Village health workers as health diplomats: negotiating health and study participation in a malaria elimination trial in The Gambia

Background Although many success stories exist of Village Health Workers (VHWs) improving primary health care, critiques remain about the medicalisation of their roles in disease-specific interventions. VHWs are placed at the bottom of the health system hierarchy as cheap and low-skilled volunteers, irrespective of their highly valued social and political status within communities. In this paper, we shed light on the political role VHWs play and investigate how this shapes their social and medical roles, including their influence on community participation. Method The study was carried out within the context of a malaria elimination trial implemented in rural villages in the North Bank of The Gambia between 2016 and 2018. The trial aimed to reduce malaria prevalence by treating malaria index cases and their potentially asymptomatic compound members, in which VHWs took an active role advocating their community and the intervention, mobilising the population, and distributing antimalarial drugs. Mixed-methods research was used to collect and analyse data through qualitative interviews, group discussions, observations, and quantitative surveys. Results and discussion We explored the emic logic of participation in a malaria elimination trial and found that VHWs played a pivotal role in representing their community and negotiating with the Medical Research Council to bring benefits (e.g. biomedical care service) to the community. We highlight this representative role of VHWs as ‘health diplomats’, valued and appreciated by community members, and potentially increasing community participation in the trial. We argue that VHWs aspire to be politically present and be part of the key decision-makers in the community through their health diplomat role. Conclusion It is thus likely that in the context of rural Gambia, supporting VHWs beyond medical roles, in their social and political roles, would contribute to the improved performance of VHWs and to enhanced community participation in activities the community perceive as beneficial.

DNA methylation signatures associated with cardiometabolic risk factors in children from India and The Gambia: results from the EMPHASIS study

Background The prevalence of cardiometabolic disease (CMD) is rising globally, with environmentally induced epigenetic changes suggested to play a role. Few studies have investigated epigenetic associations with CMD risk factors in children from low- and middle-income countries. We sought to identify associations between DNA methylation (DNAm) and CMD risk factors in children from India and The Gambia. Results Using the Illumina Infinium HumanMethylation 850 K Beadchip array, we interrogated DNAm in 293 Gambian (7–9 years) and 698 Indian (5–7 years) children. We identified differentially methylated CpGs (dmCpGs) associated with systolic blood pressure, fasting insulin, triglycerides and LDL-Cholesterol in the Gambian children; and with insulin sensitivity, insulinogenic index and HDL-Cholesterol in the Indian children. There was no overlap of the dmCpGs between the cohorts. Meta-analysis identified dmCpGs associated with insulin secretion and pulse pressure that were different from cohort-specific dmCpGs. Several differentially methylated regions were associated with diastolic blood pressure, insulin sensitivity and fasting glucose, but these did not overlap with the dmCpGs. We identified significant cis-methQTLs at three LDL-Cholesterol-associated dmCpGs in Gambians; however, methylation did not mediate genotype effects on the CMD outcomes. Conclusion This study identified cardiometabolic biomarkers associated with differential DNAm in Indian and Gambian children. Most associations were cohort specific, potentially reflecting environmental and ethnic differences.

Prevalence and factors associated with unplanned pregnancy in The Gambia: findings from 2018 population-based survey

Background Unplanned pregnancy is a public health issue that has detrimental implications for the mother and baby alike. However, few studies have been conducted in The Gambia on this subject. As a result, the prevalence of unplanned pregnancy among women of reproductive age in The Gambia was investigated, as well as the factors associated with it. Methods The Gambia's Multiple Indicators Cluster Survey (MICS) was used to evaluate the 2018 results. Data was obtained from 3790 women aged 15 to 49 who had also given birth. The univariate analysis was conducted using percentage. The adjusted odds ratios (AOR) were determined using a multivariable logistic regression model (with corresponding 95% confidence interval (CI)). The degree of statistical significance was set at 5%. Results Approximately 25.3% (95% CI: 23.1%-27.6%) of the women reported unplanned pregnancy. Women aged 30–34 years had 45% reduction in unplanned pregnancy, when compared with those aged 15–19 years (AOR = 0.55; 95% CI: 0.32–0.94). The Fula and non-Gambian women had 30% and 45% reduction in unplanned pregnancy respectively, when compared with Mandinka women. Those who had no functional difficulties had 47% reduction in unplanned pregnancy, when compared with women who had functional difficulties (AOR = 0.53; 95% CI: 0.30, 0.91). Respondents who had given births to 3–4 and 5 + children were 1.79 and 3.02 times as likely to have unplanned pregnancy, when compared with women who had given birth to 1–2 children. Single/unmarried women were 11.38 times as likely to have unplanned pregnancy, when compared with women currently married/in union (AOR = 11.38; 95% CI: 6.38, 20.29). Local Government Area of residence was significantly associated with unplanned pregnancy. Furthermore, women who were neither happy nor unhappy and 18 + at sexual debut were 1.39 and 1.34 times as likely to have unplanned pregnancy, when compared with the very happy women and those < 18 at sexual debut respectively. Conclusion The rate of unintended pregnancies was large (25.3%). Several causes have been linked to unplanned pregnancies. These results suggest that further efforts are required to enhance women's sex education, expand access to family planning services, and provide affordable health care to high-risk women in order to minimize unintended pregnancies.

Maternal and Child Health Services in Rural Settings of The Gambia: Contextual Determinants of Postnatal Care from Mothers’ Perspectives—A Community-Based Analytical Cross-Sectional Study

Background. Maternal and child health in The Gambia is a trending public health burden. The postnatal period is critical and vital to the lives and health of the maternal mothers and their newborns, and pieces of evidence deduced that a majority of maternal and newborn deaths occur during this period. Hence, this research aimed to assess the prevalence and determinants of postnatal care utilization across women in rural Gambia. Methods. A community-based cross-sectional design was conducted in January 2020, with 265 women of childbearing age were recruited from the selected households in rural communities across the Upper River Region (URR), Gambia, using multistage sampling technique. A structured-interview questionnaire was developed to elicit contextual sociodemographic characteristics regarding the use of postnatal care. Percentages, chi-square/Fisher’s exact test for variables with p value ≤0.15 were considered for inclusion into the logistic regression model. The significance level was set at p < 0.05 . The adjusted odds ratios (aOR) with 95% confidence interval (CI) were computed to declare significance. Results. The study revealed that 90% of women utilize postnatal care (PNC) services in the rural settings of URR, Gambia. Factors such as women’s occupation, location, number of pregnancies, attending in last pregnancy, current uptake of family planning, and complication(s) in last labor were found to be associated with PNC utilization. Women who attended antenatal care (ANC) services in their last pregnancy were 10.8 times (aOR = 10.795, 95% CI: 1.025–113.694), current users of FP were 10.7 times (aOR = 10.708, 95% CI: 1.379–83.152), women’s number of pregnancies increases by a factor of 4.6 times (aOR = 4.649, 95% CI: 1.518–14.243) more likely to utilize PNC while women’s number of children alive were less likely by 76.1% (aOR = 0.239, 95% CI: 0.071–0.810) as compared to those who were not utilizing PNC services. Conclusion. The findings showed that attending ANC services, current uptake of FP, women’s number of pregnancies, and number of children alive were associated with PNC. Strengthening women empowerment and designing responsive ANC programs especially for rural women to improve PNC services are required.

Differentials in prevalence and correlates on uptake of tetanus toxoid and intermittent preventive treatment with sulfadoxine-pyrimethamine during pregnancy: A community-based cross-sectional study in The Gambia

Objectives: The study examined the differentials in prevalence and correlates on the uptake of tetanus toxoid and intermittent preventive treatment of malaria among pregnant women in The Gambia. Methods: The 2018 data from The Gambia Multiple Indicators Cluster Survey were analyzed. Data from 6143 women of reproductive age who have given birth were extracted for the analysis. Percentages and Chi-square tests were used. In addition, a multivariable logistic regression model was used to calculate the adjusted odds ratios (with a corresponding 95% confidence interval). The level of significance was set at p < 0.05. Results: The prevalence of tetanus toxoid uptake among women in The Gambia was 88.2%, while that of the adequate tetanus toxoid doses was 34.8%. The prevalence of intermittent preventive treatment with sulfadoxine-pyrimethamine uptake among maternal women in The Gambia was 98.6%, while that of the adequate intermittent preventive treatment with sulfadoxine-pyrimethamine doses taken was 34.3%. The identified statistically significant covariates of tetanus toxoid immunization and intermittent preventive treatment with sulfadoxine-pyrimethamine uptake includes women’s age, local government areas, parity, use of radio, use of newspaper, and antenatal care visits. Conclusion: The current utilization rate for adequate intermittent preventive treatment with sulfadoxine-pyrimethamine and tetanus toxoid immunization during pregnancy in The Gambia is very low and even below universal levels. The country needs to strengthen more and effective mass media advocacy programs that would target both rural and urban populace, and motivate maternal women to ensure adequate vaccination against malaria and tetanus.