Quantitative results
Table 1 below shows the coverage per SMC cycle and proportion of children aged 3–59 months who received all five SMC cycles in Mangodara district and all four SMC cycles in the other 22 districts in 2019. Results of chi-squared tests for differences between Mangodara and the other 22 districts are shown.
Coverage of Day 1 SPAQ among eligible children was 87.67% in Mangodara in cycle 0. Although this proportion was marginally lower than in cycles 1-4, coverage in cycle 1 in the 22 other health districts was also lower than in subsequent cycles.
The results of the chi-squared tests show that coverage of Day 1 SPAQ was significantly higher in Mangodara than in the 22 other districts in cycles 1, 2 and 3. In addition, a significantly higher proportion of eligible children in Mangodara received Day 1 SPAQ in at least two or more cycles than in the remaining 22 districts.
Table 1 SMC coverage per cycle to eligible children in Mangodara compared to 22 other SMC districts.
Variable
|
Mangodara
District n=1063
N (%)
|
22 Districts
n=3909
N (%)
|
χ2 value
(df=1)
|
p-value
|
Proportion coverage of eligible children by cycle
|
Cycle 0
|
932 (87.67%)
|
N/A
|
|
|
Cycle 1
|
956 (89.9%)
|
3419 (87.46%)
|
4.82
|
0.028
|
Cycle 2
|
998 (93.89%)
|
3471 (88.79%)
|
23.81
|
<0.001
|
Cycle 3
|
1005 (94.54%)
|
3483 (89.10%)
|
28.16
|
<0.001
|
Cycle 4
|
1009 (94.92%)
|
3760 (96.19%)
|
3.43
|
0.063
|
Proportion coverage of eligible children by number of cycles*
|
No cycle
|
5 (0.47%)
|
22 (0.56%)
|
0.13
|
0.716
|
1 Cycle
|
1058 (99.9%)
|
3887 (97.8%)
|
0.13
|
0.716
|
2 Cycles
|
1034 (97.27%)
|
3637 (90.97%)
|
26.29
|
<0.001
|
3 Cycles
|
1006 (94.63%)
|
3556 (90.46%)
|
14.86
|
<0.001
|
4 Cycles
|
944 (88.88%)
|
3297 (84.34%)
|
13.26
|
<0.001
|
5 Cycles
|
872 (81.65%)
|
N/A
|
|
|
*Each indicator refers to whether a child received at least a given number of cycles during the 2020 SMC round: for example, while 1,034 eligible children sampled received at least two cycles of Day 1. SPAQ, 1,006 of those received three or more cycles.
|
Qualitative results
Table 2 below outlines the sociodemographic characteristics of participants in the qualitative component of the study; caregivers, community distributors and key informants.
Table 2 Sociodemographic characteristics of qualitative participants.
Characteristic
|
|
Caregivers
|
CDs
|
KIs
|
Age (years)
|
Min
Max
Mean
|
21
58
35.4
|
22
48
30.79
|
33
72
50.90
|
Sex (M/F)
|
M
F
|
20 (50%)
20 (50%)
|
22 (75.86%)
7 (24.14%)
|
10 (90.91%)
1 (9.09%
|
Religion
|
Catholic
Protestant
Muslim
|
5 (12.5%)
4 (10%)
31 (77%)
|
1 (3.45%)
0 (0%)
28 (96.55%)
|
5 (45.45%)
0 (0%)
6 (54.55%)
|
Education level
|
Literate
Primary (grades 1-6)
Middle (grades 7-10)
Secondary (grades 11-13)
University
Other (Bible School)
|
28 (70%)
6 (15%)
5 (12.5%)
0 (0%)
0 (0%)
1 (2.5%)
|
8 (27.59)
9 (31.03)
12 (41.38)
0 (0%)
0 (0%)
0 (0%)
|
3 (27.27%)
0 (0%)
1 (9.09%)
1 (9.09%)
0 (0%)
|
Reactions to the SMC five cycle campaign
Knowledge about the five cycle campaign
Male and female caregivers knew the campaign began ‘earlier’, started ‘early compared to last year’s’ and that the campaign lasted for a longer time. Both men and women recognised that a cycle had been ‘added’, that the ‘number of passages has increased’ and that the drugs were distributed five times instead of four in previous years. Men and women associated the start of the campaign with the ‘beginning of the rainy season’ and women with the start of farming and field activities including ‘collecting shea nuts’ and ‘clearing fields’. CDs and supervisors also acknowledged the campaign started early, that the programme had ‘decided to add another month’ and comprised five instead of four cycles.
“The SMC drugs in past years were different from this year's because in past years they were distributed four times, but this year it is like adding one more and it became like five, five times...” (01_PERS._F_FARADJAN_PS_191119)
“…another difference is that the number of passages has increased and that also has increased the health of the children here. The campaign was limited to four passages but this year I found that it reached five. That is the difference between this year’s and last year’s” (04_PERS._H_MADIASSO_GS_25112019)
Perceptions of reasons for five cycles
Male caregivers recognised the campaign started earlier to coincide with the rainy season ‘which brings malaria’ they explained that ‘starting the campaign before the critical period’ will prevent malaria and that this benefits children. Female caregivers discussed various possible reasons for the campaign starting early. Some thought there had been more rainfall this year, and ‘more sick children’ suffering from malaria and so the campaign had started early to ‘fight against this disease’. Others felt that there had been a delay in distributing bed nets, and because of this ‘they distributed the medicines earlier to prevent the disease’. Some men and women were unsure why the campaign started earlier. Male and female CDs and supervisors recognised that the SMC campaign had started in June because that is when the rains start, and mosquitoes tend to appear. For example, the group of male and female CDs mentioned that ‘malaria generally begins in the rainy season’ and the rainy season starts in June and it’s also in that period that mosquitoes are active’. Male CDs also suggested the earlier start was because ‘in June the rain starts so there are mosquitoes’. Female CDs were of the view that because malaria ‘kills a lot of people every year’ and there are ‘a lot of cases of malaria’ the programme decided to adopt five cycles. In addition, the female CDs suggested the extra cycle was added to ‘determine if five cycles will cure malaria more than four cycles’ and to see if ‘cases of malaria would decrease compared to previous years’.
“In my opinion, last year they let the rainy season approach before starting the distribution. Maybe if they did this year, it was to eliminate malaria. In my opinion, that is why they started early to ensure that there is health, because it is the rainy season that brings malaria…” (02_PERS._H_FARADJAN_PS_22112019)
“In my opinion, the campaign started early this year because malaria was much more threatening and the cases of malaria in children were very early” (01_PERS._F_FARADJAN_PS_191119)
Children’s reaction to the additional cycle
Male and female caregivers described various ways children had reacted to the additional SMC cycle. Both men and women described how some children got fever, diarrhoea, vomited or became dizzy after being given ‘the medicines’ or specifically the first dose. Men and women also mentioned that some people believe the medicine causes illness in children; those children who receive the medicine ‘will manifest the illness’ or that ‘the drugs get the children sick’. Although it was acknowledged that not all children reacted, and some had not experienced any ‘abnormal reaction or experience’. However, caregivers in all group discussions mentioned how the reactions they saw in children made them question whether to continue taking the medicine in subsequent cycles. For example, women described how seeing children suffer ‘scares you’ and ‘if you are not courageous enough, you cannot continue’. Men also explained that ‘even if the medicine cures it, the fact it makes the child sick does not motivate you to give the medicine’ and that ‘fear sets in’ and ‘doubt occurs if a child has a problem’. Many male and female caregivers agreed that children could tolerate or ‘bear’ five cycles of SMC. Women explained that ‘children can handle them’ and ‘the campaign is not year-round, only one visit per month’ and men also noticed that ‘children can bear the five doses [cycles]’ because after taking the doses ‘they did not get sick anymore’. However, several men were concerned that the dosage was too high for children, suggesting ‘you may have to decrease the dosage’ and ‘instead of five times let them do four times’. Several women mentioned that their children had not received five doses; reasons included that their child had fever or was sick at the time, or the child or caregiver was not at home at the time the distributors called.
“At the beginning of the distribution of the drugs in June, my child took the first dose, it made it suffer. In fact, it vomited and had diarrhoea and fever too. But I continued to give the rest, and it felt good. So I can say that at the first dose, if you are not courageous enough, you cannot continue. Because it scares you. It knocked the child down (laughs), it knocked the child down” (01_PERS._F_MADIASSO_GS_19112019)
“In fact, people talk too much, some say that the drugs get the children sick. Those who say that just witnessed cases of negative effects. Some who noticed the negative effects in their children even tell the drug distributors not to come to them” (04_PERS._H_MADIASSO_GS_25112019)
Reactions at policy and programme level
Although the pilot study was ‘welcomed’ there seemed to be some apprehension among key informants at national level about implementing five cycles of SMC. This stemmed from the fact that the pilot deviates from current WHO recommendations of four cycles. Several informants mentioned ‘some apprehension’ in the technical community over resistance because children are ‘exposed to the drug for longer periods’, and any intervention that does not comply with the guidelines ‘may raise concerns’ about resistance in young children. Others emphasized that the ministry ‘operates according to WHO guidelines’ and cannot do anything differently until the WHO ‘formally authorizes’ such a change.
“Exactly, because for the moment, the recommendation is four passages. That's what I was saying earlier, the five passages are pilot and are designed as a study…Now, if we want to move to a large-scale intervention…almost all traditional partners will ask you first what WHO says about this or that?” (11_NAT_PNLP_AT_13012020)
“As I say it's resistance to treatment also the fact that the WHO has not yet formally authorized that” (11_NAT_PNLP_AT_13012020)
Feasibility of five cycles
Campaign coincides with and disrupts farming season
An overriding concern among caregivers was that the earlier start to the SMC campaign coincided with farming responsibilities, which was disruptive and meant that the CDs may not find people at home. Women and men described how they were ‘in a hurry to get to the field’ and ‘at that time many people care more about their fields’ and ‘prioritize their fields’ so the distributors ‘find nobody at home’. Men further explained that women are unable to wait at home for the CD because ‘it is a waste of time’ and if they do not work on the farm ‘you won’t have something to eat in the evening’. Further to this, some men mentioned that some ‘husbands do not care about the SMC campaign’ and expect their wives to join them in the fields. Because of this many suggested starting the campaign even earlier, in April or May, when men and women are available and ‘people are easily found at home’. The campaign starting in June affected the work of CDs too, who also have farming responsibilities. They explained how the month of June ‘coincides with our work in the fields’ and ‘we start farming works in April and in June we start sowing’. Some CDs mentioned that the campaign ‘delayed our farming job’ and that their fields were still ‘half covered with grasses’ by the time they could start work on them. Key informants also recognized that the SMC campaign happens ‘during the agricultural period’ or ‘the intense farming period’. They acknowledged that most CDs are farmers who may not be available during the distribution period ‘on constraint of being on their farms’.
“We cannot know everything about the difficulties related to their field work, but they may come to certain compounds and find no one since it is the field work period. This is a difficulty” (01_PERS._F_FARADJAN_PS_191119)
“In June here, frankly speaking, everyone is struggling because this is the basis of cultivation, everybody has to prepare his field at the moment…Once the rainy season starts, it's complicated for CDs to find someone at home. That's why the CDs cannot find people in the concessions right now. That is different from ignorance. The period of caterpillars (caterpillars are eaten as food in some parts of Burkina) collection is also a period of difficulties. Personally, I also go to collect because such things feed me. When I get up in the morning, I go to my workplace, my wife as well, so the CDs may come at home without finding someone” (04_PERS._H_MADIASSO_GS_25112019)
Acceptability of five cycles
Benefit or usefulness of the earlier campaign
Female caregivers thought that the earlier SMC campaign had contributed to ‘improvement of our children’s health’ and had ‘really fought against malaria’; men also expressed how it had ‘brought us good health’ and had ‘given health to children’. Both men and women talked about fewer visits to the hospital because of malaria, noticed that fewer children were on intravenous fluids at hospital and there was decreased attendance at the dispensary due to malaria. Female caregivers also felt the campaign period was ‘well-chosen’ because it coincided with the first rains, which is when mosquitoes appear, and this allowed for ‘better prevention of malaria since the disease had not yet spread’. They compared it to last year when ‘the campaign started late’ when ‘we were already at the full rainy season and malaria had already contaminated the children’. CDs and supervisors shared many of the same views as caregivers; those children suffered less from malaria and they had seen the number of cases of ‘children’s malaria’ in the health centre decrease with the additional SMC cycle. They also compared the additional cycle to previous years, when children used to get malaria ‘before the SMC campaign began’. Key informants at national level also recognized that the earlier start to the campaign had contributed to fewer cases of malaria and fewer sick children. They also mentioned that there was ‘enthusiasm for SMC’ among the population and they had accepted the additional dose. One also stated that ‘sparing one episode of malaria for each child in a family’ was important and helped reduce the financial burden for families.
“This year it has been observed that the children who have benefited from the medicines do not have fever and the attendance of the dispensary due to malaria has strongly decreased. Then the SMC campaign has greatly contributed to reduce the high rate of consultations at the health facility” (01_PERS._F_FARADJAN_PS_191119)
“We're comfortable. It has brought us good health. The way malaria made us suffer in the previous years, we saw that it didn't make us suffer like other years. At least for us, it has brought us health” (02_PERS._H_FARADJAN_PS_22112019)
CD workload
Female CDs said the additional cycle did not impact on their workload. Instead they said distributing the drugs was ‘a lot more valuable’ than four days of work and they could continue with their other work afterwards. Their responses implied that they were willing to carry out the extra work and it ‘did not prove difficult’ because they valued the health of children and the village. Male CDs were more likely to say that the additional cycle of SMC had affected their work; they talked about how the cycle in June had increased their tasks, meant they couldn’t work in their fields, increased their expenses and debts. However, men also said that they were ‘proud of the SMC campaign’ that ‘health comes first’ and ‘we want the children to be healthy’. One group of male and female CDs seemed to share a different view, that the job ‘had increased but not the support’ and they talked about feeling ‘obliged’ to do the work even if it ‘takes most of your time’ and they had other responsibilities at the same time.
“What impact do four days of work have on us? What we are going to do through the distribution of the drugs will be a lot more valuable than those four days of work. It is better we spend the four days to dispense the drugs, and if we finish dispensing the drugs, we shall continue with our work later” (03_PERS._CD_F_FARADJAN_PS_25112019)
“It did not prove difficult because we want our village to be healthy. It did not prove to be a difficulty at our level. We want to achieve health” (03_PERS._CD_F_FARADJAN_PS_25112019)
“This increased our expenses, walking fatigue and difficulties. Because we left the work we were supposed to do in June for the June SMC campaign. And at that time we got into trouble, but we had to go and get fuel for the campaign. So we can say that this June cycle increased our task during the campaign; but thanks to the benefits of this additional June cycle, we are taking the courage to do the campaign in this month of June so that malaria can be reduced in our community” (03_PERS._CD_M_MADIASSO_GS_21112019)
Views on future campaigns
Caregivers support continuation of five cycles
Men and women expressed obvious support for the SMC campaign and the extra cycle. Many comments indicated caregivers were ‘in favour’ and supportive of the five cycles and wanted the campaign to continue. They discussed having ‘seen the benefits’ or ‘advantages’ of five cycles and that these positive outcomes have led to ‘acceptance’ and ‘support’ of the government campaign. Some women even suggested they would be happy ‘even if the ministry decides to go to six phases’. Men also expressed support and said there was ‘no difficulty’ or problem with this year’s campaign, and they would participate if it continues because the five cycles ‘have brought good health to our children’.
A few women and men mentioned the need ‘to know more about’ the drugs and be able to ask questions before understanding and accepting SMC; some were concerned about the side effects and ‘the fact that it weakens’ children. Others suggested a need ‘to find a way to raise awareness’ to increase people’s knowledge of the side effects and difficulties that can arise, because ‘it sometimes confuses people’ and ‘it freaks people out’. Some comments suggested that even if some in the community didn’t want to support the initiative, the government ‘knows about the number of sick children’ and ‘knows why’ they give medicines, so they will ‘go along with them’.
“We will agree with the Ministry because the SMC campaign was very successful. Given that, even if the Ministry decides to go to six phases, we're ready.” (01_PERS._F_FARADJAN_PS_191119)
“We are going to support them because we have seen the benefits of the five cycles. They helped us and if it continues it is good for us” (01_PERS._F_MADIASSO_GS_19112019)
“We are going to agree because there are advantages. We also see the benefits; that is why we are going to support them” (01_PERS._F_MADIASSO_GS_19112019)
Community distributors face many difficulties but are driven to improve health of the village
An important overarching concern among CDs was that they faced numerous difficulties in delivering the SMC campaign; because of this they felt ‘discouraged’ and the problems were significant enough for many to consider ‘giving up working on it’ in the future. An important challenge raised by most CDs was the delay in remuneration for their drug distribution work, which often left them out of pocket for significant amounts of time. Some requested to be paid more quickly after the campaign and complained that the conditions this year meant they worked for three cycles and only received payment for the first month, or that the only payment they had received early was for training. Another challenge was sourcing fuel to travel to distant farming villages for drug distribution; many talked about having to borrow fuel or obtain it on credit, others mentioned feeling ‘disgraced’ spending months without being able to repay creditors. Others talked about having to borrow motorbikes ‘to perform the campaign’ and wanted transportation to be provided. Male CDs felt that supervisors did not ‘know the reality’ of having to visit ‘farming hamlets’ and emphasised that if working conditions remained the same in coming years, they ‘will not be able to do it’, ‘we will resign’ and if there is no change in conditions ‘there is no need to call us for the coming years’. Despite these challenges dominating the discussions, most groups of CDs were quick to acknowledge the importance of the fifth cycle and getting SMC drugs to children, and affirmed that the health of children is what ‘encourages us to continue with the job’. Most said they were prepared and willing to do the job and the earlier start date was not problematic; rather the campaign needed to ‘manage the situation’ and ‘solve the difficulties”.
“Another issue is the means of transportation. An important additional issue is the financial one. We actually appreciate the job because it is important for our community to get the medicines and also it is true that is it for our children but we the distributors are all farmers…But sometimes we finish the whole job without being paid. By the time you get paid, you are obliged to sell a part of your harvests in order to pay your employees. This is also a serious issue” (02_PERS._CD__M&F_MADIASSO_GS_21112019)
“If they could improve the conditions, it would be good for us because we like the work. We don't want the conditions of this year. We have done three cycles and we only got the compensation of the first month. When it is like that, it is as if you had no compensation. Because it makes us lazy. Previous years, on the same night the campaign ended, we would sign a paper and take our money and we could pay the petrol credit; but this year it is not the case” (03_PERS._CD_M_MADIASSO_GS_21112019)
Key informants concerned about the need for more evidence
Many national level key informants said they would recommend the fifth cycle, but not without ‘scientific evidence’ or until it is ‘scientifically proven’. Many discussed that the five cycles may not be needed everywhere, and a targeted approach might work, implementing where there is a good chance of ‘maximizing the impact’; one suggested a situation analysis to detect ‘peak transmission’ areas that would benefit most.
Several were appreciative of the pilot study and Malaria Consortium for helping provide ‘some answers’ and evidence on whether the fifth cycle is needed, to guide on the next steps. Key informants also realized that for sustainability there would need to be continuous advocacy and sensitization at community level to ‘get their attention’ and ‘explain to people the reasons for an additional visit’; especially information for mothers before each round, which they thought would be the ‘cornerstone’ of the campaign.
“I will say yes because if there is real value in that, why not? Because we are all, we are all working to reduce the burden (drawbacks) of malaria. It is an intervention that we are sure can reduce the rate of malaria so we can recommend it. Now what I'm saying, recommending it doesn't mean doing it systematically everywhere. Maybe we can see where we have the best chance of maximizing the impact of this intervention. As I was saying, in the Sahel it may not be necessary; it may not be necessary to do five interventions” (10_NAT_JHPIEGO_AT_16122019)
“So the problem is not, about acceptability or not, it's a problem of scientific evidence, and for us to actually align ourselves with it.” (09_NAT_PADS-GLOBAL FUND_AT_13122019)
“the additional cycle was more or less desired for specific areas. I think that's how I understood it. Areas are not the same in Burkina. There are areas where the rainfall starts a little earlier than the others. SMC being this strategy which allows to prevent malaria during the peak transmission periods, a situation analysis throughout the country is necessary, considering the different area, in order to see roughly when these peak transmission periods occur” (08_NAT_DRS_BANFORA_AT_26112019)