Applying the COM-B behaviour change model to a pilot study delivering volatile pyrethroid spatial repellents and insecticide-treated clothing to forest-exposed populations in Mondulkiri Province, Cambodia

BACKGROUND

Southeast Asia is making tremendous progress towards their 2030 malaria elimination goal but needs new interventions to stop forest malaria. This study trials two new vector control tools, a volatile pyrethroid spatial repellent (VPSR) and insecticide-treated clothing (ITC), amongst forest-exposed populations in Mondulkiri Province Cambodia to inform their potential use for eliminating forest malaria.

METHODS

21 forest-exposed individuals were given a questionnaire on their perceptions of malaria and preventive practices used, after which they trialed two products sequentially. Clothes was treated with ITC by the study team. Mixed methods were used to understand their experience, attitudes, and preferences regarding the products trialed. Quantitative data was summarized and qualitative insights were analysed using thematic analysis, applying the Capability, Opportunity, and Motivation Behaviour Change (COM-B) model and Behaviour Change Wheel Framework to identify intervention functions to support tailored product rollout amongst these populations.

RESULTS

Study participants reported a need for protection from mosquito bites in outdoor and forest-exposed settings and perceived both products trialed to be effective for this purpose. The VPSR product was preferred when travel was not required, whereas ITC was preferred for ease of use when going to the forest, especially in rainy conditions. COM-B analysis identified that key enablers for use of both products included their perceived efficacy and ease of use, which required no skill or preparation. For barriers to use, the odour of ITC was sometimes perceived as being toxic, as well as its inability to protect uncovered skin from mosquito bites, while the perceived usefulness of the VPSR product trialed was limited by its water sensitivity in rainy forest settings. Intervention components to encourage appropriate and sustained use of these products include education about how to use these products and what to expect, persuasion to use them from community leaders and targeted channels, and enablement to facilitate convenient and affordable access.

CONCLUSION

The rollout of VPSRs and ITC amongst forest-exposed populations can be useful for eliminating malaria in Southeast Asia. Study findings can be applied to increase product uptake among forest exposed populations in Cambodia, while manufacturers can aim to develop products that are rainproof, easy to use in forest settings, and have favourable odour profiles to target users.

Diabetes and blood glucose monitoring knowledge and practices among pharmacy professionals in Cambodia and Viet Nam: digital survey and education

BACKGROUND

In Southeast Asia, pharmacies are critical sources of healthcare advice for under-served communities, including those with/at risk of diabetes.

AIM

Explore knowledge/practices relating to diabetes and blood glucose monitoring (BGM) among pharmacy professionals in Cambodia and Viet Nam, using digital professional education to address gaps.

METHODS

An online survey was distributed to pharmacy professionals in Cambodia and Viet Nam registered on SwipeRx mobile application. Eligible participants dispensed medicines and/or were involved in purchasing products, and worked at retail pharmacies stocking ≥ 1 BGM product. An accredited continuing professional development module was then made available to pharmacy professionals and students on SwipeRx in both countries. After completing the 1-2 h module, users were required to correctly answer ≥ 60% (Cambodia) or ≥ 70% (Viet Nam) of knowledge assessment questions to achieve accreditation units from local partners.

RESULTS

Whereas 33% of survey respondents in Cambodia (N = 386) and 63% in Viet Nam (N = 375) reported performing blood glucose testing at the pharmacy, only 19% and 14% were aware that clients taking multiple daily doses of insulin should check blood glucose levels several times a day. Of 1,137 and 399 pharmacy professionals/students who completed the module and passed the assessment in Cambodia and Viet Nam, 1,124 (99%) and 376 (94%) received accreditation. Knowledge levels improved substantially in 10 of 14 learning areas in Cambodia and 6 of 10 in Viet Nam.

CONCLUSIONS

Digital education can strengthen pharmacy professional capacity to provide comprehensive and accurate information on diabetes management and the awareness of quality BGM products in Southeast Asia.

Applying the COM-B behavior model to inform the delivery of spatial repellents and insecticide-treated clothing among forest exposed populations in Mondulkiri Province, Cambodia

BACKGROUND

Southeast Asia is making tremendous progress towards their 2030 malaria elimination goal but needs new interventions to stop forest malaria. This study trials two new vector control tools, a volatile pyrethroid spatial repellent (VSPR) and insecticide-treated clothing (ITC), amongst forest-exposed populations in Mondulkiri Province Cambodia to inform their potential use for eliminating forest malaria.

METHODS

21 forest-exposed individuals were given a questionnaire on their perceptions of malaria and preventive practices used, after which they trialed two products sequentially. Mixed methods were used to understand their experience, attitudes, and preferences regarding the products trialed. Quantitative data was summarized and qualitative insights were analyzed using thematic analysis, applying the Capability, Opportunity, Motivation Behavior Change (COM-B) model and Behavior Change Wheel Framework to identify intervention functions to support tailored product rollout amongst these populations.

RESULTS

Study participants reported a need for protection from mosquito bites in outdoor and forest-exposed settings and perceived both products trialed to be effective for this purpose. The VPSR product was preferred when travel was not required, whereas ITC was preferred for ease of use when going to the forest, especially in rainy conditions. COM-B analysis identified that key enablers for use of both products included their perceived efficacy and ease of use, which required no skill or preparation. For barriers to use, the odor of ITC was sometimes perceived as being toxic, as well as its inability to protect uncovered skin from mosquito bites, while the perceived usefulness of the VPSR product trialed was limited by its water sensitivity in rainy forest settings. Intervention components to encourage appropriate and sustained use of these products include education about how to use these products and what to expect, persuasion to use them from community leaders and targeted ads, and enablement to guarantee access.

CONCLUSION

The rollout of VPSRs and ITC amongst forest-exposed populations can be useful for eliminating malaria in Southeast Asia. Study findings can be applied to increase product uptake in Cambodia, while research efforts can aim to develop products that are rainproof, easy to use in forest settings, and have favorable odor profiles to target users.

Opening the policy blackbox: unravelling the process for changing national diagnostic and treatment guidelines for vivax malaria in seven countries

BACKGROUND

The changing global health landscape has highlighted the need for more proactive, efficient and transparent health policy-making. After more than 60 years of limited development, novel tools for vivax malaria are finally available, but need to be integrated into national policies. This paper maps the malaria policy-making processes in seven endemic countries, to identify areas where it can be improved to align with best practices and optimal efficiency.

METHODS

Data were collected during a workshop, convened by the Asia Pacific Malaria Elimination Network's Vivax Working Group in 2019, and subsequent interviews with key stakeholders from Cambodia, Ethiopia, Indonesia, Pakistan, Papua New Guinea (PNG), Sri Lanka and Vietnam. Documentation of policy processes provided by respondents was reviewed. Data analysis was guided by an analytic framework focused on three a priori defined domains: "context," "actors" and "processes".

RESULTS

The context of policy-making varied with available funding for malaria, population size, socio-economic status, and governance systems. There was limited documentation of the process itself or terms of reference for involved actors. In all countries, the NMP plays a critical role in initiating and informing policy change, but the involvement of other actors varied considerably. Available evidence was described as a key influencer of policy change; however, the importance of local evidence and the World Health Organization's endorsement of new treatments and diagnostics varied. The policy process itself and its complexity varied but was mostly semi-siloed from other disease specific policy processes in the wider Ministry of Health. Time taken to change and introduce a new policy guideline previously varied from 3 months to 3 years.

CONCLUSIONS

In the medium to long term, a better alignment of anti-malarial policy-making processes with the overall health policy-making would strengthen health governance. In the immediate term, shortening the timelines for policy change will be pivotal to meet proposed malaria elimination milestones.

Malaria risk factors and care-seeking behaviour within the private sector among high-risk populations in Vietnam: a qualitative study

Background

Vietnam has successfully reduced malaria incidence by more than 90% over the past 10 years, and is now preparing for malaria elimination. However, the remaining malaria burden resides in individuals that are hardest to reach, in highly remote areas, where many malaria cases are treated through the informal private sector and are not reported to public health systems. This qualitative study aimed to contextualize and characterize the role of private providers, care-seeking behaviour of individuals at high risk of malaria, as well as risk factors that should be addressed through malaria elimination programmes in Vietnam.

Methods

Semi-structured qualitative interviews were conducted with 11 key informants in Hanoi, 30 providers, 9 potential patients, and 11 individuals at risk of malaria in Binh Phuoc and Kon Tum provinces. Audio recorded interviews were transcribed and uploaded to Atlas TI™, themes were identified, from which programmatic implications and recommendations were synthesized.

Results

Qualitative interviews revealed that efforts for malaria elimination in Vietnam should concentrate on reaching highest-risk populations in remote areas as well their care providers, in particular private pharmacies, private clinics, and grocery stores. Among these private providers, diagnosis is currently based on symptoms, leaving unconfirmed cases that are not reported to public health surveillance systems. Among at-risk individuals, knowledge of malaria was limited, and individuals reported not taking full courses of treatment, a practice that threatens selection for drug resistance. Access to insecticide-treated hammock nets, a potentially important preventive measure for settings with outdoor biting Anopheles vectors, was also limited.

Conclusions

Malaria elimination efforts in Vietnam can be accelerated by targeting improved treatment, diagnosis, and reporting practices to private pharmacies, private clinics, and grocery stores. Programmes should also seek to increase awareness and understanding of malaria among at-risk populations, in particular the importance of using preventive measures and adhering to complete courses of anti-malarial medicines.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-017-2060-0) contains supplementary material, which is available to authorized users.

Social marketing of low dead space syringes in Vietnam: findings from a 1-year pilot program in Hanoi, Thai Nguyen, and Ho Chi Minh City

BACKGROUND

Although a growing body of evidence suggests that low dead space syringes may reduce the risk of human immunodeficiency virus (HIV) and Hepatitis C virus infection associated with sharing syringes among people who inject drugs, there is little evidence of effective approaches to motivate people who inject drugs (PWID) to shift from high to low dead space syringes.

METHODS

Using a mix of consumer and trade marketing approaches, informed by rapid assessments of both the syringe market and PWID preferences, practices, and behaviors in Hanoi and Ho Chi Minh City, Population Services International (PSI) Vietnam piloted an intervention to increase the use of low dead space syringes (LDSS) in the three provinces of Hanoi, Ho Chi Minh City, and Thai Nguyen, where an estimated 31% of PWID are HIV positive and 58% are living with hepatitis C virus (HCV).

RESULTS

This paper provides a summary of the social marketing activities implemented and results achieved by PSI Vietnam during an initial 1-year pilot period from December 2012 to December 2013 in these three provinces to explore their effectiveness in motivating PWID to use low dead space syringes. We found major increases in sales of LDSS accompanied by increases in reported use and consistent use of LDSS among PWID in the three provinces included in the pilot program and a positive and independent association (odds ratio (OR) 21.08; 95% confidence interval (CI) 10.6-27.3) between LDSS use and exposure to social marketing activities. We also found that LDSS use had a stronger association with perceptions of LDSS product quality than with perceptions regarding LDSS potential to reduce HIV transmission risk and use.

CONCLUSIONS

We conclude that social marketing interventions have an important role to play in widening access to and the use of LDSS for PWID, as they address the need for PWID to find LDSS when and where they need them and also promote the benefits of LDSS use to PWID. High coverage of these activities among PWID appears to be the key in achieving these successes.

Feasibility of training Zambian nurse-midwives to perform postplacental and postpartum insertions of intrauterine devices

OBJECTIVE

To explore the feasibility of competency-based training of Zambian nurse-midwives in postplacental and postpartum intrauterine device (PPIUD) insertion and to estimate learning curves for this procedure.

METHODS

A pilot service-delivery project was conducted, involving 9 nurse-midwives who participated in a 10-day PPIUD insertion training course at the University Teaching Hospital, Lusaka, Zambia. US and Zambian clinicians taught the didactic and practical curriculum. Checklists were used for standardization and a pelvic model was developed to achieve PPIUD insertion competency in the classroom before moving to clinical practice. Patients were recruited during prenatal visits, in early labor, and postpartum. Informed, voluntary consent was obtained. All clinical PPIUD insertions were supervised or performed by experienced trainers.

RESULTS

All 9 nurse-midwives achieved competency on the pelvic model after 3 attempts. During the training period, 38 PPIUDs were inserted in postpartum women; no complications occurred. By the end of training, 4 of the nurse-midwives were deemed competent to independently insert PPIUDs. On average, 4 PPIUD insertions were needed to achieve clinical competency.

CONCLUSIONS

Concentrated, competency-based training in PPIUD insertion is feasible in an African setting. Replication of such training could increase the popularity and prevalence of PPIUD use among African women.