Background
Methods
Study place
The design of the trial
Study participants and sampling
Data collection
Data entry and analysis
Results
Characteristics of participants
HSA ID | Gender | Age | Location category | Population size | Length of service | No. Of visits | Level of adherence |
---|---|---|---|---|---|---|---|
HSAs with self- reported adherence (N = 12) | |||||||
ID1-HSA-01 | Male | 32 | Urban | 2219 | 9 | 1 | Partially adherent |
IDI-HSA-03 | Male | 40 | Semi-urban | 894 | 7 | 3a | Fully adherent |
IDI-HSA-04 | Female | 37 | Rural | 3077 | 10 | 1 | Partially adherent |
IDI-HSA-05 | Female | 45 | Urban | 4050 | 24 | 3 | Fully adherent |
IDI-HSA-06 | Female | 36 | Semi-rural | Unsure | 9 | 2 | Partially adherent |
IDI-HSA-07 | Male | 35 | Rural | 3090 | 9 | 1 | Partially adherent |
IDI-HSA-09 | Female | 39 | Semi-urban | 1139 | 8 | 2 | Partially adherent |
IDI-HSA-10 | Male | 30 | Rural | 3299 | 10 | 1 | Partially adherent |
IDI-HSA-11 | Male | 39 | Remote | 2360 | 14 | 2 | Partially adherent |
IDI-HSA-14 | Female | 30 | Semi-rural | 2202 | 9 | 1 | Partially adherent |
IDI-HSA-17 | Male | 42 | Semi-rural | 4500 | 17 | 3 | Fully adherent |
IDI-HSA-18 | Male | 27 | Urban | 1160 | 9 | 1 | Partially adherent |
HSAs with self-reported non-adherence (N = 8) | |||||||
IDI-HSA-02 | Female | 27 | Urban | 884 | 9 | 0 | Not adherent |
IDI-HSA-08 | Female | 42 | Urban | 599 | 21 | 0 | Not adherent |
IDI-HSA-12 | Male | 33 | Semi-rural | 1276 | 9 | 0 | Not adherent |
IDI-HSA-13 | Male | 32 | Rural | 1356 | 8 | 0 | Not adherent |
IDI-HSA-15 | Male | 32 | Rural | 4000 | 7 | 0 | Not adherent |
IDI-HSA-16 | Male | 38 | Remote rural | NA | 10 | 0 | Not adherent |
IDI-HSA-19 | Male | 36 | Remote | 940 | 9 | 0 | Not adherent |
IDI-HSA-20 | Male | 40 | Remote | 3100 | 9 | 0 | Not adherent |
HSA ID | Gender | Age | Location | Population | Length of service | Number of visits |
---|---|---|---|---|---|---|
FGD 1: HSAs with full or partial-adherence as reported by the caregiver | ||||||
FGD-HSA-01 | F | 32 | Rural | 982 | 10 | 2 |
FGD-HSA-02 | M | 42 | Rural | 3840 | 18 | 2 |
FGD-HSA-03 | F | 39 | Remote | 1796 | 20 | 3 |
FGD-HSA-04 | M | 35 | Rural | 1139 | 10 | 4 |
FGD-HSA-05 | M | 35 | Rural | 9808 | 12 | 3 |
FGD-HSA-06 | M | 38 | Rural | 2098 | 11 | 3 |
FGD-HSA-07 | F | 35 | Rural | 2876 | 10 | 2 |
FGD-HSA-08 | M | 34 | Rural | 3614 | 9 | 3 |
FGD-HSA-09 | M | 32 | Rural | 9300 | 10 | 2 |
FGD 2: HSAs with non-adherence as reported by the caregiver | ||||||
FGD-HSA-10 | F | 27 | Rural | 2070 | 10 | 0 |
FGD-HSA-11 | F | 35 | Semi urban | 890 | 8 | 0 |
FGD-HSA-12 | F | 45 | Semi urban | 883 | 10 | 0 |
FGD-HSA-13 | M | 29 | Urban | 1896 | 10 | 1 |
FGD-HSA-14 | F | 45 | Urban | 1982 | 10 | 0 |
FGD-HSA-15 | M | 38 | Remote | 1740 | 10 | 3 |
FGD-HSA-16 | F | 31 | Semi urban | 2339 | 10 | 0 |
FGD-HSA-17 | F | 32 | Semi urban | 1038 | 10 | 0 |
FGD-HSA-18 | M | 39 | Remote | 1935 | 10 | 0 |
FGD-HSA-19 | F | 51 | Rural | 2040 | 17 | 3 |
Adherence
Location | Adherence | Total (%) |
---|---|---|
Rural (N = 26) | ≥3 | 8 (30) |
1–2 | 10 (39) | |
0 | 8 (30) | |
Urban (N = 13) | ≥3 | 2 (15) |
1–2 | 4 (30) | |
0 | 7 (54) |
Professional factors
The belief that PMC is important and useful
This study has helped - the child’s frequent malaria problems have ended. Even when the child doesn’t look sick, the drugs are still given, to completely kill the malaria parasite. This would benefit the nation. (FGD1, male, 34 yrs, adherent)
Gaining new knowledge
We have gained knowledge and the kids have been helped (FGD 1, male, 34 yrs, adherent)
Everyone knew about this study, but the information was not clearly laid out to us. As my colleague has already pointed out, my plea is that next time there is a meeting, the information should be well delivered to us, and we should have enough details. The training should have been for a few days, or even a week. In my case, it turned out that the client had more information than me so it is sort of embarrassing. (FGD 1, male, 35 yrs, adherent)
Recognition by government or NGOs
As HSAs, we are supposed to be part of this because the people are ours, we live with them in the community, and we know them in and out. When they (hospital staff) come here they just register and leave. But we know their homes, how it is, what’s there, their habits, maybe their eating habits, we visit their homes and we know. But then the problem is when things like these come; they involve clinicians, nurses and so when it gets hard, that’s when they involve the HSAs at the end. (IDI-05, female, 45 yrs Adherent)
To say the truth, I was supposed to deliver the message. But the benefit is not there for me because the study was just done with me, they have just used me. So it means much benefit is gained by those getting the support of drugs, and those doing the study. I was just supposed to be doing my job as I do. (IDI-12, male, 33 yrs, non-adherent)
Genuine love for the job, sense of obligation and altruism
Of course, I like it because our role is to save people’s lives. So, after you have followed up and you find that they are getting better, you feel that you had done the job on your own, but when the person is neglecting it and then they die, you feel like you haven’t done your job, like you are the one who has killed them. (IDI-01, male, 32 yrs, partially adherent)
No personal rewards
Just as my fellow HSA has said, getting these trainings will motivate us to do the work. We shouldn’t be given allowances every time we visit a child but rather when we attend training. (FGD 2, female, 45 yrs, non-adherent)
Structural factors
Ease of the task and opportunity to conduct other activities that are within job description
It was simple; I didn’t spend much time, since it was just to go and remind them and I would come back, and continue with my work. (IDI-10, male, 30 yrs, partially adherent)
Since our job is mostly about visiting our people in the community, we are able to pass through the client’s home whilst attending to other activities. (FGD 1, male, 35 yrs. adherent)
It is not something that is done frequently, or eats up most of our time. When we visit the client we also encourage them to follow healthy methods of life such as building a toilet. Through these visits a bond is created between the clients and us. (FGD 1, male, 42 yrs, partially adherent)
Knowing the participant, distances and transport
Yes, I was given the client name and was told that I will receive a phone call but I didn’t. I did not follow up the child even though I knew him, because I was waiting for more details. I will receive a message of when to go, but I did not receive any, hence I didn’t visit the child. (FGD 2, male, 39 yrs, non-adherent)
Actually, I have an outreach site close to her home. And the dates she was given for the dosage were corresponding to those when I was having my outreach nearby. Hence, once I was done with my activities, I would go visit the child. (FDG 2, male, 38 yrs, adherent)
It was far. I had to go around a mountain to get to her place. (FGD 2, female 51 yrs, adherent)
Workload, PMC not part of HSAs regular work
We were all given work that does not even concern us but we just do it. When actually, it’s not in line with our job description. It is not there. So, they pile a lot of work on you, yet the pay itself does not match the given jobs. (IDI-13, male, 32 yrs, non-adherent)
Inadequate training and lack of supervision
The work is not demanding. My only problem was that I did not know the medicine that was administered to the child. None the less it was simple. (FGD 2, male, 29 yr, partially adherent)
You could have informed us more about the medicine during the briefing. We had no idea how they look like; hence it would be a surprise to see that kind of medicine when we visit the client. We are like doctors to the clients and if they see our ignorance about the medicine, every guardian will question whether they should really give the dosage to their children. (FGD 2, female, 31 yrs, non-adherent)
I had to check with my supervisor for details. My supervisor did not have any concrete information about it as well; though he attended the meeting he said the training wasn’t clear enough. (FGD 2, male, 39 yrs, non-adherent)
Difficulties related to text messages
I did not know the date that the medicine was supposed to be taken because the date was known by the project team so they were supposed to call me that the child is supposed to take the medicine tomorrow. And then I was supposed to go and see the child in the morning and tell them that the child is supposed to take medicine at this particular time. How would I go when I do not know the dates that the child is supposed to take the medicine? (IDI-6, female, 36, partially adherent)
I couldn’t do anything because we were told to wait for the phone messages. At least if they called us, we would have monitored the child. (FGD 2,male, 39 yrs, non-adherent)
The greatest problem I encountered was waiting to receive a message of reminder. I did not receive the message so I would go on my own to visit the client. (FGD, male, 38 yrs, adherent)
Maybe sometimes you have been calling me but you couldn’t get through, it is because my phone doesn’t get through, since the phone is a phone by name (meaning the phone is unreliable). (IDI-07, male, 35 yrs., partially adherent)
The first time I visited the child, I took the child’s health card to check out the dates on which the drugs should be taken. So, I would remind the guardian on such given date. I was motivated even more when I would find the child has already been given the drugs. I did not receive any message of reminder. The first time I visited the client, I just got the dates on which I should be reminding them. (FGD 2, male, 29 yrs, partially adherent)
Community factors
Maintaining community trust
To my understanding I have been able to help the clients and in return creating a bond with them. They will have a good perception about me and trust me when need arises. I am appreciated for the job I have done. (FGD 2, female, 51 yrs, adherent)
Caregivers see the benefit of PMC, but neighbours may be sceptical
To some people who don’t know about this study, they were very suspicious about it. They would ask why the frequent visits to that house and why health officers keep coming there. Whenever I sat outside with the mother, some people would pretend to come greet me while they just want to eavesdrop on what’s happening. I asked the lady if we could go inside, as this was irritating. The mother would feel uncomfortable about it but I had to remind her the importance of this study to her and the child. So, the challenge I had was the other people had a bad perception about the study. (FGD 1, male, 42 yrs, partially adherent)
Maybe the people may be wondering, “Why are they coming to see our children?” maybe they don’t want you to come because of what people say. But yet in the end they may accept it. (IDI-07, male, 35 yrs partially adherent)
They just say “you are giving these things to the children with an aim of destroying them so that they should not have children in future. They should not do this and that.” This is what most people ask and so you have to convince them that it is not like that. (IDI-04, female, 37 yrs,partially adherent)
If an HSA would be taught on how to dispense these drugs that they receive at the central hospital, they can be left at the facility, when the follow up date comes the HSA will take the drugs, go and give it to the mother and also see how the child is doing. (IDI-10, male 30 yrs, partially adherent)
Enabling and motivation factors | Barriers and demotivating factors | |
---|---|---|
Professional factors | - The belief that PMC is useful - Gaining new knowledge - Maintain recognition from the government and NGOs - Genuine love for the job, altruism, sense of obligation | - Sense of PMC not being part of regular work duties - No personal reward - No provision of earmarked financial incentives or other incentives like air time, bicycle or additional training with allowances |
Structural factors | - Ease of the task - Short distance to child’s home - Knowing participant location and family - Being able to combine with other duties in the same area | - High workload - Not knowing participant or family location - Long distance to child’s home, lack of transport - Inadequate information and lack of supervision - No refresher trainings - Not receiving SMS/No phone - Had not seen the study medication, fear of losing care takers’ respect because of this |
Community factors | - To maintain community trust and respect as ‘doctors’ - “Love for the community” - Care takers see the benefit for their child - Being informed by the care taker about the dosing schedule | - Curiousness and suspicion from neighbours - Caretakers may fear stigmatisation - Fear that the study medicine may be harmful |