MATTERN Chiarella

Résumé : Le risque de décès, d’aggravation d’une maladie, ou d’endettement dans ses suites, dépend des dispositifs et moyens disponibles et accessibles à la population pour y faire face. Ainsi, la vulnérabilité liée au paludisme dépend du contexte socio-économique et géoclimatique qui déterminent le risque de transmission, des comportements individuels ou collectifs, et des moyens des ménages pour faire face à la maladie, pour la prendre en charge ou la prévenir. La présente étude vise à identifier les déterminants de la vulnérabilité liée au paludisme de la population de Madagascar, en analysant le contexte et les comportements de prévention et de recours aux soins médicaux en cas de fièvre. Une étude quantitative sur 4043 personnes de 803 ménages a été combinée à une étude qualitative reposant sur une soixantaine d’entretiens, dans deux districts, Ankazobe (Hautes Terres) et Brickaville (côte est), où le risque de paludisme et les contextes psycho-sociaux différaient. Les données ont été collectées en 2014 dans le cadre d’une thèse et d’une étude pluridisciplinaire, multicentrique et internationale (projet PALEVALUT1) pour laquelle un questionnaire et des guides d’entretien ont été développés, standardisés et validés. À Brickaville, les conditions bioclimatiques (chaudes et humides) sont plus favorables au développement des moustiques vecteurs du paludisme qu’à Ankazobe. La survenue de fièvre, la connaissance d’une personne décédée du paludisme, la perception de la dangerosité de cette maladie, la citation de fausses croyances à son sujet, l’utilisation de moustiquaires, le recours à un professionnel de santé et à un test sanguin pour son diagnostic, et le paiement de frais pour le déplacement vers une structure de santé ou pour obtenir des soins en cas de fièvre, y étaient significativement plus fréquentes. En revanche, l’exposition à l’éducation pour la santé, la compréhension du paludisme, le recours aux agents communautaires et la prise d’une combinaison thérapeutique à base d’artémisinine en cas de prise d’antipaludique, y étaient significativement moins fréquent qu’à Ankazobe. Ainsi, à Brickaville où la prévalence du paludisme était la plus élevée, certaines connaissances, attitudes et pratiques, associées à la prévention ou au traitement étaient plus fréquentes alors que d’autres, notamment en matière thérapeutique, étaient plus souvent inappropriées. L’écosystème, la disponibilité, l’accessibilité et la nature des lieux de recours, l’exposition à l’éducation pour la santé, les pratiques médicales des soignants et des patients, différaient significativement dans ces sites distants de moins de 300 km ou entre des sous-populations d’un même site. Ces déterminants de la vulnérabilité liée au paludisme, multidimensionnels et complexes, sont présentés et discutés ici sur les plans quantitatifs et qualitatifs.

Résumé : Background In the last decade, an important scale-up was observed in malaria control interventions. Madagascar entered the process for pre-elimination in 2007. Policy making needs operational indicators, but also indicators about effectiveness and impact of malaria control interventions (MCI). This study is aimed at providing data about malaria infection, morbidity, and mortality, and MCI in Madagascar. Methods Two nationwide surveys were simultaneously conducted in 2012–2013 in Madagascar: a study about non-complicated clinical malaria cases in 31 sentinel health facilities, and a cross-sectional survey (CSS) in 62 sites. The CSS encompassed interviews, collection of biological samples and verbal autopsies (VA). Data from CSS were weighted for age, sex, malaria transmission pattern, and population density. VA data were processed with InterVA-4 software. Results CSS included 15,746 individuals of all ages. Parasite rate (PR) as measured by rapid diagnostic tests was 3.1%, and was significantly higher in five to 19 year olds, in males, poorer socio-economic status (SES) quintiles and rural areas. Long-lasting insecticidal nets (LLIN) use was 41.7% and was significantly lower in five to 19 year olds, males and wealthier SES quintiles. Proportion of persons covered by indoor residual spraying (IRS) was 66.8% in targeted zones. Proportion of persons using other insecticides than IRS was 22.8%. Coverage of intermittent preventive treatment during pregnancy was 21.5%. Exposure to information, education and communication messages about malaria was significantly higher in wealthier SES for all media but information meetings. The proportion of fever case managements considered as appropriate with regard to malaria was 15.8%. Malaria was attributed as the cause of death in 14.0% of 86 VA, and 50% of these deaths involved persons above the age of five years. The clinical case study included 818 cases of which people above the age of five accounted for 79.7%. In targeted zones, coverage of LLIN and IRS were lower in clinical cases than in general population. Conclusions This study provides valuable data for the evaluation of effectiveness and factors affecting MCI. MCI and evaluation surveys should consider the whole population and not only focus on under-fives and pregnant women in pre-elimination or elimination strategies.

Résumé : Objectives Madagascar faces many difficulties in accessing diagnosis and treatment of hepatitis B. The prevalence of chronic hepatitis B infection is estimated at 6.9%. The costs associated with screening and treatment are high and not easily accessible. This article proposes a reflection on the challenges and difficulties of access to diagnosis and treatment for patients with chronic hepatitis B. Method The “Neo Vac” study aimed to document the life paths of people living with chronic hepatitis B, their difficulties and their perceptions of HBV. Twenty-three semi-structured interviews were conducted in 2019 in Antananarivo with patients and gastroenterologists. Results The study describes the numerous obstacles that mark the therapeutic pathways of chronic HBV patients. The first result indicates lack of knowledge of the disease by chronic HBV patients and the varied circumstances in which the disease is discovered. None of the persons interviewed had been screened on their own initiative, the screening having taken place during prenatal consultations or emergency hospitalizations or during a morbidity episode. The care pathway was characterized by doubt and anxiety due to lack of knowledge about the possible disease outcome and concern about the costs of care. Discussion Little known by the population and health professionals, hepatitis B is rarely the subject of voluntary screening and is most often detected during an apparently unrelated health event. The exorbitant cost of treatment for patients, the cost of medical analyses and secondary costs, and the unavailability of follow-up tests outside the capital constitute barriers to access to care that are insurmountable for the majority of the Malagasy population. Conclusions This first qualitative study on the experiences of HBV-infected persons in terms of access to care and treatment in Madagascar underlines the extent to which access to treatment remains limited, due to the absence of a national policy for the prevention, screening and management of hepatitis B, which remains a highly neglected and unrecognized disease in Madagascar as well as internationally. Résumé Objectifs Madagascar rencontre de nombreuses difficultés dans l'accès au diagnostic et au traitement de l'hépatite B. La prévalence de l'infection chronique de l'hépatite B y est estimée à 6,9 %. Les coûts associés au dépistage et aux traitements sont payants et peu accessibles. Cet article propose une réflexion autour des enjeux et des difficultés de l'accès au diagnostic et aux traitements pour les patients atteints d'hépatite B chronique. Méthode L’étude « Néo Vac » avait pour objectif de documenter les parcours de vie des personnes vivant avec une hépatite B chronique, leurs difficultés et leurs perceptions du VHB. Vingt-trois entretiens semi-directifs ont été conduits en 2019 à Antananarivo avec des patients et des gastro-entérologues. Résultats L’étude décrit les nombreux obstacles qui jalonnent les parcours thérapeutiques des patients porteurs chroniques de VHB. Le premier résultat indique la méconnaissance de la maladie par les patients porteurs chroniques de VHB et les circonstances variées de découverte de la maladie. Aucune personne interviewée n'a été dépistée de sa propre initiative, le dépistage ayant eu lieu lors d'examens à l'occasion de consultations prénatales ou d'hospitalisations d'urgence ou d'un épisode de morbidité. Le parcours de soins est caractérisé par le doute et l'angoisse du fait de la méconnaissance sur l'issue possible de la maladie et l'inquiétude quant aux coûts de la prise en charge. Discussion Peu connue des populations et des professionnels de santé, l'hépatite B fait rarement l'objet de dépistages volontaires et se fait le plus souvent à l'occasion d'un événement de santé. Le coût exorbitant du traitement à la charge des patients, le coût des analyses médicales et les coûts secondaires ainsi que l'indisponibilité des tests de suivi en dehors de la capitale, constituent des barrières à l'accès aux soins, infranchissables pour la majorité de la population malgache. Conclusions Cette première étude qualitative sur le vécu des personnes infectées par le VHB en matière d'accès aux soins et aux traitements à Madagascar souligne combien l'accès au traitement reste limité, du fait de l'absence d'une politique nationale de prévention, de dépistage et de prise en charge de l'hépatite B, qui reste une maladie fortement négligée et méconnue à Madagascar comme au niveau international.

Résumé : Background Although its incidence has been decreasing during the last decade, malaria is still a major public health issue in Madagascar. The use of Long Lasting Insecticidal Nets (LLIN) remains a key malaria control intervention strategy in Madagascar, however, it encounters some obstacles. The present study aimed to explore the local terminology related to malaria, information channels about malaria, attitude towards bed nets, and health care seeking practices in case of fever. This article presents novel qualitative findings about malaria. Until now, no such data has been published for Madagascar. Methods A comparative qualitative study was carried out at four sites in Madagascar, each differing by malaria epidemiology and socio-cultural background of the populations. Seventy-one semi-structured interviews were conducted with biomedical and traditional caregivers, and members of the local population. In addition, observations of the living conditions and the uses of bed net were conducted. Results Due to the differences between local and biomedical perspectives on malaria, official messages did not have the expected impact on population in terms of prevention and care seeking behaviors. Rather, most information retained about malaria was spread through informal information circulation channels. Most interviewees perceived malaria as a disease that is simple to treat. Tazomoka (“mosquito fever”), the Malagasy biomedical word for malaria, was not used by populations. Tazo (“fever”) and tazomahery (“strong fever”) were the terms more commonly used by members of the local population to refer to malaria related symptoms. According to local perceptions in all areas, tazo and tazomahery were not caused by mosquitos. Each of these symptoms required specific health recourse. The usual fever management strategies consisted of self-medication or recourse to traditional and biomedical caregivers. Usage of bed nets was intermittent and was not directly linked to protection against malaria in the eyes of most Malagasy people. Conclusions This article highlights the conflicting understanding of malaria between local perceptions and the biomedical establishment in Madagascar. Local perceptions of malaria present a holistic vision of the disease that includes various social and cultural dimensions, rather than reflecting one universal understanding, as in the biomedical image. The consideration of this “holistic vision” and other socio-cultural aspects surrounding the understanding of malaria is essential in implementing successful control intervention strategies.

Résumé : Although it is accepted that long-lasting insecticidal net (LLIN) use is an effective means to prevent malaria, children aged 5 to 15 years do not appear to be sufficiently protected in Madagascar; the malaria prevalence is highest in this age group. The purpose of this research is to summarize recent qualitative studies describing LLIN use among the Malagasy people with a focus on children aged 5–15 years.

Résumé : A Madagascar, le recours à l’avortement, pratique interdite, est fréquent. On estime que les complications d’avortement constituent la deuxième cause de décès maternels dans les formations sanitaires. Afin d’identifier les facteurs de risques pouvant mener à des complications de l’avortement, une étude anthropologique a été réalisée en 2015-2016 dans deux zones de Madagascar en milieu rural et urbain. Des entretiens qualitatifs semi-directifs ont été menés auprès de 60 femmes ayant eu l’expérience de complications d’avortement, et de 40 professionnels de santé et tradipraticiens. L’objectif de cette présentation est de présenter les caractéristiques des femmes qui utilisent le misoprostol à des fins abortives, les modes d’approvisionnement et d’utilisation du médicament, et les recours mobilisés. Sur les 60 femmes enquêtées, 19 ont pris du misoprostol à des fins abortives. L’étude met en évidence la variété des modes d’approvisionnement et d’utilisation du médicament (mode d’administration, posologie, terme de la grossesse) et des recours mobilisés. L’accessibilité du misoprostol (dans les pharmacies, avec ou sans ordonnance, les dépôts de médicament, auprès des vendeurs sur le marché informel), son faible coût, la perception d’une utilisation facile et d’une grande efficacité expliquent le recours fréquent à cette méthode abortive, en milieu urbain et en milieu rural.

Résumé : Objectives: To learn what complications some women experienced in Madagascar following use of misoprostol for abortion and what treatment they received post-misoprostol use. Study design: This was a qualitative study in 2015-16 among women who had experienced complications after use of misoprostol, with or without additional methods, for abortion, what information they received before use, what dosage and regimens they used, what complications they experienced and what treatment they received post-use. We initially conducted in-depth, semistructured interviews with 60 women who had undergone an abortion that resulted in complications. The results presented here are based on interviews with the sub-set of 19 women who had used misoprostol. Results: The 19 women were aged 16-40, with an average age of 21-26 at interview and average age of 18-21 at abortion. To obtain an abortion, they sought advice from partners, friends, family members, and/or traditional practitioners and healthcare providers. Misoprostol was easily accessible through the formal and informal sectors, but the dosages and regimens the women used on the advice of others were extremely variable, did not match WHO guidelines, and were apparently ineffective, resulting in failed abortion, incomplete abortion, heavy bleeding/hemorrhage, strong pain, and/or infection. Conclusions: This study provides data on complications from the use of misoprostol as an abortifacient in Madagascar. Healthcare providers need training in correct misoprostol use and how to treat complications. Law and policy reform are needed to support such training and to ensure the provision of safe abortion services in the public health system.

Résumé : In Madagascar, a country where over 60% of deliveries are not attended by a healthcare professional, late or inadequate responses to complications during childbirth account for a great number of maternal deaths. In this article, we analyse local perceptions of birth-related risks and strategies used to avoid these risks or manage complications of childbirth. We conduct this analysis in light of the social meanings of childbirth and the social expectations placed upon women in a context of socio-economic vulnerability and a challenged public health system. We conducted two separate studies in the district of Morondava (Menabe region) in June 2014 and March 2015, comprising semi-directive interviews with 111 people (59 mothers, 18 members of their immediate entourage and 34 institutional or healthcare stakeholders), and eight focus groups discussions – two with community leaders, and six with fathers. The results show that the social pressure exerted on women to give birth without complications leads them to practices aimed at avoiding a "big" baby including dietary restrictions, physical activity, and refusal of iron supplementation intake. During pregnancy, women are usually accompanied by a traditional birth attendant or matron (reninjaza). Further, they use the public health system by attending antenatal consultations. However, women are reluctant to deliver in a health facility, where the practices of health professionals are in discordance with the social realities of women and local beliefs around childbirth. If complications arise, they are explained by social causes. The parturient woman is only taken to a healthcare facility after carrying out rituals and if the problems do not resolve themselves. These findings support recommendations to reduce the cultural distance between health workers and childbearing women, strengthen the collaborations with reninjazas, and inform women and their decision makers (mother, reninjaza, spouse) about nutrition during pregnancy and signs of complications.

Résumé : À Antananarivo, lors de la première vague de la pandémie de Covid-19, les modes et les lieux de distribution des médicaments antirétroviraux ont dû être réorganisés afin de maintenir le traitement médical des personnes vivant avec le VIH (PvVIH). Ce texte s’appuie sur une étude par entretiens semi-directifs réalisée auprès d’acteurs et actrices du VIH (PvVIH, professionnel·le·s de santé, acteur·rice·s associatif·ve·s) entre janvier et juillet 2021. Alors que l’une des structures de soins enquêtées a réaménagé un espace dans l’enceinte de l’hôpital pour y délivrer les médicaments, d’autres structures ont délocalisé leur distribution à l’extérieur, au plus près des PvVIH. Ces réorganisations ont été guidées par le souci du maintien de la confidentialité et ont affecté les mobilités des personnes et des molécules. L’article met en lumière les compétences spatiales et sociales des patient·e·s ainsi que le rôle des médiateurs et médiatrices associatif·ive·s et l’importance du lien téléphonique comme support de care dans un contexte de distance géographique entre patient·e·s, soignant·e·s et acteur·rice·s associatif·ve·s.

Résumé : Objectives To describe the epidemiological situation of the HIV/AIDS epidemic and to identify the main drivers for vulnerability in Madagascar. Design Literature review, qualitative research and situational analysis. Data sources Search of electronic bibliographic databases, national repositories of documentation from 1998 to 2018. Search keywords included Madagascar, HIV, sexually transmitted infections, men who have sex with men (MSM), sex workers (SWs), transactional sex (TS), injecting drug users (IDUs), vulnerability and sexual behaviour. Qualitative sources were interviews and focus group discussions. Review methods Studies focused on HIV and/or vulnerability of HIV in Madagascar in general, and key populations (KPs) and HIV/AIDS response were taken into account. National reports from key HIV response actors were included. Results Madagascar is characterised by a low HIV/AIDS epidemic profile in the general population (GP) (0.3%) combined with a high prevalence of HIV among KPs (SWs, MSM and IDUs).An increase in HIV prevalence among KP has been observed during recent years. Hospital-based data suggest an increase in HIV prevalence among the GP. The vulnerability traits are inconsistent use of condoms, multipartner relationships and other contextual factors like widespread TS and gender inequality. A high prevalence/incidence of sexually transmitted infections could indicate a high vulnerability to HIV/AIDS. However, there are no reports of HIV prevalence of >1% in antenatal consultation. Conclusion There is not enough evidence to make a conclusion about the HIV epidemiological situation in Madagascar due to the scarcity of the epidemiological data. However, Madagascar may be closer to a turning point towards a high-prevalence epidemic with severe consequences, particularly when taking into account its socioeconomical fragility and underlying vulnerabilities. More precise epidemiological data and improved HIV/AIDS diagnosis and case management should be a public health priority.

Résumé : Madagascar has restrictive abortion laws with no explicit exception to preserve the woman’s life. This study aimed to estimate the incidence of abortion in the country and examine the methods, consequences, and risk factors of these abortions.