COVID-19 vaccinations in The Gambia: efforts, challenges, and future directions.

On March 11, 2020, the novel coronavirus disease (COVID-19) was declared a pandemic. Since the declaration, countries have implemented response measures to stop the spread of the virus, while multiple vaccines combatting the virus have also been developed. However, vaccine rollout and providing vaccine access has been very challenging in many African countries, including The Gambia. This article briefly assesses the efforts and challenges facing The Gambia´s COVID-19 vaccine rollout and implementation. The article also provides recommendations that policymakers and program implementers can use to address the low COVID-19 vaccination rate in The Gambia. It is based on a narrative review of existing literature on COVID-19 vaccination efforts and challenges in The Gambia.

Research priorities to reduce the impact of COVID-19 in low- and middle-income countries.

Background: The COVID-19 pandemic has caused disruptions to the functioning of societies and their health systems. Prior to the pandemic, health systems in low- and middle-income countries (LMIC) were particularly stretched and vulnerable. The International Society of Global Health (ISoGH) sought to systematically identify priorities for health research that would have the potential to reduce the impact of the COVID-19 pandemic in LMICs. Methods: The Child Health and Nutrition Research Initiative (CHNRI) method was used to identify COVID-19-related research priorities. All ISoGH members were invited to participate. Seventy-nine experts in clinical, translational, and population research contributed 192 research questions for consideration. Fifty-two experts then scored those questions based on five pre-defined criteria that were selected for this exercise: 1) feasibility and answerability; 2) potential for burden reduction; 3) potential for a paradigm shift; 4) potential for translation and implementation; and 5) impact on equity. Results: Among the top 10 research priorities, research questions related to vaccination were prominent: health care system access barriers to equitable uptake of COVID-19 vaccination (ranked 1st), determinants of vaccine hesitancy (4th), development and evaluation of effective interventions to decrease vaccine hesitancy (5th), and vaccination impacts on vulnerable population/s (6th). Health care delivery questions also ranked highly, including: effective strategies to manage COVID-19 globally and in LMICs (2nd) and integrating health care for COVID-19 with other essential health services in LMICs (3rd). Additionally, the assessment of COVID-19 patients' needs in rural areas of LMICs was ranked 7th, and studying the leading socioeconomic determinants and consequences of the COVID-19 pandemic in LMICs using multi-faceted approaches was ranked 8th. The remaining questions in the top 10 were: clarifying paediatric case-fatality rates (CFR) in LMICs and identifying effective strategies for community engagement against COVID-19 in different LMIC contexts. Interpretation: Health policy and systems research to inform COVID-19 vaccine uptake and equitable access to care are urgently needed, especially for rural, vulnerable, and/or marginalised populations. This research should occur in parallel with studies that will identify approaches to minimise vaccine hesitancy and effectively integrate care for COVID-19 with other essential health services in LMICs. ISoGH calls on the funders of health research in LMICs to consider the urgency and priority of this research during the COVID-19 pandemic and support studies that could make a positive difference for the populations of LMICs.

Knowledge, attitude and perception of West Africans towards COVID-19: a survey to inform public health intervention.

BACKGROUND: The first case of the novel coronavirus disease-2019 (COVID-19) in West Africa was first confirmed in Nigeria in February 2020. Since then, several public health interventions and preventive measures have been implemented to curtail transmission of the causative agent, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Therefore, this study was performed to assess the knowledge, attitudes, and perceptions of West Africans towards COVID-19. METHODS: An online survey was conducted between 29 September to 29 October 2020 among West Africans. Thirty-three survey questions were designed to collect sociodemographic data and participants' knowledge, attitude and perception towards COVID-19. The study targeted all West African nationals who were 18 years and above, and willing to participate in the study. Participants were either in-country or abroad. RESULTS: Overall, 1106 respondents (≥18 years) from 16 West African countries, with about 12.1% of them residing outside the West African subregion, participated in the survey. The respondents had an average COVID-19 knowledge score of 67.82 ± 8.31, with knowledge of the disease significantly associated with the country of residence (p = 0.00) and marginally (p = 0.05) so with settlement types (i.e., urban, suburban and rural areas). Most respondents (93.4%) could identify the main COVID-19 symptoms, and 73.20% would consult a healthcare professional if infected with SARS-CoV-2. Also, 75.2% of the respondents are willing to receive the COVID-19 vaccine, whereas 10.40% and 14.40% are unwilling and undecided, respectively. Perceptions of what constitute COVID-19 preventive measures were highly variable. Approximately, 8% of the respondents felt that their government responded excellently in managing the pandemic while a third felt that the response was just good. Also, more than half (54%) opined that isolation and treatment of COVID-19 patients is a way of curbing SARS-CoV-2 spread. CONCLUSIONS: Most West Africans have basic knowledge of COVID-19 and showed a positive attitude, with likely proactive practice towards the disease. However, results showed that these varied across countries and are influenced by the types of settlements. Therefore, the health and education authorities in various countries should develop focused measures capturing people in different settlements to improve their preventative measures when designing public health interventions for COVID-19 and any future epidemics or pandemics.

Sexual and reproductive health of adolescents and young people in the Gambia: a systematic review.

INTRODUCTION: in the Gambia, adolescents and young people make up 32% of the national population. Observations indicate that this population group lack access to quality information and services on sexual and reproductive health. This systematic review explored some sexual and reproductive health indicators relevant to adolescents and young people in the Gambia. METHODS: published studies on some sexual and reproductive health indicators were searched in PubMed, Google Scholar and African Journals Online. Moreover, national reference documents containing relevant in-country data on adolescents and young people's sexual and reproductive health were also collected and reviewed. Search terms for published studies focused on modern contraceptives, sexually transmitted infections (STIs) prevalence rates, availability and accessibility to sexual and reproductive health (SRH) services and adolescents and young people's satisfaction with SRH services among adolescents and young people (aged 10-24 years). RESULTS: the review showed that contraceptive prevalence rates among adolescents and young people in Gambia ranged from 7% to 9%. Reasons for low contraceptive prevalence among adolescents and young people included limited knowledge and access to sexual and reproductive health information and services, provider attitudes, stigma, shame, lack of money, cultural and religious misconceptions associated with contraception. Overall, the review found limited information on STI prevalence among adolescents and young people, with a single published study reporting a prevalence rate of 8.4%. In addition, inadequate counseling, complaints related to physical environment as well as the process of providing sexual and reproductive health services and information were significant factors associated with satisfaction with SRH services among adolescents and young people. CONCLUSION: this review provides important baseline data that may be useful for policymakers and program managers to improve adolescents and young people's sexual and reproductive health in Gambia.

Examining ethnic differences in age at sexual debut among adolescent girls in the Gambia.

Whether age at sexual debut is influenced by adolescents' ethnicity has not been examined in the Gambia. The aim of this study was to assess ethnic differences in age at sexual debut among girls in 24 rural Gambian settlements. A cross-sectional household survey of 181 respondents aged (10-19 years) was conducted among girls belonging to the three main ethnic groups (Mandinka, Fula and Wolof). Descriptive statistics and ordinal logistic regression were used to show the onset of sexual intercourse and describe the patterns of sexual debut by ethnic group among respondents. All the analyses were conducted in Stata 12.0. The study findings showed that the lowest median age at sexual debut is among Mandinka and Wolof girls (14 years). The results of ordinal logistic regression indicate that girls in the Mandinka and Wolof ethnic groups are approximately 20% less likely to initiate sex at an early age than girls in the Fula ethnic group. On the other hand, girls with more than 1 year of education are less likely to initiate sex at an early age than those with less than 1 year of education. It was also found that girls who live with their mothers are 71% less likely to have an early sexual debut than those who do not. These findings suggest ethnic differences in age at sexual debut among girls in the Gambia. The findings also highlight the importance of female education and living with a mother in reducing the chances of early sexual debut among adolescent girls.

COVID-19 Highlights the Need for Inclusive Responses to Public Health Emergencies in Africa.

COVID-19 is a global public health emergency affecting many countries around the world. Although African governments and other stakeholders are making efforts to contain the pandemic, the outbreak continues to impact human rights and exacerbates inequalities and disparities that are already in existence. The concept of inclusive health focuses on good health and well-being for everyone, and this entails health services that are equitable, affordable, and efficacious. Creating equitable access to mainstream health and healthcare services and ensuring inclusive health responses remain a means of addressing health inequities and disparities. In this article, we argue on the need for inclusive responses to public health emergencies in Africa using COVID-19 as a case example. Africa's response to public health emergencies needs to recognize that for every marginalized/vulnerable group, it is important to strategize to address their particular needs in such a way to surmount any barrier to the right to health. For Africa's public health response to be more inclusive, we therefore need to be more strategic and proactive in reaching out to specific groups and to identify and address their needs. Strengthening the healthcare systems of African countries through increased political will, increased funding to health care, collaboration and cooperation among stakeholders, and effective leadership remains essential in ensuring inclusive responses to health emergencies.

Examining the perceptions and behaviors of Gambian adults in response to COVID-19 social mitigation strategies.

The objective of this study was to examine the perceptions and behaviors of Gambian adults in response to COVID-19 social mitigation strategies. An online survey of 200 respondents was conducted. The survey inquired about respondents´ motivation to comply with a social distancing strategy and their ability to adopt 3 recommended social distancing strategies (avoiding public transport without wearing facemask, avoiding public gatherings and self-isolation). Respondents were also asked about the level of trust they had in the information about COVID-19 from the government and their confidence in the handling of the COVID-19 situation by the authorities. Fifty two percent (52%) of respondents reported that they would be motivated to comply with a social distancing strategy because they believed it is the right thing to do. Avoiding public transport without wearing facemask (n=154, 78.9%), followed by avoiding public gatherings (n=143, 73.3%) were considered to have high to very high capacity to adopt ratings among respondents. Whereas, only (n=132, 68.7%) thought that their ability to self-isolate, would be high to very high. Only (n=87, 44.2%) stated that they have high to very high level of trust in the information about COVID-19 from the government. The rest, (n=110, 55.8%) ranked their trust level as intermediate, low, very low or don´t know. Majority of respondents (n=114, 58.7%) disagreed to strongly disagreed that the authorities are doing a good job in handling the COVID-19 situation. These findings can be used to improve adoption of COVID-19 mitigation strategies and ensure trust and confidence in response efforts.

Social and cultural factors perpetuating early marriage in rural Gambia: an exploratory mixed methods study.

Background: Over the last two decades, early marriage in the Gambia declined significantly (from 58% to 30%). Yet evidence indicates that nearly 8.6% of marriages in the Gambia involved girls younger than 15, and 46.5% of marriages are with girls aged 18 or below. The reasons for the decline but continuing practice of early marriage, despite existing legislation prohibiting child marriage, are not very well understood. Very few studies have been conducted to find out what and how local factors influence decisions about early marriage in the Gambia. More information is therefore needed on underlying reasons for the persistence of early marriage in the Gambia so that program managers can use this information to design strategies towards accelerating the decline of early marriages.  Methods: The study was conducted in 24 rural settlements in Lower Baddibu District in the North Bank Region of the Gambia. It was based on a mixed-methods design including a cross-sectional household survey with a sample of 181 female adolescents and focus group discussions with 16 male and female parents. Focus group discussions were digitally-recorded, transcribed verbatim and analyzed using thematic content analysis, while survey data were analyzed using Stata. Results: Using multiple regression analysis, this study found that ethnicity more than other factors, exerts an independent effect on early marriage. Themes identified during focus group discussions also revealed that fear of premarital sex and loss of virginity outside marriage were major reasons for the perpetuation of early marriage. Conclusions: These findings suggest that the practice of early marriage in rural Gambia is associated with ethnicity and practices related to social and cultural norms. The findings also suggest that in order to decrease early marriages, future efforts should focus on allaying the fears around premarital sex and loss of virginity related to delay in marriage.

Social and cultural barriers to husbands' involvement in maternal health in rural Gambia.

INTRODUCTION: While many studies have documented a number of socio-cultural barriers to male involvement in maternal health, in The Gambia very little information is known about the social and cultural practices that characterized male involvement in maternal health. This study aims to explore some of the underlying social and cultural factors affecting husbands' involvement in maternal health issues pertaining to pregnancy and delivery in rural Gambia. METHODS: Five focus group discussions and six in-depth interviews were conducted among rural men and traditional birth attendants in five areas of rural Gambia. The discussion was directed to the roles of male partners in pregnancy and delivery and the difficulties they face regarding taking care of their wives. The data resulting from the discussion was audio-recorded, transcribed verbatim, and analyzed thematically. RESULTS: In general, rural Gambian men and traditional birth attendants (TBAs) reported that husbands' involvement in maternal health is highly desirable, but is influenced by many factors, such as the traditional conceptualization associated with pregnancy and delivery as women's domain. In addition, many men do not believe that pregnancy chores warrant their efforts compared to other competing social responsibilities. This issue may be more complicated in polygamous marriages where there is rivalry among co-wives and in neighborhoods where men who help with house chores may be subjected to mockery. CONCLUSION: These findings suggest that husbands' involvement in maternal health in The Gambia is influenced by the prevailing social and cultural practices of gender role and norms, which are also at the root of maternal health problems.

Factors influencing the migration of West African health professionals.

INTRODUCTION: The West African health sector is characterized by a human resource base lacking in numbers and specialized skills. Among the contributory factors to this lack of human resource for health workforce include but not limited to the migration of health professionals. METHODS: This cross-sectional survey targeted 118 young professionals who have participated in the Young Professional Internship Program (YPIP) of the West African Health Organization (WAHO), from (2005-2013). It inquired about their socio-demographic characteristics associated with migration and reasons for going to their preferred or most likely destinations through online survey. RESULTS: Of the 118 young professionals, 100 responded to the online survey, of which (28%) have migrated and (72%) did not migrate. Migration was more common among males and those (age≤31 years old), single with high dependency level and no previous work experience. Having a medical profession and being posted to urban or semi-urban area was also associated with their emigration. Their most important reasons for going to preferred or most likely destinations were to have fair level of workload, job promotion and limited occupational risks. CONCLUSION: This finding suggests that the migration of health professionals is situation dependent, mediated by basic socio-demographic variables and work related conditions. These issues have implications for curbing the brain drain potential of health professionals in the West African health sector.

Social and Cultural Factors Affecting Maternal Health in Rural Gambia: An Exploratory Qualitative Study.

BACKGROUND: The high rate of maternal mortality reported in The Gambia is influenced by many factors, such as difficulties in accessing quality healthcare and facilities. In addition, socio-cultural practices in rural areas may limit the resources available to pregnant women, resulting in adverse health consequences. The aim of this study is to depict the gender dynamics in a rural Gambian context by exploring the social and cultural factors affecting maternal health. METHODS AND FINDINGS: Five focus group discussions that included 50 participants (aged 15-30 years, with at least one child) and six in-depth interviews with traditional birth attendants were conducted to explore perceptions of maternal health issues among rural women. The discussion was facilitated by guides focusing on issues such as how the women perceived their own physical health during pregnancy, difficulties in keeping themselves healthy, and health-related problems during pregnancy and delivery. The data resulting from the discussion was transcribed verbatim and investigated using a qualitative thematic analysis. In general, rural Gambian women did not enjoy privileges in their households when they were pregnant. The duties expected of them required pregnant women to endure heavy workloads, with limited opportunities for sick leave and almost nonexistent resources to access prenatal care. The division of labor between men and women in the household was such that women often engaged in non-remunerable field work with few economic resources, and their household duties during pregnancy were not alleviated by either their husbands or the other members of polygamous households. At the time of delivery, the decision to receive care by trained personnel was often beyond the women's control, resulting in birth-related complications. CONCLUSIONS: Our findings suggest that despite women's multiple roles in the household, their positions are quite unfavorable. The high maternal morbidity and mortality rate in The Gambia is related to practices associated with gender inequality.