Introduction
Methods
VHW in a malaria elimination trial
Study population
Study design
Qualitative strands
Data collection
Sampling
Analysis
Quantitative strands
Data collection
Sampling
Analysis
Ethical consideration
Results and discussion
Breaking down ‘participation’
Individual and collective participation logic
In a society where social cohesion is an essential value, like in The Gambia, access and distribution of public goods are communal and shared with community members, and therefore, individual choice and action are expected to lead to collective benefits in addition to personal ones. According to our respondents, participation in a health intervention like RHOST happens when there is interest (ite), will/desire (bëgbëg), and/or obligation/responsibility (warugal). These elements of participation have personal ‘my’ (sama) and communal ‘our’ (sunu) aspects. The value of sunu, such as social cohesion (juboo – can also be translated as harmony), is considered necessary leverage for community participation, and is associated with increased participation in healthier acts [20, 49]. For example, taking medication to treat malaria is an individual (sama) action; however, it can be dependent on social (sunu) associations such as public perceptions, norms, responsibility and shared community value [50‐52]. Following the local understanding, the logic of taking medication to treat malaria would be: my interest or willingness (sama ite or bëgbëg) to take antimalarial drugs contributes to the interruption of malaria transmission, which is in the community’s interest (sunu ite), and therefore, it is my/our responsibility (sama/sunu warugal) to participate in this activity and take the medicine that benefits the community’s health (Fig. 1).[Participation] will not be forced because of the social cohesion (juboo) within us. So, when I make my call, people will be curious to know why I call them. That will make them answer to my call, but we don’t force anyone to come. – Alkalo, village-17
Perceived benefits of participating in the MRCG trial
Staying healthy is considered everyone’s benefit in a place where sickness can lead to economic burden not only to oneself but to the whole compound [59‐61]. When someone is sick, compound members sacrifice working days on the farm to take care of the sick. This reduces farm productivity while also having to spend cash to seek medical care [62, 63]. In this setting, participating in MRCG activities – recognised as an effective institution for health development – is perceived to be a way to address general burdens including health, financial, and social hazards [64].You (MRCG) are here to assist us. If the project stays here, it will benefit the whole village. – VHW, village-1
Therefore, since gaining social recognition and prestige were considered beneficial for the community, it led to motivation to participation [58]. However, as Boyart reminds us, distribution of and access to benefits is highly inegalitarian and hierarchical [68]. Thus, we carefully note that collectively pursued communal benefits might not be equally distributed in the community.You (MRCG) just always have your minds here. That is what we need, just do not forget about us. Always your minds be on us. – Man, village-15
VHWs as health diplomats
VHWs are an important link between communities and health systems. Often they are perceived as being a ‘facilitator’, ‘mediator’, or ‘broker’ to deliver health care on behalf of health systems or vertical health interventions [6, 14, 69]. In our study, we preferred to view the representation of VHWs as ‘on behalf of the communities’ than ‘on behalf of health systems/interventions’. VHWs represented their communities; they negotiated with the MRCG to obtain community benefits, adequately informed local populations, and tried to minimise health-related issues experienced in their villages. Because of these qualities [70] and capabilities, we consider viewing VHWs as health diplomats, rather than health-facilitators, −mediators, or -brokers for selective health interventions.Health is not only at the main hospitals, but health starts at the communities. [ … ] It’s not easy for the doctors to identify all sick persons in the communities. If there is a representative in the village who can support [sick persons] is good. – VHW, village-17
Political selection and positioning of VHWs
However, community embeddedness alone is insufficient to bridge the community and health system [15]. The capability to represent a village and to negotiate with others, such as outsiders with influential assets like the government and the MRCG, is an additional requirement of VHWs. In the rural Gambia, generally men are perceived to have these capacities.If [medicine] is from you (MRCG nurses/fieldworkers), we will take it. But if [the VHW] gives us the medicine, we will be more comfortable with that because he is the one we know. – Compound head, village-17
Moreover, in the study area, VHWs were often linked to influential personages in society such as the Alkalo or the head of Village Development Committee (VDC). Similarly, they often had reputations of being active in community development. In this manner, VHWs were endowed with structural advantages (e.g. having a good social network, being familiar with ‘leading’ the village, being able to negotiate) to execute their role and responsibility as health diplomats. This structural advantage was likely to allow VHWs to advocate to address health disparities and related economic, social, and political issues of communities [34]. This further allowed them to nurture their VHW skill-sets and capabilities to help the community achieve a healthy living [39, 51]. In our study, it enabled VHWs to voice concerns about the disadvantaged situations communities endure (i.e. limited access to health care services), and continuously campaign for better access to care. Despite VHWs being considered at the bottom of the hierarchical health system as village volunteers who are not fully skilled to be paid professionals [13, 75], within their communities, VHWs are highly regarded as capable representatives.Why we select men here is because most of our activities [are] with the government. When we delegate him, he always does his best. – Alkalo, Village-4
A pathway to political status
Nonetheless, going up the political ladder does not happen in an instant. For instance, a relatively young (~late 20s) and newly appointed VHW usually relied on higher powers and the hierarchy above him to enhance his role.Now people see the MRC[G] staff coming to collect data from me. They have more trust [in me] now because they are seeing (MRCG) doctors coming to me. – VHW, village-7
Whenever I want to summon a meeting, I inform Alkalo about it. […] You know if I mention my name probably many would not come. So, if I want a meeting, I just go to the Alkalo and inform him about it. [Then] meetings [are] always successful. – VHW, village-4
Health diplomats and its impacts
Does the VHW have RDT? | Baseline | Endline | Total |
Always | 14.6 | 23.9 | (35) |
Most of the times | 6.7 | 33.7 | (37) |
Sometimes | 18.0 | 26.1 | (40) |
Never | 34.8 | 5.4 | (36) |
Don’t know (DK) | 25.8 | 10.9 | (33) |
N (100%) | 89 | 92 | 181 |
Chi-square = 44.7 (df = 4); prob. < 0.0001; Cramer’s V = 0.50 (missing: 49) | |||
Does the VHW have antimalarials? | Baseline | Endline | Total |
Always | 12.2 | 28.4 | (38) |
Most of the times | 13.3 | 31.6 | (42) |
Sometimes | 46.7 | 30.5 | (71) |
Never | 12.2 | 1.1 | (12) |
DK | 15.6 | 8.4 | (22) |
N (100%) | 90 | 95 | 185 |
Chi-square = 26.7 (df = 4); prob. < 0.0001; Cramer’s V = 0.38 (missing: 45) |
When you are ill, do you go to the VHW? | Baseline | Endline | Total |
Always | 17.7 | 29.2 | (45) |
Most of the times | 21.9 | 34.4 | (54) |
Sometimes | 50.0 | 27.1 | (74) |
Never | 10.4 | 9.4 | (19) |
DK | - | - | - |
N (100%) | 96 | 96 | 192 |
Chi-square = 11.9 (df = 3); prob. < 0.01; Cramer’s V = 0.25 (missing: 38) | |||
Where do you go in case of fever? | Baseline | Endline | Total |
Traditional healer/Marabout | 0.8 | 2.0 | (3) |
VHW | 12.0 | 22.0 | (37) |
Health facility | 86.4 | 76.0 | (184) |
DK | 0.8 | 0.0 | (1) |
N (100%) | 125 | 100 | 225 |
Chi-square = 5.51 (df = 3); prob. < 0.14; Cramer’s V = 0.17 (missing: 5) | |||
In case you don’t recover, where do you go next? | Baseline | Endline | Total |
Traditional healer/Marabout | 2.4 | 1.0 | (4) |
VHW | 0.0 | 0.0 | (0) |
Health facility | 96.8 | 99.0 | (220) |
DK | 0.8 | 0.0 | (1) |
N (100%) | 125 | 100 | 225 |
Chi-square = 1.42 (df = 3); not significant; Cramer’s V = 0.08 (missing: 4) * the null (0.0) cells are due to small sample size |
Is the VHW available when you need him? | Baseline | Endline | Total |
Always | 40.2 | 39.6 | (75) |
Most of the times | 30.4 | 26.0 | (53) |
Sometimes | 22.8 | 29.2 | (49) |
Never | 3.3 | 1.0 | (4) |
DK | 3.3 | 4.2 | (7) |
N (100%) | 92 | 96 | 188 |
Chi-square = 2.26 (df = 4); not significant; Cramer’s V = 0.11 (missing: 42) | |||
Do you think the VHW provides good advice regarding health? | Baseline | Endline | Total |
Very good | 27.5 | 28.1 | (52) |
Good | 60.4 | 67.7 | (120) |
Bad | 1.1 | 0.0 | (1) |
No advice | 6.6 | 1.0 | (7) |
DK | 4.4 | 3.1 | (7) |
N (100%) | 91 | 96 | 187 |
Chi-square = 5.5 (df = 4); not significant; Cramer’s V = 0.17 (missing: 43) |
While well-equipped VHWs in general tend to improve access to care, they can also contribute to intra-village inequalities. VHWs, as village residents, depended on their social networks [21] that influenced whom they can or cannot reach, and consequently determined who were included or excluded from benefitting the pursuit of collective healthy living. As Green critiques, promoting community health through VHWs can be a selective empowerment [76]. The more VHWs are placed within central positions of society, the harder it can get for marginalised populations to access their services, perpetuating inequality. When individuals are excluded, their capability to participate in society is even more reduced [77], resulting in further disadvantaged situations in forming the social relationship [78]. For instance, during our study, we observed a family in one village who had migrated from Guinea and were not completely integrated into the village. According to a VHW, “They are Fula (ethnic group) but Fula Fouta (Fula from Guinea)” (VHW, Village-4), meaning that they are not well linked with the rest of the village. Without having a strong social network, this Guinean family was found to not be participating in village activities. Nevertheless, important to note, in general in study villages where social cohesion is highly regarded, the ethnic difference is not a barrier to VHWs providing health services to all ethnic groups. If issues arise, Alkalo and ethnic group representatives intervene to solve the issues.He (VHW) is doing great work here. You know, if you are sick you can go to him or he would pack his stuff and come to your compound. He is very willing and active. That is the reason why some people who were not interested in the [trial] are now all willing to participate. – Marabout/Compound head, village-4
Contradicting expectations
Moreover, some community members perceived that VHWs were not sharing but “eating” the benefits [68] they received from the MRCG. This translated to perceptions that VHWs failed to prioritise community’s interest (sunu ite) over their own interest (sama ite), acting selfishly (añan), thereby undeserved to get community support.[The government] said, “when you [become VHW] there is no payment, but the villagers would help and weed your farm for you”. But when it starts raining and you have not sown your farm, will you think of helping another person? The farm is spoiled before you realise. […] People will not [support] me because even today after you (MRCG) leave, they will think you have given me money. – VHW, village-2
Lack of medicine can cause people to stop coming to me. If I’m running out of medicine all the time, people will not come to me. […] People will perceive that I always don’t have medicine so it’s better not to go to [VHW]. – VHW, village-5