Using an intervention mapping approach for planning, implementing and assessing a community-led project towards malaria elimination in the Eastern Province of Rwanda

Assessing the implementation fidelity, feasibility, and sustainability of community-based house improvement for malaria control in southern Malawi: a mixed-methods study

BACKGROUND

Despite significant success in the fight against malaria over the past two decades, malaria control programmes rely on only two insecticidal methods: indoor residual spraying and insecticidal-treated nets. House improvement (HI) can complement these interventions by reducing human-mosquito contact, thereby reinforcing the gains in disease reduction. This study assessed the implementation fidelity, which is the assessment of how closely an intervention aligns with its intended design, feasibility, and sustainability of community-led HI in southern Malawi.

METHODS

The study, conducted in 22 villages (2730 households), employed a mixed-methods approach. Implementation fidelity was assessed using a modified framework, with longitudinal surveys collecting data on HI coverage indicators. Quantitative analysis, employing descriptive statistics, evaluated the adherence to HI implementation. Qualitative data came from in-depth interviews, key informant interviews, and focus groups involving project beneficiaries and implementers. Qualitative data were analysed using content analysis guided by the implementation fidelity model to explore facilitators, challenges, and factors affecting intervention feasibility.

RESULTS

The results show that HI was implemented as planned. There was good adherence to the intended community-led HI design; however, the adherence could have been higher but gradually declined over time. In terms of intervention implementation, 74% of houses had attempted to have eaves closed in 2016-17 and 2017-18, compared to 70% in 2018-19. In 2016-17, 42% of houses had all four sides of the eaves closed, compared to 33% in 2018-19. Approximately 72% of houses were screened with gauze wire in 2016-17, compared to 57% in 2018-19. High costs, supply shortages, labour demands, volunteers' poor living conditions and adverse weather were reported to hinder the ideal HI implementation. Overall, the community described community-led HI as feasible and could be sustained by addressing these socioeconomic and contextual challenges.

CONCLUSION

Our study found that although HI was initially implemented as planned, its fidelity declined over time. Using trained volunteers facilitated the fidelity and feasibility of implementing the intervention. A combination of rigorous community education, consistent training, information, education and communication, and intervention modifications may be necessary to address the challenges and enhance the intervention's fidelity, feasibility, and sustainability.

Using intervention mapping to develop an implementation strategy to improve timely uptake of streamlined birth-dose vaccines in the Democratic Republic of the Congo

Despite the policy recommendation and effectiveness of administering the hepatitis B birth-dose vaccine (HepB-BD) to newborns to prevent mother-to-child hepatitis B transmission, timely uptake remains an issue. Countries adopting the HepB-BD to their national immunization schedule report programmatic challenges to administering the vaccine within the recommended 24-hour window after delivery. Further, while the World Health Organization recommends streamlining three birth-dose vaccines (HepB-BD, BCG, and OPV0), scarce Sub-Saharan(SSA)-based literature reports on a streamlined and timely approach to birth-dose vaccines. As more SSA countries adopt the new birth-dose vaccine to their immunization schedules, a systematically developed implementation strategy-Vaccination of Newborns-Innovative Strategies to Hasten Birth-Dose vaccines' delivery (VANISH-BD)-will facilitate the adoption and implementation of timely birth-dose vaccine uptake. In this paper, we describe the development of the implementation strategy using intervention mapping, an evidence-based and theory-driven approach. We report on the development of our intervention, beginning with the needs assessment based in Kinshasa Province, Democratic Republic of the Congo (DRC), informing step 1 of intervention mapping. The intervention is contextually relevant, locally produced, sustainable, and designed to improve timely birth-dose vaccine uptake in the DRC. We intend to inform future implementers about improving timely and streamlined birth-dose vaccine uptake and for VANISH-BD to be adapted for similar contexts.

Towards an integrated vector management approach for sustainable control of schistosomiasis and malaria in Mwea, Kirinyaga County, Kenya: Baseline epidemiological and vector results

Background

Vector control is an important approach in the control of most parasitic and vector-borne diseases including malaria, and schistosomiasis. Distribution of these two infections often overlaps and in such areas it's more economically viable to employ an integrated approach in the control of their vectors which largely shares the same breeding ecosystem. We carried out a baseline epidemiological and vector surveys for malaria and schistosomiasis in Mwea, Kirinyaga County, in preparation for the upscaling of integrated vector management (IVM) for the two diseases.

Methods

This was a repeated cross sectional survey, where mosquito and snails were sampled during dry and wet seasons in three different ecological zones, Kiamaciri, Thiba and Murinduko to identify possible breeding sites. Mosquito larvae were collected using standard dippers, adults using CDC miniature light traps while snail vectors were sampled using standard snail scoops in different breeding habitats. A total of 1200 pupils from 12 primary schools were tested for malaria using rapid diagnostic tests (Malaria Pf/PAN Ag combo). Stool samples were processed using the Kato Katz technique for intestinal schistosomiasis.

Results

The overall prevalence of intestinal schistosomiasis was 9.08 % (95 % CI: 07.00-11.00), with Kiamaciri zone recording the highest prevalence at 19 % (95%CI: 15.00-23.00) and Murinduko zone the least at 0.17 % (95%CI: 0.00-0.01). Majority of the infections were of light intensity 78.9 % (95%CI: 70.04-86.13). There was no positive malaria case detected in this study. Of the 3208 adult mosquitoes sampled during the dry season, 20.6 % (95 % CI: 19.25-22.08) were Anopheles gambiae s.l while 79.4 % (95 % CI: 77.92-80.75) were culicines. During the wet season, 3378 adult mosquitoes were collected, of which 14.7 % (95 % CI: 13.56-15.98) were Anopheles gambiae s.l and 85.3 % (95 % CI: 84.02-86.44) culicines. Overall, 4085 mosquito larvae were collected during the two seasons, of which, 57.3 % and 42.7 % were anopheles and culicine respectively. Majority of the larvae (85.1 % (95%CI: 84.01-86.10) were collected during the wet season, with only 14.9 % (95%CI: 14.10-16.00) being collected during the dry season. A total of 2292 fresh water vector snails were collected with a majority (69.6 % (95%CI: 68.00-71.10) being Biomphalaria pffeiferi responsible for transmission of intestinal schistosomiasis.

Conclusion

This study demonstrates that intestinal schistosomiasis is prevalent in Kiamaciri and Thiba zones, and points to the possibility of active transmission of schistosomiasis in Murinduko zone. Malaria vectors were predominantly observed in all sites despite there being no malaria positive case. Culex quinquefaciatus responsible for the spread of several arboviruses was also observed. The presence of these vectors may lead to future disease outbreaks in the area if concerted control initiatives are not undertaken. The disease vectors shared the same breeding sites and thus its economical and feasible to adopt an integrated vector management approach in control efforts for these disease in the study area.

"A comparative analysis of risk factors of malaria" case study Gisagara and Bugesera District of Rwanda. RDHS 2014/2015. A retrospective study

BACKGROUND

Malaria is a public health concern worldwide. A figure of 3.2 billion people is at risk of malaria a report of World Health Organization in 2013. A proportion of 89 and 91 cases of malaria reported during 2015 were respectively attributed to malaria cases and malaria deaths in Sub-Saharan Africa. Rwanda is among the Sub-Saharan Africa located in East Africa. The several reports indicate that from 2001 to 2011, malaria cases increased considerably especially in Eastern and Southern Province with five million cases. The affected districts included Bugesera in the Eastern and Gisagara in the Southern Province of Rwanda with a share of 41% of the country prevalence in 2014 and during 2017-2018 a figure of 11 deaths was attributed to malaria and both Gisagara and Bugesera Districts were the high burdened.

METHODOLOGY

The RDHS 2014-2015 data was used for the study and a cross-sectional survey was used in which two clusters were considered both Gisagara and Bugesera Districts in the Southern and Eastern Province of Rwanda. Bivariate analysis was used to determine the significant predictors with malaria and reduced logistic regression model was used.

RESULTS

The results of the study show that not having mosquito bed nets for sleeping is 0.264 times less likely of having malaria than those who have mosquito bed nets in Gisagara District. In Bugesera District, living in low altitude is 2.768 times more likely associated with the risk of getting malaria than living in high altitude.

CONCLUSION

The results of the study concluded that environmental and geographical factor such as low altitude is the risk factor associated with malaria than the high altitude in Bugesera District. While not having mosquito bed nets for sleeping is the protective factor for malaria than those who have it in Gisagara District. On the other hand, socio-economic and demographic characteristics do not have any effect with malaria on the results of the study.

Implementing and Evaluating Community Health Worker-Led Cardiovascular Disease Risk Screening Intervention in Sub-Saharan Africa Communities: A Participatory Implementation Research Protocol

The increasing burden of non-communicable diseases (NCDs), particularly cardiovascular diseases (CVD) in low- and middle-income countries (LMICs) poses a considerable threat to public health. Community-driven CVD risk screening, referral and follow-up of those at high CVDs risk is essential to supporting early identification, treatment and secondary prevention of cardiovascular events such as stroke and myocardial infarction. This protocol describes a multi-country study that aims to implement and evaluate a community health worker (CHW)-led CVD risk screening programme to enhance referral linkages within the local primary care systems in sub-Saharan Africa (SSA), using a participatory implementation science approach. The study builds upon a prior community-driven multicentre study conducted by the Collaboration for Evidence-based Health Care and Public Health in Africa (CEBHA+). This is a participatory implementation research. The study will leverage on the CVD risk citizen science pilot studies conducted in the four selected CEBHA+ project countries (viz. Ethiopia, Rwanda, Malawi, and South Africa). Through planned engagements with communities and health system stakeholders, CHWs and lay health worker volunteers will be recruited and trained to screen and identify persons that are at high risk of CVD, provide referral services, and follow-up at designated community health clinics. In each country, we will use a multi-stage random sampling to select and then screen 1000 study participants aged 35-70 years from two communities (one rural and one urban). Screening will be done using a simple validated non-laboratory-based CVD risk assessment mobile application. The RE-AIM model will be used in evaluating the project implementation outcomes, including reach, fidelity, adoption and perceived effectiveness. Developing the capacities of CHWs and lay health worker volunteers in SSA to support population-based, non-invasive population-based CVD risk prevention has the potential to impact on early identification, treatment and secondary prevention of CVDs in often under-resourced communities. Using a participatory research approach to implementing mobile phone-based CHW-led CVD risk screening, referral and follow-up in SSA will provide the evidence needed to determine the effectiveness of CVD risk screening and the potential for scaling up in the wider region.

Community engagement: The key to tackling Antimicrobial Resistance (AMR) across a One Health context?

Antimicrobial resistance (AMR) is a One Health problem underpinned by complex drivers and behaviours. This is particularly so in low - and middle-income countries (LMICs), where social and systemic factors fuel (mis)use and drive AMR. Behavioural change around antimicrobial use could safeguard both existing and future treatments. However, changing behaviour necessitates engaging with people to understand their experiences. This publication describes a knowledge-exchange cluster of six LMIC-based projects who co-designed and answered a series of research questions around the usage of Community Engagement (CE) within AMR. Findings suggest that CE can facilitate AMR behaviour change, specifically in LMICs, because it is a contextualised approach which supports communities to develop locally meaningful solutions. However, current CE interventions focus on human aspects, and demand-side drivers, of AMR. Our cluster suggests that broader attention should be paid to AMR as a One Health issue. The popularity of mixed methods approaches within existing CE for AMR interventions suggests there is interdisciplinary interest in the uptake of CE. Unfortunately, the specificity and context-dependency of CE can make it difficult to evaluate and scale. Nevertheless, we suggest that in synthesising learnings from CE, we can develop a collective understanding of its scope to tackle AMR across contexts.   .

Community-Based Control of Malaria Vectors Using Bacillus thuringiensis var. Israelensis (Bti) in Rwanda

Larval source management (LSM) programs for control of malaria vectors are often vertically organized, while there is much potential for involving local communities in program implementation. To address this, we evaluated the entomological impact of community-based application of Bacillus thuringiensis var. israelensis (Bti) in a rice irrigation scheme in Ruhuha, Rwanda. A non-randomized trial with control compared a Bti implementation program that was supervised by the project team (ES) with a program that was led and carried out by local rice farming communities (CB). One other area served as a control to assess mosquito populations without Bti application. Entomological surveys were carried out every two weeks and assessed the presence and abundance of the larval, pupal, and adult stages of Anopheles mosquitoes. In ES, the per round reduction in Anopheles larval habitats was estimated at 49%. This reduction was less in CB (28%) and control (22%) although the per round reduction in CB was still significantly higher than in control. Pupal production was almost completely prevented from round 5 (out of 10) onwards in both CB (average habitat occupancy 0.43%) and ES intervention arms (average habitat occupancy 0.27%), whereas pupal occupancy rates were on average 12.8% from round 5 onwards in the control. Emergence of adult mosquitoes from rice fields was thus prevented although this was not directly noticeable in adult An. gambiae populations in houses nearby the rice fields. Together with our earlier work on the willingness to financially contribute to the LSM program and the high perceived safety and acceptance of the Bti product, the current study demonstrates that, in an environment with limited resources, communities could become more engaged in LSM program implementation and contribute directly to malaria vector control in their environment.

Co-creation and prototyping of an intervention focusing on health literacy in management of malaria at community-level in Ghana

INTRODUCTION

Collaborating with end-users to develop interventions tailored to fit unique circumstances is proposed as a way to improve relevance and effectiveness of an intervention. This study used a local needs driven approach to develop a health literacy intervention for caregivers in Ghana concerning management of malaria in children under 5 years.

METHOD

For the period, November 2017-February 2019, we carried out the study using a three-phase framework including: 1) Needs assessment based on data from questionnaires, focus groups, individual interviews and observations, 2) Co-creation of a board game and brochures for health education at Child Welfare Clinics to address needs in health literacy concerning malaria and 3) Development of a prototype of the game, brochures as well as determining feasibility. In addition to the research team, health administrators, community health workers, designers and caregivers contributed to the development of the intervention.

FINDINGS

The needs assessment contributed to the development of interactive and useful materials including a board game and brochures, to help bridge the gaps in health literacy among caregivers. Co-creation of the materials and prototyping yielded a varying sense of ownership among stakeholders. End-users' engagement and participation in developing the intervention resulted in a high interest and adherence to interventions. However, high attrition rates of health workers and caregivers' inconsistent use of the Child Welfare Clinics challenged sustainability of this intervention.

CONCLUSION

Co-creation led to an interactive intervention. The interactive nature of the board game and brochures resulted in a better caregiver-health provider relationship and a sense of recognition of a more participatory approach to health delivery. We recommend co-creation as an approach to develop needs-driven interventions in a context like Ghana. Still, a stronger buy-in at the top-level of health management would improve sustainability and reach a larger audience.

Core components, concepts and strategies for parasitic and vector-borne disease elimination with a focus on schistosomiasis: A landscape analysis

Efforts to control and eliminate human schistosomiasis have accelerated over the past decade. In a number of endemic countries and settings, interruption of schistosome transmission has been achieved. In others, Schistosoma infections continue to challenge program managers at different levels, from the complexity of the transmission cycle, over limited treatment options and lack of field-friendly accurate diagnostics, to controversy around adequate intervention strategies. We conducted a landscape analysis on parasitic and vector-borne disease elimination approaches with the aim to identify evidence-based strategies, core components and key concepts for achieving and sustaining schistosomiasis control and for progressing elimination efforts towards interruption of transmission in sub-Saharan Africa. A total of 118 relevant publications were identified from Web of Science, Pubmed and the grey literature and reviewed for their content. In addition, we conducted in-depth interviews with 23 epidemiologists, program managers, policymakers, donors and field researchers. Available evidence emphasizes the need for comprehensive, multipronged and long-term strategies consisting of multiple complementary interventions that must be sustained over time by political commitment and adequate funding in order to reach interruption of transmission. Based on the findings of this landscape analysis, we propose a comprehensive set of intervention strategies for schistosomiasis control and elimination. Before deployment, the proposed interventions will require review, evaluation and validation in the frame of an expert consultation as a step towards adaptation to specific contexts, conditions and settings. Field testing to ensure local relevance and effectiveness is paramount given the diversity of socio-ecological and epidemiological contexts.

This landscape analysis explored successful concepts, approaches and interventions of past and ongoing parasitic and vector-borne disease elimination efforts and programs with regard to relevance for progress in the elimination of human schistosome infections. Schistosomiasis is a disabling, water borne parasitic disease of public health concern with an estimated 250 million people infected worldwide. The long-term morbidity of this neglected tropical disease significantly impacts growth, cognition and socioeconomic development at all ages. Despite increased global efforts to control morbidity and advance elimination, challenges in view of the complex life cycle which involves freshwater sources, intermediate snail hosts and humans, remain. This calls for targeted interventions and concerted programs. According to the evidence from the literature and as proposed by a wide range of key informants, comprehensive, multipronged and long-term strategies supported by strong political commitment and adequate funding are required in order to achieve and sustain the set goals. Based on the findings, we propose here a comprehensive set of intervention strategies for schistosomiasis control and elimination for review and evaluation to inform implementation research needs and elimination program design.

Reflexive Intervention Development: Using Qualitative Research to Inform the Development of an Intervention for Women With Metastatic Breast Cancer

There is growing consensus around the limited attention given to documenting the process of intervention development, specifically the role of qualitative research. In this article, we seek to describe a missing piece of this process: how qualitative research, and related methodologies and theories, informs intervention development. We use our research as a case study of "reflexive intervention development." We begin by describing our interview study, consisting of 23 in-depth interviews with women diagnosed with metastatic breast cancer, and go on to detail our methodological framework and research team. We then explain how this interview study directly informed our development of the intervention materials, allowing us to attend carefully to language and its potential implications for women. We conclude by inviting researchers to reflect on the knowledge production process that is inherent in intervention development to consider not only their role in this process but also the role of qualitative research.

Co-Designing a Citizen Science Program for Malaria Control in Rwanda

Good health and human wellbeing is one of the sustainable development goals. To achieve this goal, many efforts are required to control infectious diseases including malaria which remains a major public health concern in Rwanda. Surveillance of mosquitoes is critical to control the disease, but surveillance rarely includes the participation of citizens. A citizen science approach (CSA) has been applied for mosquito surveillance in developed countries, but it is unknown whether it is feasible in rural African contexts. In this paper, the technical and social components of such a program are described. Participatory design workshops were conducted in Ruhuha, Rwanda. Community members can decide on the technical tools for collecting and reporting mosquito species, mosquito nuisance, and confirmed malaria cases. Community members set up a social structure to gather observations by nominating representatives to collect the reports and send them to the researchers. These results demonstrate that co-designing a citizen science program (CSP) with citizens allows for decision on what to use in reporting observations. The decisions that the citizens took demonstrated that they have context-specific knowledge and skills, and showed that implementing a CSP in a rural area is feasible.

Qualitative analysis of the health system effects of a community-based malaria elimination program in Rwanda

Purpose

To identify the health system-strengthening role of a community-based malaria elimination program in Ruhuha, Rwanda, and the ways by which health system effects may have been achieved.

Materials and methods

Qualitative data were collected through 14 semi-structured in-depth interviews and five focus group discussions with various stakeholders. These data were supported by analysis of project documents.

Results

Use of a transdisciplinary approach allowed the program to influence several crosscutting issues spanning four broad areas – social collaboration; capacity building; structural alignment; and knowledge translation. Health system effects were identified mostly at the micro (i.e., district) level, with limited impact on strengthening national and subnational policies. Although systems thinking was not explicitly applied, the project had positive spillover effects on the health system. These include expanding the informal health workforce and introducing innovative approaches aligned to the national malaria strategy for vector control. Findings also show that the elimination program contributed to an increased understanding of the transmission dynamics of malaria in Ruhuha.

Conclusion

The community-based malaria elimination program in Ruhuha successfully created a stable foundation for community mobilization toward malaria control, and explored innovative ways for long-term financing for malaria elimination. The transdisciplinary nature of the project, use of horizontal facilitation techniques for community engagement, and the sociocultural context in which the program was implemented are possible mechanisms by which systems strengthening was achieved. The knowledge gained from this assessment can be used to improve future community-focused interventions for malaria control, and develop a sustainable strategy for community engagement in health care.

Prevention Efforts for Malaria

PURPOSE OF REVIEW

Malaria remains a global burden contributing to morbidity and mortality especially in children under 5 years of age. Despite the progress achieved towards malaria burden reduction, achieving elimination in more countries remains a challenge. This article aims to review the prevention and control strategies for malaria, to assess their impact towards reducing the disease burden and to highlight the best practices observed.

RECENT FINDINGS

Use of long-lasting insecticide-treated nets and indoor residual spraying has resulted a decline in the incidence and prevalence of malaria in Sub-Saharan Africa. Other strategies such as larval source management have been shown to reduce mosquito density but require further evaluation. New methods under development such as house improvement have demonstrated to minimize disease burden but require further evidence on efficacy. Development of the RTS,S/AS01 malaria vaccine that provides protection in under-five children has provided further progress in efforts of malaria control.

SUMMARY

There has been a tremendous reduction in malaria burden in the past decade; however, more work is required to fill the necessary gaps to eliminate malaria.

Local stakeholders' perceptions of community sensitization for school-based deworming programme in Kenya

Background

In Kenya, the National School-Based Deworming Programme (NSBDP) for soil-transmitted helminthes and schistosomiasis in prioritized areas has been going on since the year 2012. By the year 2013 over 6 million School Age Children (SAC) had been treated. A community sensitization supplement containing key messages and answers to frequently asked questions was developed as a guiding tool. Awareness creation methods used include county sensitization meetings, stakeholder forums, town criers and posters. To assess the local stakeholders’ perceptions of community sensitization for programme implementation, a qualitative cross-sectional survey was conducted in four-sub-counties of coastal region.

Methods

In-depth interviews (IDIs) were administered to 40 purposively selected opinion leaders so as to explore their perceptions of awareness creation sources, adequacy of information given, length of period of awareness creation and period between which information is given and drugs are administered. Separate IDIs were administered to pre-school teachers (41), community health extension workers (34) and primary school teachers (38). To elicit more information, 20 focus group discussions (FGDs) categorized by gender and age were conducted among parents of school-age children. Data was audio recorded, transcribed, coded and analyzed manually by study themes.

Results

The most commonly reported source of information was school pupils. Due to low literacy levels, use of posters was regarded as ineffective and religious institutions, town criers and vernacular radio stations considered more effective. The information given during programme implementation was considered inadequate and use of complementary methods to reach all targeted children including the non-enrolled, and relay adequate information reported as important. Use of school and chief’s meetings with health personnel being present was mentioned as a useful method that would allow for interaction with participants indicating that they did not understand why adults were not being treated. Repeated awareness creation before deworming day to serve as a reminder and to reach those missing initial messages was also mentioned as important. Furthermore, the awareness creation period needed to be extended as 85% of the participants indicated that they learnt of deworming a day before it took place or after their children had received the drugs.

Conclusion

Awareness creation is a key factor in the success of NSBDP implementation. For programme sustainability, preferences of local stakeholders need to be considered as control of worms can only be achieved through an integrated approach of deworming, health education and use of safe water and sanitation facilities which require collaboration with local stakeholders.