial was carried out in 50 villages: 34 in 2017 and 16 additional villages in 2018. At the end of the 2018 transmission season, malaria prevalence was 0.8% (16/1924, range 0-4%) and 1.1% (20/1814, range 0-17%) in the intervention and control arms, respectively. The odds of malaria infection were 29% lower in the intervention than in the control arm after adjustment for age (OR 0.71, 95% CI 0.27-1.84, p = 0.48). Adherence to treatment was high, with 98% (964/979) of those treated completing the 3-day treatment. Over the course of the study, only 37 villages, 20 in the intervention and 17 in the control arm, reported at least one clinical case. The distribution of clinical cases by month in both transmission seasons was similar and the odds of new clinical malaria cases during the trial period did not vary between arms (OR 1.04, 95% CI 0.57-1.91, p = 0.893). All adverse events were classified as mild to moderate and resolved completely. CONCLUSION The systematic and timely administration of an anti-malarial treatment to residents of compounds with confirmed malaria cases did not significantly decrease malaria prevalence and incidence in communities where malaria prevalence was already low. Treatment coverage and adherence was very high. Results were strongly influenced by the lower-than-expected malaria prevalence, and by no clinical cases in villages with asymptomatic malaria-infected individuals. TRIAL REGISTRATION This study is registered with ClinicalTrials.gov, NCT02878200. Registered 25 August 2016. https://clinicaltrials.gov/ct2/show/NCT02878200 .
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Affiliation(s)
- Joseph Okebe
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Edgard Dabira
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Fatou Jaiteh
- Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium
- Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands
| | - Nuredin Mohammed
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - John Bradley
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Ndey-Fatou Drammeh
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Amadou Bah
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Yoriko Masunaga
- Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium
- Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands
| | - Jane Achan
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- Malaria Consortium, Cambridge Heath, London, UK
| | | | - Shunmay Yeung
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Julie Balen
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | | | - Umberto D'Alessandro
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia.
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Fehr A, Nieto-Sanchez C, Muela J, Jaiteh F, Ceesay O, Maneh E, Baldeh D, Achan J, Dabira E, Conteh B, Bunders-Aelen J, Smekens T, Broekhuizen H, D'Alessandro U, Peeters Grietens K. From informed consent to adherence: factors influencing involvement in mass drug administration with ivermectin for malaria elimination in The Gambia. Malar J 2021; 20:198. [PMID: 33902611 PMCID: PMC8073909 DOI: 10.1186/s12936-021-03732-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 04/08/2021] [Indexed: 11/29/2022] Open
Abstract
Background The World Health Organization (WHO) recommends consideration of mass drug administration (MDA) for malaria control in low-endemic settings approaching elimination. However, MDA remains a controversial strategy, as multiple individual, social, and operational factors have shown to affect its acceptability at local levels. This is further complicated by inconsistent definitions of key indicators derived from individual and community involvement—coverage, adherence, and compliance—that cast doubts about the actual and potential epidemiological impact of MDA on disease control and elimination. This study aimed to identify limitations and enabling factors impacting involvement at different stages of a large cluster-randomized trial assessing the effect of combining dihydroartemisinin-piperaquine (DP) and ivermectin (IVM) in malaria transmission in The Gambia. Methods This social science study used a mixed-methods approach. Qualitative data were collected in intervention and control villages through ethnographic methods, including in-depth interviews (IDIs), focus group discussions (FGDs), and participant observation conducted with trial participants and decliners, community leaders, and field staff. A cross-sectional survey was conducted in the intervention villages after the first year of MDA. Both strands of the study explored malaria knowledge and opinions, social dynamics influencing decision-making, as well as perceived risks, burdens, and benefits associated with this MDA. Results 157 IDIs and 11 FGDs were conducted, and 864 respondents were included in the survey. Barriers and enabling factors to involvement were differentially influential at the various stages of the MDA. Issues of social influence, concerns regarding secondary effects of the medication, costs associated with malaria, and acceptability of the implementing organization, among other factors, differently affected the decision-making processes throughout the trial. Rather than a linear trajectory, involvement in this MDA trial was subjected to multiple revaluations from enrolment and consent to medicine intake and adherence to treatment. Conclusions This study went beyond the individual factors often associated with coverage and adherence, and found that nuanced social dynamics greatly influence the decision-making process at all phases of the trial. These issues need to be consider for MDA implementation strategies and inform discussions about more accurate ways of reporting on critical effectiveness indicators. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-03732-z.
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Affiliation(s)
- Alexandra Fehr
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - Claudia Nieto-Sanchez
- Unit of Socio-Ecological Health Research, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Joan Muela
- Medical Anthropology Research Center, Universitat Rovira I Virgill, Tarragona, Spain
| | - Fatou Jaiteh
- Unit of Socio-Ecological Health Research, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Omar Ceesay
- Medical Research Council Unit Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Ebrima Maneh
- Medical Research Council Unit Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Dullo Baldeh
- Medical Research Council Unit Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Jane Achan
- Medical Research Council Unit Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Edgard Dabira
- Medical Research Council Unit Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Bakary Conteh
- Medical Research Council Unit Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | | | - Tom Smekens
- Unit of Socio-Ecological Health Research, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Umberto D'Alessandro
- Medical Research Council Unit Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Koen Peeters Grietens
- Unit of Socio-Ecological Health Research, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Jaiteh F, Ribera JM, Masunaga Y, Okebe J, D'Alessandro U, Balen J, Achan J, Gerrets R, Peeters Grietens K. Complexities in Defining the Unit of Intervention for Reactive Community-Based Malaria Treatment in the Gambia. Front Public Health 2021; 9:601152. [PMID: 33718317 PMCID: PMC7952428 DOI: 10.3389/fpubh.2021.601152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 02/02/2021] [Indexed: 11/24/2022] Open
Abstract
With significant declines in malaria, infections are increasingly clustered in households, or groups of households where malaria transmission is higher than in surrounding household/villages. To decrease transmission in such cases, reactive interventions target household members of clinical malaria cases, with the intervention unit (e.g., the "household/s") derived from an epidemiological and operational perspective. A lack of unanimity regarding the spatial range of the intervention unit calls for greater importance to be placed on social context in conceptualizing the appropriate unit. A novel malaria elimination strategy based on reactive treatment was recently evaluated by a cluster randomized trial in a low transmission setting in The Gambia. Transdisciplinary research was used to assess and improve the effectiveness of the intervention which consisted, among others, of reflecting on whether the household was the most adequate unit of analysis. The intervention was piloted on the smallest treatment unit possible and was further adapted following a better understanding of the social and epidemiological context. Intervention units defined according to (i) shared sleeping spaces and (ii) household membership, showed substantial limitations as it was not possible to define them clearly and they were extremely variable within the study setting. Incorporating local definitions and community preference in the trial design led to the appropriate intervention unit-the compound-defined as an enclosed space containing one or several households belonging to the same extended patrilineal family. Our study demonstrates the appropriateness of using transdisciplinary research for investigating alternative intervention units that are better tailored to reactive treatment approaches.
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Affiliation(s)
- Fatou Jaiteh
- Medical Research Council Unit the Gambia at the London School of Hygiene and Tropical Medicine, Banjul, Gambia
- Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium
- Faculty of Social and Behavioural Sciences, Amsterdam Institute of Social Science Research, Amsterdam, Netherlands
| | | | - Yoriko Masunaga
- Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium
- Faculty of Social and Behavioural Sciences, Amsterdam Institute of Social Science Research, Amsterdam, Netherlands
| | - Joseph Okebe
- Medical Research Council Unit the Gambia at the London School of Hygiene and Tropical Medicine, Banjul, Gambia
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Umberto D'Alessandro
- Medical Research Council Unit the Gambia at the London School of Hygiene and Tropical Medicine, Banjul, Gambia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Julie Balen
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, United Kingdom
| | - Jane Achan
- Medical Research Council Unit the Gambia at the London School of Hygiene and Tropical Medicine, Banjul, Gambia
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Rene Gerrets
- Faculty of Social and Behavioural Sciences, Amsterdam Institute of Social Science Research, Amsterdam, Netherlands
| | - Koen Peeters Grietens
- Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium
- PASS Suisse, Neuchâtel, Switzerland
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
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Jaiteh F, Okebe J, Masunaga Y, D'Alessandro U, Achan J, Gryseels C, de Vries D, Ribera JM, Grietens KP. Understanding adherence to reactive treatment of asymptomatic malaria infections in The Gambia. Sci Rep 2021; 11:1746. [PMID: 33462329 PMCID: PMC7813830 DOI: 10.1038/s41598-021-81468-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/18/2020] [Indexed: 11/29/2022] Open
Abstract
The impact of different types of reactive case detection and/or treatment strategies for malaria elimination depends on high coverage and participants’ adherence. However, strategies to optimise adherence are limited, particularly for people with asymptomatic or no infections. As part of a cluster-randomized trial to evaluate the effect of reactive treatment in The Gambia, all residents in the compound of a diagnosed clinical malaria patient received dihydro-artemisinin–piperaquine (DP). Using a mixed method approach, we assessed which factors contribute to adherence among the contacts of malaria cases that showed no symptoms. Adherence was defined as the proportion of compound members that (1) returned all medicine bags empty and (2) self-reported (3-day) treatment completion. Among the 273 individuals from 14 compounds who received DP, 227 (83.1%) were available for and willing to participate in the survey; 85.3% (233/273) returned empty medicine bags and 91.6% (208/227) self-reported treatment completion. Although clinical malaria was not considered a major health problem, reported adherence was high. The drivers of adherence were the strong sense of responsibility towards protecting the individual, compound and the village. Adherence can be optimised through a transdisciplinary implementation research process of engaging communities to bridge the gap between research goals and social realities.
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Affiliation(s)
- Fatou Jaiteh
- Medical Research Council Unit the Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia. .,Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium. .,Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands.
| | - Joseph Okebe
- Medical Research Council Unit the Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia.,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Yoriko Masunaga
- Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium.,Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands
| | - Umberto D'Alessandro
- Medical Research Council Unit the Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Jane Achan
- Medical Research Council Unit the Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Charlotte Gryseels
- Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Daniel de Vries
- Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands
| | | | - Koen Peeters Grietens
- Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium.,PASS Suisse, Neuchâtel, Switzerland.,School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
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Jaiteh F, Masunaga Y, Okebe J, D'Alessandro U, Balen J, Bradley J, Gryseels C, Ribera JM, Grietens KP. Community perspectives on treating asymptomatic infections for malaria elimination in The Gambia. Malar J 2019; 18:39. [PMID: 30777112 PMCID: PMC6378745 DOI: 10.1186/s12936-019-2672-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/10/2019] [Indexed: 11/10/2022] Open
Abstract
Background Innovative and cost-effective strategies that clear asymptomatic malaria infections are required to reach malaria elimination goals, but remain a challenge. This mixed methods study explored people’s attitudes towards the reactive treatment of compound contacts of malaria cases with a 3-day course of dihydroartemisinin-piperaquine (DHAP), the socio-cultural representations of asymptomatic infections, and more specifically their treatment. Methods Prior to the start of the intervention, a sequential mixed method study was carried out. Qualitative data collection involved in-depth interviews and participant observations (including informal conversations) with key informants from the trial communities and the trial staff. Quantitative data were derived from a pre-trial cross-sectional survey on health literacy and health-seeking behaviour among randomly selected members of the study communities. Results In the pre-trial cross-sectional survey, 73% of respondents reported that malaria could be hidden in the body without symptoms. Whilst this may be interpreted as people’s comprehension of asymptomatic malaria, qualitative data indicated that informants had different interpretations of asymptomatic disease than the biomedical model. It was described as: (i) a minor illness that does not prevent people carrying out daily activities; (ii) an illness that oscillates between symptomatic and asymptomatic phases; and, (iii) a condition where disease agents are present in the body but remain hidden, without signs and symptoms, until something triggers their manifestation. Furthermore, this form of hidden malaria was reported to be most present in those living in the same compound with a malaria case (71%). Conclusion Treating asymptomatic malaria with pharmaceuticals was considered acceptable. However, people felt uncertain to take treatment without screening for malaria first, largely due to the lack of symptoms. Knowledge of asymptomatic malaria was not a strong re-inforcement for treatment adherence. In this study, the pre-intervention active engagement of communities existed of having people co-design accurate information messages about their personal risk of malaria, which increased their trust in expert knowledge and thus proved essential for the successful implementation of the community-based intervention.
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Affiliation(s)
- Fatou Jaiteh
- Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium. .,Medical Research Council Unit the Gambia at the London, School of Hygiene and Tropical Medicine, Fajara, The Gambia. .,Faculty of Social and Behavioural Science, Department of Sociology and Anthropology, University of Amsterdam, Amsterdam, The Netherlands.
| | - Yoriko Masunaga
- Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium.,Faculty of Social and Behavioural Science, Department of Sociology and Anthropology, University of Amsterdam, Amsterdam, The Netherlands
| | - Joseph Okebe
- Medical Research Council Unit the Gambia at the London, School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Umberto D'Alessandro
- Medical Research Council Unit the Gambia at the London, School of Hygiene and Tropical Medicine, Fajara, The Gambia.,London School of Hygiene and Tropical Medicine, London, UK
| | - Julie Balen
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - John Bradley
- London School of Hygiene and Tropical Medicine, London, UK
| | - Charlotte Gryseels
- Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium
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Compaoré A, Dierickx S, Jaiteh F, Nahum A, Bohissou TFE, Tinto H, Scott S, D'Alessandro U, Schallig H, Grietens KP. Fear and rumours regarding placental biopsies in a malaria-in-pregnancy trial in Benin. Malar J 2018; 17:425. [PMID: 30442132 PMCID: PMC6238265 DOI: 10.1186/s12936-018-2578-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 11/09/2018] [Indexed: 05/30/2023] Open
Abstract
Background A multi-country, community-based trial on scheduled screening and treatment for malaria in pregnancy was conducted in Benin, The Gambia and Burkina Faso. Despite standardized procedures and outcomes, the study became subject to rumours and accusations of placenta being sold for mystical and financial gain by trial staff, leading to drop-out rates of 30% and the consequent halting of placental biopsy sampling in Benin. This paper explores the role of socio-cultural beliefs related to placenta and identified additional factors contributing these rumours. Methods A qualitative comparative emergent-theory design was used to assess social factors related to trial implementation and uptake in the three countries. Data from participant observation, informal conversations, group discussions and interviews were triangulated and analysed with NVivo Qualitative Analysis software. Results Despite similar sociocultural beliefs about the sacred nature of the placenta in all three study countries, these beliefs did not affect participation rates in Burkina Faso and The Gambia and placenta-related rumours only emerged in Benin. Therefore, the presence of beliefs is not a sufficient condition to have generated placenta-selling fears. The rumours in Benin reflected the confluence of placenta-related beliefs and factors related to the implementation of the trial (including a catalysing adverse event and miscommunication during the informed consent procedure). Furthermore, distinct socio-political factors contributed to the emergence of rumours, including the historical distrust in governmental organizations and the tense relationship between some of the actors involved in the trial. Conclusion Transdisciplinary social science research designs should accompany the implementation of the trial. The integration of multiple stakeholders’ knowledge and involvement is required to define and solve upcoming barriers.
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Affiliation(s)
- Adélaïde Compaoré
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso.
| | - Susan Dierickx
- Medical Anthropology Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Centre of Expertise on Gender, Diversity and Intersectionality (RHEA), Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium.,Centre for Research on Culture and Gender, Ghent University, Rozier 44, 9000, Ghent, Belgium
| | - Fatou Jaiteh
- Medical Anthropology Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands.,Medical Research Council Unit The Gambia at London, School of Tropical Medicine and Hygiene, Fajara, The Gambia
| | - Alain Nahum
- Centre de Recherches Entomologiques de Cotonou, Cotonou, Benin
| | | | - Halidou Tinto
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Susana Scott
- Medical Research Council Unit The Gambia at London, School of Tropical Medicine and Hygiene, Fajara, The Gambia.,London School of Tropical Medicine and Hygiene, London, UK
| | - Umberto D'Alessandro
- Medical Research Council Unit The Gambia at London, School of Tropical Medicine and Hygiene, Fajara, The Gambia
| | - Henk Schallig
- Department of Medical Microbiology-Parasitology Unit, Academic Medical Centre, Amsterdam, 1105, AZ, The Netherlands
| | - Koen Peeters Grietens
- Medical Anthropology Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands.,Partners for Applied Social Sciences (PASS) International, Tessenderlo, Belgium.,School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
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9
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Okebe J, Ribera JM, Balen J, Jaiteh F, Masunaga Y, Nwakanma D, Bradley J, Yeung S, Peeters Grietens K, D'Alessandro U. Reactive community-based self-administered treatment against residual malaria transmission: study protocol for a randomized controlled trial. Trials 2018; 19:126. [PMID: 29463288 PMCID: PMC5819183 DOI: 10.1186/s13063-018-2506-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 01/29/2018] [Indexed: 11/18/2022] Open
Abstract
Background Systematic treatment of all individuals living in the same compound of a clinical malaria case may clear asymptomatic infections and possibly reduce malaria transmission, where this is focal. High and sustained coverage is extremely important and requires active community engagement. This study explores a community-based approach to treating malaria case contacts. Methods/design This is a cluster-randomized trial to determine whether, in low-transmission areas, treating individuals living in the same compound of a clinical malaria case with dihydroartemisinin-piperaquine can reduce parasite carriage and thus residual malaria transmission. Treatment will be administered through the local health system with the approach of encouraging community participation designed and monitored through formative research. The trial goal is to show that this approach can reduce in intervention villages the prevalence of Plasmodium falciparum infection toward the end of the malaria transmission season. Discussion Adherence and cooperation of the local communities are critical for the success of mass treatment campaigns aimed at reducing malaria transmission. By exploring community perceptions of the changing trends in malaria burden, existing health systems, and reaction to self-administered treatment, this study will develop and adapt a model for community engagement toward malaria elimination that is cost-effective and fits within the existing health system. Trial registration Clinical trials.gov, NCT02878200. Registered on 25 August 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2506-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joseph Okebe
- Disease Control & Elimination Theme, Medical Research Council Unit, Fajara, The Gambia
| | - Joan Muela Ribera
- Medial Anthropology Research Center (MARC), Universitat Rovira i Virgili, Tarragona, Spain
| | - Julie Balen
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Fatou Jaiteh
- Disease Control & Elimination Theme, Medical Research Council Unit, Fajara, The Gambia.,Medical Anthropology Unit, Department of Public health, Institute of Tropical Medicine, Antwerp, Belgium.,Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Yoriko Masunaga
- Medical Anthropology Unit, Department of Public health, Institute of Tropical Medicine, Antwerp, Belgium.,Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Davis Nwakanma
- Disease Control & Elimination Theme, Medical Research Council Unit, Fajara, The Gambia
| | - John Bradley
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Shunmay Yeung
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Koen Peeters Grietens
- Medical Anthropology Unit, Department of Public health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Umberto D'Alessandro
- Disease Control & Elimination Theme, Medical Research Council Unit, Fajara, The Gambia. .,Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
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10
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Dierickx S, O'Neill S, Gryseels C, Immaculate Anyango E, Bannister‐Tyrrell M, Okebe J, Mwesigwa J, Jaiteh F, Gerrets R, Ravinetto R, D'Alessandro U, Peeters Grietens K. Community sensitization and decision-making for trial participation: A mixed-methods study from The Gambia. Dev World Bioeth 2017; 18:406-419. [PMID: 28816023 PMCID: PMC6585980 DOI: 10.1111/dewb.12160] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ensuring individual free and informed decision-making for research participation is challenging. It is thought that preliminarily informing communities through 'community sensitization' procedures may improve individual decision-making. This study set out to assess the relevance of community sensitization for individual decision-making in research participation in rural Gambia. METHODS This anthropological mixed-methods study triangulated qualitative methods and quantitative survey methods in the context of an observational study and a clinical trial on malaria carried out by the Medical Research Council Unit Gambia. RESULTS/DISCUSSION Although 38.7% of the respondents were present during sensitization sessions, 91.1% of the respondents were inclined to participate in the trial when surveyed after the sensitization and prior to the informed consent process. This difference can be explained by the informal transmission of information within the community after the community sensitization, expectations such as the benefits of participation based on previous research experiences, and the positive reputation of the research institute. Commonly mentioned barriers to participation were blood sampling and the potential disapproval of the household head. CONCLUSION Community sensitization is effective in providing first-hand, reliable information to communities as the information is cascaded to those who could not attend the sessions. However, further research is needed to assess how the informal spread of information further shapes people's expectations, how the process engages with existing social relations and hierarchies (e.g. local political power structures; permissions of heads of households) and how this influences or changes individual consent.
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11
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Jaiteh F, Dierickx S, Gryseels C, O'Neill S, D'Alessandro U, Scott S, Balen J, Grietens KP. 'Some anti-malarials are too strong for your body, they will harm you.' Socio-cultural factors influencing pregnant women's adherence to anti-malarial treatment in rural Gambia. Malar J 2016; 15:195. [PMID: 27068760 PMCID: PMC4827243 DOI: 10.1186/s12936-016-1255-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 03/31/2016] [Indexed: 12/13/2022] Open
Abstract
Background Despite declining prevalence of malaria in The Gambia, non-adherence to anti-malarial treatment still remains a challenge to control efforts. There is limited evidence on the socio-cultural factors that influence adherence to anti-malarial treatment in pregnancy. This study explored perceptions of malaria in pregnancy and their influence on adherence to anti-malarial treatment in a rural area of The Gambia. Methods An exploratory ethnographic study was conducted ancillary to a cluster-randomized trial on scheduled screening and treatment of malaria in pregnancy at village level in the Upper River Region of The Gambia from June to August 2014. Qualitative data were collected through interviewing and participant observation. Analysis was concurrent to data collection and carried out using NVivo 10. Results Although women had good bio-medical knowledge of malaria in pregnancy, adherence to anti-malarial treatment was generally perceived to be low. Pregnant women were perceived to discontinue the provided anti-malarial treatment after one or 2 days mainly due to non-recognition of symptoms, perceived ineffectiveness of the anti-malarial treatment, the perceived risks of medication and advice received from mothers-in-law. Conclusion Improving women’s knowledge of malaria in pregnancy is not sufficient to assure adherence to anti-malarial treatment. Addressing structural barriers such as unclear health workers’ messages about medication dosage, illness recognition, side effects of the medication and the integration of relatives, especially the mothers-in-law, in community-based programmes are additionally required.
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Affiliation(s)
- Fatou Jaiteh
- Department of Geography, The University of Sheffield, Sheffield, UK. .,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium. .,Medical Research Council Unit, Fajara, The Gambia.
| | - Susan Dierickx
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands
| | - Charlotte Gryseels
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands
| | - Sarah O'Neill
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Umberto D'Alessandro
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Medical Research Council Unit, Fajara, The Gambia.,London School of Hygiene and Tropical Medicine, London, UK
| | - Susana Scott
- Medical Research Council Unit, Fajara, The Gambia.,London School of Hygiene and Tropical Medicine, London, UK
| | - Julie Balen
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Koen Peeters Grietens
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.,Partners for Applied Social Sciences (PASS) International, Tessenderlo, Belgium
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12
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Dierickx S, Gryseels C, Mwesigwa J, O’Neill S, Bannister-Tyrell M, Ronse M, Jaiteh F, Gerrets R, D’Alessandro U, Grietens KP. Factors Associated with Non-Participation and Non-Adherence in Directly Observed Mass Drug Administration for Malaria in The Gambia. PLoS One 2016; 11:e0148627. [PMID: 26866685 PMCID: PMC4750858 DOI: 10.1371/journal.pone.0148627] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 01/20/2016] [Indexed: 11/27/2022] Open
Abstract
Introduction The potential benefits of Mass Drug Administration (MDA) for malaria elimination are being considered in several malaria endemic countries where a decline in malaria transmission has been reported. For this strategy to work, it is important that a large proportion of the target population participates, requiring an in-depth understanding of factors that may affect participation and adherence to MDA programs. Methodology This social science study was ancillary to a one-round directly observed MDA campaign with dihydroartemisinin-piperaquine, carried out in 12 villages in rural Gambia between June and August 2014. The social science study employed a mixed-methods approach combining qualitative methods (participant observation and in-depth interviewing) and quantitative methods (structured follow-up interviews among non-participating and non-adhering community members). Results Of 3942 people registered in the study villages, 67.9% adhered to the three consecutive daily doses. For the remaining villagers, 12.6% did not attend the screening, 3.5% was not eligible and 16% did not adhere to the treatment schedule. The main barriers for non-participation and adherence were long and short-term mobility of individuals and specific subgroups, perceived adverse drug reactions and rumors, inconveniences related to the logistics of MDA (e.g. waiting times) and the perceived lack of information about MDA. Conclusion While, there was no fundamental resistance from the target communities, adherence was 67.9%. This shows the necessity of understanding local perceptions and barriers to increase its effectiveness. Moreover, certain of the constraining factors were socio-spatially clustered which might prove problematic since focal areas of residual malaria transmission may remain allowing malaria to spread to adjacent areas where transmission had been temporarily interrupted.
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Affiliation(s)
- Susan Dierickx
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands
- Rhea, Centre of Expertise Gender, Diversity and Intersectionality, Vrije Universiteit Brussel, Brussels, Belgium
- * E-mail:
| | - Charlotte Gryseels
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands
| | | | - Sarah O’Neill
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Maya Ronse
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Fatou Jaiteh
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Medical Research Council Unit, Fajara, The Gambia
| | - René Gerrets
- Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands
| | - Umberto D’Alessandro
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Medical Research Council Unit, Fajara, The Gambia
- London School of Tropical Medicine and Hygiene, London, Unoted Kingdom
| | - Koen Peeters Grietens
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Partners for Applied Social Sciences (PASS) International, Tessenderlo, Belgium
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
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