Does mass drug administration for the integrated treatment of neglected tropical diseases really work? Assessing evidence for the control of schistosomiasis and soil-transmitted helminths in Uganda

This paper was one of four papers commissioned to review the role of social sciences in NTD control by TDR, the Special Programme for Research and Training on Tropical Diseases, which is executed by WHO and co-sponsored by UNICEF, UNDP, the World Bank and WHO.This article has been made available through the Brunel Open Access Publishing Fund.Background: Less is known about mass drug administration [MDA] for neglected tropical diseases [NTDs] than is suggested by those so vigorously promoting expansion of the approach. This paper fills an important gap: it draws upon local level research to examine the roll out of treatment for two NTDs, schistosomiasis and soil-transmitted helminths, in Uganda. Methods: Ethnographic research was undertaken over a period of four years between 2005-2009 in north-west and south-east Uganda. In addition to participant observation, survey data recording self-reported take-up of drugs for schistosomiasis, soil-transmitted helminths and, where relevant, lymphatic filariasis and onchocerciasis was collected from a random sample of at least 10% of households at study locations. Data recording the take-up of drugs in Ministry of Health registers for NTDs were analysed in the light of these ethnographic and social survey data. Results: The comparative analysis of the take-up of drugs among adults revealed that although most long term residents have been offered treatment at least once since 2004, the actual take up of drugs for schistosomiasis and soil-transmitted helminths varies considerably from one district to another and often also within districts. The specific reasons why MDA succeeds in some locations and falters in others relates to local dynamics. Issues such as population movement across borders, changing food supply, relations between drug distributors and targeted groups, rumours and conspiracy theories about the 'real' purpose of treatment, subjective experiences of side effects from treatment, alternative understandings of affliction, responses to social control measures and historical experiences of public health control measures, can all make a huge difference. The paper highlights the need to adapt MDA to local circumstances. It also points to specific generalisable issues, notably with respect to health education, drug distribution and more effective use of existing public health legislation. Conclusion: While it has been an achievement to have offered free drugs to so many adults, current standard practices of monitoring, evaluation and delivery of MDA for NTDs are inconsistent and inadequate. Efforts to integrate programmes have exacerbated the difficulties. Improved assessment of what is really happening on the ground will be an essential step in achieving long-term overall reduction of the NTD burden for impoverished communities.This article is available through the Brunel Open Access Publishing Fund

Selecting sites to prove the concept of IAR4D in the Lake Kivu Pilot Learning Site

Selecting sites is an essential step in enabling the assessment of the impact of Integrated Agricultural Research for Development (IAR4D) in the Lake Kivu Pilot Learning Site. This paper reports on the process of identifying distinct administrative territories (sites) in which to establish innovation platforms and to monitor similar communities that are experiencing alternative agricultural research for development interventions. We show how the research design for the Sub- Saharan Africa Challenge Programme (SSACP) has been modified to take into account the key conditioning factors of the LKPLS without relinquishing robustness. A key change is the explicit incorporation of accessibility to multiple markets. Candidate sites were stratified according to the national political context, followed by good and poor accessibility to markets and finally according to security considerations and agro-ecology. Randomisation was carried out at all levels, although the need for paired counterfactual sites required the diagnosis of conditioning factors at the site level. Potential sites were characterised in terms of existing or recent agricultural research initiatives, as well as local factors that would have a direct effect on the success of interventions seeking to improve productivity, ameliorate the degradation of natural resources and enhance incomes through better links to markets. Fourteen sites were selected during the initial phase, and a further ten sites were added one year afterwards due to the need for more innovation platforms to test IAR4D. The site selection was successful in pairing action and counterfactual sites in terms of the baseline socioeconomic conditions of farming households. The unavoidable proximity of action and counterfactual sites, however, allows the possibility of spill-over effects and could reduce the measurable impact of IAR4D

Child malaria treatment decisions by mothers of children less than five years of age attending an outpatient clinic in south-west Nigeria: an application of the PEN-3 cultural model

<p>Abstract</p> <p>Background</p> <p>Using the PEN-3 cultural model, this study sought to understand mothers treatment decisions about their child febrile illness by examining positive health beliefs and practices held by mothers, examine existential (unique) practices that are indigenous to mothers and have no harmful health consequences, and explore negative beliefs and practices that limit recommended responses to febrile illness in children.</p> <p>Methods</p> <p>This qualitative study was conducted in the paediatric section of an outpatient clinic in south-west Nigeria. A total of 123 mothers with children less than five years of age with febrile illness diagnosed as malaria by physicians were individually interviewed on their treatment-seeking practices prior to visiting the clinic and their reasons for attendance at the clinic.</p> <p>Results</p> <p>For some mothers interviewed, effective treatment from the clinic for their child's febrile illness, coupled with physician's approach with malaria diagnosis and treatment practices was important in generating positive maternal treatment-seeking responses to child febrile illness. In addition, beliefs related to a child teething highlighted existential decisions with treatment-seeking for child febrile illness in this setting. Finally, the belief that febrile illness is not all that severe despite noticeable signs and symptoms was a concerning negative perception shared by some mothers in this study.</p> <p>Conclusion</p> <p>The findings highlight the need to consider not only the responses that may serve as barriers to effective treatment, but also an acknowledgment of the positive and existential responses that are equally critical in influencing mothers' management of malaria in their children.</p

Adherence of community caretakers of children to pre-packaged antimalarial medicines (HOMAPAK(®)) among internally displaced people in Gulu district, Uganda

BACKGROUND: In 2002, home-based management of fever (HBMF) was introduced in Uganda, to improve access to prompt, effective antimalarial treatment of all fevers in children under 5 years. Implementation is through community drug distributors (CDDs) who distribute pre-packaged chloroquine plus sulfadoxine-pyrimethamine (HOMAPAK(®)) free of charge to caretakers of febrile children. Adherence of caretakers to this regimen has not been studied. METHODS: A questionnaire-based survey combined with inspection of blister packaging was conducted to investigate caretakers' adherence to HOMAPAK(®). The population surveyed consisted of internally displaced people (IDPs) from eight camps. RESULTS: A total of 241 caretakers were interviewed. 95.0% (CI: 93.3% – 98.4%) of their children had received the correct dose for their age and 52.3% of caretakers had retained the blister pack. Assuming correct self-reporting, the overall adherence was 96.3% (CI: 93.9% – 98.7%). The nine caretakers who had not adhered had done so because the child had improved, had vomited, did not like the taste of the tablets, or because they forgot to administer the treatment. For 85.5% of cases treatment had been sought within 24 hours. Blister packaging was considered useful by virtually all respondents, mainly because it kept the drugs clean and dry. Information provided on, and inside, the package was of limited use, because most respondents were illiterate. However, CDDs had often told caretakers how to administer the treatment. For 39.4% of respondents consultation with the CDD was their reported first action when their child has fever and 52.7% stated that they consult her/him if the child does not get better. CONCLUSION: In IDP camps, the HBMF strategy forms an important component of medical care for young children. In case of febrile illness, most caretakers obtain prompt and adequate antimalarial treatment, and adhere to it. A large proportion of malaria episodes are thus likely to be treated before complications can arise. Implementation in the IDP camps now needs to focus on improving monitoring, supervision and general support to CDDs, as well as on targeting them and caretakers with educational messages. The national treatment policy for uncomplicated malaria has recently been changed to artemether-lumefantrine. Discussions on a suitable replacement combination for HBMF are well advanced, and have raised new questions about adherence

Community coverage of an antimalarial combination of artesunate and amodiaquine in Makamba Province, Burundi, nine months after its introduction

BACKGROUND: In 2003, artesunate-amodiaquine (AS+AQ) was introduced as the new first-line treatment for uncomplicated malaria in Burundi. After confirmed diagnosis, treatment was delivered at subsidized prices in public health centres. Nine months after its implementation a study was carried out to assess whether children below five years of age with uncomplicated malaria were actually receiving AS+AQ. METHODS: A community-based study was conducted in Makamba province. Randomly selected households containing one or more children under five with reported fever onset within fourteen days before the study date were eligible. Case-management information was collected based on caregiver recall. A case definition of symptomatic malaria from observations of children presenting a confirmed malaria episode on the day of the survey was developed. Based on this definition, those children who had probable malaria among those with fever onset in the 14 days prior to the study were identified retrospectively. Treatment coverage with AS+AQ was then estimated among these probable malaria cases. RESULTS: Out of 195 children with fever on the day of the study, 92 were confirmed as true malaria cases and 103 tested negative. The combination of 'loss of appetite', 'sweating', 'shivering' and 'intermittent fever' yielded the highest possible positive predictive value, and was chosen as the case definition of malaria. Out of 526 children who had had fever 14 days prior to the survey, 165 (31.4%) were defined as probable malaria cases using this definition. Among them, 20 (14.1%) had been treated with AS+AQ, 10 with quinine (5%), 68 (41%) received non-malaria treatments, and 67 got traditional treatment or nothing (39.9%). Most people sought treatment from public health centres (23/99) followed by private clinics (15/99, 14.1%). The median price paid for AS+AQ was 0.5 US$. CONCLUSION: AS+AQ was the most common treatment for patients with probable malaria at public health centres, but coverage was low due to low health centre utilisation and apparently inappropriate prescribing. In addition, AS+AQ was given to patients at a price ten times higher than the subsidized price. The availability and proper use of ACTs should be monitored and maximized after their introduction in order to have a significant impact on the burden of malaria

The Recognition of and Care Seeking Behaviour for Childhood Illness in Developing Countries: A Systematic Review

Background: Pneumonia, diarrhoea, and malaria are among the leading causes of death in children. These deaths are largely preventable if appropriate care is sought early. This review aimed to determine the percentage of caregivers in low- and middle-income countries (LMICs) with a child less than 5 years who were able to recognise illness in their child and subsequently sought care from different types of healthcare providers. Methods and Findings: We conducted a systematic literature review of studies that reported recognition of, and/or care seeking for episodes of diarrhoea, pneumonia or malaria in LMICs. The review is registered with PROSPERO (registration number: CRD42011001654). Ninety-one studies met the inclusion criteria. Eighteen studies reported data on caregiver recognition of disease and seventy-seven studies on care seeking. The median sensitivity of recognition of diarrhoea, malaria and pneumonia was low (36.0%, 37.4%, and 45.8%, respectively). A median of 73.0% of caregivers sought care outside the home. Care seeking from community health workers (median: 5.4% for diarrhoea, 4.2% for pneumonia, and 1.3% for malaria) and the use of oral rehydration therapy (median: 34%) was low. Conclusions: Given the importance of this topic to child survival programmes there are few published studies. Recognition of diarrhoea, malaria and pneumonia by caregivers is generally poor and represents a key factor to address in attempts to improve health care utilisation. In addition, considering that oral rehydration therapy has been widely recommended for over forty years, its use remains disappointingly low. Similarly, the reported levels of care seeking from community health workers in the included studies are low even though global action plans to address these illnesses promote community case management. Giving greater priority to research on care seeking could provide crucial evidence to inform child mortality programmes

De-politicizing parasites: reflections on attempts to control the control of neglected tropical diseases.

Large amounts of funding are being allocated to the control of neglected tropical diseases. Strategies primarily rely on the mass distribution of drugs to adults and children living in endemic areas. The approach is presented as morally appropriate, technically effective, and context-free. Drawing on research undertaken in East Africa, we discuss ways in which normative ideas about global health programs are used to set aside social and biological evidence. In particular, there is a tendency to ignore local details, including information about actual drug take up. Ferguson's 'anti-politics' thesis is a useful starting point for analyzing why this happens, but is overly deterministic. Anti-politics discourse about healing the suffering poor may shape thinking and help explain cognitive dissonance. However, use of such discourse is also a means of strategically promoting vested interests and securing funding. Whatever the underlying motivations, rhetoric and realities are conflated, with potentially counterproductive consequences