Community engagement for malaria elimination in the Greater Mekong Sub-region: a qualitative study among malaria researchers and policymakers.

BACKGROUND: Community engagement has increasingly received attention in malaria research and programme interventions, particularly as countries aim for malaria elimination. Although community engagement strategies and activities are constantly developing, little is known about how those who implement research or programmes view community engagement. This article explores the perspectives of researchers and policy makers in the Greater Mekong Sub-region (GMS) on community engagement for malaria control and elimination. METHODS: Semi-structured interviews were conducted among 17 policymakers and 15 senior researchers working in the field of malaria. All interviews were audio-recorded and transcribed in English. Transcribed data were analysed using deductive and inductive approaches in QSR NVivo. Themes and sub-themes were generated. RESULTS: Researchers and policymakers emphasized the importance of community engagement in promoting participation in malaria research and interventions. Building trust with the community was seen as crucial. Respondents emphasized involving authority/leadership structures and highlighted the need for intense and participatory engagement. Geographic remoteness, social, cultural, and linguistic diversity were identified as barriers to meaningful engagement. Local staff were described as an essential 'connect' between researchers or policymakers and prospective participants. Sharing information with community members, using various strategies including creative and participatory methods were highlighted. CONCLUSIONS: Policymakers and researchers involved in malaria prevention and control in the GMS viewed community engagement as crucial for promoting participation in research or programmatic interventions. Given the difficulties of the 'last mile' to elimination, sustained investment in community engagement is needed in isolated areas of the GMS where malaria transmission continues. Involving community-based malaria workers is ever more critical to ensure the elimination efforts engage hard-to-reach populations in remote areas of GMS.

Prospects and strategies for malaria elimination in the Greater Mekong Sub-region: a qualitative study.

BACKGROUND: As malaria elimination becomes a goal in malaria-endemic nations, questions of feasibility become critical. This article explores the potential challenges associated with this goal and future strategies for malaria elimination in the Greater Mekong Sub-region. METHODS: Thirty-two semi-structured interviews were conducted with policy makers (n = 17) and principal investigators (n = 15) selected based on their involvement in malaria prevention, control and elimination in the GMS. Interviews were audio-recorded and transcribed for qualitative content (thematic) analysis using QSR NVivo. RESULTS: All respondents described current malaria control and elimination strategies, such as case detection and management, prevention and strengthening of surveillance systems as critical and of equal priority. Aware of the emergence of multi-drug resistance in the GMS, researchers and policy makers outlined the need for additional elimination tools. As opposed to a centralized strategy, more targeted and tailored approaches to elimination were recommended. These included targeting endemic areas, consideration for local epidemiology and malaria species, and strengthening the peripheral health system. A decline in malaria transmission could lead to complacency amongst funders and policy makers resulting in a reduction or discontinuation of support for malaria elimination. Strong commitment of policymakers combined with strict monitoring and supervision by funders were considered pivotal to successful elimination programmes. CONCLUSION: Against a backdrop of increasing anti-malarial resistance and decreasing choices of anti-malarial regimens, policy makers and researchers stressed the urgency of finding new malaria elimination strategies. There was consensus that multi-pronged strategies and approaches are needed, that no single potential tool/strategy can be appropriate to all settings. Hence there is a need to customize malaria control and elimination strategies based on the better surveillance data.

Community engagement, social context and coverage of mass anti-malarial administration: Comparative findings from multi-site research in the Greater Mekong sub-Region.

BACKGROUND: Between 2013 and 2017, targeted malaria elimination (TME), a package of interventions that includes mass drug administration (MDA)-was piloted in communities with reservoirs of asymptomatic P. falciparum across the Greater Mekong sub-Region (GMS). Coverage in target communities is a key determinant of the effectiveness of MDA. Drawing on mixed methods research conducted alongside TME pilot studies, this article examines the impact of the community engagement, local social context and study design on MDA coverage. METHODS AND FINDINGS: Qualitative and quantitative data were collected using questionnaire-based surveys, semi-structured and in-depth interviews, focus group discussions, informal conversations, and observations of study activities. Over 1500 respondents were interviewed in Myanmar, Vietnam, Cambodia and Laos. Interview topics included attitudes to malaria and experiences of MDA. Overall coverage of mass anti-malarial administration was high, particularly participation in at least a single round (85%). Familiarity with and concern about malaria prompted participation in MDA; as did awareness of MDA and familiarity with the aim of eliminating malaria. Fear of adverse events and blood draws discouraged people. Hence, community engagement activities sought to address these concerns but their impact was mediated by the trust relationships that study staff could engender in communities. In contexts of weak healthcare infrastructure and (cash) poverty, communities valued the study's ancillary care and the financial compensation. However, coverage did not necessarily decrease in the absence of cash compensation. Community dynamics, affected by politics, village conformity, and household decision-making also affected coverage. CONCLUSIONS: The experimental nature of TME presented particular challenges to achieving high coverage. Nonetheless, the findings reflect those from studies of MDA under implementation conditions and offer useful guidance for potential regional roll-out of MDA: it is key to understand target communities and provide appropriate information in tailored ways, using community engagement that engenders trust.

The promise, problems and pitfalls of mass drug administration for malaria elimination: a qualitative study with scientists and policymakers.

BACKGROUND: The emergence of artemisinin resistance in the Greater Mekong Subregion (GMS) has prompted urgent containment measures. One possible approach is mass drug administration (MDA). This article explores attitudes towards and perceptions of MDA for malaria elimination among policymakers and leading malariologists. METHODS: Thirty-two semistructured interviews (SSI) were conducted with policymakers (n=17) and principal investigators (n=15) selected based on their involvement in malaria prevention, control and elimination in the GMS. Interviews were audio recorded and transcribed for qualitative content (thematic) analysis using NVivo (QSR International, Doncaster, Victoria, Australia). RESULTS: Researchers and policymakers described reluctance and consequently delays to pilot MDA for malaria elimination. Most policymakers and some researchers reported concerns around the evidence base, citing a lack of data on its effectiveness and appropriate target populations. There were also worries about promoting resistance. Other issues included a previous lack of support from the World Health Organization, past MDAs, the remoteness of target populations and challenges explaining the rationale for MDA. CONCLUSIONS: The complex rationale for MDA for malaria elimination, mistaking pilot studies for implementation, past experiences with MDA, difficulties in selecting appropriate sites and the WHO's lack of clear backing undermined the support for MDA for malaria elimination.

Perceived stigma of leprosy among community members and health care providers in Lalitpur district of Nepal: A qualitative study.

BACKGROUND: Leprosy remains a major stigmatizing condition. Stigma is a dynamic process resulting from the interaction between physical attributes caused by leprosy and the existing stereotypes in a community. Leprosy has pervasive impacts on all areas of life including psychosocial burden to an individual, social interaction, marriage, and employment. These impacts vary and are largely dependent on a particular culture and community. The main objective of this study was to explore the perceived stigma of leprosy amongst community members and health care providers in Lalitpur district of Nepal. METHODS: A total of six focused group discussions (FGDs) with 43 participants from a community living close to Anandaban Leprosy Hospital and ten semi structured interviews (SSIs) with health care providers were conducted between October and December 2016. An interview guide was used for the FGDs and SSIs. All qualitative data were transcribed and translated into English and were thematically analyzed using Atlas.ti software. RESULTS: Visible deformities due to leprosy was one of the major contributing factors for stigma. Stigma was further exacerbated by an attitude to conceal the disease due to perceived fear of potential discrimination. While over the years, stigma was felt to be decreasing, various aspects of life were still affected by leprosy stigma including marriage, employment and social interaction. This was largely attributed to leprosy and its consequences, specifically the disability and deformity caused by leprosy. CONCLUSION: Leprosy was still perceived to be feared and concealed because of potential discrimination, even within the community that was close to a long established leprosy hospital. Various aspects such as marriage, employment and social interaction were still affected by the stigma which was strongly associated with visible deformities. In addition to ongoing rehabilitation and stigma reduction programs, integrating strategies such as community engagement wherein community and leprosy affected person jointly take a role in stigma reduction programs can be helpful.

Earthquakes, Fuel Crisis, Power Outages, and Health Care in Nepal: Implications for the Future.

Earthquakes are a major natural calamity with pervasive effects on human life and nature. Similar effects are mimicked by man-made disasters such as fuel crises and power outages in developing countries. Natural and man-made disasters can cause intangible human suffering and often leave scars of lifelong psychosocial damage. Lessons from these disasters are frequently not implemented. The main objective of this study was to review the effects of the 2015 earthquakes, fuel crisis, and power outages on the health services of Nepal and formulate recommendations for the future. The impacts of earthquakes on health can be divided into immediate, intermediate, and long-term effects. Power outages and fuel crises have health hazards at all stages. It is imperative to understand the temporal effects of earthquakes, because the major needs soon after the earthquake (emergency care) are vastly different from long-term needs such as rehabilitation and psychosocial support. In Nepal, the inadequate and nearly nonexistent specialized health care at the peripheral level claimed many lives during the earthquakes and left many people disproportionately injured. Preemptive strategies such as mobile critical care units at primary health centers, intensive care training for health workers, and alternative plans for emergency care must be prioritized. Similarly, infrastructural damage led to poor sanitation, and alternative plans for temporary settlements (water supply, food, settlements logistics, space for temporary settlements) must be in place where the danger of disease outbreak is imminent. While much of these strategies are implementable and are often set as priorities, long-term effects of earthquakes such as physical and psychosocial supports are often overlooked. The burden of psychosocial stresses, including depression and physical disabilities, needs to be prioritized by facilitating human resources for mental health care and rehabilitation. In addition, inclusion of mental health and rehabilitation facilities in government health care services of Nepal needs to be prioritized. Similarly, power outages and fuel crises affect health care disproportionately. In the current context where permanent solutions may not be possible, mitigating health hazards, especially cold chain maintenance for essential medicines and continuation of life-saving procedures, are mandatory and policies to regulate all health care services must be undertaken. (Disaster Med Public Health Preparedness. 2017;11:625-632).

Hidden Costs of Hospital Based Delivery from Two Tertiary Hospitals in Western Nepal.

INTRODUCTION: Hospital based delivery has been an expensive experience for poor households because of hidden costs which are usually unaccounted in hospital costs. The main aim of this study was to estimate the hidden costs of hospital based delivery and determine the factors associated with the hidden costs. METHODS: A hospital based cross-sectional study was conducted among 384 post-partum mothers with their husbands/house heads during the discharge time in Manipal Teaching Hospital and Western Regional Hospital, Pokhara, Nepal. A face to face interview with each respondent was conducted using a structured questionnaire. Hidden costs were calculated based on the price rate of the market during the time of the study. RESULTS: The total hidden costs for normal delivery and C-section delivery were 243.4 USD (US Dollar) and 321.6 USD respectively. Of the total maternity care expenditures; higher mean expenditures were found for food & drinking (53.07%), clothes (9.8%) and transport (7.3%). For postpartum women with their husband or house head, the total mean opportunity cost of "days of work loss" were 84.1 USD and 81.9 USD for normal delivery and C-section respectively. Factors such as literate mother (p = 0.007), employed house head (p = 0.011), monthly family income more than 25,000 NRs (Nepalese Rupees) (p = 0.014), private hospital as a place of delivery (p = 0.0001), C-section as a mode of delivery (p = 0.0001), longer duration (>5days) of stay in hospital (p = 0.0001), longer distance (>15km) from house to hospital (p = 0.0001) and longer travel time (>240 minutes) from house to hospital (p = 0.007) showed a significant association with the higher hidden costs (>25000 NRs). CONCLUSION: Experiences of hidden costs on hospital based delivery and opportunity costs of days of work loss were found high. Several socio-demographic factors, delivery related factors (place and mode of delivery, length of stay, distance from hospital and travel time) were associated with hidden costs. Hidden costs can be a critical factor for many poor and remote households who attend the hospital for delivery. Current remuneration (10-15 USD for normal delivery, 30 USD for complicated delivery and 70 USD for caesarean section delivery) for maternity incentive needs to account the hidden costs by increasing it to 250 USD for normal delivery and 350 USD for C-section. Decentralization of the obstetric care to remote and under-privileged population might reduce the economic burden of pregnant women and can facilitate their attendance at the health care centers.

Perceived Stigma towards Leprosy among Community Members Living Close to Nonsomboon Leprosy Colony in Thailand.

BACKGROUND: Interpretation of Leprosy as a sickness differs among society. The set of beliefs, knowledge and perceptions towards a disease play a vital role in the construction of stigma towards a disease. The main purpose of this study was to explore the extent and correlates of the perceived stigma towards leprosy in the community living close to the leprosy colony in Non Somboon region of Khon Kaen Province of Thailand. METHODS: A cross-sectional study was conducted among 257 leprosy unaffected community participants, above the age of 18 who were living close to the Leprosy colony in Non Somboon region of Thailand. Each participant was asked a questionnaire containing characteristics of the participants in terms of socio-demographic background and knowledge regarding the disease. In addition perceived stigma towards leprosy was measured using EMIC (Explanatory Model Interview Catalogue) questionnaire. RESULTS: Among EMIC items, shame or embarrassment in the community due to leprosy was felt by 54.5%, dislike to buy food from leprosy affected persons were 49.8% and difficulty to find work for leprosy affected persons were perceived by 47.1%. Higher total EMIC score was found in participants age 61 years or older (p = 0.021), staying longer in the community (p = 0.005), attending fewer years of education (p = 0.024) and who were unemployed (p = 0.08). Similarly, perceptions about leprosy such as difficult to treat (p = 0.015), severe disease (p = 0.004) and punishment by God (p = 0.011) were significantly associated with higher perceived stigma. CONCLUSIONS: Perceived stigma towards leprosy was found highest among participants with age 61 years or older, longer duration of stay in community close to the leprosy colony, lower duration of education and participants who were unemployed had higher perceived stigma. Similarly, participants with perceptions of leprosy such as difficult to treat, severe disease and punishment by God had higher perceived stigma towards leprosy. There is an urgent need of stigma reduction strategies focused on education and awareness concerning leprosy.

Factors affecting perceived stigma in leprosy affected persons in western Nepal.

BACKGROUND: There are various factors which construct the perception of stigma in both leprosy affected persons and unaffected persons. The main purpose of this study was to determine the level of perceived stigma and the risk factors contributing to it among leprosy affected person attending the Green Pastures Hospital, Pokhara municipality of western Nepal. METHODS: A cross-sectional study was conducted among 135 people affected by leprosy at Green Pastures Hospital and Rehabilitation Centre. Persons above the age of 18 were interviewed using a set of questionnaire form and Explanatory Model Interview Catalogue (EMIC). In addition, two sets of focused group discussions each containing 10 participants from the ward were conducted with the objectives of answering the frequently affected EMIC items. RESULTS: Among 135 leprosy affected persons, the median score of perceived stigma was 10 while it ranged from 0-34. Higher perceived stigma score was found in illiterate persons (p=0.008), participants whose incomes were self-described as inadequate (p=0.014) and who had changed their occupation due to leprosy (p=0.018). Patients who lacked information on leprosy (p=0.025), knowledge about the causes (p=0.02) and transmission of leprosy (p=0.046) and those who had perception that leprosy is a severe disease (p<0.001) and is difficult to treat (p<0.001) had higher perceived stigma score. Participants with disfigurement or deformities (p=0.014), ulcers (p=0.022) and odorous ulcers (p=0.043) had higher perceived stigma score. CONCLUSION: The factors associated with higher stigma were illiteracy, perceived economical inadequacy, change of occupation due to leprosy, lack of knowledge about leprosy, perception of leprosy as a severe disease and difficult to treat. Similarly, visible deformities and ulcers were associated with higher stigma. There is an urgent need of stigma reduction strategies focused on health education and health awareness programs in addition to the necessary rehabilitation support.

Sexual behavior of foreign backpackers in the Khao San Road area, Bangkok.

Travelers play a role in the spread of sexually transmitted diseases, including HIV because of having unprotected sex. We studied the incidence of casual sex among foreign backpack tourists in the Khao San Road area of Bangkok, Thailand. We also evaluated their attitudes about sexual health and their actual practices. A cross sectional study was conducted using a self-administered, anonymous questionnaire. The target population was backpackers aged > or =18 years, from Europe, North America and Australia. In total, 415 questionnaires were filled out and analyzed. Sixty-four percent of participants were male, the overall median age was 27 years and the mean duration of stay was 14.6 days. One hundred seven respondents (25%) had casual sex while staying in Thailand; of these, 55% always used condoms. The selection of sex partner influenced the use of condoms. The highest rate of condom use was among backpackers who had sex with sex workers (63%), while those who had sex with their travel partners had the lowest rate of condom use (35.6%). One-fourth of backpackers in our study had casual sex during their trip. Their attitudes towards safe sex practices were not ideal. Methods to change attitudes and behavior about unprotected sex need to be explored in this population.

Maximal strength training in postmenopausal women with osteoporosis or osteopenia.

Current guidelines recommend weight-bearing activities, preferably strength training for improving skeletal health in patients with osteoporosis. What type of strength training that is most beneficial for these patients is not established. Maximal strength training (MST) is known to improve 1-repetition maximum (1RM) and rate of force development (RFD), which are considered as important covariables for skeletal health. Squat exercise MST might serve as an effective intervention for patients with low bone mass. We hypothesized that 12 weeks of squat exercise MST would improve 1RM and RFD in postmenopausal women with osteoporosis or osteopenia and that these changes would coincide with improved bone mineral density (BMD) and bone mineral content (BMC), and serum markers of bone metabolism. The participants were randomized to a training group (TG, n = 10) or control group (CG, n = 11). The TG underwent 12 weeks of supervised squat exercise MST, 3 times a week, with emphasis on rapid initiation of the concentric part of the movement. The CG was encouraged to follow current exercise guidelines. Measurements included 1RM, RFD, BMD, BMC, and serum bone metabolism markers; type 1 collagen amino-terminal propeptide (P1NP) and type 1 collagen C breakdown products (CTX). At posttest, 8 participants remained in each group for statistical analyses. The TG improved the 1RM and RFD by 154 and 52%, respectively. Lumbar spine and femoral neck BMC increased by 2.9 and 4.9%. The ratio of serum P1NP/CTX tended to increase (p = 0.09), indicating stimulation of bone formation. In conclusion, squat exercise MST improved 1RM, RFD, and skeletal properties in postmenopausal women with osteopenia or osteoporosis. The MST can be implemented as a simple and effective training method for patients with reduced bone mass.

Plantar flexion: an effective training for peripheral arterial disease.

This study examined whether a training intervention likely to elicit adaptations in the leg could result in reduced leg pain and increased whole body physical capacity. Twenty-seven peripheral arterial disease (PAD) patients were randomized to either an individual leg plantar flexion training group (TG) training 4 x 4 min intervals at 80% of maximal work rate three times per week for 8 weeks or a control group. The TG significantly increased plantar flexion peak oxygen uptake and power output by 23.5 and 43.9%, respectively. Treadmill peak oxygen uptake (VO(2peak)) significantly increased 12.3% in the TG and was associated with a significant increased time to exhaustion of 20.0% when treadmill walking. Eleven of 14 patients no longer reported leg pain limitations at VO(2peak). No differences in cardiac output measured at VO(2peak), or walking economy were observed. Plantar flexion training was effective in increasing VO(2peak) and walking performance, and may be a useful strategy in treatment of PAD.

Pressure during compaction of morsellised bone gives an increase in stiffness: an in vitro study.

Morsellised bone impaction is used in joint prosthesis revision surgery to repair structural damage to the periarticular bone stock. The initial stiffness of the impacted bone is crucial for the survival of the revised hip joint. Impaction of morsellised bone in a femoral canal can cause fractures that may induce implant loosening in both femur and acetabulum. Alternative techniques to increase stiffness can therefore be of major interest. In this study we analyse whether applying a constant pressure during impaction can increase the stiffness of the morsellised bone. We constructed bone pellets by impaction with and without applying a constant pressure. The constrained stiffness and coefficient of secondary strain were determined by unidirectional load testing after construction of the pellets. A significant increase in constrained stiffness (P < 0.001) from 3.9 to 5.5 MPa and a decrease in the coefficient of secondary strain (P < 0.001) from 1.1 to 0.5 were found.

Partial antagonism of endothelin 1-induced vasoconstriction in the human choroid by topical unoprostone isopropyl.

BACKGROUND: There is increasing evidence that reduced ocular blood flow plays a role in the pathogenesis of glaucoma. In patients with normal-tension glaucoma, ocular blood flow abnormalities may be associated with dysfunction of the endothelin 1 (ET-1) regulation system. OBJECTIVE: To test the hypothesis that unoprostone, a topical docosanoid, may affect ET-1--induced vasoconstriction in the human choroid. METHODS: In a placebo-controlled, randomized, double-masked, 2-way crossover design, ET-1 (2.5 ng/kg per minute for 150 minutes) was administered intravenously to 24 healthy individuals. Thirty minutes after the start of ET-1 infusion, 1 drop of unoprostone or placebo was instilled into the right eye. After another 30 minutes, 2 drops of unoprostone or placebo was topically administered. This procedure was continued and the dose was increased further until 4 drops of unoprostone or placebo was reached. Subfoveal and pulsatile choroidal blood flow were assessed using laser Doppler flowmetry and laser interferometric measurement of fundus pulsation amplitude, respectively. RESULTS: Administration of exogenous ET-1 decreased choroidal blood flow (mean +/- SEM, 17% +/- 2%; P<.001) and fundus pulsation amplitude (mean +/- SEM, 19% +/- 2%; P<.001). This effect was significantly blunted when topical unoprostone was coadministered (mean +/- SEM decrease in choroidal blood flow, 7% +/- 2%; P =.04 vs. placebo; mean +/- SEM decrease in fundus pulsation amplitude, 12% +/- 2%; P<.001 vs. placebo). CONCLUSION: There is a functional antagonism between ET-1 and topical unoprostone in the choroidal vasculature. CLINICAL RELEVANCE: Our findings of a functional antagonism between ET-1 and topical unoprostone in the choroidal vasculature may be important in vascular eye diseases associated with increased ET-1.