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1.  Community acceptability of use of rapid diagnostic tests for malaria by community health workers in Uganda 
Malaria Journal  2010;9:203.
Many malarious countries plan to introduce artemisinin combination therapy (ACT) at community level using community health workers (CHWs) for treatment of uncomplicated malaria. Use of ACT with reliance on presumptive diagnosis may lead to excessive use, increased costs and rise of drug resistance. Use of rapid diagnostic tests (RDTs) could address these challenges but only if the communities will accept their use by CHWs. This study assessed community acceptability of the use of RDTs by Ugandan CHWs, locally referred to as community medicine distributors (CMDs).
The study was conducted in Iganga district using 10 focus group discussions (FGDs) with CMDs and caregivers of children under five years, and 10 key informant interviews (KIIs) with health workers and community leaders. Pre-designed FGD and KII guides were used to collect data. Manifest content analysis was used to explore issues of trust and confidence in CMDs, stigma associated with drawing blood from children, community willingness for CMDs to use RDTs, and challenges anticipated to be faced by the CMDs.
CMDs are trusted by their communities because of their commitment to voluntary service, access, and the perceived effectiveness of anti-malarial drugs they provide. Some community members expressed fear that the blood collected could be used for HIV testing, the procedure could infect children with HIV, and the blood samples could be used for witchcraft. Education level of CMDs is important in their acceptability by the community, who welcome the use of RDTs given that the CMDs are trained and supported. Anticipated challenges for CMDs included transport for patient follow-up and picking supplies, adults demanding to be tested, and caregivers insisting their children be treated instead of being referred.
Use of RDTs by CMDs is likely to be acceptable by community members given that CMDs are properly trained, and receive regular technical supervision and logistical support. A well-designed behaviour change communication strategy is needed to address the anticipated programmatic challenges as well as community fears and stigma about drawing blood. Level of formal education may have to be a criterion for CMD selection into programmes deploying RDTs.
PMCID: PMC2914066  PMID: 20626863
2.  Community participation for malaria elimination in tafea province, vanuatu: part ii. social and cultural aspects of treatment-seeking behaviour 
Malaria Journal  2011;10:204.
Early diagnosis and prompt effective case management are important components of any malaria elimination strategy. Tafea Province, Vanuatu has a rich history of traditional practices and beliefs, which have been integrated with missionary efforts and the introduction of modern constructions of health. Gaining a detailed knowledge of community perceptions of malarial symptomatology and treatment-seeking behaviours is essential in guiding effective community participation strategies for malaria control and elimination.
An ethnographic study involving nine focus group discussions (FGD), 12 key informant interviews (KII) and seven participatory workshops were carried out on Tanna Island, Vanuatu. Villages in areas of high and low malaria transmission risk were selected. Four ni-Vanuatu research officers, including two from Tanna, were trained and employed to conduct the research. Data underwent thematic analysis to examine treatment-seeking behaviour and community perceptions of malaria.
Malaria was perceived to be a serious, but relatively new condition, and in most communities, identified as being apparent only after independence in 1980. Severe fever in the presence of other key symptoms triggered a diagnosis of malaria by individuals. Use of traditional or home practices was common: perceived vulnerability of patient and previous experience with malaria impacted on the time taken to seek treatment at a health facility. Barriers to health care access and reasons for delay in care-seeking included the availability of health worker and poor community infrastructure.
Due to programme success of achieving low malaria transmission, Tafea province has been identified for elimination of malaria by 2012 in the Government of Vanuatu Malaria Action Plans (MAP). An effective malaria elimination programme requires interactions between the community and its leaders, malaria workers and health providers for success in diagnosis and prompt treatment. As malaria becomes more uncommon, utilizing unique motivators for communities to seek early diagnosis and treatment is important, particularly as other health conditions that cause fevers become increasingly more common. The design of these interventions are dependent upon robust understanding of community perceptions of disease, and the evolving nature of these perceptions.
PMCID: PMC3160431  PMID: 21787434
3.  Determinants of concurrent sexual partnerships within stable relationships: a qualitative study in Tanzania 
BMJ Open  2014;4(2):e003680.
Concurrent sexual partnerships (CP) have been identified as a potential driver in the HIV epidemic in southern Africa, making it essential to understand motivating factors for engagement in CP. We aimed to assess community attitudes and beliefs about relationship factors that influence men and women in stable relationships to engage in CP in Tanzania. Social exchange theory was used for interpreting the data.
Qualitative study with focus group discussions (FGDs).
Semiurban/rural communities in four regions across Tanzania (Dar es Salaam, Shinyanga, Iringa and Mbeya).
120 women aged 17–45 years and 111 men aged 18–49 years from four study areas participated in 32 FGDs.
Outcome measures
FGD participants were asked the following questions about CP: definitions and types, motivations and justifications for engaging or not engaging, cultural factors, gender and socialisation, and local resources and efforts available for addressing CP. Our analysis focused specifically on beliefs about how relationship factors influence engagement in CP.
Dissatisfaction with a stable relationship was believed to be a contributing factor for engagement in CP for both men and women. Participants more commonly reported financial dissatisfaction as a contributing factor for women engaging in CP within stable relationships, whereas emotional and sexual dissatisfaction were reported as contributing factors for men and women. Furthermore, participants described how potential outside partners are often evaluated based on what they are able to offer compared with stable partners.
Efforts to reach men and women in stable relationships with HIV prevention messages must consider the various dimensions of motivation for engaging in CP, including relationship dynamics.
PMCID: PMC3918978  PMID: 24508848
Tanzania; HIV/AIDS; Concurrent Sexual Partnerships; Relationship Satisfaction; Qualitative Research
4.  Exploring the Ethics of Observational Research: The Case of an HIV Study in Tanzania 
AJOB primary research  2012;3(4):30-39.
Observational studies have generally been viewed as incurring minimal risk to participants, resulting in fewer ethical obligations for investigators than intervention studies. In 2004, the lead author (AN) carried out an observational study measuring sexual behavior and the prevalence of HIV, syphilis, and herpes simplex virus type 2 (HSV-2), among Tanzanian agricultural plantation residents (results reported elsewhere). This article uses an ethical lens to consider the consequences of the observational study and explore what, if any, effects it had on participants and their community.
Using a case study approach, we critically examine three core principles of research ethics—respect for persons/autonomy; beneficence/nonmaleficence; and distributive justice—as manifested in the 2004 observational study. We base our findings on three sources: discussions with plantation residents following presentations of observational research findings; in-depth interviews with key informants; and researcher observations.
The observational research team was found to have ensured confidentiality and noncoercive recruitment. Ironically, maintenance of confidentiality and voluntary participation led some participants to doubt study results. Receiving HIV test results was important for participants and contributed to changing community norms about HIV testing.
Observational studies may act like de facto intervention studies and thus incur obligations similar to those of intervention studies. We found that ensuring respect for persons may have compromised the principles of beneficence and distributive justice. While in theory these three ethical principles have equal moral force, in practice, researchers may have to prioritize one over the others. Careful community engagement is necessary to promote well-considered ethical decisions.
PMCID: PMC3779918  PMID: 24069546
Africa; autonomy; beneficence; cross-sectional; distributive justice; ethics; observational research
5.  Knowledge, attitudes and practices of AIDS associated malignancies among people living with HIV in Nigeria 
The epidemic of HIV in sub-Saharan Africa varies significantly across countries in the region with high prevalence in Southern Africa and Nigeria. Cancer is increasingly identified as a complication of HIV infection with higher incidence and mortality in this group than in the general population. Without cancer prevention strategies, improved cancer treatment alone would be an insufficient response to this increasing burden among people living with HIV (PLHIV). Although previous studies have noted low levels of awareness of cancers in sub-Saharan Africa none has examined the knowledge and perceptions of cancer among people living with HIV/AIDS.
Focus group discussions (FGD) and Key Informant Interviews (KII) were carried out in 4 high volume tertiary care institutions that offer HIV care and treatment in Nigeria. FGD and KII assessed participants’ knowledge of cancer, attitudes towards cancer risk and cancer screening practices.
The mean age (SD) of the FGD participants was 38 (2.8) years. Most participants had heard about cancer and considered it a fatal disease but displayed poor knowledge of the causes of cancer in general and of AIDs associated cancers in particular. PLHIV in Nigeria expressed fear, denial and disbelief about their perceived cancer risk. Some of the participants had heard about cancer screening but very few participants had ever been screened.
Our findings of poor knowledge of cancer among PLHIV in Nigeria indicate the need for health care providers and the government to intervene by developing primary cancer prevention strategies for this population.
PMCID: PMC3527187  PMID: 23098099
Knowledge; Attitudes; Practices (KAP); People living with HIV (PLHIV); HIV-associated cancers; Cancer screening
6.  Community perceptions of malaria and malaria treatment behaviour in a rural district of Ghana: implications for artemisinin combination therapy 
BMC Public Health  2010;10:409.
Artesunate-amodiaquine (AS-AQ) was introduced in Ghana as the first line drug for treatment of uncomplicated malaria in 2004. We report the perceptions of malaria and malaria treatment behaviour, the community awareness of and perceptions about AS-AQ two years after the introduction of this ACT treatment for malaria.
Two surveys were conducted; a cross-sectional survey of 729 randomly selected household heads (urban-362, rural-367) and 282 women with children < 5 years (urban-121, rural-161) was conducted in 2006. A district wide survey was conducted in 2007 to assess awareness of AS-AQ. These were complemented with twenty-eight focus group discussions (FGDs) and 16 key informant interviews (KII) among community members and major stakeholders in the health care delivery services. All nine (9) health facilities and five (5) purposively selected drug stores were audited in order to identify commonly used anti-malarials in the study area at the time of the survey.
Majority of respondents ( > 75%) in the sampled survey mentioned mosquito bites as the cause of malaria. Other causes mentioned include environmental factors (e.g. dirty surroundings) and standing in the sun. Close to 60% of the household heads and 40% of the care-givers interviewed did not know about AS-AQ. The community respondents who knew about and had ever taken AS-AQ perceived it to be a good drug; although they mentioned they had experienced some side effects including headaches and body weakness. Co-blistered AS-AQ was available in all the government health facilities in the study area. Different formulations of ACTs were however found in urban chemical shops but not in rural chemical stores where monotherapy antimalarials were predominant.
The knowledge of fever as a symptom of malaria is high among the study population. The awareness of AS-AQ therapy and its side-effect was low in the study area. Community education and sensitization, targeting all categories of the population, has to be intensified to ensure an efficient implementation process.
PMCID: PMC2914078  PMID: 20624306
7.  Urban settings do not ensure access to services: findings from the immunisation programme in Kampala Uganda 
Previous studies on vaccination coverage in developing countries focus on individual- and community-level barriers to routine vaccination mostly in rural settings. This paper examines health system barriers to childhood immunisation in urban Kampala Uganda.
Mixed methods were employed with a survey among child caretakers, 9 focus group discussions (FGDs), and 9 key informant interviews (KIIs). Survey data underwent descriptive statistical analysis. Latent content analysis was used for qualitative data.
Of the 821 respondents in the survey, 96% (785/821) were mothers with a mean age of 26 years (95% CI 24–27). Poor geographical access to immunisation facilities was reported in this urban setting by FGDs, KIIs and survey respondents (24%, 95% CI 21–27). This coupled with reports of few health workers providing immunisation services led to long queues and long waiting times at facilities. Consumers reported waiting for 3–6 hours before receipt of services although this was more common at public facilities. Only 33% (95% CI 30–37) of survey respondents were willing to wait for three or more hours before receipt of services. Although private-for-profit facilities were engaged in immunisation service provision their participation was low as only 30% (95% CI 27–34) of the survey respondents utilised these facilities. The low participation could be due to lack of financial support for immunisation activities at these facilities. This in turn could explain the rampant informal charges for services in this setting. Charges ranged from US$ 0.2 to US$4 and these were more commonly reported at private (70%, 95% CI 65–76) than at public (58%, 95% CI 54–63) facilities. There were intermittent availability of vaccines and transport for immunisation services at both private and public facilities.
Complex health system barriers to childhood immunisation still exist in this urban setting; emphasizing that even in urban areas with great physical access, there are hard to reach people. As the rate of urbanization increases especially in sub-Saharan Africa, governments should strengthen health systems to cater for increasing urban populations.
PMCID: PMC3975865  PMID: 24602169
Urban; Immunisation; Health system; Barriers; Resources; Service delivery; Public health; Mixed methods
8.  Knowledge and attitudes to personal genomics testing for complex diseases among Nigerians 
BMC Medical Ethics  2014;15:34.
The study examined the knowledge and attitudes to personal genomics testing for complex diseases among Nigerians and identified how the knowledge and attitudes vary with gender, age, religion, education and related factors.
Data were collected using qualitative method in 2 districts of the Federal Capital Territory. In the study, eight (8) Focused Group Discussions (FGDs) and twenty seven (27) Key Informant Interviews (KIIs) were conducted. Participants for the research were recruited among healthy Nigerians, individuals with complex diseases, health care professionals, community leaders and health policy makers.
Analysis of the result showed that most respondents in both FGDs and KIIs had limited knowledge about genomics test initially. Their understanding of the test however improved after explanation on its concept. Participants showed positive attitude towards genomics tests. Nevertheless they expressed fear over direct to consumer personal genomics testing, testing unborn babies and disclosure of results to third parties. Culture and religion were found to influence the perspectives of respondents on genomics test particularly those aspects that could either directly contradict their beliefs and practices or lead to actions which contradict them.
In conclusion, most Nigerians interviewed had limited knowledge of genomics test but with supportive attitude towards its use in predicting future risk of complex diseases after understanding the test concept. Genomics testing for complex diseases was not a common practice in Nigeria.
PMCID: PMC4005395  PMID: 24766930
Genomics testing; Personal; Ethics; Abortion; Religion; Complex diseases
9.  A qualitative study of the feasibility and community perception on the effectiveness of artemether-lumefantrine use in the context of home management of malaria in south-west Nigeria 
In Nigeria ACT use at the community level has not been evaluated and the use of antimalarial drugs (commonly chloroquine (CQ)) at home has been shown to be largely incorrect. The treatment regimen of ACT is however more complicated than that of CQ. There is thus a need to determine the feasibility of using ACT at the home level and determine community perception on its use.
A before and after qualitative study using key informant interviews (KII) and focus group discussions (FGDs) was conducted in selected villages in Ona-Ara local government area. At baseline, 14 FGDs and 14 KIIs were conducted. Thereafter, community medicine distributors (CMDs) were trained in each village to dispense artemeter-lumenfantrine (AL) to febrile children aged 6–59 months presumed to have uncomplicated malaria. After one year of drug distribution, nine KIIs and 10 FGDs were conducted. Participants and key informants were mothers and fathers with children under five years, traditional heads of communities, opinion leaders and health workers.
None of the participants have heard of AL prior to study. Participants were favourably disposed to introduction of AL into the community. Mothers/caregivers were said to have used AL in place of the orthodox drugs and herbs reported commonly used prior to study after commencement of AL distribution. The use of CMDs for drug distribution was acceptable to the participants and they were judged to be efficient as they were readily available, distributed correct dose of AL and mobilised the community effectively. AL was perceived to be very effective and no significant adverse event was reported. Major concerns to the sustainability of the program were the negative attitudes of health workers towards discharge of their duties, support to the CMDs and the need to provide CMDs incentives. In addition regular supply of drugs and adequate supervision of CMDs were advised.
Our findings showed that the use of AL at home and community level is feasible with adequate training of community medicine distributors and caregivers. Community members perceived AL to be effective thus fostering acceptability. The negative attitudes of the health workers and issue of incentives to CMDs need to be addressed for successful scaling-up of ACT use at community level.
PMCID: PMC2429909  PMID: 18513447
10.  Participation and significance of self-help groups for social development: exploring the community capacity in Ethiopia 
SpringerPlus  2014;3:189.
There are various Civil Society Organizations (CSOs) in Ethiopia among which the ‘Idir’ is a social and financial institution widespread both in urban and rural areas of the country. So the objectives of this study is to investigate how women members perceive the contribution of iddirs toward improving their lives and to determine whether and to what extent participation in iddirs has social impacts on their lives.
A cross-sectional qualitative study using Key Informant In-Depth Interviews (KII) and Focus Group Discussions (FGDs) was conducted in Addis Ababa, Addis Ketema Sub-city. Ethiopia. Data was collected using a semi-structured interview questionnaire and FGD guideline. Analysis of the data was made manually using thematic framework analysis method.
Though their iddir doesn’t provide financial assistance, all the participants revealed the importance of installing credit mechanisms in their iddirs. However, they mentioned the inability of their respective iddirs in assisting members with their financial needs. One major difficulty mentioned was lack of capital. The participants demonstrated that the contribution of iddir in their well-being was more indispensable than the contributions of other voluntary associations they are acquainted with, such as iqub and mahiber. Especially iddir was regarded as crucial and unique in meeting emotional needs. As well, iddirs’ meetings are ideal places where women share experience; discuss issues of pressing concern and their worries. Other benefit of iddir include opportunities for social interaction, risk sharing and development of friendships, dispute resolution, Sharing and using timely information more effectively, Lower level of funeral services anxiety, Improvement of self confidence and leadership role, reciprocity and coexistence and trust.
Women’s iddirs are the viable basis in the creation of social network which plays crucial roles in providing solutions to social and economic challenges women are facing. There was a general consensus by the participants that their iddirs were unable to offer financial assistances. Enabling women’s iddirs to be independent of borrowing from banks is also indispensable and trainings on effective use of credits and the positive role of social capital formed in women’s iddirs is relevant.
PMCID: PMC4000359  PMID: 24790831
11.  Lack of effective communication between communities and hospitals in Uganda: a qualitative exploration of missing links 
Community members are stakeholders in hospitals and have a right to participate in the improvement of quality of services rendered to them. Their views are important because they reflect the perspectives of the general public. This study explored how communities that live around hospitals pass on their views to and receive feedback from the hospitals' management and administration.
The study was conducted in eight hospitals and the communities around them. Four of the hospitals were from three districts from eastern Uganda and another four from two districts from western Uganda. Eight key informant interviews (KIIs) were conducted with medical superintendents of the hospitals. A member from each of three hospital management boards was also interviewed. Eight focus group discussions (FGDs) were conducted with health workers from the hospitals. Another eight FGDs (four with men and four with women) were conducted with communities within a five km radius around the hospitals. Four of the FGDs (two with men and two with women) were done in western Uganda and the other four in eastern Uganda. The focus of the KIIs and FGDs was exploring how hospitals communicated with the communities around them. Analysis was by manifest content analysis.
Whereas health unit management committees were supposed to have community representatives, the representatives never received views from the community nor gave them any feed back from the hospitals. Messages through the mass media like radio were seen to be non specific for action. Views sent through suggestion boxes were seen as individual needs rather than community concerns. Some community members perceived they would be harassed if they complained and had reached a state of resignation preferring instead to endure the problems quietly.
There is still lack of effective communication between the communities and the hospitals that serve them in Uganda. This deprives the communities of the right to participate in the improvement of the services they receive, to assume their position as stakeholders. Various avenues could be instituted including using associations in communities, rapid appraisal methods and community meetings.
PMCID: PMC2731748  PMID: 19671198
12.  Lower Acetylcholinesterase Activity among Children Living with Flower Plantation Workers 
Environmental Research  2012;114:53-59.
Children of workers exposed to pesticides are at risk of secondary pesticide exposure. We evaluated the potential for lower acetylcholinesterase activity in children cohabiting with fresh-cut flower plantation workers, which would be expected from organophosphate and carbamate insecticide exposure. Parental home surveys were performed and acetylcholinesterase activity was measured in 277 children aged 4–9 years in the study of Secondary Exposure to Pesticides among Infants, Children and Adolescents (ESPINA). Participants lived in a rural county in Ecuador with substantial flower plantation activity.
Mean acetylcholinesterase activity was 3.14 U/ml, standard deviation (SD): 0.49. It was lower by 0.09 U/ml (95% confidence interval (CI) −0.19, −0.001) in children of flower workers (57% of participants) than non-flower workers’ children, after adjustment for gender, age, height-for-age, hemoglobin concentration, income, pesticide use within household lot, pesticide use by contiguous neighbors, examination date and residence distance to nearest flower plantation. Using a 4 level polychotomous acetylcholinesterase activity dependent variable, flower worker cohabitation (vs. not) had odds ratio 3.39 (95% CI 1.19, 9.64) for being <15th percentile compared to the highest tertile. Children cohabitating for ≥5 years (vs. never) had OR of 4.11 (95% CI: 1.17, 14.38) of AChE activity within <15th percentile compared to the highest tertile.
Cohabitation with a flower worker was related to lower acetylcholinesterase activity in children. This supports the hypothesis that the amount of take-home pesticides from flower workers suffices to decrease acetylcholinesterase activity, with lower activity associated with longer exposure.
PMCID: PMC3319289  PMID: 22405996
Acetylcholinesterase; AChE; children; pesticide; organophosphate
13.  Assessment of strategies for male involvement in the prevention of mother-to-child transmission of HIV services in Blantyre, Malawi 
Global Health Action  2013;6:10.3402/gha.v6i0.22780.
Despite the documented benefits of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) services, the uptake remains low in sub-Saharan Africa. The lack of male involvement (MI) may be one of the reasons for this. However, there are limited data on strategies for MI in PMTCT.
The objective of this study was to identify strategies that may promote MI in PMTCT services in antenatal care (ANC) services in Blantyre, Malawi.
Study design
An exploratory qualitative study was conducted from December 2012 to January 2013 at South Lunzu Health Centre (SLHC) in Blantyre, Malawi. It consisted of six face-to-face key informant interviews (KIIs) with healthcare workers and four focus group discussions (FGDs) with 18 men and 17 pregnant women attending ANC at SLHC. The FGDs were divided according to sex and age. All FGDs and KIIs were digitally recorded and simultaneously transcribed and translated verbatim into English. Data were analyzed using thematic content analysis.
Three major themes with several subcategories emerged. Theme 1 was a gatekeeping strategy with two subcategories: (1) healthcare workers refusing service provision to women accessing antenatal clinic without their partners and (2) women refusing ANC attention in the absence of a partner. Theme 2 comprised extending invitations and had six subcategories: (1) word of mouth, (2) card invites, (3) woman's health passport book invites, (4) telephonic invites, (5) use of influential people, and (6) home visits. Theme 3 was information education and communication, such as health education forums and advertisements. Of all the strategies, an invitation card addressed to the male partner was most preferred by study participants.
There are several strategies by which men may be involved in PMTCT. Healthcare workers should offer a pregnant woman all strategies available for MI for her to select the appropriate one. Further research and consultations with men should continue to achieve higher levels of MI.
PMCID: PMC3866839  PMID: 24345635
male involvement; HIV and AIDS; PMTCT
14.  Challenges in universal coverage and utilization of insecticide-treated bed nets in migrant plantation workers in Myanmar 
Malaria Journal  2014;13:211.
High coverage of the bed nets can reduce mortality and morbidity of mosquito-borne diseases including malaria. Although the migrant workers are at high risk of malaria, there are many hidden challenges in universal coverage and utilization of the insecticide-treated nets (ITNs) in this populations.
Cross sectional study was conducted in 170 migrant workers in palm oil plantation sites in Tanintharyi Region and 175 in rubber plantation sites in Mon State. A multistage stratified cluster sampling was applied to select the participants. During household visit, face-to-face interviews using structured pre-coded, pre tested questionnaires and direct observation on installation of the bed nets was conducted. Two focus group discussions in each site were done by sample stratified purposive sampling method mainly focused on effective utilization of bed nets.
Among them, 332 (96.2%) had a bed net and 284 (82.3%) had an ITN, while 204 (59.1%) had unused extranets. Among the ITNs users, 28.9% reported problems including insecticide smell (56.9%), dizziness (20.2%), headache (12.8%) and itchiness (9.2%). More than 75% received ITNs from health authorities and NGOs free-of-charge. More than 70% wanted to buy a net but they were unaffordable for 64% of them. On observation, only five families could show no bed net, but 80% showed 1–3 ITNs. Consistent utilization in all seasons was noted in 189 (53.1%), that was higher in palm oil plantation than rubber plantation workers (p = 0.0001) due to the nature of the work at night. Perceived malaria risk was also significantly higher ITNs consistent users than non-users (p = 0.0004) and better willingness to buy an ITN by themselves (p = 0.0005). They said that effectiveness of the ITNs was reduced after 6 months and 2–3 times washing. They wished to receive more durable smooth nets with small holes in lace. Misuses of the ITNs such as use the nets for animals and fishing, were also noted.
There should be efforts to improve effective utilization of ITNs by continuous mass free distribution, durability monitoring, surveillance of insecticide resistance of the vector and behaviour change interventions in migrant plantation workers.
PMCID: PMC4058704  PMID: 24888548
Malaria; ITN; LLIN; Migrant worker; Myanmar
15.  Community participation for malaria elimination in Tafea Province, Vanuatu: Part I. Maintaining motivation for prevention practices in the context of disappearing disease 
Malaria Journal  2010;9:93.
In the 1990s, the experience of eliminating malaria from Aneityum Island, Vanuatu is often given as evidence for the potential to eliminate malaria in the south-west Pacific. This experience, however, cannot provide a blueprint for larger islands that represent more complex social and environmental contexts. Community support was a key contributor to success in Aneityum. In the context of disappearing disease, obtaining and maintaining community participation in strategies to eliminate malaria in the rest of Tafea Province, Vanuatu will be significantly more challenging.
Nine focus group discussions (FGDs), 12 key informant interviews (KIIs), three transect walks and seven participatory workshops were carried out in three villages across Tanna Island to investigate community perceptions and practices relating to malaria prevention (particularly relating to bed nets); influences on these practices including how malaria is contextualized within community health and disease priorities; and effective avenues for channelling health information.
The primary protection method identified by participants was the use of bed nets, however, the frequency and motivation for their use differed between study villages on the basis of the perceived presence of malaria. Village, household and personal cleanliness were identified by participants as important for protection against malaria. Barriers and influences on bed net use included cultural beliefs and practices, travel, gender roles, seasonality of mosquito nuisance and risk perception. Health care workers and church leaders were reported to have greatest influence on malaria prevention practices. Participants preferred receiving health information through visiting community health promotion teams, health workers, church leaders and village chiefs.
In low malaria transmission settings, a package for augmenting social capital and sustaining community participation for elimination will be essential and includes: 'sentinel sites' for qualitative monitoring of evolving local socio-cultural, behavioural and practical issues that impact malaria prevention and treatment; mobilizing social networks; intersectoral collaboration; integration of malaria interventions with activities addressing other community health and disease priorities; and targeted implementation of locally appropriate, multi-level, media campaigns that sustain motivation for community participation in malaria elimination.
PMCID: PMC2873527  PMID: 20380748
16.  Interface of culture, insecurity and HIV and AIDS: Lessons from displaced communities in Pader District, Northern Uganda 
Conflict and Health  2010;4:18.
Northern Uganda unlike other rural regions has registered high HIV prevalence rates comparable to those of urbanized Kampala and the central region. This could be due to the linkages of culture, insecurity and HIV. We explored community perceptions of HIV and AIDS as a problem and its inter-linkage with culture and insecurity in Pader District.
A cross sectional qualitative study was conducted in four sub-counties of Pader District, Uganda between May and June 2008. Data for the study were collected through 12 focus group discussions (FGDs) held separately; 2 FGDs with men, 6 FGDs with women, and 4 FGDs with the youth (2 for each sex). In addition we conducted 15 key informant interviews with; 3 health workers, 4 community leaders at village and parish levels, 3 persons living with HIV and 5 district officials. Data were analysed using the content thematic approach. This process involved identification of the study themes and sub-themes following multiple reading of interview and discussion transcripts. Relevant quotations per thematic area were identified and have been used in the presentation of study findings.
The struggles to meet the basic and survival needs by individuals and households overshadowed HIV as a major community problem. Conflict and risky sexual related cultural practices were perceived by communities as major drivers of HIV and AIDS in the district. Insecurity had led to congestion in the camps leading to moral decadence, rape and defilement, prostitution and poverty which increased vulnerability to HIV infection. The cultural drivers of HIV and AIDS were; widow inheritance, polygamy, early marriages, family expectations, silence about sex and alcoholism.
Development partners including civil society organisations, central government, district administration, religious and cultural leaders as well as other stakeholders should mainstream HIV in all community development and livelihood interventions in the post conflict Pader district to curtail the likely escalation of the HIV epidemic. A comprehensive behaviour change communication strategy is urgently needed to address the negative cultural practices. Real progress in the region lies in advocacy and negotiation to realise lasting peace.
PMCID: PMC2995777  PMID: 21092165
17.  The Expansion of Farm-Based Plantation Forestry in Vietnam 
Ambio  2010;39(8):567-579.
This study targets plantation forestry by farm households (small holders), which is increasing globally and most rapidly in China and Vietnam. By use of an interdisciplinary approach on three study sites in Vietnam, we examined the trends in farmers’ tree planting over time, the various pre-requisites for farm-based plantation forestry and its impact on rural people’s livelihood strategies, socio-economic status, income and security. The findings indicated a change from subsistence to cash-based household economy, diversification of farmers’ incomes and a transformation of the landscape from mainly natural forests, via deforestation and shifting cultivation, to a landscape dominated by farm-based plantations. The trend of transformation, over a period of some 30 years, towards cash crops and forestry was induced by a combination of policy, market, institutional, infrastructural and other conditions and the existence of professional farming communities, and was most rapid close to the industrial market.
PMCID: PMC3357683  PMID: 21141776
Smallholder households; Livelihood strategies; Landscape; Land use; Policy; Market
18.  Use of traditional medicine for the treatment of diabetes in Eastern Uganda: a qualitative exploration of reasons for choice 
While there are biomedical drugs for managing diabetes mellitus, some patients with diabetes use traditional medicine. The aim of the study was to explore why patients with diabetes use traditional medicine for the treatment of diabetes.
The study was conducted in Iganga and Bugiri districts in Eastern Uganda using four focus group discussions (FGDs) with patients with diabetes; two with female patients and two with male patients, thirteen key informant interviews (KIIs); nine with health workers working with patients with diabetes and four with herbalists. FGDs and KIIs focused on what respondents perceived as reasons for patients with diabetes taking traditional medicine. Analysis was done using content analysis.
Reasons for taking traditional medicine included finding difficulties accessing hospitals, diabetic drugs being out of stock, traditional medicine being acceptable and available within community, as well as being supplied in big quantities. Others were traditional medicine being cheaper than biomedical treatment and payment for it being done in installments. Traditional medicine was also more convenient to take and was marketed aggressively by the herbalists. Influence of family and friends as well as traditional healers contributed to use of traditional medicine.
Possibilities of putting diabetic drugs at facilities closer to patients need to be considered and health facilities should have a constant supply of diabetic drugs. Community members need to be sensitized on the proper treatment for diabetes mellitus and on the dangers of taking traditional medicine.
PMCID: PMC3544563  PMID: 23282020
19.  A Refined Methodology for Defining Plant Communities Using Postagricultural Data from the Neotropics 
The Scientific World Journal  2012;2012:365409.
How best to define and quantify plant communities was investigated using long-term plot data sampled from a recovering pasture in Puerto Rico and abandoned sugarcane and banana plantations in Ecuador. Significant positive associations between pairs of old field species were first computed and then clustered together into larger and larger species groups. I found that (1) no pasture or plantation had more than 5% of the possible significant positive associations, (2) clustering metrics showed groups of species participating in similar clusters among the five pasture/plantations over a gradient of decreasing association strength, and (3) there was evidence for repeatable communities—especially after banana cultivation—suggesting that past crops not only persist after abandonment but also form significant associations with invading plants. I then showed how the clustering hierarchy could be used to decide if any two pasture/plantation plots were in the same community, that is, to define old field communities. Finally, I suggested a similar procedure could be used for any plant community where the mechanisms and tolerances of species form the “cohesion” that produces clustering, making plant communities different than random assemblages of species.
PMCID: PMC3317650  PMID: 22536137
20.  Only connect – the role of PLHIV group networks in increasing the effectiveness of Ugandan HIV services 
AIDS Care  2012;24(11):1368-1374.
In recent years, Uganda has experienced rapid growth in networked groups of people living with HIV (PLHIV) who provide support, engage in advocacy, treatment and care and raise the profile of HIV in the public domain. This qualitative study focused the benefits of joining a networked group, relationships between groups, impact of networked groups on the community and shaping private and public experience living with HIV. Data were collected from two Ugandan districts, using semi-structured interviews, focus group discussions (FGDs), observation and reviews of group records and archives. Respondents (n = 46) were adults living with HIV, and members of rural and urban PLHIV groups. Narratives from PLHIV (n = 27) were gathered, and records from PLHIV group service-registers (n = 20) reviewed. Key Informants (n = 15) were purposively selected for interview, based on participation in PLHIV groups, utilisation of network services and their positions as key stakeholders. FGDs were held with network support agents (NSAs), members of PLHIV groups, and their leaders. Following qualitative analysis, findings suggest that for respondents, PLHIV networks enhance the impact and effectiveness of individual groups: the whole is greater than the sum of the parts. For groups, being part of a wider network allows for diversity of service delivery, and well-defined roles for individuals to participate in community support and sensitisation, with a reduction in the experience of stigma. We conclude that networking PLHIV groups is an effective strategy for improving the quality and reach of community-based HIV services. Governments should be encouraged to support networks and include them in policy-making at the national level. Local and regional groups should explore further ways to collaborate and expand support to PLHIV in Uganda.
PMCID: PMC3483863  PMID: 22316108
networks; PLHIV; disclosure; health systems strengthening; HIV care
21.  Measuring Coverage in MNCH: Population HIV-Free Survival among Children under Two Years of Age in Four African Countries 
PLoS Medicine  2013;10(5):e1001424.
Population-based evaluations of programs for prevention of mother-to-child HIV transmission (PMTCT) are scarce. We measured PMTCT service coverage, regimen use, and HIV-free survival among children ≤24 mo of age in Cameroon, Côte D'Ivoire, South Africa, and Zambia.
Methods and Findings
We randomly sampled households in 26 communities and offered participation if a child had been born to a woman living there during the prior 24 mo. We tested consenting mothers with rapid HIV antibody tests and tested the children of seropositive mothers with HIV DNA PCR or rapid antibody tests. Our primary outcome was 24-mo HIV-free survival, estimated with survival analysis. In an individual-level analysis, we evaluated the effectiveness of various PMTCT regimens. In a community-level analysis, we evaluated the relationship between HIV-free survival and community PMTCT coverage (the proportion of HIV-exposed infants in each community that received any PMTCT intervention during gestation or breastfeeding). We also compared our community coverage results to those of a contemporaneous study conducted in the facilities serving each sampled community. Of 7,985 surveyed children under 2 y of age, 1,014 (12.7%) were HIV-exposed. Of these, 110 (10.9%) were HIV-infected, 851 (83.9%) were HIV-uninfected, and 53 (5.2%) were dead. HIV-free survival at 24 mo of age among all HIV-exposed children was 79.7% (95% CI: 76.4, 82.6) overall, with the following country-level estimates: Cameroon (72.6%; 95% CI: 62.3, 80.5), South Africa (77.7%; 95% CI: 72.5, 82.1), Zambia (83.1%; 95% CI: 78.4, 86.8), and Côte D'Ivoire (84.4%; 95% CI: 70.0, 92.2). In adjusted analyses, the risk of death or HIV infection was non-significantly lower in children whose mothers received a more complex regimen of either two or three antiretroviral drugs compared to those receiving no prophylaxis (adjusted hazard ratio: 0.60; 95% CI: 0.34, 1.06). Risk of death was not different for children whose mothers received a more complex regimen compared to those given single-dose nevirapine (adjusted hazard ratio: 0.88; 95% CI: 0.45, 1.72). Community PMTCT coverage was highest in Cameroon, where 75 of 114 HIV-exposed infants met criteria for coverage (66%; 95% CI: 56, 74), followed by Zambia (219 of 444, 49%; 95% CI: 45, 54), then South Africa (152 of 365, 42%; 95% CI: 37, 47), and then Côte D'Ivoire (3 of 53, 5.7%; 95% CI: 1.2, 16). In a cluster-level analysis, community PMTCT coverage was highly correlated with facility PMTCT coverage (Pearson's r = 0.85), and moderately correlated with 24-mo HIV-free survival (Pearson's r = 0.29). In 14 of 16 instances where both the facility and community samples were large enough for comparison, the facility-based coverage measure exceeded that observed in the community.
HIV-free survival can be estimated with community surveys and should be incorporated into ongoing country monitoring. Facility-based coverage measures correlate with those derived from community sampling, but may overestimate population coverage. The more complex regimens recommended by the World Health Organization seem to have measurable public health benefit at the population level, but power was limited and additional field validation is needed.
Please see later in the article for the Editors' Summary
Editors' Summary
For a pregnant woman who is HIV-positive, the discrepancy across the world in outlook for mother and child is stark. Mother-to-child transmission of HIV during pregnancy is now less than 1% in many high-income settings, but occurs much more often in low-income countries. Three interventions have a major impact on transmission of HIV to the baby: antiretroviral drugs, mode of delivery, and type of infant feeding. The latter two are complex, as the interventions commonly used in high-income countries (cesarean section if the maternal viral load is high; exclusive formula feeding) have their own risks in low-income settings. Minimizing the risks of transmitting HIV through effective drug regimes therefore becomes particularly important. Monitoring progress on reducing the incidence of mother-to-child HIV transmission is essential, but not always easy to achieve.
Why Was This Study Done?
A research group led by Stringer and colleagues recently reported a study from four countries in Africa: Cameroon, Côte D'Ivoire, South Africa, and Zambia. The study showed that even in the health facility setting (e.g., hospitals and clinics), only half of infants whose mothers were HIV-positive received the minimum recommended drug treatment (one dose of nevirapine during labor) to prevent HIV transmission. Across the population of these countries, it is possible that fewer receive antiretroviral drugs, as the study did not include women who did not access health facilities. Therefore, the next stage of the study by this research group, reported here, involved going into the communities around these health facilities to find out how many infants under two years old had been exposed to HIV, whether they had received drugs to prevent transmission, and what proportion were alive and not infected with HIV at two years old.
What Did the Researchers Do and Find?
The researchers tested all consenting women who had delivered a baby in the last two years in the surrounding communities. If the mother was found to be HIV-positive, then the infant was also tested for HIV. The researchers then calculated how many of the infants would be alive at two years and free of HIV infection.
Most mothers (78%) agreed to testing for themselves and their infants. There were 7,985 children under two years of age in this study, of whom 13% had been born to an HIV-positive mother. Less than half (46%) of the HIV-positive mothers had received any drugs to prevent HIV transmission. Of the children with HIV-positive mothers, 11% were HIV-infected, 84% were not infected with HIV, and 5% had died. Overall, the researchers estimated that around 80% of these children would be alive at two years without HIV infection. This proportion differed non-significantly between the four countries (ranging from 73% to 84%). The researchers found higher rates of infant survival than they had expected and knew that they might have missed some infant deaths (e.g., if households with infant deaths were less likely to take part in the study).
The researchers found that their estimates of the proportion of HIV-positive mothers who received drugs to prevent transmission were fairly similar between their previous study, looking at health facilities, and this study of the surrounding communities. However, in 14 out of 16 comparisons, the estimate from the community was lower than that from the facility.
What Do These Findings Mean?
This study shows that it would be possible to estimate how many infants are surviving free of HIV infection using a study based in the community, and that these estimates may be more accurate than those for studies based in health facilities. There are still a large proportion of HIV-positive mothers who are not receiving drugs to prevent transmission to the baby. The authors suggest that using two or three drugs to prevent HIV may help to reduce transmission.
There are already community surveys conducted in many low-income countries, but they have not included routine infant testing for HIV. It is now essential that organizations providing drugs, money, and infrastructure in this field consider more accurate means of monitoring incidence of HIV transmission from mother to infant, particularly at the community level.
Additional Information
Please access these websites via the online version of this summary at
The World Health Organization has more information on mother-to-child transmission of HIV
The United Nations Children's Fund has more information on the status of national PMTCT responses in the most affected countries
PMCID: PMC3646218  PMID: 23667341
22.  Community perception on biomedical research: A case study of malariometric survey in Korogwe District, Tanga Region, Tanzania 
BMC Public Health  2014;14:385.
Community perception in biomedical research remains critical in Africa with many participants being driven by different motives. The objective of this study was to explore the perceived motives for women or females guardians to volunteer for their children to participate in biomedical research and to explore experiences and challenges faced by Community Owned Resource Persons (CORPs) when mobilizing community members to participate in biomedical research.
This cross sectional study was conducted in Korogwe district, in north-eastern Tanzania. Qualitative methods combining random and purposive sampling techniques were used for data collection. A randomly selected sample using random table method from the existing list of households in the ward office was used to select participants for Focus Group Discussions (FGDs). A purposive sampling technique was used for In-Depth Interviews (IDIs) with CORPs. Thematic framework analysis was used to analyze the data.
Need for better health services, availability of qualified clinicians, and better access to services provided at the research points were reported as main motives for community members to participate in biomedical research. With regard to experience and challenges faced by CORPs, the main reasons for mothers and guardians not participating in biomedical research were linked to misconception of the malariometric surveys, negative perception of the validity and sensitivity of rapid diagnostic tests, fear of knowing Human Immunodeficiency Virus Infection (HIV)/Acquired Immune Deficiency Syndrome (HIV/AIDS) sero status, and lack of trust for the medical information provided by the CORPs. Challenges reported by CORPs included lack ofawareness of malariometric surveys among participants, time consumption in mobilization of the community, difficulties in identifying individual results, and family responsibilities.
This study has shown that majority of community members had positive perceptions of the about malariometric surveys services provided. The availability of free health services was the major determining factor for community members’ participation in malariometric surveys. CORPs are instrumental in mobilizing community members participation during malariometric surveys, despite their experiences and the challenges they face.
PMCID: PMC4000435  PMID: 24755404
Community; Perception; Biomedical research; Experience; Challenges; Community owned resource persons; Tanzania
23.  Malariometric Indices among Nigerian Children in a Rural Setting 
Malaria Research and Treatment  2013;2013:716805.
Malaria contributes to high childhood morbidity and mortality in Nigeria. To determine its endemicity in a rural farming community in the south-south of Nigeria, the following malariometric indices, namely, malaria parasitaemia, spleen rates, and anaemia were evaluated in children aged 2–10 years. This was a descriptive cross-sectional survey among school-age children residing in a rubber plantation settlement. The children were selected from six primary schools using a multistaged stratified cluster sampling technique. They were all examined for pallor, enlarged spleen, or liver among other clinical parameters and had blood films for malaria parasites. Of the 461 children recruited, 329 (71.4%) had malaria parasites. The prevalence of malaria parasitaemia was slightly higher in the under fives than that of those ≥5 years, 76.2% and 70.3%, respectively. Splenic enlargement was present in 133 children (28.9%). The overall prevalence of anaemia was 35.7%. Anaemia was more common in the under-fives (48.8%) than in those ≥5 years (32.8%). The odds of anaemia in the under fives were significantly higher than the odds of those ≥5 years (OR = 1.95 [1.19–3.18]). Malaria is highly endemic in this farming community and calls for intensification of control interventions in the area with special attention to school-age children.
PMCID: PMC3603376  PMID: 23533951
24.  Living with death in a time of AIDS: A rural South African case study1 
To examine how a rural community profoundly affected by escalating rates of largely AIDS-related deaths of young and middle-aged people makes sense of this phenomenon and its impact on their everyday lives.
Data were collected in Agincourt subdistrict, Limpopo Province. Twelve focus groups were constituted according to age and gender and met three times (a total of 36 focus-group discussions [FGDs]). The FGDs explored sequentially people’s expectations of their lives in the “new” South Africa, their interpretations of the acceleration of death amongst the young and middle-aged, and their understandings of HIV/AIDS. Discussions were recorded, fully transcribed, and thematically analysed.
Respondents acknowledged escalating death rates in their community, yet few referred directly to HIV/AIDS as the cause. Rather, respondents focused on the social and cultural causes of death, including the erosion of cultural norms and traditions such as cultural taboos on sex. There are many competing versions of what HIV/AIDS is, what causes it and how it is spread, ranging from scientific explanations to conspiracy theories. Findings highlight the relationship between AIDS and other traditional diseases with some respondents suggesting that AIDS is a new form of other longstanding illnesses.
This study points to the centrality of cultural explanations in understanding “bad death” (AIDS death) in the Agincourt area. Physical illness is understood to be a symptom of “cultural damage”. Implications of this for public health practice and research are outlined.
PMCID: PMC2825806  PMID: 17676515
Culture; death; generation; HIV/AIDS illness; indigenous health beliefs; public health; rural; sex; South Africa
25.  Waist circumference and obesity-related abnormalities in French and Cameroonian adults: the role of urbanization and ethnicity 
To evaluate the effect of urbanization and ethnicity on correlations between waist circumference (WC) and obesity related cardiovascular risk factors.
1471 rural and urban Cameroonians, and 4185 French, from community based studies, aged ≥25 years, not treated for hypertension, diabetes and dyslipidemia participated to this study. Slopes of obesity related abnormalities with WC were compared using an interaction term between place of residence and WC.
Women in urban Cameroon and men in France had significantly higher WC and BMI relative to their gender counterparts. Urban Cameroonians had higher abdominal adiposity, but lower BP and better metabolic profile than the French. WC was positively associated to all the obesity related abnormalities in the three sites except to FPG (both genders) and blood lipids (women) in rural Cameroon. A 5cm larger WC was associated with a higher increment among urban than rural Cameroonians for diastolic blood pressure (DBP) (women, 1.95/0.63mmHg; men, 2.56/1.44mmHg), HOMA-IR (women, 0.11/0.05), fasting plasma glucose (FPG) (men, 0.09/−0.01mmol/l) and triglycerides (women, 0.06/0.01mmol/l; men, 0.09/0.03mmol/l), all p<0.05. A 5cm larger WC was associated with a higher increment among urban Cameroon than French people for DBP (women, 1.95/1.28mmHg, p<0.01; men, 2.56/1.49mmHg, p<0.01), but with a lower increment for HOMA-IR (women, 0.11/0.14, p<0.05), FPG (women, 0.05/0.09mmol/l), total cholesterol (women, 0.07/0.11mmol/l; men, 0.10/0.13mmol/l) and triglycerides (women, 0.06/0.11mmol/l; men, 0.09/0.13mmol/l) all p<0.05.
Ethnicity and urbanization modify the association of WC with obesity related metabolic abnormalities. WC cut-off points derived from Caucasians may not be appropriate for black Sub-Saharan Africans.
PMCID: PMC2941697  PMID: 20065972
Abdominal obesity; cardiovascular risk factors; ethnicity; urbanization; Sub-Saharan Africa

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