Background
Methods
The MASSIV trial
Study design
Qualitative strand
Rationale
Data collection
Sampling strategy
Data analysis
Quantitative strand
Rationale
Data collection
Sampling
Data analysis
Ethics
Results
Respondents characteristics
Qualitative strand
Quantitative strand
N = 864 | n (%) |
---|---|
Age | |
Median (IQR) | 29 (19–41) |
Mean (SD) | 32.5 (16.1) |
Gender | |
Male | 295 (34) |
Female | 566 (66) |
Ethnic group | |
Fula | 626 (73) |
Mandinka | 172 (20) |
Serahule | 56 (5) |
Other | 9 (1) |
Marital status | |
Never married | 240 (28) |
Married | 580 (67) |
Separated/divorced | 9 (1) |
Widowed | 31 (4) |
Primary activity | |
None | 65 (8) |
Farming | 694 (80) |
Herding | 65 (8) |
Business/trade | 131 (15) |
Domestic work | 263 (30) |
Other | 56 (6) |
Education | |
None | 357 (41) |
Standard | 243 (28) |
Quranic | 261 (30) |
Household status | |
Compound head | 69 (8) |
Household head | 24 (3) |
Compound member | 226 (26) |
Wife | 360 (42) |
Child | 182 (21) |
Other | 2 (0) |
Previous MRC experience | |
Yes | 294 (34) |
None | 547 (64) |
Does not know | 10 (1) |
Does not remember | 3 (0) |
Involvement in the MDA trial
Consent and enrolment, coverage, and adherence
Of total surveyd n = 864 n (%) | Of those consented/enrolled n = 722 n (%) | Of those who took medicine 1 + times n = 606 n (%) | Of those with clinical card n = 295 n (%) | |
---|---|---|---|---|
Based on self report | ||||
Consent and enrolment | 722 (84) | – | – | – |
Coverage (1 or more doses) | 606 (70) | 606 (84) | – | – |
No/low adherence (0–6 doses) | 534 (62) | 392 (54) | 276 (46) | 115 (40) |
High adherence (7–9 doses) | 330 (38) | 330 (46) | 330 (55) | 173 (60) |
Based on clinical card | ||||
No/low adherence (0–6 doses) | 134 (16) | 133 (18) | 130 (21) | 134 (45) |
High adherence (7–9 doses) | 161 (19) | 160 (22) | 158 (26) | 161 (55) |
Barriers to individual involvement in the MDA
“R: We went from one compound to another to inform them to come out [because] the MRC staffs have come.I: Did you take the medication?R: I did not take the medicine because of the reason I told you that after I take medicine it makes me sick and makes me vomit.” (Village TBA).“R: Since they [MRC] start to give medication in the village I was the one working with them. I have not had anyone complain that he or she will not drink the medication anymore when the MRC people bring the medication.I: Do you drink the medication?R: No, I have not drunk the medication.I: Why is it that?R: You know since the MRC people came here, I am the one attached working with them. I had an emergency: one of my sisters was sick in [another village], her husband was not there, and I was the one responsible to take her to the health facility. Before I came back, I found that time has delayed, so that was the reason why I could not drink the medication.” (Male adult).
Travel/mobility
“No, I didn’t drink the medication. By then I was at the North Bank doing some electrical work. It seems like I am the guardian, but I don’t drink the medication because that very day didn’t find me here. But my wife and my children have all taken the medication.” (Village mobilizer).
Reasons for not enrolling in trial | n = 140 n (%) | Reasons for not taking full regimen | n = 566 n (%) |
---|---|---|---|
Did not know reason for medicines | 5 (4) | Did not know more than 1 dose/round | 4 (1) |
Pregnant | 14 (10) | Did not know MRC was coming | 10 (2) |
Sick at time | 6 (4) | Told to come later | 4 (1) |
Away from village | 66 (47) | Ate before | 1 (0) |
Would not be here for MDA | 1 (1) | Away from village | 234 (41) |
Busy at time | 25 (18) | Too busy | 96 (17) |
Afraid of side effects | 18 (13) | Side effects of medication | 59 (10) |
Healthy; does not need meds | 2 (1) | Meds made others sick | 12 (2) |
Too much medicine | 1 (1) | Too much medicine | 11 (2) |
Did not attend sensitization | 2 (1) | Did not like taste | 17 (3) |
Does not like medicine | 10 (7) | Got malaria | 2 (0) |
Medicines do not work | 0 (0) | Took too much time | 0 (0) |
Did not want to fast | 1 (1) | Other | 34 (6) |
Does not know | 6 (4) | Does not know | 7 (1) |
No answer | 1 (1) | No answer | 5 (1) |
“Some people are working on their groundnuts and coos farms, this is what we depend on for survival. We have only two months remaining for the farming period to be completed so we need to work harder.” (VDC Chairman).
Implementation issues
Lack of privacy
“We all [the entire compound] went to take the medicine, but I was asked to give my urine sample. I told them I am not married, and if it is about pregnancy, I know nothing has happened to me but they insisted that I must give my urine sample before they give me the medicine (…) Because the entire compound was there, and they asked me to give my urine sample, I refused because I am NOT having any relationship with any man, so I would not do it.” (Adolescent female).“R: It [the pregnancy test] was done in the open [space], so people were sitting there. When you come and give them the urine sample, they will place it there and people will be sitting there looking at it (…) It should not happen like that.I: And when did you decide to stop taking the medicine?R: I stopped taking the medicine last month.I: Can you tell us why? Anything that made you to stop taking the medicine?R: Nothing happened, just on menstruation those days. That is why I did not go there.” (Adult female).
Knowledge of medicine and perceived side effects
“Well, it is a long time I don’t drink medication; I mostly depend on herbs.” (Village TBA).
“I have drunk the medication once, but I don’t continue drinking it anymore because since I drink the medication day before yesterday me and my wife vomited a lot, so this is why I will not go and drink the medicine today although I have finished drinking the medication in the first round.” (Adult male).
You gave someone medication to take and when mosquito bites you that mosquito dies, it will also kill flies and lice and bedbugs… Will that not affect the person who took that medicine? That is the reason why some refuse.” (Alkalo).
Enabling factors for individual involvement in the MDA
Recognizing malaria as a health concern
n = 864 | n (%) |
---|---|
Believe malaria to be a problem | |
Yes | 220 (25) |
Yes, but less now than in past | 544 (63) |
No | 32 (4) |
Does not know | 35 (4) |
No answer/missing | 33 (4) |
Non-health impacts of malaria, prompted, could choose multiple (n = 561) | |
Costs of health facility | 229 (41) |
Costs of medicines | 251 (45) |
Costs of transport | 215 (38) |
Missed work | 440 (78) |
Missed school | 359 (57) |
Missed household responsibilities | 374 (67) |
None | 6 (1) |
Does not know | 14 (3) |
Other | 2 (0) |
Benefits to trial, unprompted, could choose multiple | |
None | 58 (7) |
Access to study medicine | 49 (6) |
Access to medical personnel | 7 (1) |
Access to other medicines | 4 (0) |
Improved health | 609 (70) |
Access to transportation | 1 (0) |
Material benefits | 1 (0) |
Prevents malaria | 389 (45) |
Does not know | 61 (7) |
No answer | 5 (1) |
Benefit: access to medical personnel, prompted | |
Yes | 586 (68) |
No | 122 (14) |
Does not know | 81 (9) |
No answer/missing | 75 (9) |
Benefit: access to transportation, prompted | |
Yes | 431 (50) |
No | 277 (32) |
Does not know | 84 (10) |
No answer | 72 (8) |
Preferred treatment for malaria | |
Nothing | 7 (1) |
Treat at home | 27 (3) |
Village health worker | 7 (1) |
Health facility | 748 (87) |
MRC | 61 (7) |
Other | 3 (0) |
Does not know | 6 (1) |
No answer | 5 (1) |
Treatment sought for last malaria: self, could choose multiple | |
Nothing | 1 (0) |
Treat at home | 23 (3) |
Go to VHW | 23 (3) |
Go to health facility | 518 (60) |
Go to traditional healer | 3 (0) |
Go to MRC | 26 (3) |
Other | 4 (0) |
Does not know | 7 (1) |
No answer | 1 (0) |
Non-applicable | 281 (33) |
Treatment sought for last malaria: child, could choose multiple | |
Nothing | 0 (0) |
Treat at home | 10 (1) |
Go to VHW | 8 (1) |
Go to health facility | 383 (44) |
Go to traditional healer | 1 (0) |
Go to MRC | 12 (1) |
Other | 6 (1) |
Does not know | 1 (0) |
No answer | 0 (0) |
Non-applicable | 188 (22) |
“When [field nurse] and team come here, I gather all my family and ask them to go and take the medicine. I make sure all the children take the medicine for three times. I know I am comfortable when they are healthy. I will not be visiting the healthy facility always, I have been spending two, three hundred dalasi to buy medicine; therefore, when I am to stay healthy without paying a dalasi, do you think I will not take that seriously?” (Adult male).“When the person develops any health problem is his own responsibility. From here to Basse the fare is seventy dalasi and whilst you are in Basse you cannot stay all day without food; therefore, if you people come all the way from Basse and bring us medication here if we accept taking the medication is for our own good and whoever refuses to take the medication refuses at his own detriment.” (Adult male).
Perceived benefits of the trial
“Our thoughts with MRC are that they are good and they have good medication, and if you are enrolled with the MRC, if you happen to get sick, they give you free transport from your home to the health facility. After treatment they send you home without paying anything and when they give you medication, you will not pay anything either.” (TBA female).
“My elder brother is a motor cycle mechanic. He works the whole day and before he comes back is already late. My father is also a farmer who goes and chases animals at the farms from morning until evening to make sure that the farm is not invaded by animals, and the other two are women that are in the compound are all breastfeeding, so they can’t come. That is why for me as I have time I came to participate in the MDA.” (Adult female).
Attending community sensitization meetings
Social influence | Men n (%) | Women n (%) | Total n (%) | p-value |
---|---|---|---|---|
Needed permision to participate | 156 (60) | 436 (82) | 592 (75) | < 0.0001 |
Spouse took medication | 121 (41) | 195 (35) | 316 (37) | 0.066 |
Compound head took medication | 158 (54) | 334 (59) | 492 (58) | 0.11 |
Attended sensitization meeting | 112 (38) | 237 (42) | 349 (41) | 0.268 |
“When studies like this are conducted in a village, try by all means to allow 3 or 4 people from your family to be part of the study (…) I said this because when there is future benefit for example this [other MRC trial in area], when your compound is not participating in that project you don’t benefit from this project.” (Adult male).
Social influence
“Early on we were scared to drink the medicine because some people were not talking good about the medicine (…) Some were saying that the medicine is good, others were saying that if you drink the medicine it will make you vomit, dizzy, you can have diarrhea and weak body from it. This is what scared us in taking the medication at the initial stage (…) All this information comes out from our conversations because sometimes during our conversations you will meet with your good friends who will attest to you that this medication is very good, and it is very effective.” (Adult female).
“Well in this situation if the whole village decides on something, I can’t dispute it. I will just agree to the decision made by the village leaders, because wherever the village stands that is where I will be.” (Adult male).“When a whole village is doing something, and you are not doing the same, they consider you differently.” (Adult female).
“Yes, a few numbers of them didn’t want to participate in the study. (…) But in general, all the compounds are participating (…) the lost people whom you know that they are not educated, and they don’t listen to what the educated people are preaching to them, they are the people who spread bad rumours that MRC takes people’s blood (…) In any community those kinds of people exist. Even in our village, there are a few of them here, but people will not listen to them because everyone knows what is good and bad, and in such a situation we know how to handle such people in our community.” (VDC Chairman).
“I went to [the coast]. When I came back, my elder daughter, I saw the card with her, she went and drink the medicine. I asked my daughter, ‘How you got this paper?’ and she said, ‘it was giving to me by MRC people.” I asked the mother, the mother said she was not aware. I was very angry that time, I took the card from my daughter and I keep it. I told the mother that ‘I think I told you that I do not have interested of this program, so why in the absence of me you sent my daughter to go and take the medicine?’ So, I was angry.” (Adult male).
“I: As a woman, do you agree with reason given by your household head about not to participate in the trial?R: I will discuss with my husband, try to convince him to participate because it is good. When I discuss with him, if he agrees, we will join, but if he did not agree then I will not join the trial.” (Adult female).“When they came for enrolment in this compound my mother was not around—she went to Basse to sell. The field worker found me here and asked me to come and enrol. I told him that I can’t give you my consent in the absence of my mother, because I need to seek consent from her first. Then the field worker reacted and said to me ‘you are a grownup person you can decide for yourself.’ I was not happy about that reaction from the field worker and I still insisted that I can’t give consent without my mother (…) Your elder is just your elder, and you know everyone has a position in a family, and for her, she is my parent. And the rest of the children, I am also their elder. Anything I am supposed to do I need permission from her. If she authorizes, I proceed with it; if she doesn’t give me permission, I stop it, so I can’t go beyond her decision.” (Adult female).
Social influence | Consent/enrollment | Coverage | Self reported: high adherence | |||
---|---|---|---|---|---|---|
Men | Women | Men | Women | Men | Women | |
Needed permission to participate | 0.8 (0.4–1.6) | 4.4 (2.2–9.1) | 1.3 (0.7–2.4) | 3.7 (2.3–6.2) | 1.5 (0.8–2.6) | 2.12 (1.3–3.5) |
Spouse took medication | 3.5 (1.8–6.9) | 2.6 (1.3–5.0) | 2.5 (1.4–4.5) | 1.5 (1.0–2.3) | 2.6 (1.5–4.5) | 2.3 (1.6–3.3) |
Compound head took medication | 1.1 (0.6–1.9) | 2.0 (1.1–3.3) | 1.9 (1.1–3.3) | 1.5 (1.0–2.2) | 1.1 (0.7–2.0) | 1.2 (0.8–1.8) |
“Since the beginning of the MDA when the Alkalo and the village elders came, all the elders came as one group and the drugs were given to them (…) He was the first person who came (…) Because they see their elders taking it, why not them? I think this is the step they are following. Seeing their elders taking it, their grandfathers, fathers taking it in front of them, then they should be behind them.” (MRC Field Nurse).
The role of MRC
“For me and my family, I will never step back when it comes to MRC work.” (VDC Chairman).“Yes, I always tell my people to go and take the medicine, I tell them all the time, I always tell them that MRC does not give medicine that would make people sick; they give medicine to improve our health.” (Adult male).
“My concern regarding the study is that there are people who know why they are drinking this medication, but there are others whom you know they are drinking this medication, but they don’t know why they are drinking this medication. They are just drinking it for the sake of drinking. So that being the case, I will take that responsibility before the second round. I will go and meet with these people within the compound and talk to them about why they are drinking this medication so that they will know. If not, in the second round when it is time for the MDA, they will start to take excuses by saying ‘I am going to the garden and other places.’ But if they are informed, the second round will be much better.” (Village mobilizer, male).
“We were looking at MRC. Like when you participate in an MRC study, they will come for you, but when they find a sick person in the compound, they will not attend to the patient, but they will be interested in taking the healthy person and leave the sick one at home, and that is where we think is faulty. Secondly, we were thinking like when they recruit children in their study, they will take them and bleed them, and you know? People who eat sorrel don’t have a lot of blood. This was the problem. We started discussing with them all that, but they just passed us and left. We didn’t, this was the issue.” (Adult male).