How to improve research capacity strengthening efforts: learning from the monitoring and evaluation of four research consortia in Africa.

Recent efforts to shift the control and leadership of health research on African issues to Africa have led to increased investments for scientific research capacity strengthening (RCS) on the continent and a greater demand for accountability, value for money and demonstration of return on investment. There is limited literature on monitoring and evaluation (M&E) of RCS systems and there is a clear need to further explore whether the M&E frameworks and approaches that are currently used are fit for purpose. The M&E approaches taken by four African RCS consortia funded under the Developing Excellence in Leadership, Training and Science in Africa (DELTAS) I initiative were assessed using several methods, including a framework comparison of the M&E approaches, semi-structured interviews and facilitated discussion sessions. The findings revealed a wide range in the number of indicators used in the M&E plans of individual consortium, which were uniformly quantitative and at the output and outcome levels. Consortia revealed that additional information could have been captured to better evaluate the success of activities and measure the ripple effects of their efforts. While it is beneficial for RCS consortia to develop and implement their own M&E plans, this could be strengthened by routine engagement with funders/programme managers to further align efforts. It is also important for M&E plans to consider qualitative data capture for assessment of RCS efforts. Efforts could be further enhanced by supporting platforms for cross-consortia sharing, particularly when trying to assess more complex effects. Consortia should make sure that processes for developmental evaluation, and capturing and using the associated learning, are in place. Sharing the learning associated with M&E of RCS efforts is vital to improve future efforts. Investing and improving this aspect of RCS will help ensure tracking of progress and impact of future efforts, and ensure accountability and the return on investment. The findings are also likely applicable well beyond health research.

Risks of snakebite and challenges to seeking and providing treatment for agro-pastoral communities in Tanzania.

BACKGROUND: Continuous occurrence of snakebite incidences and the vulnerability of some communities remain a critical problem in sub-Saharan Africa. Despite causing permanent disability to almost half a million people annually and numerous deaths, snakebite and associated complications are still largely neglected. This study aimed at elucidating risk factors associated with snakebite cases, treatment availability and case management practices for vulnerable agro-pastoralist communities in Northern Tanzania. METHODS: Data was collected in the Monduli (Arusha region) and the Simanjiro (Manyara region) districts in Tanzania. Interviews with 101 snakebite victims or their guardians and 13 health professionals from 3 health centers in the districts were conducted. Additionally, case records of patients admitted between 2007 and 2019 to the Meserani Snakebite Clinic were obtained. RESULTS: This study showed that appropriate treatment for snakebite including anti-venom, is difficult to access and that snakebite incidences were significantly linked to factors such as gender, age, socio-economic activity, season of the year, and whether being at home or out in the fields. Anti-venom and trained health professionals were only available at the Meserani Snake Park Clinic. Men were bitten most often (χ2 = 62.08, df = 4, p-value < 0.0001). Overall, adults between the ages of 18 and 60 years (χ2 = 62.08, df = 4, p-value < 0.0001) received most bites, usually while outdoors herding cattle in the dry season. A significant majority of victims looked for traditional treatment first (52.7%, χ2 = 29.541, df = 2, p-value = 0.0001). The results of this study present crucial information on what is needed to improve the accessibility to appropriate treatment after a snakebite among agro-pastoral communities. CONCLUSION: The situation regarding morbidity and mortality due to the inaccessibility of common treatment for snakebite in northern Tanzania is challenging. Reliance on traditional medicine exacerbates the situation. There is dire need to involve affected communities, researchers, the government, clinicians and the public in general, to work together and take part in the global snakebite initiative. Communities and health professionals recognise the underlying challenges and have valuable suggestions on how to improve the situation.

Advancing One human-animal-environment Health for global health security: what does the evidence say?

In this Series paper, we review the contributions of One Health approaches (ie, at the human-animal-environment interface) to improve global health security across a range of health hazards and we summarise contemporary evidence of incremental benefits of a One Health approach. We assessed how One Health approaches were reported to the Food and Agricultural Organization of the UN, the World Organisation for Animal Health (WOAH, formerly OIE), and WHO, within the monitoring and assessment frameworks, including WHO International Health Regulations (2005) and WOAH Performance of Veterinary Services. We reviewed One Health theoretical foundations, methods, and case studies. Examples from joint health services and infrastructure, surveillance-response systems, surveillance of antimicrobial resistance, food safety and security, environmental hazards, water and sanitation, and zoonoses control clearly show incremental benefits of One Health approaches. One Health approaches appear to be most effective and sustainable in the prevention, preparedness, and early detection and investigation of evolving risks and hazards; the evidence base for their application is strongest in the control of endemic and neglected tropical diseases. For benefits to be maximised and extended, improved One Health operationalisation is needed by strengthening multisectoral coordination mechanisms at national, regional, and global levels.

"When a dog bites someone": Community and service provider dynamics influencing access to integrated bite case management in Chad.

This study aims to identify factors on the community, the human health and the animal health provider level that determine access to Post Exposure Prophylaxis (PEP) and animal rabies diagnosis in the light of a future integrated bite case management (IBCM) approach for rabies control in Chad. The study was embedded in an overall project conducted from 2016 to 2018, to determine rabies burden and vaccine demand in West and Central Africa. Data collection took place during the projects closing workshops with stakeholders organized between August and September 2018 in the three study zones in Chad covering Logone Occidental and Ouaddaï province and parts of Hadjer Lamis and Chari Baguirmi province. A qualitative approach based on focus group discussion and in-depth interviews was used to get insights on access to care and animal investigation after suspected rabies exposure. A total of 96 participants, including 39 from the community (bite victims, dog owners) and 57 human and animal health providers (health center managers, chief veterinary officers, chief district medical officers, chiefs of livestock sectors) contributed to the study. Based on an existing conceptual framework of access to health care, several points of dissatisfaction were identified, in particular the unaffordability of human rabies vaccine for PEP (affordability) and the distance to travel to a health facility in case of a bite (accessibility). In addition, there are unfavorable attitudes observed highlighted by the importance given to traditional or local rabies care practices to the detriment of PEP (acceptability) and a low level of knowledge among Chadian communities regarding bite prevention, coupled with a very inadequate information and awareness system regarding the disease (adequacy). As for human and veterinary health services, both sectors suffer from insufficient resources for PEP on the human health and rabies diagnosis on the veterinary side impacting negatively on availability and accessibility of both these services. Action to improving provision of rabies health services and increasing knowledge about risk and prevention of the disease among the population need to be undertaken to implement IBCM, improve access to PEP and achieve the goal of eliminating dog mediated human rabies by 2030 in Chad.

Using and improving the PHISICC paper-based tools in the health facility laboratories: Examples of Human Centered Design taking systems thinking into practice, in Côte d'Ivoire and Nigeria.

Background: Health workers in low- and middle-income countries are increasingly demanded to collect more and more data to report them to higher levels of the health information system (HIS), in detriment of useful data for clinical and public health decision-making, potentially compromising the quality of their health care provison. In order to support health workers' decision-making, we engaged with partners in Côte d'Ivoire, Mozambique and Nigeria in a research project to conceive, design, produce, implement and test paper-based health information tools: the PHISICC tools. Our aim was to understand the use of PHISICC tools by health workers and to improve them based on their feedback. Methods: The design Health Facility Laboratories (HF Labs) in Côte d'Ivoire and in Nigeria were set up after months of use of PHISICC tools. Activities were structured in three phases or 'sprints' of co-creative research. We used a transdisciplinary approach, including anthropology and Human Centered Design (HCD), observations, shadowing, structured interviews and co-creation. Results: Health workers appreciated the standardization of the tools across different health care areas, with a common visual language that optimized use. Several design issues were raised, in terms of formats and contents. They strongly appreciated how the PHISICC registers guided their clinical decision-making and how it facilitated tallying and counting for monthly reporting. However, adherence to new procedures was not universal. The co-creation sessions resulted in modifications to the PHISICC tools of out-patient care and postnatal care. Discussion: Although health systems and systemic thinking allowed the teams to embrace complexity, it was the HCD approach that actually produced a shift in researchers' mind-set: from HIS as data management tools to HIS as quality of care instruments. HCD allowed navigating the complexity of health systems interventions due to its capacity to operate change: it not only allowed us to understand how the PHISICC tools were used but also how to further improve them. In the absence of (or even with) an analytical health systems framework, HCD approaches can work in real-life situations for the ideation, testing and implementation of interventions to improve health systems and health status outcomes.

General insights on obstacles to dog vaccination in Chad on community and institutional level.

Domestic dogs are responsible for 95% of all human rabies cases worldwide and continue to be the main reservoir for this fatal virus in African and Asian countries. Interrupting the spread of the disease in the domestic dog population is therefore necessary for long-term, sustainable rabies control. Chad has been recognized as a rabies-endemic country since 1961, but no national control strategy is in place to date and dog vaccination coverage is very low. This qualitative, descriptive study aims to describe the main barriers to dog vaccination on both the community and the institutional level from a socio-anthropological point of view in Chad. The study was embedded in an overall project conducted from 2016 to 2018, to determine rabies burden and vaccine demand in West and Central Africa, funded by GAVI, the vaccine alliance. Data collection was conducted on the occasion of the project's closing workshops with stakeholders organized between August to September 2018 in the four (4) project areas: Logone Occidental, Ouaddaï, Hadjer Lamis and Chari Baguirmi. We conducted interviews and focus group discussions (FGD) among veterinary officers and dog owners. Participants were selected purposively based on their place of residence (dog owners) or work place (veterinary officers) and their previous contact with the project through reporting (dog owner) or management (veterinary officers) of a suspect dog rabies case. In each region, one FGD was organized with dog owners, and one FGD with heads of veterinary posts. At the end of the FGDs, a few participants were randomly selected for interviews. In addition, in each region an interview was conducted with the head of the livestock sector, the chief district medical officers and the head of a civil society association. The identified barriers to dog vaccination access are grouped into three main aspects: the economic, the socio-cultural and the institutional level. Economic constraints encountered relate to the cost of the vaccine itself and the expenses for transporting the dogs to the vaccination site. The cultural belief that the vaccine will have an impact on the therapeutic properties of dog meat for consumers (observed in Southern Chad), and the fact that dogs are considered impure animals in Muslim faith, which prohibits handling of dogs, are obstacles identified on the sociocultural level. At the institutional level, the unavailability of vaccines in veterinary services, the lack of communication about the law on dog vaccination, the absence of rabies in the training curricula of veterinary agents, and the lack of intersectoral collaboration limit vaccination coverage. In order to improve vaccination coverage and rabies surveillance with a view to eradicate rabies by 2030, communication strategies that are adapted to the context and that take cultural obstacles into account must be put in place in a synergy of interdisciplinary action. In addition, factors such as affordability, geographical access and availability of dog rabies vaccines needs to be addressed throughout the country. Although our study design did not allow a detailed analysis of obstacles related to socio-economic level, gender and age the broad insights gained can provide general guidance for future interventions in Chad and similar countries.

The Promotion and Development of One Health at Swiss TPH and Its Greater Potential.

One Health, an integrated health concept, is now an integral part of health research and development. One Health overlaps with other integrated approaches to health such as EcoHealth or Planetary Health, which not only consider the patient or population groups but include them in the social-ecological context. One Health has gained the widest foothold politically, institutionally, and in operational implementation. Increasingly, One Health is becoming part of reporting under the International Health Legislation (IHR 2005). The Swiss Tropical and Public Health Institute (Swiss TPH) has played a part in these developments with one of the first mentions of One Health in the biomedical literature. Here, we summarise the history of ideas and processes that led to the development of One Health research and development at the Swiss TPH, clarify its theoretical and methodological foundations, and explore its larger societal potential as an integrated approach to thinking. The history of ideas and processes leading to the development of One Health research at the Swiss TPH were inspired by far-sighted and open ideas of the directors and heads of departments, without exerting too much influence. They followed the progressing work and supported it with further ideas. These in turn were taken up and further developed by a growing number of individual scientists. These ideas were related to other strands of knowledge from economics, molecular biology, anthropology, sociology, theology, and linguistics. We endeavour to relate Western biomedical forms of knowledge generation with other forms, such as Mayan medicine. One Health, in its present form, has been influenced by African mobile pastoralists' integrated thinking that have been taken up into Western epistemologies. The intercultural nature of global and regional One Health approaches will inevitably undergo further scrutiny of successful ways fostering inter-epistemic interaction. Now theoretically well grounded, the One Health approach of seeking benefits for all through better and more equitable cooperation can clearly be applied to engagement in solving major societal problems such as social inequality, animal protection and welfare, environmental protection, climate change mitigation, biodiversity conservation, and conflict transformation.

Determinants of Rabies Post-exposure Prophylaxis Drop-Out in the Region of San-Pedro, Côte d'Ivoire.

Abstract: Despite the fact that death from rabies is 100% preventable with a course of post-exposure prophylaxis (PEP) treatment, canine rabies still causes about 59,000 human deaths worldwide annually, half of which are occurring in Africa. In Côte d'Ivoire, rabies remains a threat partly due to the high drop-out rate of the life-saving human PEP treatment among people exposed to dog bites. Each year, half of the victims starting treatment, do not complete the course. The current study therefore assessed the determinants for drop-out of the life-saving treatment among people exposed to rabies in the department of San-Pedro in Côte d'Ivoire. Methods: A mixed-methods approach was used, including questionnaires, observation, individual interviews and focus group discussions, to gather socio-demographic and economic data from 235 participants about possible reasons for abandoning treatment. The study population consisted of patients and medical and veterinary health professionals who were selected using stratified sampling and purposive selection from a database available at the Rabies Center of San Pedro. Result: The drop-out of PEP treatment was related to perception bias and a habit of low attendance of health care and vaccination centers in the population. Quantitative analysis shows differences between rural and urban areas and an association with age when it comes to treatment completion. The dropout rate was most significant among patients who, in case of other illness, did not routinely see a doctor or go to vaccination centers. The rate of abandonment was higher among those who believed that dog-related injuries could be easily treated at home, and who believed that a person with rabies could be cured without completing the preventive treatment. Insufficient provision of health information on rabies and logistic constraints related to the practical organization of treatment, including the long distance to the anti-rabies center and weaknesses in the patient follow-up procedure, did not contribute to the completion of PEP. Conclusion: Established determinants for drop-out provide a framework for effective design and implementation of rabies control strategies to accelerate rabies deaths elimination efforts. In particular, access to PEP and community knowledge about rabies need to be improved and integrated in the health system and education system, respectively.

Knowledge, Attitudes, and Practices (KAP) Regarding the COVID-19 Outbreak in Côte d'Ivoire: Understanding the Non-Compliance of Populations with Non-Pharmaceutical Interventions.

At the beginning of the COVID-19 outbreak, preventive measures seemed the most appropriate method to control its spread. We assessed the knowledge, attitudes, and practices of the Ivorian public regarding preventive measures, conducting a hybrid survey across the country. Participants were invited to complete a questionnaire online, by phone, or face-to-face. Chi-squared, Fisher's exact, and Kruskal-Wallis tests were used to compare the frequency of responses regarding compliance with preventive measures. Data were validated for 564 individuals. Over one-third of respondents believed that COVID-19 was related to non-natural causes. Though the disease was perceived as severe, respondents did not consider it to be highly infectious. Overall, 35.6% of respondents fully trust health officials in the management of the pandemic, and 34.6% trusted them moderately. Individuals who believed COVID-19 was a disease caused by a pathogen and the well-educated were likely to comply with preventive measures. About 70% of respondents stated that their daily expenses had increased due to preventive measures. The study concludes that beyond unfavorable socioeconomic conditions, the level of knowledge regarding COVID-19 and trust in the government/health system are more likely to influence compliance with preventive measures such as self-reporting, physical distancing, the use of face masks, and eventually the acceptability of vaccines.

Use of Insecticides in Agriculture and the Prevention of Vector-Borne Diseases: Population Knowledge, Attitudes, Practices and Beliefs in Elibou, South Côte d'Ivoire.

People's knowledge, attitudes, practices and beliefs (KAPB) pertaining to malaria are generally well described. However, little is known about population knowledge and awareness of insecticide resistance in malaria vectors. The aim of this study was to investigate KAPB related to insecticide resistance in malaria vectors due to the use of insecticides in agriculture and the prevention against mosquitoes. In mid-2017, we carried out a cross-sectional survey in Elibou, South Côte d'Ivoire, employing a mixed methods approach. Quantitative data were obtained with a questionnaire addressed to household heads. Interviews were conducted with key opinion leaders, including village chiefs, traditional healers, heads of health centres and pesticide sellers. Focus group discussions were conducted with youth and elders. A total of 203 individuals participated in the questionnaire survey (132 males, 65%). We found that people had good knowledge about malaria and mosquitoes transmitting the disease, while they felt that preventing measures were ineffective. Pesticides were intensively used by farmers, mainly during the rainy season. Among the pesticides used, insecticides and herbicides were most commonly used. While there was poor knowledge about resistance, the interviewees stated that insecticides were not killing the mosquitoes anymore. The main reason given was that insecticides were diluted by the manufacturers as a marketing strategy to sell larger quantities. More than a third of the farmers used agricultural pesticides for domestic purposes to kill weeds or mosquitoes. We observed a misuse of pesticides among farmers, explained by the lack of specific training. In the community, long-lasting insecticidal nets were the most common preventive measure against malaria, followed by mosquito coils and insecticide sprays. The interviewees felt that the most effective way of dealing with insecticide resistance was to combine at least two preventive measures. In conclusion, population attitudes and practices related to insecticides used in agriculture and the prevention against mosquitoes could lead to resistance in malaria vectors, while people's knowledge about insecticide resistance was limited. There is a need to raise awareness in communities about the presence of resistance in malaria vectors and to involve them in resistance management.

Perceptions, knowledge, attitudes and practices for the prevention and control of lymphatic filariasis in Conakry, Republic of Guinea.

Little is known about the perceptions, attitudes and practices of lymphatic filariasis in Conakry, Republic of Guinea. Yet, such knowledge is important for an optimal design and implementation of setting-specific prevention and control measures. We conducted a cross-sectional study using a mixed methods approach. Qualitative data related to people's general experience with lymphatic filariasis, their perception of the causes of the disease, the onset of elephantiasis, care-seeking behaviour and the socioeconomic impact of lymphatic filariasis were collected through in-depth interviews with 85 respondents. Quantitative data related to strategies for prevention and the knowledge of the causes of the disease were collected by interviewing 429 people. A total of 514 individuals (313 females and 201 males), aged 10-84 years, participated. Most participants were well aware of lymphatic filariasis and they recognized the disease mainly by its disfiguring manifestation, collectively termed "elephantiasis" or "leg-swelling disease". Morbidity patterns due to filarial infection showed an increase with age (from 30 to 50 years) independent of sex. Most patients with lymphatic filariasis abandoned their jobs (73.9%) or sought other work (21.7%). The main perceived causes of acquiring lymphatic filariasis were of supernatural origin (as stated by 8.7% of patients and 5.7% of healthy subjects), while mosquito bites were mentioned by fewer participants (4.3% of patients and 4.2% of healthy subjects). A number of other causes were reported that relate to both medical and non-medical conceptions. The study also identified socioeconomic impairments and stigmatization due to elephantiasis. Taken together, community perception of lymphatic filariasis in Conakry is influenced by sociocultural conceptions. Appropriate health education campaigns aimed at enhancing community understanding of the transmission of lymphatic filariasis are required to increase the success of mass drug administration implemented for the elimination of this disease. There is a need for a morbidity management programme to alleviate lymphatic filariasis-related physical and emotional burden in Conakry.