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Annual Report The Gambia

on Thu, 03/26/2015 - 16:24


This is a report on the status of a multi-country research study in Benin, Burkina Faso and the Gambia: Community-based scheduled screening and treatment of malaria in pregnancy for improved maternal and infant health: a cluster-randomized trial (COSMIC). It examines whether community health workers can encourage more pregnant women to go to the antenatal clinics for care and to obtain treatment. It also looks at whether these health workers can identify and treat malaria in between antenatal visits, in the community where they and the pregnant women live.

The current malaria policy in the three African countries involved in this proposal (and the WHO recommended policy for all malaria endemic countries of sub-Saharan Africa) is to give an antimalarial treatment (IPTp-SP) to women when they attend an antenatal health facility clinic as a preventive. However, many women don’t go to antenatal clinics, or they go later than they should because they don’t know the value of the services.

The Medical Research Centre -The Gambia Unit is managing the Gambia study, led by Professor Umberto D’Alessandro and Dr Susana Scott. The overall project is coordinated by the Koninklijk Instituut voor de Tropen in The Netherlands, and the policy panel is being coordinated by the World Health Organization and TDR, the Special Programme for Research and Training in Tropical Diseases.

Policy panel meetings

Policy panel meetings to introduce the projects to national, regional and local policy-makers, healthcare workers, researchers and the media have been held in each of the 3 research sites – Benin in October, 2012; The Gambia in January, 2014, and Burkina Faso in February, 2014.

In all three meetings, the challenges identified were not so much about a lack of policy to support implementation of this project, but in these two areas:

  • Future funding of treatment

  • Motivation, supervision and assurance of good practice among the community health workers.

The final policy panel meetings will be held in August/September 2016. The objective of these is to review the final research evidence and develop an evidence brief. In the meantime, these interim updates are being provided at the beginning of 2015 and 2016.

Study site operations in the Gambia

The COSMIC trial is now over one year into the fieldwork and data collection. The study is based in 30 villages and eight health facilities on the South Bank of the Upper River Region. In 15 villages (intervention arm), village health workers (VHWs) are carrying out monthly scheduled screening and treatment for malaria in pregnancy for all women in their village who have been enrolled onto COSMIC. Enrolment trial began at the Antenatal Clinic (ANC) on 18 November 2013. Initially the study was based in the largest clinic (Basse health centre) so that all nurses and field assistants could work together and be supervised closely to ensure they were working effectively. Since this date, COSMIC nurses and field assistants have been deployed to the other clinics. The nurses live within the health centre compounds whilst field assistants attached to each health centre live in nearby villages. The field work is running well, there is good communication between the COSMIC staff and the community, with the community and their village health workers very committed to working on malaria case management in pregnancy.

As of January 2015, the Gambian field site has recruited 1,270 women and there have been 846 deliveries (study endpoint). Among the 43 rapid diagnostic test (RDT) positives, 23 women were detected during unscheduled visits to the ANC and 20 women during home visits.

Key statistics

Date study started: 18 November 2013

  • 30 villages with 15 in the intervention and 15 in the control arm.  Each village is clustered around one of 15 village health workers involved in study in the 15 intervention arms
  • 1,270 women recruited for study as of January 2015
  • 846 of deliveries since study started
  • 20 cases of malaria diagnosed and treated in community by CHW outside of antenatal visit


Economic research

The health economics research group has visited the study site in Gambia four times (January 2014, July 2014, October 2014 and February 2015) to familiarise with the study teams, understand the socio-economic and health system context in which the trial is being conducted and to identify the costs both to the health system (intervention at the community level and within health facilities) and to the households.

A field worker has collected in-patient and out-patient cost questionnaires. In February 2014, he started collecting the intervention costs, in particular to better understand the role of community health workers and nurses. A time and motion form has been created which have been tested in the study site, revised and adapted further to the local setting.


Social research

The social science team is investigating the acceptability of community scheduled screening and treatment. Data will be provided on the effectiveness in real life conditions of the intervention, the possible bottlenecks for the implementation of the intervention by the Community Health Workers, the adherence to treatment, the possible structural barriers to quality health care in general and the existing preventive measures.

A mixed-methods social science study triangulating qualitative and quantitative research has been set up. Explorative qualitative research is underway to understand the community perception of malaria and, consequently, health seeking behavior, treatment choice and adherence to the treatment. Additional qualitative and quantitative research starts in March and preliminary results will be communicated by December 2015.

Policy research

The policy research team is analysing the local health policies related to antenatal clinics and community case management of malaria in the three countries; assessing the integration (in the health system) and the feasibility of the new package of care; identifying bottlenecks at the levels of health policy, health system organization and actors, and formulating recommendations for possible scale up.

In the Gambia, the review of health policies resulted in recommending:

·Prevent out of stock rapid diagnostic tests in the study sites;

·Train and supervise regularly village health workers (VHWs) involved in the trial sites;

·Organise an effective referral system between VHWs and health facilities;

·Apply a motivation system taking into account the experiences in the past within each site.

Visits with the village health workers (VHWs)  [1]  have confirmed efficiency and smooth integration, since the trial is following Gambia health system standards. A database that includes these perspectives covers the following:

  • Feeling of interviewees related to the job: the VHWs feel they are better able to provide maternal care, and they have better access.
  • Perceived contribution to the trial: the village health workers view their work as providing important and vital contributions to the trial.
  • Collaboration with care providers at the antenatal clinics: this is seen as very good and vital for the trial.
  • Improvement in order to increase the job performance: a variety of incentives have been suggested, such as food instead of money, fuel for motorbikes, other essential drugs for patients, and additional community health nurses.
  • Perceived impact of the trial on tasks, job organization and individual efficacy at work: job organization has not changed significantly and individual efficacy at work increased because of training and the availability of means provided by the trial.

[1] Villages visited were: Dembakounda Kouta, Fatoto, Samehkoto, Dioulogué, Kombiga, Sare Bojo, Madina Samako, Fatoto health centre (HC); Gambissara HC; Koina HC, Basse major health centre (delivery ward), Fatoto, Koina, Kumbila, Samikoto, Saribodio.


For more information, please contact:

Susana Scott  or Umberto D’Alessandro

Medical Research Council Unit, The Gambia /

Phone: +220 4495442