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Perceptions of drones, digital adherence monitoring technologies and educational videos for tuberculosis control in remote Madagascar: a mixed-method study protocol ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2018-028073
Article Type: Protocol
Date Submitted by the 20-Nov-2018 Author:
Complete List of Authors: Nouvet, Elysée; Western University, School of Health Studies Knoblauch, Astrid; Schweizerisches Tropen- und Public Health-Institut; Institut Pasteur de Madagascar, Mycobacteria Passe, Ian; Stony Brook University Andriamiadanarivo, Andry ; Center Valbio Ravelona, Manualdo; Center Valbio Ainanomena Ramtariharisoa, Faniry ; Centre Valbio Razafimdriana, Kimmerling ; Center Valbio Wright, Patricia; Stony Brook University; Center Valbio McKinney, Jesse ; Stony Brook University; Center Valbio Small, Peter; Stony Brook University Rakotosamimanana, Niaina; Institut Pasteur de Madagascar, Mycobacteria Grandjean Lapierre, Simon; Centre de recherche du CHUM, Immunopathology; Institut Pasteur de Madagascar, Mycobacteria
Keywords: drones, eHealth, evriMED, Madagascar, mixed-method study, video
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1 2 3 1 BMJ OPEN – STUDY PROTOCOL 4 5 6 2 7 8 3 TITLE 9 10 4 Perceptions of drones, digital adherence monitoring technologies and educational videos for 11 12 5 tuberculosis control in remote Madagascar: a mixed-method study protocol 13 14 15 6 16 For peer review only 17 7 ARTICLE TYPE 18 19 20 8 Study Protocol 21 22 9 23 24 10 AUTHORS 25 26 1 2,3 4 5 27 11 Elysée Nouvet *, Astrid M. Knoblauch , Ian Passe , Andry Andriamiadanarivo , Manualdo 28 29 12 Ravelona5, Faniry Ainanomena Ramtariharisoa5, Kimmerling Razafimdriana5, Patricia C. 30 31 13 Wright4,5, Jesse McKinney4,5, Peter M. Small4, Niaina Rakotosamimanana (ORCID 0000-0002- 32 33 14 2352-9797)3, Simon Grandjean Lapierre (ORCID 0000-0003-3646-1573)3,6 34 35 36 15 37 38 16 *Corresponding author 39 40 17 41 42 43 18 AFFILIATIONS 44 45 19 1 Western University, School of Health Sciences, 1151 Richmond St, London, ON N6A 3K7, 46 47 20 Canada 48 49 2 50 21 Swiss Tropical and Public Health Institute, University of Basel, 57 Socinstrasse, Basel 4051 51 52 22 Switzerland 53 54 23 3Mycobacteria Unit, Institut Pasteur de Madagascar, Mycobactreria Unit, Ambohitrakely, 55 56 57 58 59 1 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 112
1 2 3 24 Antananarivo 101, Madagascar 4 5 4 6 25 Stony Brook University, Global Health Institute, 100 Nicholls Road, Stony Brook, NY 11794, 7 8 26 USA 9 10 27 5 Centre ValBio Research Station, BP 33 Ranomafana, Ifanadiana, Madagascar 11 12 28 6 Centre de Recherche du Centre Hospitalier de l’Université de Montréal, 900 Saint-Denis, 13 14 15 29 Montréal, QC H2X 3H8, Canada 16 For peer review only 17 30 18 19 31 CORRESPONDING AUTHOR 20 21 22 32 Simon Grandjean Lapierre 23 24 33 [email protected] 25 26 34 +1 514 743 7255 (Canada) 27 28 29 35 +261 34 32 632 47 30 31 36 32 33 37 WORD COUNT 34 35 38 Abstract: 297 36 37 38 39 Manuscript: 2850 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 2 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 112 BMJ Open
1 2 3 40 ABSTRACT 4 5 6 41 Introduction 7 8 42 To meet the End TB Strategy goal of reducing tuberculosis incidence by 90% before 2035, the 9 10 43 World Health Organization calls for intensified research and innovation including the rapid uptake 11 12 44 of new tools, interventions and strategies. Innovative technologies have the potential to support 13 14 15 45 tuberculosis control activities within challenged national tuberculosis programs and can also be 16 For peer review only 17 46 adapted to address other public health challenges. Their deployment needs to be differentially 18 19 47 adapted to context-specific factors that may impact on population ability or willingness to present 20 21 22 48 for TB testing or adopt and use new technologies in ways intended. This holds especially true in 23 24 49 remote limited literacy settings with little or no previous exposure to technology. The Drone 25 26 50 Observed Therapy System (DrOTS) project was launched in Madagascar in 2017 and integrates a 27 28 29 51 bundle of innovative technologies including drones, digital adherence monitoring technology 30 31 52 evriMEDTM, and mobile device-based educational videos to support tuberculosis control. 32 33 53 Methods and analysis 34 35 54 This mixed-methods study assesses the cultural perceptions of the DrOTS project. Perceptions of 36 37 38 55 key stakeholders including patients, members of patient households, other village members, 39 40 56 community health workers, village chiefs and NTP-DrOTS mobile health teams in three of overall 41 42 57 61 DrOTS-enrolled villages are gathered using questionnaires, semi-structured in-depth 43 44 45 58 interviews, focus group discussions, and ethnographic observations. Participant selection is 46 47 59 purposive and semi-randomized depending on data collection methods. Data collection began in 48 49 60 June 2018 and is set to end in June 2019. Analysis uses constant comparison and triangulation 50 51 52 61 across data sources to identify and explain patterns and singularities in how DrOTS project 53 54 62 stakeholders perceive and interact with DrOTS technologies, its enrollment processes, objectives, 55 56 57 58 59 3 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 112
1 2 3 63 and team. 4 5 6 64 Ethics and dissemination 7 8 65 Ethics approval was obtained by the Madagascar National Bioethics Research Committee of 9 10 66 Madagascar and Stony Brook University institutional review board. Results of the DrOTS 11 12 67 perception study will be submitted for peer-reviewed publication. 13 14 15 68 16 For peer review only 17 69 Keywords 18 19 70 drones, eHealth, evriMED, Madagascar, mixed-method study, videos 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 4 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 112 BMJ Open
1 2 3 71 STRENGHTS AND LIMITATIONS OF THIS STUDY 4 5 TM 6 72 . This study is one of the first to assess acceptance and perceptions of drones and evriMED 7 8 73 technologies that are currently being considered for scale-up in several health systems around 9 10 74 the world. 11 12 75 . Qualitative methods facilitate detailed and nuanced understanding of how and why 13 14 15 76 stakeholders with limited literacy and in remote settings perceive and use new technologies. 16 For peer review only 17 77 . Data is collected from a range of stakeholders and focused on those using these new 18 19 78 technologies on the front-lines in low-income countries (i.e. patients, national mobile 20 21 22 79 healthcare team members, community health workers, villagers). 23 24 80 . Findings from perception studies serve to deepen understanding of how contextual 25 26 81 particularities can impact on acceptance, perceptions of, and interactions with new 27 28 29 82 technologies but may not be generalizable across distinct settings and populations. 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 5 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 112
1 2 3 83 INTRODUCTION 4 5 6 84 Tuberculosis (TB) infected 10 million people in 2017 (1). To meet the End TB Strategy goal of 7 8 85 reducing incidence by 90% and mortality by 95% before 2035, the World Health Organization 9 10 86 (WHO) has called for intensified research and innovation including the rapid uptake of new tools, 11 12 87 interventions and strategies (2). In low- and middle-income countries (LMIC) that are 13 14 15 88 disproportionately more affected by disease, TB control can be hindered by any number of social 16 For peer review only 17 89 and structural factors, including limited access to centralized facilities for populations living 18 19 90 outside the capital, understaffed healthcare infrastructures, poor development of laboratory 20 21 22 91 diagnostic networks, or stigma influencing healthcare seeking behaviors and treatment adherence 23 24 92 (3, 4). In such contexts, diagnosis may be delayed or fail to occur at all, and implementation of 25 26 93 directly observed therapy (DOT) by national tuberculosis control programs (NTPs) becomes 27 28 29 94 particularly challenging, increasing secondary transmission and fatalities (5). 30 31 95 In 2017, nearly 30,000 TB cases were reported in Madagascar (6). This corresponds to half of 32 33 96 actual cases to have occurred in the country, as estimated by WHO (6). Madagascar exemplifies 34 35 97 the challenges of quality TB care delivery for remote and dispersed populations as 40% of 36 37 38 98 Malagasy people live more than 5 km from the nearest basic healthcare facility, with no public 39 40 99 transit system or even roads in many cases (7). TB diagnosis and treatment challenges in 41 42 100 Madagascar are representative of those in many areas of sub-Saharan Africa: (i) underserved 43 44 45 101 healthcare system; (ii) poverty and cultural norms hindering healthcare seeking; (iii) paucity of 46 47 102 human resource capacities with training in TB; (iv) paucity of diagnostic facilities; (v) suboptimal 48 49 103 coverage of treatment and treatment follow-up; and (vi) high prevalence of two important TB risk 50 51 52 104 factors, i.e. malnutrition and indoor air pollution (5, 8-11). 53 54 105 To leapfrog over theses impediments to quality TB care, the Drone Observed Therapy System 55 56 57 58 59 6 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 112 BMJ Open
1 2 3 106 (DrOTS) project was co-initiated with the Malagasy NTP and was deployed by Stony Brook 4 5 6 107 University’s Global Health Institute in collaboration with the Pasteur Institute of Madagascar. The 7 8 108 project was implemented in 61 randomly selected villages in Androrangavola commune, south- 9 10 109 eastern Madagascar, in August 2017. Up to 70% of the approximately 20,000 inhabitants living in 11 12 110 Androrangavola commune live more than 5 km away from the closest healthcare facility, and that 13 14 15 111 facility in turn is situated more than one day’s walk from the closest TB diagnosis center (12). 16 For peer review only 17 112 DrOTS involves an NTP-DrOTS mobile health team consisting of TB nurses and doctors that 18 19 113 collaborate with local community health workers (CHWs). DrOTS implements active case finding 20 21 22 114 and supports TB screening, diagnosis, counselling and treatment supervision within communities 23 24 115 using a suite of technologies: drones, evriMED devices, and tablet-based educational videos. In 25 26 116 this scheme, drones increase access to diagnosis and care by facilitating specimen transport and 27 28 29 117 securing the medication supply chain between diagnosis and treatment centers and remote 30 31 118 communities; evriMED digital adherence monitoring devices aim to increase adherence and 32 33 119 enable remote monitoring; and a tablet-based eHealth video curriculum supports patients and 34 35 36 120 CHWs by providing key information on TB care and prevention at every step of the pathway to 37 38 121 cure. Given the novelty of this new approach we designed and here present a study protocol for 39 40 122 the DrOTS perception study, a mixed-method cultural acceptability sub-study embedded within 41 42 43 123 the DrOTS project. 44 45 124 46 47 125 Rationale 48 49 50 126 Determining the success of the DrOTS project cannot be limited to evaluation of its impacts on 51 52 127 additional TB notifications or successfully completed treatments. Though such measures are 53 54 128 central to establishing the value and potential of innovative technologies in the global fight against 55 56 57 58 59 7 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 112
1 2 3 129 TB, the success of such innovative public health strategies is also contingent on how those on its 4 5 6 130 receiving end perceive and engage with its objectives, enrollment, participation processes and 7 8 131 technologies. The DrOTS perception study aims to build expertise on how to implement new 9 10 132 technologies in a way that is acceptable to individuals and communities that lack close or 11 12 133 affordable access to TB diagnosis and treatment, have no prior exposure to such technologies, and 13 14 15 134 may harbor understandings of TB that limit management of presumptive or confirmed infections. 16 For peer review only 17 135 Attending to these contextual and lived particularities of the DrOTS project is key to designing 18 19 136 and planning feasible and effective scale-up. At present, there exists no ethical or practical 20 21 22 137 guidance on the contextually-sensitive use of drones and digital adherence monitoring 23 24 138 technologies for disease diagnosis and treatment. This study can inform needed evidence-based 25 26 139 guidance for the future expansion of such technology suites poised to strengthen TB programs and 27 28 29 140 healthcare systems more generally. 30 31 141 32 33 142 Primary objectives 34 35 143 1. To identify prevalent perceptions (e.g. perceived benefits, concerns, misunderstandings) 36 37 38 144 related to the various technological and programmatic aspects of the DrOTS project. 39 40 145 2. To generate a description of how and why individuals, families, and villages are interacting 41 42 146 with specific components of the DrOTS project in unanticipated ways. 43 44 45 147 46 47 148 Secondary objectives 48 49 149 1. To establish rates and demographic distribution of understandings of and interactions with 50 51 52 150 the various technological and programmatic aspects of the DrOTS project. 53 54 151 2. To generate understandings of how and based on what factors individuals, families, and 55 56 57 58 59 8 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 112 BMJ Open
1 2 3 152 villages are deciding whether or not to participate in the DrOTS project. 4 5 6 153 3. To develop a set of evidence-based cultural and contextual considerations that can inform 7 8 154 the implementation of similar technology-mediated diagnostic and treatment in other 9 10 155 regions of Madagascar and in other national contexts. 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 9 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 112
1 2 3 156 METHODS AND ANALYSIS 4 5 6 157 Study design 7 8 158 The DrOTS perception study is a mixed-methods study involving cross-sectional data collection 9 10 159 through (i) questionnaires, (ii) focus group discussions (FDGs), (iii) semi-structured in-depth 11 12 160 interviews, and (iv) ethnographic observations. Quantitative questionnaire data is collected 13 14 15 161 throughout the DrOTS project period (November 2017 – December 2018) as well as an additional 16 For peer review only 17 162 6 months after project end for follow-up of TB patients adhering to a 6-months treatment regimen. 18 19 163 Data collection for the qualitative part is initiated in June 2018 with a first village visit, followed 20 21 22 164 by visits in the second and third village in August and November 2018, respectively. Ethnographic 23 24 165 observation occurs between June and July 2018 (Error! Reference source not found.). All study 25 26 166 tools were developed by content experts in dialogue with members of the DrOTS team responsible 27 28 29 167 for community engagement and/or familiar with local dialect and customs in Androrangavola 30 31 168 commune. 32 33 169 34 35 170 Questionnaire survey 36 37 38 171 Two questionnaires are used: (i) DrOTS baseline questionnaire conducted with presumptive and 39 40 172 confirmed TB cases, other village members and CHWs (see Supplementary material 1 – DrOTS 41 42 173 Perception Study Baseline Questionnaire), and (ii) DrOTS end-of-treatment questionnaire 43 44 45 174 conducted with confirmed TB cases (see Supplementary material 2 – DrOTS Perception Study 46 47 175 End of Treatment Questionnaire). Questionnaires are administered verbally by members of the 48 49 176 NTP-DrOTS mobile health team to 15-20 individuals aged ≥15 years in each of the DrOTS- 50 51 52 177 participating villages. Self-presenting TB presumptive (including later confirmed) cases and 53 54 178 CHWs are purposively invited to answer the baseline questionnaire, with remaining participants 55 56 57 58 59 10 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 112 BMJ Open
1 2 3 179 being randomly recruited in each DrOTS village. This questionnaire provides quantitative data on 4 5 6 180 basic socio-demographic characteristics, travel history, TB risk factors, TB related health seeking 7 8 181 behavior, medical history, knowledge on TB and behaviors towards TB. An end-of-treatment 9 10 182 questionnaire is administered to all enrolled TB patients upon completion of treatment. This 11 12 13 183 questionnaire addresses specific perceptions of drones, evriMED and educational videos. 14 15 184 Questionnaire data is collected using tablet-based Open Data Kit (ODK) software standardized 16 For peer review only 17 185 form. The large sub-population sampling size aims to support measurement and comparison of 18 19 20 186 key acceptability indicators between different study sub-groups (e.g. patients vs. non-patients, 21 22 187 most educated vs. least educated). 23 24 188 25 26 189 Focus Group Discussions 27 28 29 190 FGD-based qualitative data collection is taking place in three of the 61 DrOTS participating 30 31 191 villages as well as with the NTP-DrOTS mobile health team. Villages for the running of FGDs are 32 33 192 selected based on: (1) participation in the DrOTS project for at least three months; (2) accessibility 34 35 36 193 for the qualitative research team, meaning within a day’s hike from the closest vehicle-accessible 37 38 194 town; (3) willingness to host the DrOTS perception team. Collecting data in three villages enables 39 40 195 comparison of reported perceptions and acceptability of new technologies across villages, the 41 42 43 196 possibility for diversity in perceptions to be captured. Furthermore, even where similarities exist, 44 45 197 a more nuanced understanding of how village specific characteristics, such as access to livelihood 46 47 198 activities, norms of post-secondary education achievement, and historical relations to outsiders 48 49 199 travelling in the region (e.g. for mining or development initiatives) may shape perceptions of the 50 51 52 200 DrOTS project. Sampling is purposive and randomized. It is purposive inasmuch as we are aiming 53 54 201 to gather perceptions from a range of individuals who have engaged with DrOTS first-hand. For 55 56 57 58 59 11 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 112
1 2 3 202 FGDs, we also aim to have an equal representation of men and women, and an equal representation 4 5 6 203 across age groups in villages, towards capturing potential diversity in experiences of DrOTS based 7 8 204 on diverse levels or types of responsibility in the home and village. Random sampling is also being 9 10 205 used for FGD participant selection. Villagers willing to partake in a FGD provide their names to 11 12 206 the research team, and may or may not be randomly selected to join the FGD organized for their 13 14 15 207 age and gender group. Randomized selection of participants for village FGDs avoids burdening 16 For peer review only 17 208 CHWs or other leaders with the task of identifying potential participants (which could also 18 19 209 potentially result in biased responses tied to particular village interests), but is important to the 20 21 22 210 culturally respectful conduct of this study. In our experience, many are interested in participating 23 24 211 in FGDs, and this randomized selection ensures all those interested have and know they have an 25 26 212 equal chance of being selected (names of volunteers drawn from hat at village meeting). 27 28 29 213 Homosociality and age-group separation are dominant norms guiding social interaction in this part 30 31 214 of Madagascar. Hence, to facilitate participants feeling at ease and to limit the possibility of social 32 33 215 hierarchies in a FGD over-determining who feels able to express their view in a group, FGDs are 34 35 216 being organized along age and gender lines: married men, married women, unmarried men, 36 37 38 217 unmarried women, elder men, elder women. FGDs are run using a standard set of questions 39 40 218 organized into two parts. Part I focuses on deepening the understanding of the participants' day to 41 42 219 day definition and management of illness and understandings of TB prior to DrOTS and part II 43 44 45 220 focuses on perceptions and interactions with DrOTS. The set of questions for the NTP-DrOTS 46 47 221 mobile health team FGD is distinct, and probes members' understanding and concerns related to 48 49 222 DrOTS, as well as perceptions of cultural and village-specific attitudes, knowledge, and 50 51 52 223 engagements with specific aspects of DrOTS pilot project based on work in all villages (see 53 54 224 Supplementary material 3 – DrOTS Perception Study Focus Group Discussion Guide). All FGDs 55 56 57 58 59 12 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 112 BMJ Open
1 2 3 225 are moderated and/or supervised by an experienced medical anthropologist and conducted in 4 5 6 226 Malagasy local dialect with the help of a translator. With participants' permission, these are 7 8 227 digitally recorded. 9 10 228 11 12 229 Table 1 - Focus group discussion recruitment plan, DrOTS perception study, Madagascar, 13 14 15 230 2017-2019 16 For peer review only 17 231 18 19 232 Semi-structured in-depth interviews 20 21 22 233 Semi-structured in-depth interviews gather information on different stakeholders’ knowledge of, 23 24 234 attitudes towards, uses and first-hand experiences of the DrOTS project that cannot be gleaned 25 26 235 from questionnaires, and may be too sensitive or detailed to emerge in FGDs (Supplementary 27 28 29 236 material 4 – DrOTS Perception Study Semi-Structured Interview Guide). Recruitment is purposive 30 31 237 and targets in each village four categories of key stakeholders: (1) DrOTS project-enrolled adult 32 33 238 patients (over 15 years of age); (2) adults who presented for TB testing to the DrOTS team but 34 35 239 have received negative diagnostic testing results; (3) villagers hesitant, unable or have declined to 36 37 38 240 join the project; (4) CHWs; (5) village leaders, including kings and elected district chiefs. All 39 40 241 participants except for participants from category (3) are being identified with help from the NTP- 41 42 242 DrOTS mobile team. Participants in category (3) are asked to self-identify in the process of FGDs 43 44 45 243 and may be identified by other interview participants using “snowball sampling”. An estimated 46 47 244 eight interviews will be performed in the same sub-set of three villages as FGDs for a total of 24 48 49 245 interviews (Table 2). Additional interviews are performed with TB confirmed cases outside the 50 51 52 246 included villages to increase the number of DrOTS-enrolled patients. 53 54 247 55 56 57 58 59 13 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 112
1 2 3 248 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 14 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 112 BMJ Open
1 2 3 249 Table 2 – Semi-structured interview recruitment plan 4 5 6 250 7 8 251 Ethnographic observations 9 10 252 An anthropology trainee engages with DrOTS project patients and seeks permission to visit them 11 12 253 in their community over a two weeks period in order to better understand, through ethnographic 13 14 15 254 observation, how that individual interacts with the DrOTS project on a daily basis. Ethnographic 16 For peer review only 17 255 observation will gather information on patients and those in their circle of care may not realize as 18 19 256 pertinent to the DrOTS perception study and provide insight into patients’ daily management of 20 21 22 257 TB within the DrOTS project. This longitudinal and personalized observation approach will allow 23 24 258 identifying (1) novel and normative ways in which patients, villagers being tested, village leaders, 25 26 259 and CHWs and the mobile health team discuss and engage with DrOTS, (2) technical, practical 27 28 29 260 community or individual level challenges, (3) any differences or similarities in attitudes or beliefs 30 31 261 about the DrOTS pilot project study expressed in informal conversation about the project and/or 32 33 262 its technologies and, (4) contextualized information about how the patient views and uses DrOTS 34 35 263 technologies. This approach will also allow qualitative data triangulation and detailed 36 37 38 264 contextualization of the information gleaned from other data collection methods. 39 40 265 41 42 266 Analysis 43 44 45 267 Questionnaire quantitative data will be descriptively analyzed using STATA version 14.0 (Stata 46 47 268 Corporation, College Station, USA) and will address and compare levels of acceptability between 48 49 269 groups. 50 51 52 270 Interviews and FGDs will be transcribed and translated into English by a professional Malagasy 53 54 271 translator mastering the field study site local dialect. Transcripts will be uploaded into Nvivo 12.0 55 56 57 58 59 15 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 112
1 2 3 272 (QSR; Melbourne, Australia) and be subjected to thematic analysis. Categories of enquiry in 4 5 6 273 interview and FGD guides will form the basis for an initial coding structure. Three semi-structured 7 8 274 interviews will then be independently coded by two investigators to test and adjust this structure 9 10 275 in light of the data, adding themes to account for unanticipated but relevant content. In an iterative 11 12 276 process, minor adjustments and additions (e.g. change in theme names or merging of themes) to 13 14 15 277 the codebook will be made when needed. Key themes and sub-themes contents will be summarized 16 For peer review only 17 278 and reviewed to allow linkage of quantitative and qualitative data, clearly identify themes with 18 19 279 exemplary quotes, raise questions and concerns, and inform guidelines for culturally and 20 21 22 280 contextually sensitive technology implementations. Ethnographic field notes will not be coded but 23 24 281 will inform the analysis by providing support to findings from the interviews and FGDs, and/or by 25 26 282 identifying gaps knowledge gaps. 27 28 29 283 30 31 284 ETHICS 32 33 285 This study received institutional review board (IRB) approval from 34 35 286 36 both the “Comité d’Éthique de la Recherche Biomédicale” from the 37 38 287 Ministry of Public Health in Madagascar, Madagascar (073- 39 40 288 MSANP/CERBM) and Stony Brook University, New York, USA (CORIHS# 41 42 289 2017-4056-F). Following project and technology sensitization 43 44 45 290 visits and in accordance with cultural norms, consent is obtained from the local leaders to 46 47 291 present this research project to villagers under their responsibility before engaging in any activities 48 49 292 within villages. Though limited literacy is widespread in this region of Madagascar, as per national 50 51 52 293 research ethics norm, consent forms are read and explained to participants and written informed 53 54 294 consent is obtained from any and all parties agreeing to participate before conducting interviews, 55 56 57 58 59 16 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 112 BMJ Open
1 2 3 295 focus groups, and observations. Data is being anonymized rendering participants’ identification 4 5 6 296 from dissemination material impossible. Participants in this perceptions study do not face any 7 8 297 different health care as a result of participation. All patients diagnosed with TB within the DrOTS 9 10 298 projects are treated for free in accordance with national NTP and WHO guidelines. 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 17 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 112
1 2 3 299 DISCUSSION 4 5 6 300 The development of innovative technologies for TB diagnosis and control does not guarantee their 7 8 301 enthusiastic and rapid adoption in diverse settings (13). This study responds to a current gap in 9 10 302 knowledge on the feasibility and cultural acceptability of using a new suite of technologies 11 12 TM 13 303 including evriMED , drones and tablet-mediated video education to support improved TB 14 15 304 diagnosis and treatment in remote populations. This study collects data through an estimated 19 16 For peer review only 17 305 FGDs, 24 in-depth interviews, and ~600 questionnaires. 18 19 20 306 While focused on one project in Madagascar, the DrOTS perception study provides a model for 21 22 307 attending to contextual factors that may impact on target population support and intended 23 24 308 interactions with any number of other new public health initiatives around the world. Embedding 25 26 27 309 such perception studies within projects are particularly important for initiatives conceptualized 28 29 310 based on the theoretical but as of yet unproven potential of new technologies. While findings from 30 31 311 perceptions studies on new innovative technology-mediated health projects may not be readily 32 33 34 312 generalizable, as each setting is unique, such studies can generate learning that is transferable to 35 36 313 other settings by drawing attention to the range of factors that may impact on technology adoption 37 38 314 and interaction, and by shedding light on how others on the fronts lines of innovative projects have 39 40 41 315 sensitively navigated the cultural, social, political, and ethical complexities of particular contexts. 42 43 316 In these ways, perceptions studies that "localize" understandings of how theoretically promising 44 45 317 new technologies work in specific locales have an important role to play in informing evidence- 46 47 318 based guidance for context-sensitive implementation and scale-up of programs such as DrOTS 48 49 50 319 around the world. 51 52 53 54 55 56 57 58 59 18 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 112 BMJ Open
1 2 3 320 AUTHOR CONTRIBUTIONS 4 5 321 6 All authors meet criteria for authorship as per the ICJME 7 8 322 recommendations. EN, AMK, IP, NR, PS, AA & SGL designed study 9 10 323 protocol and data collection tools. EN, IP, AA, FAR, MR, JM, NR & 11 12 324 SGL 13 are involved in field implementation and data collection. EN, 14 15 325 AMK, IP, AA, PW, PS & SGL are involved in data management & 16 For peer review only 17 326 interpretation. All authors have read and approved the final 18 19 327 version of the manuscript before submission. 20 21 22 328 23 24 329 FUNDING 25 26 330 The DrOTS project was supported by the Stop TB Partnership’s TB REACH initiative and was 27 28 29 331 funded by the Government of Canada. Ian Passe receives financial support from the Stony Brook 30 31 332 University Undergraduate Research & Creative Activities Award program. AMK is supported by 32 33 333 the Rudolf Geigy Foundation, Swiss Tropical and Public Health Institute, Basel, Switzerland. 34 35 334 Elysée Nouvet receives financial support from the Western University Faculty Development Fund 36 37 38 335 Grant program. SGL is supported by the Canadian Association for Microbiology and Infectious 39 40 336 Diseases. 41 42 337 43 44 45 338 COMPETING INTEREST 46 47 339 Authors declare no financial or personal relationships with other 48 49 340 people or organizations that could inappropriately influence this 50 51 341 work. The first and corresponding author had full access to all 52 53 54 342 the data in the study and had final responsibility for the decision 55 56 343 to submit this work for publication. 57 58 59 19 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 112
1 2 3 344 4 5 6 345 ACKNOWLEDGEMENTS 7 8 346 We are grateful to the DrOTS project Malagasy team including community healthcare workers 9 10 347 involved in patient and data management. We also thank the Madagascar’s National Tuberculosis 11 12 348 Control Program personnel for their collaboration. 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 20 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 112 BMJ Open
1 2 3 349 REFERENCES 4 5 6 350 1. WHO. Global TB Report. 2018. 7 8 351 2. WHO. WHO end TB strategy. 2016. WHO, Geneva, Switzerland. 2016. 9 10 352 3. Chimbatata NBW, Zhou CM, Chimbatata CM, Xu B. Post-2015, why delay to seek healthcare? 11 12 353 Perceptions and field experiences from TB healthcare providers in northern Malawi: a qualitative 13 14 15 354 study. Infect Dis Poverty. 2017;6(1):60. 16 For peer review only 17 355 4. Cramm JM, Finkenflugel HJ, Moller V, Nieboer AP. TB treatment initiation and adherence in a 18 19 356 South African community influenced more by perceptions than by knowledge of tuberculosis. 20 21 22 357 BMC Public Health. 2010;10:72. 23 24 358 5. Yates TA, Khan PY, Knight GM, Taylor JG, McHugh TD, Lipman M, et al. The transmission 25 26 359 of Mycobacterium tuberculosis in high burden settings. Lancet Infect Dis. 2016;16(2):227-38. 27 28 29 360 6. WHO. Country Tuberculosis Profile - Madagascar 2017. 30 31 361 7. Ratovonirina NH, Rakotosamimanana N, Razafimahatratra SL, Raherison MS, Refregier G, 32 33 362 Sola C, et al. Assessment of tuberculosis spatial hotspot areas in Antananarivo, Madagascar, by 34 35 363 combining spatial analysis and genotyping. BMC Infect Dis. 2017;17(1):562. 36 37 38 364 8. MSANP, DGS, DLT. Plan stratégique national de lutte contre la tuberculose à Madagascar 39 40 365 2015-2019. Antananarivo: Ministère de la Santé Publique, Direction Générale de la Santé, 41 42 366 Direction de Luttre contre la Tuberculose; 2015. 43 44 45 367 9. Barmania S. Madagascar's health challenges. Lancet. 2015;386(9995):729-30. 46 47 368 10. INSTAT, ICF Macro. Enquête démographique et de santé 2008-2009. Antananarivo: 48 49 369 Institut National de la Statistique and ICF Macro; 2010. 50 51 52 370 11. WHO. Chest radiography in tuberculosis detection. 2016. 53 54 371 12. Miller AC, Ramananjato RH, Garchitorena A, Rabeza VR, Gikic D, Cripps A, et al. 55 56 57 58 59 21 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 112
1 2 3 372 Baseline population health conditions ahead of a health system strengthening program in rural 4 5 6 373 Madagascar. Glob Health Action. 2017;10(1):1329961. 7 8 374 13. Cazabon D, Suresh A, Oghor C, Qin ZZ, Kik SV, Denkinger CM, et al. Implementation of 9 10 375 Xpert MTB/RIF in 22 high tuberculosis burden countries: are we making progress? Eur Respir J. 11 12 376 2017;50(2). 13 14 15 377 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 22 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 112 BMJ Open
1 2 3 378 TABLES 4 5 6 379 Table 1 - Focus group discussion recruitment plan, DrOTS perception study, Madagascar, 7 8 380 2017-2019 9 10 Location Stakeholder group Target # groups Participants/group 11 12 Village 1 Unmarried women 1 4 13 Unmarried men 1 4 14 Married women 1 4 15 16 ForMarried peer men review only1 4 17 Elderly women 1 4 18 Elderly men 1 4 19 20 Village 2 Unmarried women 1 4 21 Unmarried men 1 4 22 Married women 1 4 23
24 Married men 1 4 25 Elderly women 4 26 Elderly men 4 27 28 Village 3 Unmarried women 1 4 29 Unmarried men 1 4 30 Married women 1 4 31 32 Married men 1 4 33 Elderly women 4 34 Elderly men 4 35 36 National TB Program Mobile health unit team members 1 5 37 TOTAL 19 77 38 39 381 40 41 382 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 23 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 112
1 2 3 383 Table 2 – Semi-structured interview recruitment plan, DrOTS perception study, 4 5 6 384 Madagascar, 2017-2019 7 8 Location Stakeholder group Participants 9 Sample village DrOTS enrolled patient 2 10 11 Villagers who tested negative for TB 2 12 Villagers hesitant, unable or who have declined DrOTS participation 2 13 Community health worker 1 14 15 Village leaders 1 16 TOTAL For peer review only 8 17 385 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 24 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 112 BMJ Open
1 2 3 386 SUPPLEMENTARY MATERIAL 4 5 6 387 Supplementary material 1 – DrOTS Perception Study Baseline Questionnaire 7 8 388 9 10 389 Supplementary material 2 – DrOTS Perception Study End of Treatment Questionnaire 11 12 390 13 14 391 Supplementary material 3 – DrOTS Perception Study Focus Group Discussion Guide 15 16 392 For peer review only 17 18 393 Supplementary material 4 – DrOTS Perception Study Semi-Structured Interview Guide 19 20 21 394 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 25 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 112
1 2 3 Figure 1 - Timelines, approaches and tools, DrOTS perception study, Madagascar, 2017- 4 5 6 2019 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 Figure 1 – DrOTS Perception Study components and timeline. 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 112 BMJ Open
1 2 type name label::English 3 4 start start 5 end end 6 today today 7 deviceid deviceid 8 note title DrOTS-Project: KAP questionnaire 9 note A. Basic socio-demographic information 10 select_one interviewer interviewer Name of interviewer: 11 datetime intstart Interview date and start time: 12 barcode barcode Scan barcode 13 select_one communes communes Name of commune: 14 select_one fokontanys fokontanys Name of fokontany: 15 select_one villages villages Name of village: 16 select_one partype partype Is the participant considered a (1) TB suspect, (2) a non- 17 suspect or (3) another community member? 18 For peer review only 19 20 text name Name of participant: 21 select_one gender gender Gender of participant: 22 begin group a 23 date dob Date of birth: 24 integer age1 Age of participant: 25 26 select_one age3 age3 If no age given: 27 end group a 28 select_multiple eth eth What ethic group(s) do you belong to? 29 select_multiple rel rel What is/are your religion(s)? 30 text rel2 What other religion? 31 select_one edu edu What is your highest level of education? 32 33 select_multiple occ occ What is/are your occupational activity/activities? 34 35 text occ2 What other occupation? 36 integer hh0 How many people live in your houshold?* 37 38 39 40 integer hh1 How many children under the age of 5 years does your 41 household have?* 42 43 integer hh2 How many children aged 5-14 years does your household 44 have?* 45 46 integer hh3 How many children aged 5-14 years frequent school?* 47 48 integer hh4 How many adults aged 15 years and older does your 49 household have?* 50 51 integer hh5 How many rooms does your household have? 52 53 integer hh6 How many rooms are used for sleeping? 54 integer hh7 How many people usually sleep in the same room with 55 you? 56 begin group b 57 note Which of the following assets does your household or any 58 of the regular household members possess? 59 60 select_one yndm asset1 Agricultural land select_one yndm asset2 Livestock: zebu
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1 2 select_one yndm asset3 Livestock: other 3 select_one yndm asset4 Bicycle 4 select_one yndm asset5 Generator 5 select_one yndm asset6 Radio 6 select_one yndm asset7 TV 7 select_one yndm asset8 Watch, wristwatch, clock 8 select_one yndm asset9 Toilet only for household members 9 select_one yndm asset10 Solar panel 10 select_one yndm asset11 Motorcycle 11 select_one yndm asset12 Bank account 12 select_one yndm asset13 Cell phone, telephone 13 select_one yndm asset14 Canoe, pirogue 14 select_one yndm asset15 Carpet 15 select_one yndm asset16 Internet access 16 select_one yndm asset17 Electricity 17 end group b 18 note For peerB. Travelreview history only 19 select_one yndm travel1 Were you born in this village? 20 integer travel2 Since when do you live in this village? 21 text travel3 Where did you live before? 22 select_one yndm travel4 Do you ever travel outside of this village into other villages 23 or towns? 24 text travel5 To which locations do you travel? 25 begin group c 26 note How long have you been away on your last trip? 27 28 29 30 31 integer travel7 Number of days: 32 integer travel8 Number of weeks: 33 select_one dm travel8o If no information, why? 34 end group c 35 note C. Risk factors 36 select_one yndm smoke1 Do you currently smoke? 37 On average, how many cigarettes (or other tobacco) do 38 integer smoke2 you smoke per day? 39 select_one yndm smoke3 Do other members of your household smoke? 40 41 select_one cook1 cook1 Where is the cooking done in your household? 42 43 text cook1o Where else? 44 select_one cook2 cook2 What type of fuel does your household mainly use for 45 cooking? 46 text cook2o What other fuel type? 47 select_one cook3 cook3 What type of cooking stove is used in your house? 48 49 text cook3o What other type of cooking stove? 50 note D. TB-related health seeking behaviour 51 52 begin group d 53 note Which of the following symptoms do you currently have? 54 55 select_one yndm symp1 Cough 56 select_one yndm symp2 Cough with sputum or phlegm 57 select_one yndm symp3 Cough with blood 58 select_one yndm symp4 Difficulties breathing, shortness of breath 59 select_one yndm symp5 Chest pain 60 select_one yndm symp6 Episodes of fever select_one yndm symp7 Night sweats
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1 2 select_one yndm symp8 Weight loss 3 end group d 4 select_one hsb1 hsb0 The last time you were sick, where did you medical advice 5 or treatment for your symptom(s)? 6 7 select_multiple hsb1 hsb1 Where did you seek medical advice or treatment for your 8 symptom(s)? 9 10 text hsb1o Where else? 11 12 select_multiple hsb2 hsb2 Why did you not seek medical advice or treatment? 13 14 15 text hsb2o What other reason? 16 select_multiple hsb3 hsb3 What else did you do? 17 18 text Forhsb3o peerWhat review else? only 19 select_multiple hsb4 hsb4 What care or treatment did you receive? 20 21 text hsb4o What other care or treatment did you receive? 22 select_one yndm hsb5 Where you satisfied with the care or treatment received? 23 24 select_multiple hsb6 hsb6 Why were you not satisfied? 25 text hsb6o What other reason? 26 select_multiple hsb7 hsb7 Why did you not visit a health facility? 27 28 29 30 text hsb7o What other reason? 31 select_multiple hsb8 hsb8 Which health facility have you visited? 32 33 34 35 text hsb8o Which other health facility? 36 begin group e 37 38 39 note How long after your symptoms started did you seek 40 medical advice or treatment? 41 42 integer hsb9 Number of days: 43 integer hsb10 Number of weeks: 44 select_one dm hsb10o If no information: 45 end group e 46 begin group f 47 48 note How much time did it take you to get this care and/or 49 treatment? 50 integer care1 Number of hours: 51 integer care2 Number of days: 52 select_one dm care3 If no information: 53 end group f 54 begin group g 55 56 integer care4 How much ariary did you spend in total to get this care 57 and/or treatment? 58 select_one care5 care5 If no information: 59 end group g 60 select_one yndm drug1 Do you currently take medication on a regular basis?
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1 2 text drug2 What medication do you currently take? 3 4 note E. Knowledge on TB 5 select_one yndm kap1 Have you ever heard of an illness called tuberculosis? 6 7 begin group h 8 select_multiple kap2 kap2 Where have you heard about tuberculosis? 9 text kap2o Where else? 10 select_multiple kap3 kap3 What do you think is the cause of tuberculosis? (Do not 11 prompt answers!) 12 text kap3o What other cause? 13 select_multiple kap4 kap4 When a person has tuberculosis, what could be the signs 14 and symptoms the person has? 15 16 17 text kap4o What other signs and symptoms? 18 select_one yndm Forkap5 peerDo review you think that tuberculosis only can be transmitted from 19 one person to another? 20 select_multiple kap6 kap6 How can tuberculosis be transmitted from one person to 21 another? (Do not prompt answers!) 22 text kap6o How else? 23 select_one yndm kap7 Do you think that the transmission of tuberculosis can be 24 prevented/stopped? 25 select_multiple kap8 kap8 How can the transmission from one person to another be 26 prevented/stopped? (Do not prompt answers!) 27 28 text kap8o How else? 29 select_one yndm kap9 Do you think that tuberculosis can be healed? 30 select_multiple kap10 kap10 How can tuberculosis be healed? (Do not prompt answers!) 31 32 text kap10o How else? 33 end group h 34 begin group i 35 note F. Medical history related to TB 36 select_one yndm med1 Have you ever been tested for tuberculosis? 37 Have you ever been in contact with someone that had 38 select_one yndm med2 tuberculosis? 39 What relationship(s) did you have to that person or those 40 select_one med3 med3 41 persons? 42 text med3o What other relationship? 43 select_one yndm med4 Has anyone in your household been treated for 44 tuberculosis in the past 2 years? 45 select_one yndm med5 Have you personally, in the past, ever had tuberculosis or 46 been treated for tuberculosis? 47 48 select_one yndm med6 Did you complete treatment (6 months)? 49 50 end group i 51 begin group j 52 note G. Behaviour towards TB 53 note behav1 Please indicate, whether you agree or disagree with the 54 following statements: 55 select_one agree behav2 I believe that anyone/everybody can get TB 56 57 select_one agree behav3 I would share food or drink with someone who has TB 58 59 select_one agree behav4 I would sleep in the same room with someone who has TB 60
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1 2 select_one agree behav5 If a member of my family gets TB, I would like to keep it a 3 secret 4 select_one agree behav6 I would keep distance from someone who has TB 5 6 select_one agree behav7 I am afraid of someone who has TB 7 select_one agree behav8 I believe that someone who has TB is disgusting 8 9 select_one agree behav9 I believe that community members behave differently to 10 someone who has TB 11 12 select_one agree behav10 I believe that someone who has TB is isolated/alone in our 13 community 14 15 select_one agree behav11 I believe tuberculosis is a big problem in our community 16 17 end group j 18 note For peerH. Endreview of the interview only 19 text quest Do you have any questions for me? 20 geopoint gis Coordinates: 21 text comments Other comments or observations by the interviewer: 22 time endtime Time end of interview: 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 label::French label::Malagasy 3 4 5 6 7 8 Projet DrOTS: Questionnaire CAP Projet DrOTS: Questionnaire CAP 9 A. Information sociodémographique A. Fahalalana fototra ara-tsosialy sy ara-demografika 10 Nom de l'intervieweur: Anaran’ny mpampiresaka: 11 Date et heure de début de l'interview: Daty sy ora anombohan’ny resadresaka: 12 Scannez le code à barres individuel pour patient! Tarafina tsirairay ny kaody bara hoan’ny marary! 13 Nom du commune: Nom du commune: 14 Nom du fokontany: Nom du fokontany: 15 Nom du village: Ny anaran'ny tanàna: 16 Le participant est-il considéré comme (1) un suspect de Le participant est-il considéré comme (1) un suspect de 17 tuberculose, (2) un non-suspect, ou (3) un autre membre tuberculose, (2) un non-suspect, ou (3) un autre membre 18 de la communauté? For peer reviewde la communauté? only 19 20 Nom du participant: Aanaran’ny mpandray anjara: 21 Genre du participant Lahy sa vavy ny mpandray anjara? 22 23 Date de naissance: Daty nahaterahana: 24 Age du participant: 25 Taonan'ny mpandray anjara 26 Si aucun âge est donné: Si aucun âge est donné: 27 28 Dans quel groupe ethnique appartenez-vous? Inona ny foko misy anao? 29 Quelle est votre religion? Inona ny finoanao? 30 Quelle autre religion? Misy finoana hafa ve? 31 Quel est votre niveau d’éducation le plus élevé? Hatraiza ny fianarana ambony indrindra nodiavinao na 32 vitanao? 33 Quelle(s) est/sont votre/vos activité(s) professionnelle(s)? Inona (avy ireo) no asa fivelomanao? 34 35 Quelles autres activites professionnelles ? Misy asa fivelomana hafa ve? 36 Combien de personnes habitent dans votre ménage?* Combien de personnes habitent dans votre ménage?* 37 38 39 40 Combien d’enfants de moins de 5 ans avez-vous au sein de Firy ny zaza latsaky ny 5 taona ao an-tranonao?* 41 votre ménage?* 42 43 Combien d’enfants âgé de 5 à 14 ans avez-vous au sein de Firy ny zaza 5 hatramin’ny 14 taona mipetraka ao an- 44 votre ménage?* tranonareo?* 45 46 Combien d'enfants âgés de 5-14 ans fréquentent l'école?* Firy ny zaza eo amin’ny 5-14 taona no mandeha any an- 47 tsekoly?* 48 Combien d’adulte âgé de de 15 ans et plus avez-vous au Firy ny olon-dehibe mahery ny 15 taona mipetraka ao 49 sein de votre ménage?* aminareo?* 50 51 Combien de chambres avez-vous au sein de votre ménage? Firy ny efi-trano misy ao an-tranonareo? 52 53 Combien de chambres sont utilisées pour dormir? Firy ny efi-trano ampiasaina hatoriana? 54 Combien de personnes dorment régulièrement dans la Firy ny olona miara-matory aminao anaty ny efi-trano iray? 55 même chambre avec vous? 56 57 Lequel des biens suivants est-ce que votre ménage ou l'un Inona amin’ireto fanana manaraka ireto no ananan’ny 58 des membres réguliers du ménage possèdent? (Indiquer olona mipetraka ao an-tranonareo? (Tanisao ny valin-teny 59 toutes les réponses – encercler si possédé!) rehetra – farito boribory izay ananana!) 60 Terre agricole Tany fambolena Bétail: zébu Biby fiompy: omby
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1 2 Bétail: autre Biby fiompy: hafa 3 Vélo Bisikleta 4 Générateur Milina/gropy (Generateur) 5 Radio Radio 6 Télévision Télé 7 Montre, montre-bracelet, horloge Famantaranandro, famantaranora 8 Toilette uniquement pour les membres du ménage Kabone ho an'ny ao an-trano irery ihany 9 Panneau solaire Herinaratra avy amin’ny masoandro (Pano solera) 10 Moto Moto 11 Compte bancaire Kaonty amin’ny banky 12 Téléphone mobile, téléphone Finday, telefaonina 13 Canoë, pirogue Lakana 14 Tapis Tapis (Fandiàna) 15 Accès Internet Internet 16 Electricité Elektrisite 17 18 B. Histoire de voyage For peer reviewB. Tantara momba only ny fivahinianana 19 Est-ce que vous êtes né dans ce village? Teraka teto an-tanàna ve ianao? 20 Depuis quand vous vivez dans ce village? Nanomboka oviana ianao no nipetraka teto an-tanàna? 21 Où est-ce que vous avez vécu avant? Taiza ianao no nipetraka taloha? 22 Voyagez-vous régulièrement à l'extérieur de ce village pour Ianao ve matetika mandeha ivelan’ny tanàna mitsidika 23 aller dans d'autres villages ou villes? tanàna hafa na ny tanan-dehibe? 24 Dans quel endroit voyagez-vous? Aiza ianao no mandeha? 25 26 Combien de temps avez-vous voyagé lors de votre dernier Nandeha hafiriana ianao tamin’ny dianao farany? 27 voyage? 28 29 30 31 Nombre de jours: Isan'ny andro: 32 Nombre de semaines: Isan'ny herinandro: 33 Si aucun information, pourquoi? Raha tsy fantatra, inona no antony? 34 35 C. Facteurs de risques C. Ny mety hampidi-doza 36 Est-ce que vous fumez actuellement? Mifoka ve ianao amin’izao? 37 En moyenne, combien de cigarettes fumez-vous (ou 38 Firy eo ho eo ny sigara (na paraky) fohanao isan'andro? d'autres tabacs) par jour? 39 Les autres membres de votre ménage fument-ils? Misy olona hafa mifoka sigara ve ato an-tranonareo? 40 41 Où est-ce que vous preparez la nourriture dans votre Aiza ny lakozianareo? 42 ménage? 43 Où d'autre? Sa hafa koa? 44 Quel type de carburant utilise votre ménage pour la 45 cuisine? Inona no karazana fandrehatra ampiasainareo? 46 Quel autre type? Karazana fandrehatra hafa inona? 47 Quel type de four à cuisines utilise t-on au sein de votre Inona ny karazana fatana ampiasaina ao an-trano? 48 ménage? 49 Quel autre type? 50 D. Comportement par rapport a la recherche de soins D. Fizahana ara-pahasalamana mahakasika ny 51 sanitaires tiberikilaozy 52 53 Lequel des symptômes suivants avez-vous actuellement? Inona amin’ireto sorit’aretina ireto no mahazo anao 54 amin’izao? 55 La toux Kohaka 56 La toux avec expectoration ou flegme Kohaka misy rehoka na tsiranoka 57 La toux avec du sang Kohaka misy rà 58 Difficulté à respire, essoufflement, dyspnée Fahasemporana na sempotra 59 Douleur thoracique Marary tratra 60 Episodes de fièvre Voan’ny tazo Sueurs nocturnes Tsemboka amin’ny alina
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1 2 Perte de poids Nihena ny lanja 3 4 Lorsque votre dernière maladie, où avez-vous demandé un Tamin’ny ianao narary farany, taiza avy ianao no naka 5 conseil médical ou un traitement pour votre/vos torohevitra na fanafody? (Afaka mahazo valiny maro) 6 symptôme(s)? (Réponses multiple possible) 7 Où avez-vous demandé un conseil médical ou un Taiza ianao no nitady torohevitra momban’ny ’ny 8 traitement pour votre/vos symptôme(s)? (Réponses soritr’aretinao na fanafody? (valin-teny maromaro raha 9 multiple possible) azo atao) 10 Où d'autre? Aiza koa ? 11 12 Pourquoi n'avez-vous pas consulté un médecin ou un Fa nahoana ianao no tsy nitady torohevitra ara- 13 traitement médical? (réponses multiples possibles) pahasalamana na fitsaboana? (valin-teny maro raha azo 14 atao) 15 Quelle autre raison? Inona no antony hafa? 16 Qu’avez-vous fait d’autre? Inona ny zavatra hafa nataonao? 17 18 Quoi d'autre? For peer reviewHafa koa? only 19 Quels soins ou quel traitement avez-vous reçu? Inona ny fikarakarana na fitsaboana azonao? 20 21 Quels autres soins ou traitements avez-vous reçus? Ionona ny fitsaboana hafa azonao? 22 Avez-vous été satisfait des soins ou traitements reçus? Afa-po ve ianao tamin’ny fitsaboana na fikarakarana 23 azonao? 24 Pourquoi n’avez-vous pas été satisfait? Fa maninona ianao no tsy afa-po? 25 Quelle autre raison? Inona no antony hafa? 26 Pourquoi n'avez-vous pas visité un établissement de santé? Fa naninona ianao tsy nadeha tobi-pahasalamana? 27 28 29 30 Quelle autre raison? Inona no antony hafa? 31 Quel établissement de santé avez-vous visité? Inona ny toeram-pitsaboana na CSB aiza fandehananao ? 32 33 34 35 Quel autre établissement de santé? Iza amin'ireo no mora kokoa? 36 37 38 Hafiriana taorian’ny fisehoan’ny soritr’aretina ianao no 39 Combien de temps après avoir eu vos symptômes que vous nandeha nitady torohevitra ara-pahasalamana na 40 avez demandé un conseil ou traitement médical? 41 fitsaboana? 42 Numbre de jours: Isan'ny andro: 43 Numbre de semaines: Isan'ny herinandro: 44 Si aucun information: Raha tsy misy 45 46 47 48 Combien de temps avez-vous pris pour obtenir ces soins et Adin’ny firy na firy andro vao tonga any amin’ny tobim- 49 / ou ce traitement? pahasalamana ianao ka mahazo ny fanafody? 50 Numbre d'heures: Isan'ny ora: 51 Numbre de jours: Isan'ny andro: 52 Si aucun information: Raha tsy misy 53 54 55 56 Combien d’ariary avez-vous dépensé au total pour obtenir Ohatrinona ariary no laninao vao nahazo ny fikarakarana sy 57 ce soin et / ou traitement? /na fitsaboana? 58 Si aucun information: Raha tsy misy 59 60 Actuellement, est-ce que vous prenez les médicaments sur Mihinam-panafody ara-potoana ihany ve ianao amin'izao une base régulière? fotoana izao?
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1 2 Quels médicaments est-ce que vous prenez actuellement? Inona ny fanafody ohaninao amin’izao? 3 4 E. Connaissance sur la tuberculose E. Fahalalana momba ny tberkilaozy 5 Avez-vous déjà entendu parler d'une maladie appelée Efa naheno aretina atao hoe tiberkilaozy ve ianao 6 tuberculose ou TB? hatramizay ? 7 8 Où avez-vous entendu parler de la tuberculose? Taiza no nahenoana ny resaka tiberkilaozy ? 9 Où d'autre? Aiza koa ? 10 Qu'en pensez-vous de la cause de la tuberculose? (Ne Inona ny antony mahatonga ny tiberkilaozy aminao? (Aza 11 lancez pas les réponses!) mandrosovalin-teny!) 12 Quelle autre cause? Antony hafa inona? 13 Quand une personne a une tuberculose, quels pourraient- Rehefa misy olona voan’ny tiberkilaozy , inona ny 14 être les signes et les symptômes chez la personne? (Ne famantarana na soritr’aretina miseho aminy? (Aza 15 lancez pas les réponses! Des réponses multiples sont mandroso valin-teny! Mety ho valin-teny maro) 16 possibles) 17 Quels autres signes et symptômes? Famantarana sy soritraretina inona? 18 Pensez-vous que la tuberculoseFor peut être peer transmise d'unereviewIanao ve mieritreritra only hoe mifindra amin’ny alalan’ny olona 19 personne à l'autre? hafa tsy voa ny tiberkilaozy ? 20 Comment la tuberculose se transmet-elle d'une personne à Ahoana ny fomba fifindran’ny tiberkilaozy amin’ny olona? 21 une autre? (Ne lancez pas les réponses!) (Aza mandroso valin-teny!) 22 Comment d'autre? Ahoana koa? 23 Pensez-vous que la transmission de la tuberculose peut Mino ve ianao fa azo sorohina ny fifindran’ny aretina 24 être empêchée / évitée? tiberkilaozy amin’ny olona? 25 Comment prévenir la transmission d'une personne à une Ahoana ny fomba fisorohana na fandresena ny fifindran’ny 26 autre? (Ne lancez pas les réponses!) tiberkilaozy eo amin’ny samy olona? (Aza mandroso valin- 27 teny!) 28 Comment d'autre? Ahoana koa? 29 Pensez-vous que la tuberculose peut être guérie? Ianao ve mieritreritra fa azo tsaboina ny tiberkilaozy ? 30 Comment la tuberculose peut-elle être guérie? (Ne lancez Ahoanany fomba fitsaboana ny tuberculose? (Aza 31 pas les réponses!) mandroso valin-teny!) 32 Comment d'autre? Ahoana koa? 33 34 35 F. Histoire médicale liée à la tuberculose F. Tantara ara-pahasalamana mifandray amin’ny BK 36 Avez-vous déjà été testé pour la tuberculose? Efa nanao fitiliana tuberculose ve ianao? 37 Avez-vous déjà été en contact avec une personne atteinte Efa nifanerasera tamin’ny olona voan’ny tuberculose ve 38 de tuberculose? ianao? 39 Quelle relation avez-vous eu avec cette personne ou ces Mpifaninona ianao sy izay olona izany na Mpifaninona 40 41 personnes? ianao sy ry zareo? 42 Quelle autre relation? Fifandraisana hafa inona? 43 Est-ce que quelqu'un de votre ménage a été traité pour la Nisy olona notsaboina tiberkilaozy ve tao an-trano tao 44 tuberculose au cours des 2 dernières années? anatin’ny 2 taona lasa iny? 45 Personnellement, avez-vous déjà eu de la tuberculose ou Ianao manokana ve efa voan’ny tiberkilaozy na notsaboina 46 avez-vous déjà été traité pour la tuberculose dans le tiberkilaozy taloha? 47 passé? 48 Si oui, avez-vous terminé le traitement (6 mois)? Raha eny, nahafeno ny fitsaboana enim-bolana ve ianao? 49 50 51 52 G. Comportements envers la tuberculose G. Fitondra-tena manoloana ny tuberculose 53 S’il vous plait, indiquez si vous êtes d’accord ou pas avec Mba farito azafady raha manaiky na tsy manaiky ireto 54 les énoncés suivantes: zavtra manaraka ireto ianao: 55 Je crois que tout le monde/n’importe qui peut contracter Mino aho fa ny olon-drehetra n,iza n’iza dia mety ho 56 la maladie tuberculose. voan’ny TB 57 Je voudrai partager de la nourriture et des boissons avec Afaka mizara ny sakafo sy ny rano fisotro amin’ny olona 58 une personne atteinte du TB. voan’ny TB 59 Je voudrai dormir avec quelqu’un qui a la TB dans la même Afaka miara-matory amin’ny olona voan’ny TB anaty efi- 60 chambre. trano mitovy aho.
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1 2 Si un membre de la famille est atteint de la TB, je voudrai Raha misy olona voan’ny TB ao amin’ny fianakaviana dia 3 garder cela comme un secret. ataoko tsiambaratelo 4 Je garde ma distance avec une personne qui est atteinte de Tsy hifanerasera amin’ny olona voan’ny TB aho 5 la TB. 6 J’ai peur de quelqu’un qui est atteint de la TB. Matahotra ny olona voan’ny TB aho 7 Je crois que quelqu’un qui est atteint de la TB est Mino aho fa maharikoriko ny olona voan’ny TB 8 dégoutant. 9 Je crois que les membres de la communauté se Mino aho fa hafa mihintsy ny fandraisan’ny olona ny olona 10 comportent différemment vis-à-vis de quelqu’un qui est voan’ny TB ao anaty fiaraha-monina 11 atteinte de la TB. 12 Je crois que quelqu’un qui est atteint de la TB est isolé/seul Mino aho fa ny olona voan’ny TB dia mitoka- 13 dans notre communauté. monina/manirery ao amin’ny fiaraha-monina misy anay. 14 15 Je crois que la TB est un grand problème dans notre Mino aho fa olana goavana ao amin’ny fiaraha-monina 16 communauté. misy anay ny tiberkilaozy 17 18 H. Fin de l’interview For peer reviewH. Faranan’ny only fanadihadihana 19 Est-ce que vous avez des questions pour moi? Misy fanontanianao ho ahy ve? 20 Coordonnées Arindra 21 Autre commentaire ou observation par l’intervieweur: Fanamarihana na teny avy amin’ny mpanadihady: 22 Heure de la fin de l’interview: Ora iafaran’ny fanadihadihana: 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 relevant choice_filter hint::English 3 4 5 6 7 8 9 10 11 12 13 14 communes=${communes} 15 fokontanys=${fokontanys} 16 The difference between (2) and (3) is that 17 (2), the non-supect, has done a screening 18 For peer reviewquestionnaire, only (3) has not done a 19 screening questionnaire. 20 21 22 23 24 25 26 27 28 29 30 selected(${rel}, '6') 31 32 33 34 35 selected(${occ}, '7') 36 *Regular household members that 37 usually/regularly live and sleep in the 38 household. 39 *Regular household members that 40 41 usually/regularly live and sleep in the 42 household. 43 *Regular household members that 44 usually/regularly live and sleep in the 45 household. 46 *Regular household members that 47 usually/regularly live and sleep in the 48 *Regularhousehold. household members that 49 usually/regularly live and sleep in the 50 household. 51 52 53 54 55 56 57 (Prompt all responses – circle if 58 possessed!) 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 selected(${travel1}, '2') 21 selected(${travel1}, '2') 22 23 24 selected(${travel4}, '1') 25 selected(${travel4}, '1') 26 Note 1 for a 1-day trip without spending 27 the night there. 28 Note 2 days if the trip included spending 1 29 night there. 30 31 32 33 34 35 36 37 38 selected(${smoke1}, '1') 39 40 41 42 43 selected(${cook1}, '4') 44 45 46 selected(${cook2}, '7') 47 48 49 selected(${cook3}, '4') 50 51 52 not(selected(${partype}, '3')) 53 54 55 56 57 58 59 60
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1 2 3 4 not(selected(${partype}, '1')) and 5 not(selected(${partype}, '2')) 6 7 not(selected(${partype}, '3')) 8 9 10 selected(${hsb1}, '9') or 11 selected(${hsb0}, '9') 12 selected(${hsb1}, '1') or 13 selected(${hsb0}, '1') 14 15 selected(${hsb2}, '10') 16 selected(${hsb1}, '1') or 17 selected(${hsb0}, '1') 18 selected(${hsb3}, '3') For peer review only 19 not(selected(${hsb1}, '1')) and 20 not(selected(${hsb0}, '1')) 21 selected(${hsb4}, '9') 22 not(selected(${hsb1}, '1')) and 23 not(selected(${hsb0}, '1')) 24 selected(${hsb5}, '2') 25 selected(${hsb6}, '7') 26 not(selected(${hsb1}, '5')) and 27 not(selected(${hsb1}, '6')) and 28 not(selected(${hsb0}, '5')) and 29 not(selected(${hsb0}, '6')) 30 selected(${hsb7}, '10') 31 selected(${hsb1}, '5') or 32 selected(${hsb1}, '6') or 33 selected(${hsb0}, '5') or 34 selected(${hsb0}, '6') 35 selected(${hsb8}, '7') 36 not(selected(${hsb1}, '1')) and 37 not(selected(${hsb0}, '1')) 38 39 40 41 42 43 44 45 46 not(selected(${hsb1}, '1')) and 47 not(selected(${hsb0}, '1')) 48 49 50 51 52 53 54 not(selected(${hsb1}, '1')) and 55 not(selected(${hsb0}, '1')) 56 57 58 59 60
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1 2 selected(${drug1}, '1') 3 4 5 6 7 not(selected(${kap1}, '2')) 8 9 selected(${kap2}, '7') 10 Do not prompt answers! Multiple answers 11 possible 12 selected(${kap3}, '9') 13 Do not prompt answers! Multiple answers 14 possible 15 16 17 selected(${kap4}, '15') 18 For peer review only 19 20 selected(${kap5}, '1') Do not prompt answers! Multiple answers 21 possible 22 selected(${kap6}, '8') 23 24 25 selected(${kap7}, '1') Do not prompt answers! Multiple answers 26 possible 27 28 selected(${kap8}, '7') 29 30 selected(${kap9}, '1') Do not prompt answers! Multiple answers 31 possible 32 selected(${kap10}, '5') 33 34 not(selected(${kap1}, '2')) 35 36 37 38 39 40 selected(${med2}, '1') 41 42 selected(${med3}, '4') 43 44 45 46 47 48 selected(${med5}, '1') 49 50 51 not(selected(${kap1}, '2')) 52 53 54 55 56 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 hint::French hint::Malagasy constraint constraint 3 _message 4 5 6 7 8 9 10 11 12 13 14 15 yes 16 17 18 For peer review only 19 20 21 22 23 24 . <=88 and . 25 >=15 26 27 28 29 30 31 32 33 34 35 36 *Membres réguliers du ménage qui vivent *Ireo olona ao an-trano izay mipetraka sy . <=20 37 38 et dorment au sein du ménage. matory ao an-trano. 39 40 *Membres réguliers du ménage qui vivent *Ireo olona ao an-trano izay mipetraka sy . <=20 41 et dorment au sein du ménage. matory ao an-trano. 42 43 *Membres réguliers du ménage qui vivent *Ireo olona ao an-trano izay mipetraka sy . <=20 44 et dorment au sein du ménage. matory ao an-trano. 45 46 *Membres réguliers du ménage qui vivent *Ireo olona ao an-trano izay mipetraka sy . <=20 47 et dorment au sein du ménage. matory ao an-trano. 48 *Membres réguliers du ménage qui vivent *Ireo olona ao an-trano izay mipetraka sy . <=20 49 et dorment au sein du ménage. matory ao an-trano. 50 51 . <=20 52 53 . <=20 54 . <=20 55 56 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 Notez 1 pour un voyage d'une journée Notez 1 pour un voyage d'une journée 27 sans y passer la nuit. (Retour le même sans y passer la nuit. (Retour le même 28 jour.) jour.) 29 Notez 2 jours si le voyage inclu y passer 1 Notez 2 jours si le voyage inclu y passer 1 30 nuit. nuit. 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 required appearance default read_only calculation 3 4 5 6 7 8 9 10 yes 11 yes 12 13 14 15 16 17 18 For peer review only 19 20 21 22 field-list 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 field-list 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 field-list 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 field-list 53 54 55 56 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 field-list 37 38 39 40 41 42 43 44 45 46 field-list 47 48 49 50 51 52 53 54 field-list 55 56 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 field-list 52 53 54 55 56 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 label::zambia hint::zambia image::english 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 media::audio::chinese media::video 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 list_name name label::English 3 interviewer 15 Roger Mario 4 interviewer 3 Rija 5 4 6 interviewer Haja 5 7 interviewer Marco 6 8 interviewer Mamy 9 interviewer 7 Idéal 10 interviewer 8 Andri 11 interviewer 9 Omega 12 interviewer 10 Sylvain 13 interviewer 11 Astrid 14 interviewer 12 Jesse 15 interviewer 13 Simon 16 interviewer 14 Other 17 interviewer 1 Natamby 18 interviewer 2 ForHasina peer review only 19 20 communes 0 Pilotage 21 communes 1 Androrangavola 22 communes 2 Other 23 24 fokontanys 0 Pilotage 25 fokontanys 1 Ambodifontsina 26 fokontanys 2 Ambodiara Nord 27 fokontanys 3 Ampasimpotsy 28 fokontanys 4 Androrangavola 29 fokontanys 5 Nosy Be Sud 30 fokontanys 6 Mandriamposty 31 fokontanys 7 Ambohimahavelo Betoho 32 33 fokontanys 8 Mahasoa I 34 fokontanys 10 Ambalatabaka 35 fokontanys 11 Ambohimisafy 36 fokontanys 9 Other 37 38 villages 0 Village pilotage 39 villages 1 Ambodifontsina 40 villages 2 Ambakotsialaina 41 villages 3 Ambalatamboro 42 villages 4 Ambodiaravola 43 villages 5 Ambodiara Nord 44 villages 6 Ambodiakondro 45 villages 7 Ambohimahavelo 46 villages 8 Ampasimpotsy 47 villages 9 Ambalafasina 48 villages 10 Ambatoharanana 49 villages 11 Ambohitsara Firarana 50 villages 12 Ambohimahavelona Nord 51 villages 1212 Kianja miakatra 52 villages 13 53 Androrangavola villages 14 54 Ambohimahasoa I 15 55 villages Ambohimahasoa II 16 56 villages Ambohimandroso 17 57 villages Ambodimanga 18 58 villages Ambatovaky I 59 villages 19 Ambatovaky II 60 villages 20 Ambohimiarina villages 21 Analanakondro I villages 22 Analanakondro II
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1 2 villages 23 Benavony 3 villages 24 Lavakianja Nord 4 villages 25 Mahasoa II 5 villages 26 Mahavanona 6 villages 27 Mahatsara 7 villages 28 Morafeno 8 villages 29 Nosy Be Sud 9 villages 30 Ambohimahatsinjo 10 villages 31 Ambodiara Nosy Be 11 villages 32 Ambohinamboarina 12 villages 33 Ambodirafia 13 villages 34 Kianjamiakatra 14 villages 35 Tsarakianja 15 villages 36 Tsarahonenana 16 villages 37 Vinanimasina 17 villages 38 Vohipeno I 18 villages 39 ForVohipeno peer II review only 19 villages 40 Mandriampotsy 20 villages 41 Ambalavory 21 villages 42 Ambohimahavelo 22 villages 43 Andranosariaka 23 villages 44 Betoho 24 villages 45 Mahasoa 25 villages 46 Andemaka I 26 villages 47 Andemaka II 27 villages 48 Ambohimahavelo 28 villages 49 Ankerana 29 villages 50 Analabe 30 villages 51 Ampasimpotsy 31 villages 52 Mahavanona 32 villages 53 Mahatsara I 33 villages 54 Mahatsara II 34 villages 55 Tsarahonenana 35 villages 56 Vohitraivo 36 villages 58 Ambalatabaka 37 villages 59 Ambohinihaonana I 38 villages 60 Ambohinihaonana II 39 villages 61 40 Ambohipeno 62 41 villages Antanivelona 63 42 villages Vatomena 64 43 villages Ambohimisafy 65 44 villages Ambanana 45 villages 66 Ambalatenina II 46 villages 67 Ambalafary 47 villages 68 Ambohimiarina 48 villages 69 Ambohinihaonana 49 villages 70 Amahavanona 50 villages 71 Asahavanona 51 villages 72 Avohitromby 52 villages 57 Other 53 54 yndm 1 Yes 55 yndm 2 No 56 yndm 3 Does not know 57 yndm 4 Response missing 58 59 partype 1 TB suspect 60 partype 2 Not a suspect partype 3 Other community member
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1 2 partype 4 Does not know 3 partype 5 Response missing 4 5 age3 88 unknown 6 age3 99 missing 7 8 gender 1 Male 9 gender 2 Female 10 11 eth 1 Betsileo 12 eth 2 Tanala 13 eth 3 Betsimisaraka 14 eth 4 Merina 15 eth 5 Sakalava 16 eth 6 Antandroy 17 eth 7 Antaimoro 18 eth 8 ForBara peer review only 19 eth 9 Vezo 20 eth 10 Antanosy 21 eth 11 Antaifasy 22 eth 12 Sihanaka 23 eth 13 Antakarana 24 eth 14 Bazanozano 25 eth 15 Mahafaly 26 27 rel 1 Catholic 28 rel 2 Protestant 29 rel 3 Muslim 30 rel 4 Animist / Traditional 31 rel 5 Believe in ancesters 32 rel 6 No religion 33 rel 7 Other 34 rel 8 Don't know 35 rel 9 Missing 36 37 edu 1 No schooling 38 edu 2 Primary school, incomplete 39 edu 3 Primary school, complete 40 41 edu 4 Secondary school, 1st cycle, incomplete 42 43 edu 5 Secondary school, 1st cycle, complete 44 45 edu 6 Secondary school, 2nd cycle, incomplete 46 47 edu 7 48 Secondary school, 2nd cycle, complete 49 edu 8 University 50 edu 9 Don’t know 51 edu 10 Missing 52 53 occ 1 Farming 54 occ 2 Livestock keeping 55 occ 3 Small business (sales) 56 occ 4 Craft work / Métier artisanal 57 occ 5 Services / Prestation de service(s) 58 occ 6 Nothing 59 occ 7 Other 60 occ 8 Don’t know occ 9 Missing
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1 2 3 cook1 1 In a room used for living/sleeping 4 5 cook1 2 In a separate room used as a kitchen 6 7 cook1 3 In a separate building used as a kitchen 8 9 cook1 4 Outside 10 cook1 5 Other 11 cook1 6 Don’t know 12 cook1 7 Missing 13 14 cook2 1 Wood 15 cook2 2 Charcoal, coal 16 cook2 3 Kerosene 17 cook2 4 Gas 18 cook2 5 ForAnimal dungpeer review only 19 cook2 6 Shrubs, grass 20 cook2 7 Other 21 cook2 8 Don’t know 22 cook2 9 Missing 23 24 25 cook3 1 Open fire/stove without chimney/hood 26 27 cook3 2 Open fire/stove with chimney/hood 28 cook3 3 Closed stove with chimney 29 cook3 4 Other 30 cook3 5 Don’t know 31 cook3 6 Missing 32 33 yn 1 Yes 34 yn 2 No 35 36 37 hsb0 1 Didn’t seek medical advice / treatment 38 hsb0 2 Community health worker 39 hsb0 3 Traditional healer 40 hsb0 4 Family member, friend 41 hsb0 5 Public health facility 42 hsb0 6 Private health facility 43 hsb0 7 Pharmacy 44 45 hsb0 8 Option 46 hsb0 9 Other, specify: 47 hsb0 10 Don’t know 48 hsb0 11 Missing 49 50 hsb1 1 Didn’t seek medical advice / treatment 51 52 hsb1 2 Community health worker 53 hsb1 3 Traditional healer 54 hsb1 4 Family member, friend 55 hsb1 5 Public health facility 56 hsb1 6 Private health facility 57 hsb1 7 Pharmacy 58 hsb1 8 Option 59 hsb1 9 Other, specify: 60 hsb1 10 Don’t know hsb1 11 Missing
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1 2 3 hsb2 1 No particular reason 4 hsb2 2 Symptoms were not severe enough 5 hsb2 3 Did not want to leave work Too expensive to seek medical advice or 6 hsb2 4 7 treatment 8 9 hsb2 5 Too far to seek medical advice or treatment 10 11 hsb2 6 Did not expect satisfactory quality of service 12 13 hsb2 7 Did not expect availability of drugs 14 15 No place to sleep while going to seek 16 hsb2 8 medical advice or treatment 17 18 For peer review only hsb2 9 19 Has no habit of consulting a doctor 20 hsb2 10 Other, specify: 21 hsb2 11 Don’t know 22 hsb2 12 Missing 23 24 hsb3 1 Nothing 25 hsb3 2 Self-medication 26 hsb3 3 Other, specify: 27 hsb3 4 Don’t know 28 hsb3 5 Missing 29 30 hsb4 1 Nothing 31 hsb4 2 Verbal advice 32 hsb4 3 Paracetamol 33 hsb4 4 Pain killer 34 hsb4 5 Other drugs 35 hsb4 6 Hospitalisation 36 hsb4 7 Option 37 hsb4 8 Option 38 hsb4 9 Other 39 hsb4 10 Don’t know 40 hsb4 11 Missing 41 42 hsb6 1 No particular reason 43 44 hsb6 2 Symptoms continued or gotten worse 45 46 hsb6 3 Could not afford care and treatment offered 47 48 hsb6 4 Not satisfied quality of service 49 hsb6 5 Non-availability of drugs 50 hsb6 6 Option 51 hsb6 7 Other, specify: 52 hsb6 8 Don’t know 53 hsb6 9 Missing 54 55 hsb7 1 No particular reason 56 hsb7 2 Symptoms were not severe enough Could not afford / Did not want to leave 57 hsb7 3 58 work Too expensive to seek medical advice or 59 hsb7 4 60 treatment
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1 2 3 hsb7 5 Too far to seek medical advice or treatment 4 5 hsb7 6 Did not expect satisfactory quality of service 6 7 hsb7 7 Did not expect availability of drugs 8 9 No place to sleep while going to seek hsb7 8 10 medical advice or treatment 11 12 hsb7 9 13 Has no habit to go to the health facility 14 hsb7 10 Other, specify: 15 hsb7 11 Don’t know 16 hsb7 12 Missing 17 18 hsb8 1 ForCSB Andrangavola peer review only 19 hsb8 2 CSB Mahasoa 20 hsb8 3 CSB Ranomafana 21 hsb8 4 CSB Ifanadiana 22 hsb8 5 CHRD Ifanadiana 23 hsb8 6 Option 24 hsb8 7 Other 25 hsb8 8 Don’t know 26 hsb8 9 Missing 27 28 dm 88 Don't know 29 dm 99 Missing 30 31 care5 1 Refuses to say 32 care5 88 Don't know 33 care5 99 Missing 34 35 med3 1 Family member, same household 36 med3 2 Family member, other household 37 med3 3 Neighbour, friend 38 med3 4 Other, specify: 39 med3 5 Don’t know 40 med3 6 Missing 41 42 kap2 1 Community health worker 43 44 kap2 2 Trained health worker / health facility 45 46 kap2 3 Family, friends, peers 47 kap2 4 Radio 48 kap2 5 Other media 49 kap2 6 Community sensitization visit 50 51 kap2 7 Other, where? 52 kap2 8 Don’t know 53 kap2 9 Missing 54 55 kap3 1 Bacteria 56 kap3 2 From the air 57 kap3 3 From other people 58 kap3 4 Eating certain fruits 59 kap3 5 Mosquitos 60 kap3 6 Sexual intercourse kap3 7 Smoke(s)
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1 2 kap3 8 Alcohol 3 kap3 9 Other 4 kap3 10 Don’t know 5 kap3 11 Missing 6 7 kap4 1 No symptoms 8 kap4 2 Cough 9 kap4 3 Cough with sputum 10 kap4 4 Cough with blood 11 kap4 5 05 Shortness of breath, difficulties breathing 12 13 kap4 6 Chest pains 14 kap4 7 Night sweats 15 kap4 8 Weight loss 16 kap4 9 Fever 17 kap4 10 Loss of appetite 18 kap4 11 ForHIV/AIDS peer review only 19 kap4 12 Headache 20 kap4 13 Fatigue, sleepiness 21 kap4 14 Option 22 kap4 15 Other 23 kap4 16 Don’t know 24 kap4 17 Missing 25 26 Through the air when a person kap6 1 27 coughs/sneezes 28 kap6 2 Through the air otherwise 29 30 kap6 3 By sharing objects with someone who has TB 31 32 kap6 4 By touching a person who has TB 33 kap6 5 Through sharing food 34 kap6 6 Through sexual contact 35 kap6 7 Through mosquito bites 36 kap6 8 Other 37 kap6 9 Don’t know 38 kap6 10 Missing 39 40 Avoid being in the same room with the 41 kap8 1 person who has TB 42 Avoid any contact with the person who has 43 kap8 2 TB 44 Avoid sharing drinks / food with the person 45 kap8 3 46 who has TB Avoid sharing objects with the person who 47 kap8 4 48 has TB Avoid breathing the same air with the 49 kap8 5 50 person who has TB Avoid sexual intercourse with the person 51 kap8 6 52 who has TB 53 kap8 8 Taking medication 54 kap8 9 Go to the health centre 55 kap8 7 Other, specify: 56 kap8 11 Don’t know 57 kap8 12 Missing 58 59 kap10 1 Drugs, medication 60 kap10 2 Traditional medicine kap10 3 Expulsion ritual
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1 2 kap10 4 Option 3 kap10 5 Other 4 kap10 6 Don’t know 5 kap10 7 Missing 6 7 agree 1 Agree 8 agree 2 Disagree 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 label::French label::Malagasy communes 3 Roger Mario Roger Mario 4 Rija Rija 5 6 Haja Haja 7 Marco Marco 8 Mamy Mamy 9 Idéal Idéal 10 Andri Andri 11 Omega Omega 12 Sylvain Sylvain 13 Astrid Astrid 14 Jesse Jesse 15 Simon Simon 16 Other Other 17 Natamby Natamby 18 Hasina For peerHasina review only 19 20 Pilotage Pilotage 21 Androrangavola Androrangavola 22 Autre Autre 23 24 Pilotage Pilotage 0 25 Ambodifontsina Ambodifontsina 1 26 Ambodiara Nord Ambodiara Nord 1 27 Ampasimpotsy Ampasimpotsy 1 28 Androrangavola Androrangavola 1 29 Nosy Be Sud Nosy Be Sud 1 30 Mandriamposty Mandriamposty 1 31 Ambohimahavelo Betoho Ambohimahavelo Betoho 1 32 33 Mahasoa I Mahasoa I 1 34 Ambalatabaka Ambalatabaka 1 35 Ambohimisafy Ambohimisafy 1 36 Autre Autre 1 37 38 Village pilotage Village pilotage 39 Ambodifontsina Ambodifontsina 40 Ambakotsialaina Ambakotsialaina 41 Ambalatamboro Ambalatamboro 42 Ambodiaravola Ambodiaravola 43 Ambodiara Nord Ambodiara Nord 44 Ambodiakondro Ambodiakondro 45 Ambohimahavelo Ambohimahavelo 46 Ampasimpotsy Ampasimpotsy 47 Ambalafasina Ambalafasina 48 Ambatoharanana Ambatoharanana 49 Ambohitsara Firarana Ambohitsara Firarana 50 Ambohimahavelona Nord Ambohimahavelona Nord 51 Kianja miakatra Kianja miakatra 52 53 Androrangavola Androrangavola 54 Ambohimahasoa I Ambohimahasoa I 55 Ambohimahasoa II Ambohimahasoa II 56 Ambohimandroso Ambohimandroso 57 Ambodimanga Ambodimanga 58 Ambatovaky I Ambatovaky I 59 Ambatovaky II Ambatovaky II 60 Ambohimiarina Ambohimiarina Analanakondro I Analanakondro I Analanakondro II Analanakondro II
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1 2 Benavony Benavony 3 Lavakianja Nord Lavakianja Nord 4 Mahasoa II Mahasoa II 5 Mahavanona Mahavanona 6 Mahatsara Mahatsara 7 Morafeno Morafeno 8 Nosy Be Sud Nosy Be Sud 9 Ambohimahatsinjo Ambohimahatsinjo 10 Ambodiara Nosy Be Ambodiara Nosy Be 11 Ambohinamboarina Ambohinamboarina 12 Ambodirafia Ambodirafia 13 Kianjamiakatra Kianjamiakatra 14 Tsarakianja Tsarakianja 15 Tsarahonenana Tsarahonenana 16 Vinanimasina Vinanimasina 17 Vohipeno I Vohipeno I 18 Vohipeno II For peerVohipeno review II only 19 Mandriampotsy Mandriampotsy 20 Ambalavory Ambalavory 21 Ambohimahavelo Ambohimahavelo 22 Andranosariaka Andranosariaka 23 Betoho Betoho 24 Mahasoa Mahasoa 25 Andemaka I Andemaka I 26 Andemaka II Andemaka II 27 Ambohimahavelo Ambohimahavelo 28 Ankerana Ankerana 29 Analabe Analabe 30 Ampasimpotsy Ampasimpotsy 31 Mahavanona Mahavanona 32 Mahatsara I Mahatsara I 33 Mahatsara II Mahatsara II 34 Tsarahonenana Tsarahonenana 35 Vohitraivo Vohitraivo 36 Ambalatabaka Ambalatabaka 37 Ambohinihaonana I Ambohinihaonana I 38 Ambohinihaonana II Ambohinihaonana II 39 40 Ambohipeno Ambohipeno 41 Antanivelona Antanivelona 42 Vatomena Vatomena 43 Ambohimisafy Ambohimisafy 44 Ambanana Ambanana 45 Ambalatenina II Ambalatenina II 46 Ambalafary Ambalafary 47 Ambohimiarina Ambohimiarina 48 Ambohinihaonana Ambohinihaonana 49 Amahavanona Amahavanona 50 Asahavanona Asahavanona 51 Avohitromby Avohitromby 52 Autre Autre 53 54 Oui Eny 55 Non Tsia 56 Ne sais pas Tsy fantatra 57 Reponse manquant Tsy misy valiny 58 59 Suspect de la tuberculose Suspect de la tuberculose 60 Non suspect Non suspect Autre membre de la communauté Autre membre de la communauté
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1 2 Ne sais pas Tsy fantatra 3 Reponse manquant Tsy misy valiny 4 5 Ne sais pas Tsy fantatra 6 Reponse manquant Tsy misy valiny 7 8 Masculin Lahy 9 Féminin Vavy 10 11 Betsileo Betsileo 12 Tanala Tanala 13 Betsimisaraka Betsimisaraka 14 Merina Merina 15 Sakalava Sakalava 16 Antandroy Antandroy 17 Antaimoro Antaimoro 18 Bara For peerBara review only 19 Vezo Vezo 20 Antanosy Antanosy 21 Antaifasy Antaifasy 22 Sihanaka Sihanaka 23 Antakarana Antakarana 24 Bazanozano Bazanozano 25 Mahafaly Mahafaly 26 27 Catholique Katolika 28 Protestant Protestanta 29 Musulman Silamo 30 Animist / Traditionel Fomban-drazana 31 La croyance aux ancêtres Finoana ny razana 32 Pas de religion Tsy manana antokom-pinoana 33 Autre Hafa 34 Ne sait pas Tsy fantatra 35 Reponse manquant Tsy misy valiny 36 37 Pas d'éducation, analphabète Tsy nianatra 38 N’a pas terminé le primaire Ambaratonga voalohany, tsy vita 39 Terminé le primaire Ambaratonga voalohany, vita 40 Ambaratonga faharoa, tsingerina voalohany, 41 N’a pas terminé le secondaire, 1er cycle tsy vita 42 Ambaratonga faharoa, tsingerina voalohany, 43 Terminé le secondaire, 1er cycle vita 44 Ambaratonga faharoa, tsingerina faharoa 45 ème 46 N’a pas terminé le secondaire, 2 cycle vita Ambaratonga faharoa, tsingerina faharoa, 47 Terminé le secondaire, 2ème cycle 48 tsy vita 49 Université Ambaratonga ambony (Université) 50 Ne sait pas Tsy fantatra 51 Reponse manquant Tsy misy valiny 52 53 Agriculture Fambolena sy fiompiana 54 Elevage Fiompiana biby isan-karazany 55 Vendeur, Petites entreprises Fivarotana 56 Métier artisanal Taozavatra / Asa tanana 57 Prestation de service(s) Servisy / Fanomezana servisy 58 Chômeur Tsy misy 59 Autre Hafa 60 Ne sait pas Tsy fantatra Reponse manquant Tsy misy valiny
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1 2 3 4 Dans une pièce utilisée pour vivre / dormir Ao an-trano ipetrahana/fatoriana 5 Dans une pièce séparée utilisée comme Amin’ny efi-trano hafa ao an-trano atao 6 cuisine lakozia 7 Dans un bâtiment séparé utilisé comme 8 cuisine Amin’ny trano hafa atao lakozia 9 A l’extérieur Ivelany 10 Autre Hafa 11 Ne sait pas Tsy fantatra 12 Reponse manquant Tsy misy valiny 13 14 Bois Hazo 15 Charbon Saribao, arin-tany 16 Kérosène Kerosene 17 Gaz Gaz 18 Fumier animal, bouse animalFor peerDikim-biby review only 19 Arbuste, herbe Hazo madinika, bozaka 20 Autre Hafa 21 Ne sait pas Tsy fantatra 22 Reponse manquant Tsy misy valiny 23 24 Feu ouvert / cuisinière sans cheminée / Afo tsotra/fatana tsy misy lalan- 25 hotte tsetroka/fatana 26 Feu ouvert / cuisinière avec cheminée / 27 hotte Afo tsotra/fatana misy lalan-tsetrok/fatana 28 Four fermé avec cheminée Fatana anaty misy lalan-tsetroka 29 Autre Hafa 30 Ne sait pas Tsy fantatra 31 Reponse manquant Tsy misy valiny 32 33 Oui Eny 34 Non Tsia 35 36 N'a pas demandé conseil médical / Tsy nitady torohevitra ara-pahasalamana / 37 traitement fitsaboana 38 Agent de santé communautaire Mpiasan’ny fahasalamana 39 Guérisseur traditionnel Mpitsabo nentim-paharazana 40 Membre de la famille, amis Fianakaviana, namana 41 Etablissement de santé (publique) Toeram-pitsaboana iombonana 42 Etablissement de santé (privé) Toeram-pitsaboana tsy miankina 43 Pharmacie Fivarotam-panafody 44 45 Option Safidy 46 Autre, spécifier: Hafa, faritana: 47 Ne sait pas Tsy fantatra 48 Reponse manquant Tsy misy valiny 49 50 N'a pas demandé conseil médical / Tsy nitady torohevitra ara-pahasalamana / 51 traitement fitsaboana 52 Agent de santé communautaire Mpiasan’ny fahasalamana 53 Guérisseur traditionnel Mpitsabo nentim-paharazana 54 Membre de la famille, amis Fianakaviana, namana 55 Etablissement de santé (publique) Toeram-pitsaboana iombonana 56 Etablissement de santé (privé) Toeram-pitsaboana tsy miankina 57 Pharmacie Fivarotam-panafody 58 Option Safidy 59 Autre, spécifier: Hafa, faritana: 60 Ne sait pas Tsy fantatra Reponse manquant Tsy misy valiny
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1 2 3 Sans raison particulière Tsy misy antony manokana 4 Les symptômes n'étaient pas assez graves Tsy natahorana loatra ny soritr’aretina 5 Ne pas vouloir quitter le travail Tsy te handao ny asa 6 Trop coûteux de consulter un médecin ou un Lafo loatra ny mitady torohevitra ara- 7 traitement médical pahasalamana na fanafody. 8 9 Trop loin pour chercher une consultation Toerana: lavitra loatra ny mitady torohevitra 10 médicale ou un traitement médical ara-pahasalamana na fanafody 11 Ne s'attendait pas à une qualité de service 12 satisfaisante Tsy nanantena fikarakarana mahafam-po 13 Ne s'attendait pas à la disponibilité de 14 médicaments Tsy nanantena fa hisy fanafody 15 Pas d'endroit où dormir pendant que vous Tsy misy toerana hatoriana raha mandeha 16 allez chercher un conseil ou un traitement mitady torohevitra ara-pahasalamana na 17 médical fanafody 18 N’a pas l’habitude de consulterFor un médecin peerTsy mahazatra review ny mandeha mamonjyonly 19 ou chercher un traitement Dokotera na hopitaly 20 Autre, spécifier: Hafa, faritana: 21 Ne sait pas Tsy fantatra 22 Reponse manquant Tsy misy valiny 23 24 Rien Tsy nisy 25 Auto-medication Manao dokotera tena 26 Autre, a specifier: Hafa, faritana: 27 Ne sait pas Tsy fantatra 28 Reponse manquant Tsy misy valiny 29 30 Rien Tsy nisy 31 Conseil verbal Torohevitra am-bava 32 Paracétamol Paracetamol 33 Anti douleur Fanafody mampijanona fanaintainana 34 Autres médicaments Fanafody hafa 35 Hospitalisation Fampidirana hopitaly 36 Option safidy 37 Option safidy 38 Autre, spécifier: Hafa, faritana: 39 Ne sait pas Tsy fantatra 40 Tsy misy valiny 41 Reponse manquant 42 Sans raison particulière Tsy misy antony manokana 43 44 45 Les symptômes ont continué ou ont empiré Tsy nisy fiovana ny soritr’aretina na nihombo 46 Ne pouvait pas se payer des soins et des 47 traitements offerts Tsy mahavoavidy ny fanafody omena 48 Non satisfait de la qualité du service Tsy afa-po tamin’ny fikarakarana 49 Indisponibilité des médicaments Tsy nisy ny fanafody 50 Option safidy 51 Autres, spécifier: Hafa, faritana: 52 Ne sait pas Tsy fantatra 53 Reponse manquant Tsy misy valiny 54 55 Sans raison particulière Tsy misy antony manokana 56 Les symptômes n'étaient pas assez graves Tsy natahorana loatra ny soritr’aretina 57 58 Ne pas vouloir quitter le travail Tsy te handao ny asa 59 Trop coûteux de consulter un médecin ou un Lafo loatra ny mitady torohevitra ara- 60 traitement médical pahasalamana na fanafody.
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1 2 3 Trop loin pour chercher une consultation Toerana: lavitra loatra ny mitady torohevitra 4 médicale ou un traitement médical ara-pahasalamana na fanafody 5 Ne s'attendait pas à une qualité de service 6 satisfaisante Tsy nanantena fikarakarana mahafam-po 7 Ne s'attendait pas à la disponibilité de 8 médicaments Tsy nanantena fa hisy fanafody 9 Pas d'endroit où dormir pendant que vous Tsy misy toerana hatoriana raha mandeha 10 allez chercher un conseil ou un traitement mitady torohevitra ara-pahasalamana na 11 médical fanafody 12 N’a pas l’habitude d’aller à l’établissement Tsy mahazatra ny mandeha mamonjy 13 de santé Dokotera na hopitaly 14 Autre, spécifier: Hafa, faritana: 15 Ne sait pas Tsy fantatra 16 Reponse manquant Tsy misy valiny 17 18 CSB Andrangavola For peerCSB Andrangavola review only 19 CSB Mahasoa CSB Mahasoa 20 CSB Ranomafana CSB Ranomafana 21 CSB Ifanadiana CSB Ifanadiana 22 CHRD Ifanadiana CHRD Ifanadiana 23 Option Option 24 Autre, specifier: Hafa, faritana: 25 Ne sait pas Tsy fantatra 26 Reponse manquant Tsy misy valiny 27 28 Ne sait pas Tsy fantatra 29 Reponse manquant Tsy misy valiny 30 31 Refuser de parler Mandà ny tsy hiteny 32 Ne sait pas Tsy fantatra 33 Reponse manquant Tsy misy valiny 34 35 Membre de la famille, même ménage Fianakaviana, miray trano 36 Membre de la famille, autre ménage Fianakaviana, samy hafa trano 37 Voisin, ami Mpifanolobodi-rindrina, namana 38 Autre, specifier: Hafa, faritana: 39 Ne sait pas Tsy fantatra 40 Tsy misy valiny 41 Reponse manquant 42 Agent communautaire (AC) Mpanentana ara-pahasalamana 43 Mpiasan’ny fahasalamana voahofana / 44 45 Personnel de sante formé / centre de sante tobim-pahasalamana 46 Famille, amis Fianakaviana, namana 47 Radio Onjam-peo 48 Autre média Fitaovam-pifandraisana hafa 49 Mnandalo manao fitsidihana an-tanana ny 50 Visite d'une equipe médicale dans le village ekipan'ny fahasalamana 51 Autre, où? Hafa, taiza? 52 Ne sait pas Tsy fantatra 53 Reponse manquant Tsy misy valiny 54 55 Bactérie Bakteria 56 De l’air Avy amin’ny rivotra 57 D’autre personne Avy amin’ny olon-kafa 58 En mangeant certains fruits Fihinana voankazo sasany 59 Moustiques Moka 60 Relation sexuelle Firaisana ara-nofo Fumée(s) Setroka
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1 2 Alcool Alkola 3 Autre, où? Hafa, taiza? 4 Ne sait pas Tsy fantatra 5 Reponse manquant Tsy misy valiny 6 7 Aucun symptôme Tsy misy soritr’aretina 8 La toux Kohaka 9 La toux avec expectoration Kohaka misy rehoka 10 La toux avec du sang Kohaka misy rà 11 Un essoufflement, des difficultés à respirer, 12 dyspnée Tsy fahazoana aina, fahasemporana 13 Douleur à la poitrine Aretin-tratra 14 Sueurs nocturnes Tsemboka amin’ny alina 15 Perte de poids Mihena ny lanja 16 Fièvre Tazo 17 Perte de l’appétit Tsy mazoto homana 18 VIH/SIDA For peerVIH/SIDA review only 19 Maux de tête Aretin-doha 20 Fatigue, envi de dormir Reraka, te hatory lava 21 option safidy 22 Autre, où? Hafa, taiza? 23 Ne sait pas Tsy fantatra 24 Reponse manquant Tsy misy valiny 25 26 Par l’air quand on tousse ou quand on Amin’ny rivotra rehefa mikohaka ny olona 27 éternue na mievona 28 Par l’air ou autrement Amin’ny alalan’ny rivotra 29 En partageant des objets avec la personne Amin’ny alalan’ny fampiasana fitaovana 30 atteinte du TB nampiasain’ny olona voan’ny TB 31 Amin’ny alalan’ny fikasihana olona voan’ny 32 En touchant une personne atteinte du TB TB 33 En partageant de la nourriture Amin’ny alalan’ny fizarana sakafo 34 Par le rapport sexuel Amin’ny alalan’ny firaisana ara-nofo 35 Par piqure de moustiques Amin’ny alalan’ny kaikitry ny moka 36 Autre Hafa, taiza? 37 Ne sait pas Tsy fantatra 38 Reponse manquant Tsy misy valiny 39 40 Évitez d'être dans la même pièce avec la Sorohina ny miara-mipetraka amin’ny olona 41 personne qui a la TB voan’ny TB 42 Évitez tout contact avec la personne atteinte 43 de la TB Sorohina amin’ny olona voan’ny TB 44 45 Évitez la partage des boissons/ et de la Sorohina ny miara-misotro na miara- 46 nourriture avec la personne qui a une TB misakafo ami’ny olona voan’ny TB 47 Évitez la partage des objets avec la personne Sorohina ny mampiasa fitaovana 48 qui a la TB nampiasain’ny olona voan’ny TB 49 Évitez de respirer le même air avec la Sorohina ny miara-mifoka rivotra amin’ny 50 personne qui a la TB olona voan’ny TB 51 Évitez les rapports sexuels avec la personne Sorohina ny firaisana ara-nofo amin’ny 52 atteinte de TB olona voan’ny TB 53 Prendre des médicaments, traitement Prendre des médicaments, traitement 54 Aller au centre du santé Aller au centre du santé 55 Autre, spécifier: Hafa, taiza? 56 Ne sait pas Tsy fantatra 57 Reponse manquant Tsy misy valiny 58 59 Médicaments Fanafody, fanàfana 60 Médecine traditionnelle Fitsaboana nentim-paharazana Rituel d'expulsion Fombafomba fandroahana
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1 2 safidy safidy 3 Autre, préciser: Hafa, taiza? 4 Ne sait pas Tsy fantatra 5 Reponse manquant Tsy misy valiny 6 7 D’accord Manaiky 8 Pas d’accord Tsy manaiky 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 fokontanys 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 0 39 1 40 1 41 1 42 1 43 2 44 2 45 2 46 3 47 3 48 3 49 3 50 3 51 3 52 4 53 4 54 4 55 4 56 4 57 4 58 59 4 60 4 4 4
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1 2 4 3 4 4 4 5 4 6 4 7 4 8 5 9 5 10 5 11 5 12 5 13 5 14 5 15 5 16 5 17 5 18 5 For peer review only 19 6 20 6 21 7 22 7 23 7 24 8 25 8 26 8 27 8 28 8 29 8 30 8 31 8 32 8 33 8 34 8 35 8 36 10 37 10 38 10 39 10 40 10 41 10 42 11 43 11 44 45 11 46 11 47 11 48 11 49 11 50 11 51 11 52 9 53 54 55 56 57 58 59 60
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1 2 form_title form_id 3 2.1_CAP_questionnaire_3 2.1_CAP_questionnaire_3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 public_key submission_url default_language 3 Malagasy 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 type name label::English 3 4 start startft 5 end endft 6 today todayft 7 deviceid deviceidft 8 note titleft DrOTS-Project: End of treatment questionnaire 9 note A. Basic socio-demographic information 10 select_one interviewerp interviewerft Name of interviewer: 11 datetime intstartft Interview date and start time: 12 barcode barcode Scan barcode of patient 13 select_one communes communeft Name of commune: 14 select_one fokontanys fokontanyft Name of fokontany: 15 select_one villages villageft Name of village: 16 text nameft Name of patient: 17 select_one genderp genderft Gender of patient: 18 integer Forweightft peerWeight review of the patient: only 19 note B. Treatment follow-up 20 begin group a 21 integer evri1ft evriMED: 22 Discuss with the patient: 23 1. If everything went well with the evriMED. 24 2. If applicable, discuss results from the last evriMED output. 25 3. Number of daily doses remaining: 26 27 end group a 28 select_one yndm fu1ft The patient has been shown all relevant videos. 29 30 Which DrOTS technologies have you been exposed to? select_multiple tech tech 31 begin group d 32 33 note C. Drones Did you know that a drone was coming to your village before you saw 34 select_one yndm drone1 it? 35 36 37 select_multiple drone2 drone2 If yes, how did you find out about the drone coming to your village? 38 text drone2o Where else? 39 select_one yndm drone3 Were you afraid when you first saw the drone flying? 40 41 select_one yndm drone4 Were you surprised when you first saw the drone flying? 42 select_one yndm drone5 Were you happy when you first saw the drone flying? 43 44 select_one yndm drone6 Do you know why a drone came to your village? 45 select_multiple drone7 drone7 Do you know where the drone goes to? 46 text drone7o Where else? 47 Do you think that the drones bring something positive to your 48 select_one yndm drone8 community? 49 Do you think that the drones bring something negative to your 50 select_one yndm drone9 community? 51 52 Do yoy think that the drones can help you receive health care in your 53 select_one yndm drone10 village? 54 55 select_multiple uav1 uav1 What do you think that the drones could transport? 56 text uav1o What else? 57 58 select_one yndm uav2 Do you think that the drones could hurt somebody? 59 60 text uav3 Is there anything you do not like about the drones? select_one yndm uav4 Do you want the drones to continue coming to your village?
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1 2 text uav5 Why not? 3 end group d 4 begin group e 5 note D. Evrimed / boaty 6 In your opinion, what are the advantages of the evriMED and taking the 7 text evrimed1 pills with the evriMED? 8 In your opinion, what are the disadvantages of the evriMED and taking 9 text evrimed2 the pills with the evriMED? 10 text evrimed3 What difficulties did you experience while using the evriMED? 11 select_one yndm evrimed4 Did the audio signal (reminding sound) help you taking your pills? 12 select_one yndm evrimed5 Did the visual signal (colour) help you taking your pills? 13 select_one yndm evrimed6 Overall, did the evriMED help you take your pills? 14 Do you think you could have forgotten taking your mediation if the 15 select_one yndm evrimed7 evriMED didn’t remind you? 16 17 select_one yndm evrimed8 Did any problems/challenges influence you in using the evriMED? 18 text Forevrimed9 peerWhat influencedreview you using theonly evriMED? 19 How did your family (or the people you live with) perceive the 20 text evrimed10 evriMED? What did they think or say about evriMED? 21 22 text evrimed11 Did you like to size of the evriMED? Was it too small or too big? 23 Would you recommend using evriMED to others that need to take pills 24 select_one yndm evrimed12 regularly? 25 If you could change something about the evriMED, what would you 26 text evrimed13 change? 27 end group e 28 begin group f 29 note E. Videos 30 31 text video1 32 33 text video2 34 35 select_one yndm video3 36 37 select_one yndm video4 Do you think you have learnt about TB from the videos shown to you? 38 39 Do you think that other people could benefit from seeing the video/s 40 select_one yndm video5 that you did? 41 select_one yndm video6 Would you like to see more videos? 42 text video7 If yes, what would you like to learn about? 43 end group f 44 note H. End of the interview 45 note questp Do you have any questions for me? 46 geopoint gisp Coordinates of the household of the patient: 47 text commentsp Other comments or observations by the interviewer: 48 time endtimep Time end of interview: 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 label::French 3 4 5 6 7 8 Projet DrOTS: Questionnaire fin de traitement 9 A. Information sociodémographique 10 Nom de l'intervieweur: 11 Date et heure de début de l'interview: 12 Scannez le code à barres individuel pour patient! 13 Nom du commune: 14 Nom du fokontany: 15 Nom du village: 16 Nom du patient: 17 Genre du patient: 18 Poids du patient (en kg): For peer review only 19 B. Suivi du traitement 20 21 22 evriMED: 23 Discuter avec le patient: 24 1. Si tout s'est bien passé avec l'evriMED. 25 2. Si ça s'applique, discutez les données d'evriMED du mois dernier. 26 3. Nombre de doses journalières restantes: 27 28 Le patient a été montré toutes les vidéos pertinentes. 29 30 Quelles technologies DrOTS le patient a été exposé? 31 32 33 C. Drones 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 4 5 D. Evrimed / boaty 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 E. Videos 30 Qu’est-ce que vous aimez à propos de l’utilisation des vidéos éducatifs? 31 32 Qu’est-ce que vous n’aimez pas à propos de l’utilisation des vidéos 33 éducatifs ? 34 Sentiez-vous que vous pouviez comprendre le contenu présenté dans le 35 vidéo ? 36 37 38 39 40 41 42 43 44 H. Fin de l’interview 45 Est-ce que vous avez des questions pour moi? 46 Coordonnées du ménage du patient: 47 Autre commentaire ou observation par l’intervieweur: 48 Heure de la fin de l’interview: 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 label::Malagasy relevant 3 4 5 6 7 8 Projet DrOTS: Questionnaire fin de traitement 9 10 Anaran’ny mpampiresaka: 11 Daty sy ora anombohan’ny resadresaka: 12 Tarafina tsirairay ny kaody bara hoan’ny marary! 13 Nom du commune: 14 Nom du fokontany: 15 Nom du village: 16 Anaran’ny mpandray anjara: 17 Lahy sa vavy ny mpandray anjara? 18 Poids du patient (en kg): For peer review only 19 20 21 22 evriMED: 23 Discuter avec le patient: 24 1. Si tout s'est bien passé avec l'evriMED. 25 2. Si ça s'applique, discutez les données d'evriMED du mois dernier. 26 3. Nombre de doses journalières restantes: 27 28 Le patient a été montré toutes les vidéos pertinentes. 29 30 Inona tamin'ny fitaovana ara-teknolojian'ny DrOTS no naseho taminao? 31 selected(${tech}, '1') 32 33 C. Drones Nahafantatra ve ianao fa hoe hisy Drones hoavy eto aminareo 34 talohan’ny nahitanao azy io? 35 Raha eny, ahoana ny nahafantaranareo fa hisy Drones ho tonga eto 36 37 aminareo? 38 selected(${drone2}, '6') 39 Natahotra ve inao tamin’ny nahita Drones nanidina voalohany? 40 Talanjona be ve ianao tamin’ny nahita Drones nanidina voalohany? 41 42 Faly ve ianao tamin’ny nahita Drones nanidina voalohany? 43 Fantatrao ve hoe ahoana no fomba nahatongavan’ny Drones teto 44 aminareo? 45 Fantatrao ve hoe aiza no andeha hanidina io Drones io? 46 selected(${drone7}, '6') 47 Mieritreritra ve ianao fa hitondra zava-tsoa ho an’ny mponina na 48 tanana eto aminareo ny Drones? 49 Mieritreritra ve ianao fa hitondra zava-dratsy ho an’ny mponina na 50 tanananareo ny Drones? 51 Mieritreritra ve ianao fa afaka hanampy anareo amin’ny fahazoana 52 fiahiana ara-pahasalamana ho an’ny tanananareo ny Drones? 53 54 Inona ihany koa araka ny hevitrao ny zavatra azon’ny Drones hoentina? 55 56 selected(${uav1}, '8') 57 Manahy ve ianao fa mety tsy hahafaly ny hafa ny fisian’ny Drones? 58 59 Misy zavatra hafa tsy tianao na tsy mety aminao ve momban’io Drones 60 io? Tianao ve raha mbola hoavy aty aminareo ihany ny Drones?
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1 2 selected(${uav4}, '2') 3 4 selected(${tech}, '2') 5 D. Boaty EvriMED 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer reviewselected(${evrimed8}, only '1') 19 20 21 22 23 24 25 26 27 28 selected(${tech}, '3') 29 E. Video an-tsary 30 31 32 33 34 35 36 37 38 Mieritreritra ve ianao fa ny olon-kafa izay fantatrao dia afaka mahazo 39 tombotsoa amin’ny alalan’ny fijerena video an-tsary tahakan’ny 40 nataonao? 41 Mbola te hijery video hafa indray ve ianao? 42 Raha eny, inona no zavatra tianao ho fantatra misimisy koakoa? 43 44 45 Est-ce que vous avez des questions pour moi? 46 Coordonnées du ménage du patient: 47 Autre commentaire ou observation par l’intervieweur: 48 Heure de la fin de l’interview: 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 choice_filter hint::English 3 4 5 6 7 8 9 10 11 12 13 14 communes=${communeft} 15 fokontanys=${fokontanyft} 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 hint::French constraint constraint required 3 _message 4 5 6 7 8 9 10 yes 11 yes 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 appearance default read_only calculation 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 field-list 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 label::zambia hint::zambia image::english 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 media::audio::chinese media::video 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 list_name name label::English 3 interviewerft 3 Rija 4 interviewerft 4 Haja 5 5 6 interviewerft Marco 6 7 interviewerft Mamy 7 8 interviewerft Idéal 9 interviewerft 8 Andri 10 interviewerft 9 Omega 11 interviewerft 10 Sylvain 12 interviewerft 11 Astrid 13 interviewerft 12 Jesse 14 interviewerft 13 Simon 15 interviewerft 14 Kimmerling 16 interviewerft 1 Natamby 17 interviewerft 2 Hasina 18 For peer review only 19 yndm 1 Yes 20 yndm 2 No 21 yndm 3 Does not know 22 yndm 4 Response missing 23 24 age3ft 88 unknown 25 age3ft 99 missing 26 27 genderft 1 Male 28 genderft 2 Female 29 30 communesft 0 Pilotage 31 communesft 1 Androrangavola 32 communesft 2 Other 33 34 fokontanysft 0 Pilotage 35 fokontanysft 1 Ambodifontsina 36 fokontanysft 2 Ambodiara Nord 37 fokontanysft 3 Ampasimpotsy 38 fokontanysft 4 Androrangavola 39 fokontanysft 5 Nosy Be Sud 40 fokontanysft 6 Mandriamposty 41 fokontanysft 7 Ambohimahavelo Betoho 42 fokontanysft 8 Mahasoa I 43 fokontanyft 10 Ambalatabaka 44 fokontanysft 9 Other 45 46 villageft 0 Village pilotage 47 villageft 1 48 Ambodifontsina 49 villageft 2 Ambakotsialaina 50 villageft 3 Ambalatamboro 51 villageft 4 Ambodiaravola 52 53 villageft 5 Ambodiara Nord 54 villageft 6 Ambodiakondro 55 villageft 7 Ambohimahavelo 56 villageft 8 Ampasimpotsy 57 58 villageft 9 Ambalafasina 59 villageft 10 Ambatoharanana 60 villageft 11 Ambohitsara Firarana villageft 12 Ambohimahavelona Nord
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1 2 villageft 13 Androrangavola 3 villageft 14 Ambohimahasoa I 4 villageft 15 Ambohimahasoa II 5 16 6 villageft Ambohimandroso 7 villageft 17 Ambodimanga 8 villageft 18 Ambatovaky I 9 villageft 19 Ambatovaky II 10 11 villageft 20 Ambohimiarina 12 villageft 21 Analanakondro I 13 villageft 22 Analanakondro II 14 villageft 23 Benavony 15 16 villageft 24 Lavakianja Nord 17 villageft 25 Mahasoa II 18 villageft For26 Mahavanona peer review only 19 villageft 27 20 Mahatsara 21 villageft 28 Morafeno 22 villageft 29 Nosy Be Sud 23 villageft 30 Ambohimahatsinjo 24 villageft 31 25 Ambodiara Nosy Be 26 villageft 32 Ambohinamboarina 27 villageft 33 Ambodirafia 28 villageft 34 Kianjamiakatra 29 35 30 villageft Tsarakianja 31 villageft 36 Tsarahonenana 32 villageft 37 Vinanimasina 33 villageft 38 Vohipeno I 34 35 villageft 39 Vohipeno II 36 villageft 40 Mandriampotsy 37 villageft 41 Ambalavory 38 villageft 42 Ambohimahavelo 39 40 villageft 43 Andranosariaka 41 villageft 44 Betoho 42 villageft 45 Mahasoa 43 villageft 46 Andemaka I 44 45 villageft 47 Andemaka II 46 villageft 48 Ambohimahavelo 47 villageft 49 Ankerana 48 villageft 50 49 Analabe 50 villageft 51 Ampasimpotsy 51 villageft 52 Mahavanona 52 villageft 53 Mahatsara I 53 54 54 villageft Mahatsara II 55 villageft 55 Tsarahonenana 56 villageft 56 Vohitraivo 57 villageft 58 Ambalatabaka 58 59 villageft 59 Ambohinihaonana I 60 villageft 60 Ambohinihaonana II villageft 61 Ambohipeno
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1 2 villageft 62 Antanivelona 3 villageft 63 Vatomena 4 villageft 57 Other 5 6 tech 1 Drones 7 tech 2 MERM / evriMED 8 tech 3 Videos 9 tech 4 GeneXpert 10 tech 5 none 11 12 drone2 1 CHW 13 drone2 2 DrOTS health team 14 drone2 3 Mayor 15 drone2 4 King 16 drone2 5 Other villagers 17 drone2 6 Other 18 For peer review only 19 drone2 7 Did not know 20 21 drone7 1 Does not know 22 drone7 2 Health Facility 23 drone7 3 Androrangavola (capital) 24 drone7 4 Ifanadiana 25 drone7 5 CVB 26 drone7 6 Other 27 28 uav1 1 Medication 29 uav1 2 Diagnostic tests 30 uav1 3 Vaccines 31 uav1 4 Phone credit 32 uav1 5 Small groceries 33 uav1 6 Items 34 uav1 7 News 35 uav1 8 Other 36 37 video2 1 CVB DrOTS mobile health team member 38 video2 2 CHW 39 video2 3 CSB Doctor 40 video2 4 CSB Nurse 41 video2 5 Foreigner 42 video2 6 Other 43 44 video3 1 Health 45 video3 2 Sanitation 46 video3 3 Conservation 47 video3 4 Animals 48 video3 5 Latrines 49 video3 6 Washing hands 50 video3 7 Boiling water 51 video3 8 Tuberculosis 52 video3 9 HIV/AIDS 53 video3 10 Music 54 video3 11 Mosquitoes 55 video3 12 Other 56 57 58 59 60
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1 2 label::French label::Malagasy communes 3 Rija 4 Haja 5 6 Marco 7 Mamy 8 Idéal 9 Andri 10 Omega 11 Sylvain 12 Astrid 13 Jesse 14 Simon 15 Kimmerling 16 Natamby 17 Hasina 18 For peer review only 19 Oui 20 Non 21 Ne sais pas 22 Reponse manquant 23 24 inconnu(e) 25 réponse manquant 26 27 Masculin 28 Féminin 29 30 Pilotage 31 Androrangavola 32 Autre 33 34 Pilotage 0 35 Ambodifontsina 1 36 Ambodiara Nord 1 37 Ampasimpotsy 1 38 Androrangavola 1 39 Nosy Be Sud 1 40 Mandriamposty 1 41 Ambohimahavelo Betoho 1 42 Mahasoa I 1 43 Ambalatabaka 1 44 Autre 45 46 Village pilotage 47 48 Ambodifontsina 49 Ambakotsialaina 50 Ambalatamboro 51 Ambodiaravola 52 53 Ambodiara Nord 54 Ambodiakondro 55 Ambohimahavelo 56 Ampasimpotsy 57 58 Ambalafasina 59 Ambatoharanana 60 Ambohitsara Firarana Ambohimahavelona Nord
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1 2 Androrangavola 3 Ambohimahasoa I 4 Ambohimahasoa II 5 6 Ambohimandroso 7 Ambodimanga 8 Ambatovaky I 9 Ambatovaky II 10 11 Ambohimiarina 12 Analanakondro I 13 Analanakondro II 14 Benavony 15 16 Lavakianja Nord 17 Mahasoa II 18 Mahavanona For peer review only 19 20 Mahatsara 21 Morafeno 22 Nosy Be Sud 23 Ambohimahatsinjo 24 25 Ambodiara Nosy Be 26 Ambohinamboarina 27 Ambodirafia 28 Kianjamiakatra 29 30 Tsarakianja 31 Tsarahonenana 32 Vinanimasina 33 Vohipeno I 34 35 Vohipeno II 36 Mandriampotsy 37 Ambalavory 38 Ambohimahavelo 39 40 Andranosariaka 41 Betoho 42 Mahasoa 43 Andemaka I 44 45 Andemaka II 46 Ambohimahavelo 47 Ankerana 48 49 Analabe 50 Ampasimpotsy 51 Mahavanona 52 Mahatsara I 53 54 Mahatsara II 55 Tsarahonenana 56 Vohitraivo 57 Ambalatabaka 58 59 Ambohinihaonana I 60 Ambohinihaonana II Ambohipeno
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1 2 Antanivelona 3 Vatomena 4 Autre 5 6 Drones Drones 7 Boaty / evriMED Boaty / evriMED 8 Video-antsary Video-antsary 9 GeneXpert GeneXpert 10 Tsisy Tsisy 11 12 AC 13 Ekipan'ny fahsalamana DrOTS 14 Ben'ny Tanana 15 Ampanjaka 16 Tanana hafa 17 Hafa 18 For peer review only 19 Tsy fantatra 20 21 Tsy fantany 22 Tobi-mpahasalamana 23 Androrangavola(Renivohitra) 24 Ifanadiana 25 CVB 26 Hafa 27 28 Fanafody 29 fizahana sy fitiliana 30 Vakisiny 31 Kiredy 32 Enta-madinika 33 entana kely 34 Vaovao 35 Hafs 36 37 Mpikambana ao amin'ny ekipan'ny fahasalamana DrOTS 38 AC 39 Dokoteran'ny CSB 40 Mpitsabo mpanampy eny amin'ny CSB 41 Vahiny (Vazaha) 42 Hafa 43 44 Fahasalamana 45 Fanadiovana 46 Fiarovana ny tontoloiainana 47 Biby 48 Kabone 49 Fanasana tanana 50 Fampangotrahana rano 51 Tiberkilaozy 52 VIH SIDA 53 Mozika 54 Moka 55 Hafa 56 57 58 59 60
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1 2 fokontanys 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 0 47 1 48 49 1 50 1 51 1 52 53 2 54 2 55 2 56 3 57 58 3 59 3 60 3 3
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1 2 4 3 4 4 4 5 4 6 7 4 8 4 9 4 10 11 4 12 4 13 4 14 4 15 16 4 17 4 18 4 For peer review only 19 4 20 21 4 22 5 23 5 24 5 25 26 5 27 5 28 5 29 5 30 31 5 32 5 33 5 34 35 5 36 6 37 6 38 7 39 40 7 41 7 42 8 43 8 44 45 8 46 8 47 8 48 8 49 50 8 51 8 52 8 53 8 54 55 8 56 8 57 10 58 59 10 60 10 10
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1 2 10 3 10 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 form_title form_id 3 7.1._FinTraitement_questionnaire 7.1._FinTraitement_questionnaire 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 public_key submission_url default_language 3 Malagasy 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 4 5 Supplementary material 3: DrOTS Acceptability and Perceptions Study 6 7 Focus Group Discussion Guides 8 9 10 FGD For DrOTS enrolled villagers 11 12 Part 1: General context for The TB Project perceptions and experiences 13 1.1 What are the most common sicknesses here in the village? 14 15 1.2 What do you think are the main causes of sickness here in the village? 16 1.3 What do people inFor your household peer do usually review when they get sick? only 17 1.4 Do some people still like to visit traditional healers? 18 1.5 In what situations would you go to the healthcare center? 19 1.6 What if somebody is too sick to get to the healthcare center? What then? 20 1.7 Is there a village health coordinator or a community health worker for this village? What is their role 21 in the community? 22 23 24 1.8 Have other foreigners ever come to this village before this The TB Project program? 25 1.9 Have any medical teams ever come to the village before this TB project? 26 Probes: (If answer yes): 27 When? What services did those other teams offer? 28 Did someone in your community invite them so that they come or they just arrive? 29 Is the TB project team doing something pretty similar to what those earlier teams did, in your 30 view then? 31 Do the projects seem organized and run in a similar way? Are you involved in a similar way with 32 these visiting teams? Do you find interactions between the medical teams and the villagers 33 34 similar to those you have observed in the past between villagers and visiting medical teams? Is 35 it unusual to have the same group of people coming back? 36 37 PART II: PERCEPTIONS AND ENGAGEMENT WITH DROTS 38 2: Understanding of and first contact with The TB Project/TB Project 39 2.1 Have you told anyone outside the village about the TB project? What did you tell them? 40 Rephrase: How would you explain what the TB team is doing here to a friend or cousin in another 41 village? 42 43 2.2 What is the TB Project team trying to do, in your understanding? Who, in your understanding, is 44 organizing this Project? 45 2.3 How did you first find out about (or hear or learn: whichever most contextually appropriate) The TB 46 Project? 47 Probes: Was that the first time you learnt about TB? 48 2.4 Did you attend an information meeting? Why/why not? 49 2.5 When you first found out/heard/learnt about The TB Project, what went through your mind? 50 Rephrase/Probes: What did you think? Were you excited? Did you have any concerns? Did you ask any 51 52 questions? 53 2.6 Are there some in the village who have different ideas or feelings about the TB Project? 54 55 3: Perceptions and experiences of TB testing by The TB Project team 56 57 58 59 1 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 105 of 112 BMJ Open
1 2 3 3.1 The TB Project medical team does tests to see who might have TB. How did you feel about getting 4 tested by the team? 5 Probes: Did you want to get tested? Did you feel obligated in any way? Had you been tested before? 6 7 3.2 Was anything about the testing process difficult for you? 8 Probes: Did anything surprise you about the testing? Please explain. 9 3.3 Did you discuss with anyone in your house, or with neighbors, before getting tested by the team? 10 Probe: (If yes) : What did you discuss with them? What did they think about this testing? 11 (If did not discuss with anyone) Why did you not discuss the testing with anyone before deciding to do 12 it? 13 3.4 Did the healthcare team use a tablet? If yes: what did they use it for? Did you see a video on it? Was 14 it helpful? 15 16 3.5 Is there anything aboutFor the testingpeer process review you wished had been only done differently? 17 Probe: Please explain why that is important to you. 18 3.6 If you have to get a TB test: Do you prefer getting a TB test in a healthcare centre outside 19 the village, or being tested by a team that comes to your village? Why? 20 21 4: Perceptions and experiences of the drones 22 4.1 What did you think when you first saw the drones? 23 24 4.2 Do you like this idea of using drones/this flying bus to transport medications and test results in and 25 out of the community? Why/why not? 26 4.3 Does anything about these flying in and out of your community bother you? 27 Probes: Have you had any unpleasant experiences with the drones? Have the drones scared any one 28 here in the village? 29 4.4 If you had TB, how would you feel about receiving your medications through a drone? 30 Probe: Do you think medications for TB coming in on a drone will make it easier to know who has TB in 31 the village? Is that a concern for you? 32 33 4.5 Do you think you would feel the same way about receiving medications for another disease? 34 4.6 You spoke of a number of health problems at the beginning: do you imagine these drones could 35 help with other problems in the village, health-related or others? 36 Rephrase: What other uses might drones have in villages such as yours in the future? 37 38 5: Perceptions and experiences of the tablets and Evrimeds 39 5.1 Who here had a chance to watch any videos about TB? Which one(s)? 40 Probes (For each): What did you think of it How many times did you watch it? Who showed it to you? 41 42 5.2 What was the message of this video, as you remember it? 43 Probe: Do you think that what it talks about is important? Did you feel differently about TB after 44 watching the video? 45 5.3 Do you think sharing information about health and treatments for sicknesses through tablets is a 46 good strategy for getting people in the village to learn about these things? Why or why not? 47 48 6: Closing reflections on The TB Project and technologies for health 49 6.1 Has anything surprised you in your experience with the The TB Project team so far? 50 6.2 What do you think could be improved in the The TB Project program? 51 52 Rephrase: Has anything about this program been a little difficult for some in the village? 53 6.3 Do you think The TB Project will change how people think about TB or healthcare in the village? 54 6.4 Is the TB Project visiting the village something you want to see continued in the future? Why or why 55 not? 56 57 58 59 2 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 106 of 112
1 2 3 4 Conclusion 5 Thank you. We have learnt so much. Is there anything you would like to add? Is there anything we 6 7 missed? 8 9 10 11 12 FGD guide for Mobile Health Unit Focus Group Discussion Guide 13 14 Thank you agreeing to take part in this interview. In our discussion today, I am going to ask you 15 16 some questions aboutFor your experiencepeer with review The TB Project. Youonly are one of the first people in 17 Madagascar and the world to participate in such a program. It is very important we learn from 18 you what it has been like to introduce this program here at the village-level in Madagascar. 19 20 21 Introduction 22 Could you please share with me what your roles are within The TB Project? 23 24 Part 1: Understanding and experiences of DrOTS/The TB Project 25 1.1 How did you first find out about The TB Project? 26 27 1.2 Had you heard about TB before this? 28 1.3 When you first found out/heard/learnt about DrOTS/ The TB Project, what went through 29 your mind? 30 Probes: What did you think? Were you excited? Did you have any concerns? Did you ask any 31 32 questions? 33 1.4 Tell me what it is like to work in the villages with this project. 34 1.5 Have you encountered a village or a group of individuals or an individual that does not seem 35 happy with your presence in the village? 36 1.6 Do people in the villages ask you many questions? What sorts of questions do they ask? 37 38 1.7 Has a community member in a village – a patient, a community health worker, a king, 39 anyone - ever expressed any concerns/worry with you about The TB Project? 40 1.8 Do you find it easy or difficult to work with the community health worker? 41 Probe: What makes it easy? What makes it difficult? 42 43 1.9 Has anything changed in the way you work with villages since the start of the Project? 44 Rephrase: Have you learnt anything in the course of working in the villages that has helped you 45 improve your communication or process of testing with villagers? 46 47 Part 2: Experiences and perceptions of TB testing and patient enrollment 48 49 2.1 The The TB Project mobile health unit provides testing in villages to see who might have TB. 50 In many parts of the world, people do not like to talk about illness or about TB. Are you 51 observing any attitudes or ideas about TB in the villages that might be acting as barriers to 52 testing or treatment for TB? 53 54 2.2 Are there any other cultural ideas, beliefs, or practices that you have observed that seem to 55 make it difficult for people to get tested for TB or accept treatment? (if yes Has your team 56 developed any strategies to address those?) 57 58 59 3 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 107 of 112 BMJ Open
1 2 3 2.3 What happens once a patient tests positive for TB? 4 5 Probe: How are test results shared with patients (to the best of your knowledge)? 6 Could you describe what that involves? Were you involved at all in disclosing or discussing the 7 treatment plan with the patient? If yes, did you feel well prepared for that? 8 2.4 Do people comply with the treatment normally in your experience? If not, why not? 9 2.5 In your experience, what motivates some to seek testing? 10 11 12 Part 3 – Perceptions and experiences of the Tablets and education videos 13 3.1 How have you used the tablets and educational videos put out by The TB Project? 14 3.2 How does the community respond when you show them the videos? 15 3.3 Have you observed any challenges related to the use of these tablets? 16 For peer review only 17 3.4 Did you get a chance to actually operate the tablet? If yes, was it easy to use or difficult? 18 19 Part 4 – Perceptions and experiences of Evrimeds 20 4.1 You show the Evrimeds to the entire community during sensitization. Do people ask any 21 22 questions? 23 4.2 What is the process for giving the Evrimeds? What do you tell the patient? 24 Probe: Why is important things to say those things? 25 4.3 Have you observed any challenges related to Evrimeds? 26 27 Probe: Has anyone ever rejected the Evrimed? 28 4.4 Have you made any changes to the way in which you present the Evrimeds to the patient 29 over time? 30 31 Part 5 - Closing reflections on The TB Project and technologies for health 32 33 5.1 What has been the best part of working with The TB Project? 34 5.2 What challenges have you encountered? 35 5.3 Has anything surprised you in your experience with The TB Project? 36 5.4 Do you worry what will happen when The TB Project ends? 37 38 5.5 Do you think The TB Project will change how people think about TB? 39 5.6 Do you think anything about the The TB Project program could be improved? 40 Rephrase: Has anything about this program been a little difficult for some in the village? 41 42 Close 43 44 Thank you. We have learnt so much. Is there anything you would like to add? Is there anything 45 we missed? 46 47 48 49 50 51 52 53 54 55 56 57 58 59 4 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 108 of 112
1 2 3 4 5 Supplementary material 4 - DrOTS Perception Study Semi-Structured 6 7 Interview Guides 8 9 Interview guide for DrOTS enrolled patient 10 (can be pared down for villagers who have tested negative for TB through The TB Project, and 11 12 for villagers hesitant, unable or who have declined The TB Project participation) 13 14 Introduction 15 Thank you agreeing to take part in this interview. In our discussion today, I am going to ask you 16 some questions aboutFor your experiencepeer with review The TB Project. Youonly are one of the first people in 17 18 Madagascar and the world to engage with this new tuberculosis elimination program that 19 involves these new technologies – drones, tablets, and medical event reminder boxes. It is very 20 important we learn about your experience. 21 22 23 Part 1: First contact with The TB Project 24 1.1 How did you first find out about (or hear or learn: whichever most contextually appropriate) 25 The TB Project? 26 1.2 Can you remember how you felt when you first found out/heard/learnt about The TB 27 Project? What did you think?? Did you ask any questions? 28 29 1.3 Did you (also) attend an information meeting in the village? Why/why not? 30 1.4 Had you ever heard of TB before? 31 32 Part 2: Perception and experience of TB testing 33 34 2.1 The TB Project medical team does tests to see who might have TB. What motivated you to 35 get tested? 36 2.2 When and where did you get tested? 37 2.3 Did you consult anyone in making your decision about whether or not to be tested? 38 Probe: Why/why not? If yes, what did they think/say? How did that impact on your decision? 39 40 2.4 Was that the first time you had ever been tested for TB? 41 2.5 Was anything about getting tested difficult for you? 42 2.6 Did the healthcare team use a tablet? 43 Probe: What was your understanding of what they were using the tablet for? 44 2.7 Did you watch a video on the tablet? 45 If yes: what was the message of that video? 46 47 2.8 (If tested) When and how did you receive the results? 48 2.9 How did you feel and what went through your mind when you got the results? (If positive 49 result: Did you worry about people finding out about the results? What worried you about people 50 finding out (if the case)?) 51 2.91 What happened next? 52 53 2.92 Did you share the results with anyone? Why/why not? If yes, what was their reaction? 54 How did that make you feel? 55 2.93 Do you think people outside those in your family know you have TB? 56 57 58 59 1 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 109 of 112 BMJ Open
1 2 3 Probe: Was it your choice to tell them? If not your choice, how did they find out? 4 5 2.94 Is there anything the medical team or healthcare workers could do to that would make it 6 easier for people with TB to stop their neighbors or other villagers finding out about their TB 7 status if they want to keep this secret? 8 9 Part 3: Experience of The TB Project as a patient 10 11 Note: Skip section 3 for villagers who have tested negative for TB 12 3.1 What is involved in receiving TB treatment through this project? 13 3.2 Who is the CHW that you see for your treatment? How often do you see them? Where do 14 you see them (do they come to your house)? 15 3.3 Is this the first time you are speaking regularly with the Community Health Worker about a 16 For peer review only 17 health problem? 18 3.4 Tell me about the medicines: What has it been like for you, taking the medicine? 19 Probe: Have you experienced any side effects? 20 3.5 Has it been difficult or easy for you to follow the treatment? 21 22 3.6 What do you think of the little boxes / MERMS? 23 3.7 Have you ever had to travel with the MERM? If so: Is that difficult? 24 3.8 What is hardest thing about being a The TB Project patient, in your experience? 25 26 27 Part 4: Enrolled Patient general reflection on their experience 28 4.1 Are you happy you became a patient in this program? Why/why not? 29 4.2 What do you think is the most important thing for someone to know or consider before 30 they decide whether or not to accept receiving treatment through this program? 31 4.3 Is there anything about the testing or treatment process you wished had happened 32 33 differently? 34 Probe: Please explain why that is important to you. 35 36 37 38 Part 5: General reflections on The TB Project in the village 39 5.1 Have you recommend to anyone else in your house or village to get tested for TB with this 40 team? Why/why not? 41 5.2 In your view, are there any advantages or disadvantages to getting tested through The TB 42 Project as opposed to at a healthcare centre outside the village? 43 44 5.3 You are one of the few Malagasy with The TB Project experience. Has anything in this 45 experience really marked you or surprised you? 46 5.4 Is there anything you had trouble understanding when you first heard about The TB Project, 47 that those running the program might explain more clearly to future patients? 48 49 5.5 Do you think anything about the The TB Project program could be improved? 50 Rephrase: Has anything about this program been a little difficult for some in the village 51 5.6 What will be the impact here in the village if funding for The TB Project ends? 52 5.7 Would you like to see drones used for more things in your village in the future? 53 Rephrase: Do you envision drones being useful in other ways for your village in the future? 54 55 56 Conclusion 57 58 59 2 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 110 of 112
1 2 3 Thank you. I have learnt so much. Is there anything you would like to add? Is there anything we 4 5 missed? 6 7 8 9 10 Semi-Structured Interview Guide for leaders (Community health 11 12 worker, King, Chief Fokontany) 13 14 Part 1: General context for The TB Project 15 1.1 What are your responsibilities related to health in the village? 16 For peer review only 17 1.2 What do people in the villages for which you are responsible usually do if they get sick? 18 Probe: Do people use home remedies? Go to the pharmacy? What if somebody is too sick to 19 get to the healthcare center? What then? 20 1.1 Have other groups of foreigners come to this area/or village in the past? 21 22 Probe: What were they doing here? 23 1.2 Have other projects with medical teams come to these villages before this The TB Project 24 program? 25 Probes: When? What services did those other teams offer? (Or, why do you think no one has 26 27 come before?) Did you invite these medical teams? How did they decide to come to this/these 28 villages in particular, in your understanding? 29 1.5 Is the The TB Project team doing something pretty similar to what those earlier teams did, 30 in your view then? 31 Probes: Do the projects seem organized and run in a similar way? Are you involved in a similar 32 33 way with these visiting teams? Do you find interactions between the medical teams and the 34 villagers similar to those you have observed in the past between villagers and visiting medical 35 teams? Is it unusual to have the same group of people coming back? 36 37 38 Part 2: Understanding of and first contact with the TB project of Centre ValBio 39 2.1 How did you first find out about (or hear or learn: whichever most contextually appropriate) 40 the TB project of Centre ValBio? 41 Probes: Did you ask any questions that first time you heard about it? 42 2.2 When you first found out/heard/learnt about this TB project, what went through your 43 44 mind? 45 Rephrase/Probes: What did you think? Were you excited? Did you have any concerns? 46 2.3 Do you still see TB project in this way? 47 Probe: What made you change your mind? Are there some in the village who think differently 48 49 about the project? 50 2.4 How has this experience been for you? Does the TB project create more work for you? 51 Probe: Why? How? 52 How do you make time for this project? 53 2.5 How do you explain what the TB project/The TB Project is to the villagers? (for example, 54 55 when you called them to attend the first meeting, what did you tell them?) 56 57 58 59 3 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 111 of 112 BMJ Open
1 2 3 Probe: Do you explain it in the same way to all villagers, regardless of their education level? 4 5 What do you say exactly? 6 2.6 Have you encountered any challenges in terms of mobilizing support for The TB Project in 7 these villages? 8 Probe: How did they react? What did they say? If yes, why do you think? If there is an 9 exception, ask for details: Could you tell me more? What do you think that caused that? What 10 11 did you do? Did that help? 12 2.7 Have people in the village(s) asked you any questions about the project? 13 2.8 Has a The TB Project patient or their family ever shared any concerns with you about The TB 14 Project? 15 Probes: What is that concern about? What was your response? Is that common in your 16 For peer review only 17 experience? 18 19 Part 3: Perceptions and experiences of TB testing and patient enrollment 20 3.1 The The TB Project medical team provides testing in villages to see who might have TB. In 21 22 many parts of the world, people do not like to talk about illness or about T. Did you have any 23 concerns about their plan to test for TB in the villages with whom you work? 24 3.2 Was it difficult to ask villagers to get tested for TB? 25 Probe: How/why? What was your role when it comes to mobilizing villagers for testing? Do you 26 27 help explain the testing to villagers? 28 3.3 What response have you observed when villagers are invited to get tested for TB? 29 Probe: Has that been the same in all villages where you work? What do you think accounts for 30 that response? 31 3.4 Are there any cultural ideas, beliefs, or practices that might make it difficult for people to 32 33 get tested? 34 Probe: Have you observed such things? 35 3.5 How are test results shared with patients (to the best of your knowledge)? 36 3.6 What happens once a patient tests positive for TB, now that The TB Project is here? 37 38 Probe: Could you describe what that involves? Were you involved at all in discussing the 39 treatment plan with the patient? If yes, did you feel well prepared for that? 40 3.7 Did the patient or their family have any concerns about joining the The TB Project program 41 that they shared with you? 42 Probe: Do you understand those concerns? What did you tell them? 43 44 3.8 Is there anything about the way the The TB Project team goes about testing or informing 45 patients of their results that you might recommend be done differently? 46 3.9 In your view, are there any advantages or disadvantages to getting tested through this TB 47 project as opposed to at a healthcare centre outside the village? 48 49 50 Part 4: Perceptions and experiences of the Drones 51 4.1 What did you think when you first saw the drones? 52 4.2 Do you like this idea of using drones to transport medications and test results in and out of 53 the community? Why/why not? 54 55 Probe: Why is the The TB Project team using drones? Would you prefer a person going by 56 ground to transport medications in and out of the village? 57 58 59 4 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 112 of 112
1 2 3 4.3 Does anything about these flying in and out of your community bother you? 4 5 Probe: Have you experienced any challenges related to the use of these technologies in the 6 village? Have you had any unpleasant experiences with the drones? Have the drones scared any 7 one here in the village? 8 4.4 If you had TB, how would you feel about receiving your medications through a drone? 9 Probes: Would you feel the same way about receiving medications for other conditions? Do you 10 11 think medications for TB coming in on a drone will make it easier to know who has TB in the 12 village? Is that a concern for you? Do you think some patients and families might not want to 13 receive medicines through drones? 14 4.5 You spoke of a number of health problems at the beginning: do you imagine these drones 15 could help with other problems in the village, health-related or others? 16 For peer review only 17 Rephrase: Do you envision drones being useful in other ways for your village in the future? 18 19 Part 5: Perceptions and experiences of the tablets and education videos 20 5.1 How have you used the tablets and educational videos put out by The TB Project? 21 22 5.2 Do you feel these are an effective strategy for sharing information about TB and The TB 23 Project? 24 Probes: Why/why not? Have you observed any challenges related to the use of these tablets? 25 5.3 Did you get a chance to actually operate the tablet? If yes, was it easy to use or difficult? 26 27 Probe: for specifics of what was easy or difficult and why. 28 5.4 Do you think sharing information about health and treatments for sicknesses through tablets is a 29 good strategy for getting people in the village to learn about these things? Why or why not? 30 31 Part 6 – Perceptions and experiences of Evrimeds 32 6.1 The entire community gets to see the Evrimeds/little boxes during sensitization. Did people 33 34 ask any questions when they saw those? 35 6.2 Have you heard of any challenges related to Evrimeds? 36 37 Part 7: Closing reflections on The TB Project and technologies for health 38 39 7.1 What has been the best part of working with The TB Project? 40 7.2 What challenges have you encountered? 41 7.3 You have experience with The TB Project now. What health problems can technologies 42 solve, and which ones can they not solve, in your view? 43 7.4 What about the The TB Project program could be improved? 44 45 Rephrase: Has anything about this program been a little difficult for some in the village? 46 47 Conclusion 48 Thank you. We have learnt so much. Is there anything you would like to add? Is there anything 49 50 we missed? 51 52 53 54 55 56 57 58 59 5 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open
Perceptions of drones, digital adherence monitoring technologies and educational videos for tuberculosis control in remote Madagascar: a mixed-method study protocol ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2018-028073.R1
Article Type: Protocol
Date Submitted by the 22-Feb-2019 Author:
Complete List of Authors: Nouvet, Elysée; Western University, School of Health Studies Knoblauch, Astrid; Schweizerisches Tropen- und Public Health-Institut; Institut Pasteur de Madagascar, Mycobacteria Passe, Ian; Stony Brook University Andriamiadanarivo, Andry ; Center Valbio Ravelona, Manualdo; Center Valbio Ainanomena Ramtariharisoa, Faniry ; Centre Valbio Razafimdriana, Kimmerling ; Center Valbio Wright, Patricia; Stony Brook University; Center Valbio McKinney, Jesse ; Stony Brook University; Center Valbio Small, Peter; Stony Brook University Rakotosamimanana, Niaina; Institut Pasteur de Madagascar, Mycobacteria Grandjean Lapierre, Simon; Centre de recherche du CHUM, Immunopathology; Institut Pasteur de Madagascar, Mycobacteria
Primary Subject Health services research Heading:
Secondary Subject Heading: Health services research, Infectious diseases
drones, Madagascar, Tuberculosis < INFECTIOUS DISEASES, biomedical Keywords: technology, global health, medication adherence
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1 2 3 1 BMJ OPEN – STUDY PROTOCOL 4 2 5 6 3 TITLE 7 8 9 4 Perceptions of drones, digital adherence monitoring technologies and educational videos 10 5 for tuberculosis control in remote Madagascar: a mixed-method study protocol 11 6 12 13 7 ARTICLE TYPE 14 15 16 8 Study Protocol For peer review only 17 9 18 19 10 AUTHORS 20 21 22 11 Elysée Nouvet (ORCID 0000-0002-1607-3453)1, Astrid M. Knoblauch2,3, Ian Passe4, Andry 23 12 Andriamiadanarivo5, Manualdo Ravelona5, Faniry Ainanomena Ramtariharisoa5, Kimmerling 24 13 Razafimdriana5, Patricia C. Wright4,5, Jesse McKinney4,5, Peter M. Small4, Niaina 25 14 Rakotosamimanana (ORCID 0000-0002-2352-9797)3, Simon Grandjean Lapierre (ORCID 0000- 26 3,6* 27 15 0003-3646-1573) 28 16 29 17 *Corresponding author 30 18 31 32 19 AFFILIATIONS 33 34 1 35 20 Western University, School of Health Sciences, 1151 Richmond St, London, ON N6A 3K7, 36 21 Canada 37 22 2 Swiss Tropical and Public Health Institute, University of Basel, 57 Socinstrasse, Basel 4051 38 23 Switzerland 39 24 3Mycobacteria Unit, Institut Pasteur de Madagascar, Mycobactreria Unit, Ambohitrakely, 40 25 Antananarivo 101, Madagascar 41 4 42 26 Stony Brook University, Global Health Institute, 100 Nicholls Road, Stony Brook, NY 11794, 43 27 USA 44 28 5 Centre ValBio Research Station, BP 33 Ranomafana, Ifanadiana, Madagascar 45 29 6 Centre de Recherche du Centre Hospitalier de l’Université de Montréal, 900 Saint-Denis, 46 30 Montréal, QC H2X 3H8, Canada 47 31 48 49 32 CORRESPONDING AUTHOR 50 51 52 33 Simon Grandjean Lapierre 53 34 [email protected] 54 35 +1 514 743 7255 (Canada) 55 36 +261 34 32 632 47 56 57 58 59 1 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 46
1 2 3 37 4 5 38 WORD COUNT 6 7 8 39 Abstract: 298 9 40 Manuscript: 3846 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 2 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 46 BMJ Open
1 2 3 4 41 ABSTRACT 5 6 7 42 Introduction 8 9 43 Poor road and communication infrastructure pose major challenges to TB (tuberculosis) control 10 11 44 in many regions of the world. TB surveillance and patient support often fall to Community 12 13 14 45 Health Workers (CHWs) who may lack the time or knowledge needed for this work. To meet 15 16 46 the End TB StrategyFor goal of reducingpeer tuberculosis review incidence byonly 90% by 2035, the World Health 17 18 47 Organization calls for intensified research and innovation including the rapid uptake of new 19 20 21 48 tools, interventions and strategies. Technologies that “leapfrog” infrastructure challenges and 22 23 49 support CHWs in TB control responsibilities have the potential to dramatically change TB 24 25 50 outcomes in remote regions. Such technologies may strengthen TB control activities within 26 27 51 challenged national tuberculosis treatment and control programs (NTPs), and be adapted to 28 29 30 52 address other public health challenges. The deployment of innovative technologies needs to be 31 32 53 differentially adapted to context-specific factors. The Drone Observed Therapy System (DrOTS) 33 34 54 project was launched in Madagascar in 2017 and integrates a bundle of innovative technologies 35 36 37 55 including drones, digital adherence monitoring technology, and mobile device-based educational 38 39 56 videos to support tuberculosis control. 40 41 57 Methods and analysis 42 43 44 58 This mixed methods study gathers and analyses cultural perceptions of the DrOTS project 45 46 59 amongst key stakeholders: patients, community members, community health workers, village 47 48 60 chiefs and NTP-DrOTS mobile health teams. Data from questionnaires, semi-structured 49 50 51 61 interviews, focus group discussions, and ethnographic observation gathered from June 2018 to 52 53 62 June 2019 are thematically analysed and compared to identify patterns and singularities in how 54 55 56 57 58 59 3 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 46
1 2 3 63 DrOTS stakeholders perceive and interact with DrOTS technologies, its enrollment processes, 4 5 6 64 objectives, and team. 7 8 65 Ethics and dissemination 9 10 66 Ethics approval was obtained from the National Bioethics Research Committee of Madagascar 11 12 13 67 and Stony Brook University institutional review board. Study results will be submitted for peer- 14 15 68 reviewed publication. In Madagascar, results will be presented in person to Ministry and other 16 For peer review only 17 69 Malagasy decision-makers through the Institut Pasteur de Madagascar. 18 19 20 70 21 22 71 Patient and Public Involvement 23 24 72 This study is designed to foreground the voices of patients and potential patients in the DrOTS 25 26 27 73 program. CHW participants in this study also supported the design of study information sessions 28 29 74 and recruitment strategies. One member of the mobile health team provided detailed input on the 30 31 75 wording and content of FGD and interview guides. Study findings will be presented via a report 32 33 76 in French and Malagasy to CHW, mobile health team, and other village-level participants who 34 35 36 77 have email/internet access. 37 38 78 Keywords 39 40 79 drones, tuberculosis, biomedical technology, global health, medication adherence, Madagascar 41 42 43 80 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 4 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 46 BMJ Open
1 2 3 4 81 STRENGHTS AND LIMITATIONS OF THIS STUDY 5 6 TM 7 82 . This study is one of the first to assess acceptance and perceptions of drones and evriMED 8 9 83 pillboxes (medication reminder and digital remote treatment adherence monitoring devices), 10 11 84 technologies currently being considered for scale-up in several health systems around the 12 13 14 85 world. The bundle of technologies at the core of this study is one that could be applied in 15 16 86 response to otherFor health needspeer in other reviewcontexts. only 17 18 87 . Qualitative methods facilitate detailed and nuanced understanding of how and why 19 20 21 88 stakeholders with limited literacy and in remote settings perceive and use new technologies. 22 23 89 . Data is collected from a range of stakeholders and focused on those using these new 24 25 90 technologies on the front-lines in low-income countries (i.e. patients, national mobile 26 27 91 healthcare team members, community health workers, villagers). 28 29 30 92 . Findings from perception studies serve to deepen understanding of how contextual 31 32 93 particularities can impact on acceptance, perceptions of, and interactions with new 33 34 94 technologies but may not be generalizable across distinct settings and populations. 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 5 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 46
1 2 3 4 95 INTRODUCTION 5 6 7 96 Ten million people developed active TB disease in 2017 (1). To meet the End TB Strategy goal 8 9 97 of reducing incidence by 90% and mortality by 95% before 2035, the World Health Organization 10 11 98 (WHO) has called for intensified research and innovation including the rapid uptake of new 12 13 14 99 tools, interventions and strategies (2). In low- and middle-income countries (LMIC) that are 15 16 100 disproportionately moreFor affected peer by disease, review TB control can beonly hindered by any number of social 17 18 101 and structural factors, including limited access to centralized facilities for populations living 19 20 21 102 outside the capital, understaffed healthcare infrastructures, poor development of laboratory 22 23 103 diagnostic networks, or stigma influencing healthcare seeking behaviors and treatment adherence 24 25 104 (3, 4). In such contexts, diagnosis may be delayed or fail to occur at all, and implementation of 26 27 105 TB control essential strategies such as case finding, access to laboratory diagnosis, directly 28 29 30 106 observed therapy (DOT) and contact tracing by national tuberculosis control programs (NTPs) 31 32 107 becomes particularly challenging, increasing secondary transmission and fatalities (5). 33 34 108 In 2017, nearly 30,000 TB cases were reported in Madagascar (6). This corresponds to half of 35 36 37 109 actual cases to have occurred in the country, as estimated by WHO (6). Treatment adherence and 38 39 110 success rates are reported to be highly variable between regions of the country respectively 40 41 111 averaging 60% and 84% in the DrOTS intervention area and at national level (6, 7). Madagascar 42 43 44 112 exemplifies the challenges of quality TB care delivery for remote and dispersed populations as 45 46 113 40% of Malagasy people live more than five km from the nearest basic healthcare facility, with 47 48 114 no public transit system or even roads in many cases (8). TB diagnosis and treatment challenges 49 50 115 in Madagascar are representative of those in many areas of sub-Saharan Africa: (i) underserved 51 52 53 116 healthcare system; (ii) poverty and cultural norms hindering healthcare seeking; (iii) paucity of 54 55 117 human resource capacities with training in TB; (iv) paucity of diagnostic facilities; (v) 56 57 58 59 6 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 46 BMJ Open
1 2 3 118 suboptimal coverage of treatment and treatment follow-up; and (vi) high prevalence of two 4 5 6 119 important TB risk factors, i.e. malnutrition and indoor air pollution (5, 7, 9, 10). Conversely, 7 8 120 factors of good prognosis for TB control in Madagascar include very low rates of both MDR-TB 9 10 121 infection and HIV-TB co-infection in the country (6, 11). 11 12 122 To leapfrog over theses impediments to quality TB care, the Drone Observed Therapy System 13 14 15 123 (DrOTS) project was co-initiated with the Malagasy NTP and was deployed by Stony Brook 16 For peer review only 17 124 University’s Global Health Institute in collaboration with the Pasteur Institute of Madagascar. 18 19 125 The project was implemented in 61 randomly selected villages in Androrangavola commune, 20 21 22 126 south-eastern Madagascar, in August 2017. Up to 70% of the approximately 27,000 inhabitants 23 24 127 living in Androrangavola commune live more than 5 km away from the closest healthcare 25 26 128 facility, and that facility in turn is situated more than one day’s walk from the closest TB 27 28 29 129 diagnosis center (12). DrOTS involves an NTP-DrOTS mobile health team consisting of TB 30 31 130 nurses and doctors that collaborate with local community health workers (CHWs). DrOTS 32 33 131 implements active case finding and supports TB screening, diagnosis, counselling and treatment 34 35 36 132 supervision within communities using a suite of technologies: drones, evriMED pillboxes, and 37 38 133 tablet-based educational videos. In this scheme, drones increase access to diagnosis and care by 39 40 134 facilitating specimen transport and securing the medication supply chain between diagnosis and 41 42 43 135 treatment centers and remote communities; the evriMED supports TB treatment adherence and 44 45 136 monitoring by beeping when patients need to take their medication, and tracking for healthcare 46 47 137 providers when the evriMED has been opened (equated with dose being taken); and a tablet- 48 49 50 138 based eHealth video curriculum supports patients and CHWs by providing key information on 51 52 139 TB care and prevention at every step of the pathway to cure. Given the novelty of this new 53 54 55 56 57 58 59 7 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 46
1 2 3 140 approach we designed and here present a study protocol for the DrOTS perception study, a 4 5 6 141 mixed-method cultural acceptability sub-study embedded within the DrOTS project. 7 8 142 Several organizations are exploring the economic and practical feasibility of using drones for 9 10 143 healthcare purposes including: support to rescue missions in disasters; enhanced epidemiological 11 12 144 monitoring for disease outbreaks and vectors; delivery of critical resources such as blood or 13 14 15 145 defibrillators in emergencies; delivery of other routine and occasional medical payloads such as 16 For peer review only 17 146 samples for laboratory analysis, vaccines, medication and supplies for community healthcare 18 19 147 centres (13-18). Medication reminder and remote treatment adherence monitoring devices, such 20 21 TM 22 148 as the EvriMED pillbox, may augment treatment adherence and facilitate more effective 23 24 149 allocation of limited HCP resources in contexts where populations are hard to reach, or health 25 26 150 systems under-resourced (19-21). While the potential of new digital technologies to transform 27 28 29 151 healthcare is enormous, this potential is contingent on user- and context-specific needs, 30 31 152 engagements with technologies and digital health strategies, and may imply different impacts 32 33 153 and challenges in different contexts (22). 34 35 154 This study will shed light on cultural and individual perceptions, barriers and facilitators to 36 37 38 155 implementation of the unique bundle of technologies that make up the DrOTS system. To 39 40 156 facilitate the implementation of such innovative technologies, other challenges such as sustained 41 42 157 funding, creation of a LMIC-riendly market environment for drone supplies and aviation 43 44 45 158 regulation approval also need to be overcome: such barriers are not be addressed here. 46 47 159 48 49 160 Rationale 50 51 52 161 Determining the success of the DrOTS project cannot be limited to evaluation of its impacts on 53 54 162 additional TB notifications or completed treatments. Though such measures are central to 55 56 57 58 59 8 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 46 BMJ Open
1 2 3 163 establishing the value and potential of innovative technologies in the global fight against TB, the 4 5 6 164 success of innovative public health strategies is also contingent on how those on the receiving 7 8 165 end of these perceive and engage with its objectives, enrollment, participation processes and 9 10 166 technologies. The DrOTS perception study aims to build expertise on how to implement new 11 12 167 technologies in a way that is acceptable to individuals and communities that lack close or 13 14 15 168 affordable access to TB diagnosis and treatment, have no prior exposure to such technologies, 16 For peer review only 17 169 and may harbor understandings of TB that limit management of presumptive or confirmed 18 19 170 infections. Attending to these contextual and lived particularities of the DrOTS project is key to 20 21 22 171 designing and planning feasible and effective scale-up. Recently published WHO guidelines will 23 24 172 certainly help TB control programs choosing and implementing digital adherences monitoring 25 26 173 technologies (22). At present, there exists no ethical or practical guidance on the contextually- 27 28 29 174 sensitive use of such technologies or for the use of drones for disease diagnosis and treatment. 30 31 175 This study can inform needed evidence-based guidance for the future expansion of such 32 33 176 technology suites poised to strengthen TB programs and healthcare systems more generally. 34 35 177 36 37 178 Primary objectives 38 39 179 1. To identify prevalent perceptions (e.g. perceived benefits, concerns, misunderstandings) 40 41 180 related to the various technological and programmatic aspects of the DrOTS project at the 42 43 44 181 level of TB patients, members of patient households, other village members, community 45 46 182 health workers, village chiefs and NTP-DrOTS mobile health team. 47 48 183 2. To generate a description of how and why individuals, families, and villages are interacting 49 50 184 with specific components of the DrOTS project in unanticipated ways. 51 52 53 185 54 55 56 57 58 59 9 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 46
1 2 3 186 Secondary objectives 4 5 6 187 1. To establish rates and demographic distribution of understandings of and interactions with 7 8 188 the various technological and programmatic aspects of the DrOTS project. 9 10 189 2. To generate understandings of how and based on what factors individuals, families, and 11 12 190 villages are deciding whether or not to participate in the DrOTS project. 13 14 15 191 3. To develop a set of evidence-based cultural and contextual considerations that can inform 16 For peer review only 17 192 the implementation of similar technology-mediated diagnostic and treatment in other 18 19 193 regions of Madagascar and in other national contexts. 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 10 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 46 BMJ Open
1 2 3 4 194 METHODS AND ANALYSIS 5 6 7 195 Study design 8 9 196 The DrOTS perception study is a mixed-methods study involving cross-sectional data collection 10 11 197 through (i) questionnaires (~750), (ii) focus group discussions (FGDs, ~19), (iii) semi-structured 12 13 14 198 in-depth interviews (~24), and (iv) ethnographic observation (Figure 1). Quantitative questionnaire 15 16 199 data are collected throughoutFor peer the DrOTS projectreview period (November only 2017 – December 2018) as 17 18 200 well as an additional 6 months after project end for follow-up of TB patients adhering to a 6- 19 20 21 201 months treatment regimen. Data collection for the qualitative part is initiated in June 2018 with a 22 23 202 first village visit, followed by visits in the second and third village in August and November 2018, 24 25 203 respectively. Ethnographic observation occurs between June and July 2018. All study tools were 26 27 204 developed by content experts in dialogue with members of the DrOTS team responsible for 28 29 30 205 community engagement and/or familiar with local dialect and customs in Androrangavola 31 32 206 commune. 33 34 207 35 36 208 Questionnaire survey 37 38 209 The use of the questionnaire survey in this mixed methods study aims to support measurement 39 40 210 and comparison of key acceptability indicators between different study sub-groups (e.g. patients 41 42 211 vs. non-patients, most educated vs. least educated). The questionnaire is being administered to 43 44 45 212 different groups including: patients, members of patient households, other village members, 46 47 213 community health workers, village chiefs and NTP-DrOTS mobile health teams. 48 49 214 Two questionnaires are being used: (i) DrOTS baseline questionnaire conducted with 50 51 52 215 presumptive and confirmed TB cases, other village members and CHWs (see Supplementary 53 54 216 material 1 – DrOTS Perception Study Baseline Questionnaire), and (ii) DrOTS end-of-treatment 55 56 57 58 59 11 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 46
1 2 3 217 questionnaire conducted with confirmed TB cases (see Supplementary material 2 – DrOTS 4 5 6 218 Perception Study End of Treatment Questionnaire). Questionnaires are administered verbally by 7 8 219 members of the NTP-DrOTS mobile health team to 10-15 individuals aged ≥15 years in each of 9 10 220 the DrOTS-participating villages, amounting to a total of around 750 completed baseline 11 12 221 questionnaires. The sample size was calculated based on (i) a total population size of 27,000 in 13 14 15 222 Androrangavola commune, (ii) on the assumption that 50% reply ‘Yes’ to one main question on 16 For peer review only 17 223 drone perception (i.e. “Do you think that the drones bring something positive to your 18 19 224 community?“, (iii) a 95% confidence level, and (iv) a 10% drop-out rate. This resulted in a 20 21 22 225 sample size of 417. However, the overall DrOTS-project design, lifespan and geographic 23 24 226 coverage allowed us to sample a larger population. All self-presenting presumptive (including 25 26 227 later confirmed) TB cases and CHWs are purposively invited to answer the baseline 27 28 29 228 questionnaire, with remaining participants being randomly recruited in each DrOTS village. This 30 31 229 questionnaire provides quantitative data on basic socio-demographic characteristics, travel 32 33 230 history, TB risk factors, TB related health seeking behavior, medical history, knowledge on TB 34 35 231 and behaviors towards TB. An end-of-treatment questionnaire is administered to all enrolled TB 36 37 38 232 patients upon completion of treatment. This questionnaire addresses specific perceptions of 39 40 233 drones, evriMED and educational videos. Questionnaire data are collected using tablet-based 41 42 43 234 Open Data Kit (ODK) software standardized form. 44 45 235 46 47 236 Focus Group Discussions 48 49 50 237 FGD-based qualitative data collection is taking place in three of the 61 DrOTS participating 51 52 238 villages as well as with the NTP-DrOTS mobile health team. Villages for the running of FGDs 53 54 239 are selected based on: (1) participation in the DrOTS project for at least three months; (2) 55 56 57 58 59 12 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 46 BMJ Open
1 2 3 240 accessibility for the qualitative research team, meaning within a day’s hike from the closest 4 5 6 241 vehicle-accessible town; (3) willingness to host the DrOTS perception team. Collecting data in 7 8 242 three villages enables comparison of reported perceptions and acceptability of new technologies 9 10 243 across villages, the possibility for diversity in perceptions to be captured. Furthermore, even 11 12 244 where similarities exist, a more nuanced understanding of how village specific characteristics, 13 14 15 245 such as access to livelihood activities, norms of post-secondary education achievement, and 16 For peer review only 17 246 historical relations to outsiders travelling in the region (e.g. for mining or development 18 19 247 initiatives) may shape perceptions of the DrOTS project. 20 21 22 248 23 24 249 Sampling of FGD participants is purposive and randomized. It is purposive inasmuch as we are 25 26 27 250 aiming to gather perceptions from a range of individuals who have engaged with DrOTS first- 28 29 251 hand. For FGDs, we also aim to have an equal representation of men and women, and an equal 30 31 252 representation across age groups in villages, towards capturing potential diversity in experiences 32 33 253 of DrOTS based on diverse levels or types of responsibility in the home and village. Villagers 34 35 36 254 willing to partake in a FGD provide their names to the research team, and may or may not be 37 38 255 randomly selected to join the FGD organized for their age and gender group. Randomized 39 40 256 selection of village FGD participants avoids burdening CHWs or other leaders with the task of 41 42 43 257 identifying potential participants (which could also potentially result in biased responses tied to 44 45 258 particular village interests). Also, in our experience, many are interested in participating in 46 47 259 FGDs, and this randomized selection ensures all those interested have and know they have an 48 49 50 260 equal chance of being selected (names of volunteers drawn from hat at village meeting). 51 52 261 Homosociality and age-group separation are dominant norms guiding social interaction in this 53 54 262 part of Madagascar. Hence, to facilitate participants feeling at ease and to limit the possibility of 55 56 57 58 59 13 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 46
1 2 3 263 social hierarchies in a FGD over-determining who feels able to express their view in a group, 4 5 6 264 FGDs are being organized along age and gender lines: married men, married women, unmarried 7 8 265 men, unmarried women, elder men, elder women (Table 1). FGDs are run using a standard set 9 10 266 of questions organized into two parts. Part I focuses on deepening the understanding of the 11 12 267 participants' day to day definition and management of illness and understandings of TB prior to 13 14 15 268 DrOTS and part II focuses on perceptions and interactions with DrOTS. The set of questions for 16 For peer review only 17 269 the NTP-DrOTS mobile health team FGD is distinct, and probes members' understanding and 18 19 270 concerns related to DrOTS, as well as perceptions of cultural and village-specific attitudes, 20 21 22 271 knowledge, and engagements with specific aspects of DrOTS pilot project based on work in all 23 24 272 villages (see Supplementary material 3 – DrOTS Perception Study Focus Group Discussion 25 26 273 Guide). All FGDs are moderated and/or supervised by an experienced medical anthropologist 27 28 29 274 and conducted in Malagasy local dialect with the help of a translator. With participants' 30 31 275 permission, these are digitally recorded. 32 33 276 34 35 277 Table 1 - Focus group discussion recruitment plan, DrOTS perception study, Madagascar, 36 37 38 278 2017-2019 39 40 279 41 42 280 Semi-structured in-depth interviews 43 44 45 281 Semi-structured in-depth interviews gather information on different stakeholders’ knowledge of, 46 47 282 attitudes towards, uses and first-hand experiences of the DrOTS project that cannot be gleaned 48 49 283 from questionnaires, and may be too sensitive or detailed to emerge in FGDs (Supplementary 50 51 52 284 material 4 – DrOTS Perception Study Semi-Structured Interview Guide). Recruitment is 53 54 285 purposive and targets in each village four categories of key stakeholders: (1) DrOTS project- 55 56 57 58 59 14 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 46 BMJ Open
1 2 3 286 enrolled adult patients (over 15 years of age); (2) adults who presented for TB testing to the 4 5 6 287 DrOTS team but have received negative diagnostic testing results; (3) villagers hesitant, unable 7 8 288 or have declined to join the project; (4) CHWs; (5) village leaders, including kings and elected 9 10 289 district chiefs. All participants except for participants from category (3) are being identified with 11 12 290 help from the NTP-DrOTS mobile team. Participants in category (3) are invited to self-identify 13 14 15 291 in the process of FGDs and may be identified by other interview participants using “snowball 16 For peer review only 17 292 sampling”. An estimated eight interviews will be performed in the same sub-set of three villages 18 19 293 as FGDs for a total of 24 interviews (Table 2). Additional interviews are performed with TB 20 21 22 294 confirmed cases outside the included villages to increase the number of DrOTS-enrolled patients. 23 24 295 25 26 296 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 15 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 46
1 2 3 297 Table 2 – Semi-structured interview recruitment plan 4 5 6 298 7 8 299 Ethnographic observation 9 10 300 An anthropology trainee will seek permission to stay with one DrOTS patient in their village 11 12 301 over a two-week period in order to better understand, through ethnographic observation, how 13 14 15 302 that individual lives with TB disease on a daily basis and interacts with DrOTS. The trainee will 16 For peer review only 17 303 keep a record of what they notice and learn (field notes), attending to: (1) ways in which 18 19 304 patients, villagers, village leaders, the CHW in the village, or any members of the mobile health 20 21 22 305 team present in this two-week period discuss DrOTS with the patient or one another, (2) 23 24 306 technical, practical community or individual level challenges, (3) any differences or similarities 25 26 307 in attitudes or beliefs about the DrOTS pilot project study expressed in informal conversation 27 28 29 308 about the project and/or its technologies and, (4) contextualized information about how the 30 31 309 patient at the centre of this observation views and uses DrOTS technologies. Ethnographic 32 33 310 observation often occurs over a period of months or even years; however, even shorter 34 35 311 applications of this method can build contextual understanding of healthcare projects. Use of this 36 37 38 312 method in this study may confirm or reveal gaps in the information gathered through the other 39 40 313 data collection methods, and serve to identify questions for future research. 41 42 314 43 44 45 315 Analysis 46 47 316 Questionnaire quantitative data will be descriptively analyzed using STATA version 14.0 (Stata 48 49 317 Corporation, College Station, USA) and will address and compare levels of acceptability 50 51 52 318 between groups. 53 54 55 56 57 58 59 16 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 46 BMJ Open
1 2 3 319 Interviews and FGDs will be transcribed and translated into English by a professional Malagasy 4 5 6 320 translator mastering the field study site local dialect. Transcripts will be uploaded into Nvivo 7 8 321 12.0 (QSR; Melbourne, Australia) and be subjected to thematic analysis. Categories of enquiry in 9 10 322 interview and FGD guides will form the basis for an initial coding structure. Three semi- 11 12 323 structured interviews will then be independently coded by two investigators to test and adjust this 13 14 15 324 structure in light of the data, adding themes to account for unanticipated but relevant content. In 16 For peer review only 17 325 an iterative process, minor adjustments and additions (e.g. change in theme names or merging of 18 19 326 themes) to the codebook will be made when needed. Key themes and sub-themes contents will 20 21 22 327 be summarized and reviewed to allow linkage of quantitative and qualitative data, clearly 23 24 328 identify themes with exemplary quotes, raise questions and concerns, and inform guidelines for 25 26 329 culturally and contextually sensitive technology implementations. Ethnographic field notes will 27 28 29 330 not be coded but will inform the analysis by providing support to findings from the interviews 30 31 331 and FGDs, and/or by identifying gaps knowledge gaps. 32 33 332 34 35 36 333 ETHICS AND DISSEMINATION 37 38 39 334 This study received institutional review board (IRB) approval from both the “Comité 40 41 42 43 335 d’Éthique de la Recherche Biomédicale” from the Ministry of Public Health in 44 45 46 336 Madagascar, Madagascar (073-MSANP/CERBM) and Stony Brook University, New 47 48 49 50 337 York, USA (CORIHS# 2017-4056-F). Following project and technology sensitization 51 52 53 338 visits and in accordance with cultural norms, consent is obtained from the local leaders to 54 55 56 57 58 59 17 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 46
1 2 3 339 present this research project to villagers under their responsibility before engaging in any 4 5 6 340 activities within villages. Though limited literacy is widespread in this region of Madagascar, as 7 8 341 per national research ethics norm, consent forms are read and explained to participants and 9 10 342 written informed consent is obtained from any and all parties agreeing to participate before 11 12 343 conducting interviews, focus groups, and observations. Data are being anonymized rendering 13 14 15 344 participants’ identification from dissemination material impossible. Participants in this 16 For peer review only 17 345 perceptions study do not face any different health care as a result of participation. All patients 18 19 346 diagnosed with TB within the DrOTS projects are treated for free in accordance with national 20 21 22 347 NTP and WHO guidelines. 23 24 348 One issue that requires managing in such a study is the risk of social stigma for participants. TB 25 26 27 349 and association with TB are stigmatized in contexts around the world, and well-documented in 28 29 350 Sub-Saharan Africa (e.g., 3, 4, 23-25). While there is no evidence of TB stigma in the Malagasy 30 31 351 context of our research, we are adopting strategies to mitigate the risk of TB-related stigma 32 33 352 developing for participants in our TB-focused study. In our initial meeting with community 34 35 36 353 health workers (CHWs) in each village, we are stressing our interest in speaking with DrOTS- 37 38 354 enrolled patients (TB active) but also our commitment to keeping the TB-active status of these 39 40 355 patients private. We will be working with CHWs in villages to identify strategies to protect the 41 42 43 356 TB-active status of any patients we interview. In presenting the study to the entire village, we are 44 45 357 stressing our interest in understanding the villagers’ – and not just presumptive or confirmed TB 46 47 358 positive individuals’ - perceptions of the DrOTS programme. The number of individuals, 48 49 50 359 including respected elders, and range of visible healthiness of those who are participating in 51 52 360 either an interview or FGD in each village does reduce the possibility of a single individual 53 54 361 amongst a village’s participants being associated with TB. We will not carry out the 55 56 57 58 59 18 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 46 BMJ Open
1 2 3 362 ethnographic observation component of this study if doing so risks rendering public a currently 4 5 6 363 private TB diagnosis. 7 8 364 9 10 11 365 Results of the DrOTS perception study will be submitted for peer-review publication. A two- 12 13 366 page summary of results will be prepared in French and Malagasy and included as an appendix 14 15 367 to the results paper, and shared with participants and collaborators for whom we have contact 16 For peer review only 17 18 368 information. In Madagascar, results will be presented in person to Ministry and other Malagasy 19 20 369 decision-makers through the Institut Pasteur Madagascar. 21 22 370 23 24 25 371 DISCUSSION 26 27 28 372 This study responds to a current gap in knowledge on the feasibility and cultural acceptability of 29 30 373 using a new suite of technologies including evriMEDTM, drones and tablet-mediated video 31 32 33 374 education to support improved TB diagnosis and treatment in remote populations. Digital 34 35 375 technologies that enable remote monitoring and faster delivery of medical care and supplies are 36 37 376 potential game changers for healthcare landscapes struggling with long-standing or temporary 38 39 377 (e.g. due to disasters) barriers to healthcare delivery. Still, the development of innovative 40 41 42 378 healthcare technologies does not guarantee their enthusiastic and rapid adoption in diverse 43 44 379 settings (26-28). Perceived benefits and risks, use, and challenges of adopting such innovation is 45 46 380 not likely to be uniform across distinct socio-cultural, health system, and economic settings. 47 48 49 381 These may vary depending on any number of factors, including (to name just a few) the presence 50 51 382 or lack of alternative options for care, association of use with a context-specific stigmatized 52 53 383 condition, as well as prior direct or rumored experiences with interventions deemed to be similar 54 55 56 384 in some way to the new ones. There is inherent ethical complexity in using devices such as 57 58 59 19 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 46
1 2 3 385 drones for “surgical strikes” on “wicked” global health challenges, if key determinants of poor 4 5 6 386 health remain unaddressed (29). Recent studies conducted with intended users and ‘beneficiaries’ 7 8 387 of new digital health systems in LMIC contexts reveal other context- and culture-specific 9 10 388 concerns or limitations of these technologies, such as concerns these could dehumanize 11 12 389 assistance (28), infringe on private spaces (30), and be too expensive for some governments (30). 13 14 15 390 Findings from the DrOTS cultural acceptability study may or may not reveal similar concerns in 16 For peer review only 17 391 the Malagasy context, and will be situated within growing literature on perceptions and 18 19 392 acceptability of TB remote digital medical monitoring and adherence strategies. 20 21 22 393 23 24 394 While focused on one project in Madagascar, the DrOTS perception study provides a model for 25 26 395 attending to contextual factors that may affect target population support and intended interactions 27 28 29 396 with any number of other new public health initiatives around the world. Embedding such 30 31 397 perception studies within projects is particularly important for initiatives conceptualized based 32 33 398 on the theoretical but as of yet unproven potential of new technologies. While findings from 34 35 399 perceptions studies on new innovative technology-mediated health projects may not be readily 36 37 38 400 generalizable, as each setting is unique, such studies can generate learning that is transferable to 39 40 401 other settings by drawing attention to the range of factors that may impact on technology 41 42 402 adoption and interaction, and by shedding light on how others on the front line of innovative 43 44 45 403 projects have sensitively navigated the cultural, social, political, and ethical complexities of 46 47 404 particular contexts. In these ways, perceptions studies that "localize" understandings of how 48 49 405 theoretically promising new technologies work in specific locales have an important role to play 50 51 52 406 in informing evidence-based guidance for context-sensitive implementation and scale-up of 53 54 407 programs such as DrOTS around the world. 55 56 57 58 59 20 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 46 BMJ Open
1 2 3 408 4 5 6 409 Limitations and potential challenges 7 8 410 The significance of results from this study will be difficult to ascertain given limited research on 9 10 11 411 drone supported TB or other public health programs at this juncture. Future research on similar 12 13 412 programs introduced in Madagascar or elsewhere will be helpful in assessing the generalizability 14 15 413 of our eventual results to other regions and populations where such technologies for increased 16 For peer review only 17 18 414 healthcare provision are being introduced. This study does not include interviews or FGDs with 19 20 415 National TB program policy-makers and decision-makers. Understanding rationales underlying 21 22 416 government approval of pilot programs such as DrOTS amongst individuals working for national 23 24 417 TB control in the country, as well as the challenges and perception of outcomes and impact 25 26 27 418 amongst these stakeholders constitute equally important research as we work towards clarifying 28 29 419 what it means to develop context-appropriate use of innovative technologies in TB control. 30 31 32 420 Respondents may over-emphasize positive perceptions of DrOTS. Social desirability bias is a 33 34 421 challenge in perceptions studies, especially where there may be unspoken assumption amongst 35 36 422 participants that their responses to study questions could negatively impact future programs (31). 37 38 39 423 Our work across multiple villages will increase our ability to detect and probe overly positive 40 41 424 accounts from participants. We are confident in the study’s design and its ability to generate 42 43 425 accurate and detailed insight into perceptions of DrOTS; however, we recognize the possibility 44 45 426 that with a focus on only three of the 61 DrOTS-enrolled villages, our qualitative data collection 46 47 48 427 may not capture the full range of perceptions that may be present amongst Malagasy villagers 49 50 428 enrolled in DrOTS. 51 52 53 429 54 55 430 56 57 58 59 21 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 46
1 2 3 431 4 5 6 432 AUTHOR CONTRIBUTIONS 7 8 9 10 433 All authors meet criteria for authorship as per the ICJME recommendations. EN, AMK, 11 12 13 434 IP, NR, PS, AA & SGL designed study protocol and data collection tools. EN, IP, AA, 14 15 16 For peer review only 17 435 KR, FAR, MR, JM, NR & SGL are involved in field implementation and data collection. 18 19 20 436 EN, AMK, IP, AA, PW, PS & SGL are involved in data management & interpretation. All 21 22 23 24 437 authors have read and approved the final version of the manuscript before submission. 25 26 27 438 28 29 439 FUNDING 30 31 32 33 440 The DrOTS project was supported by the Stop TB Partnership’s TB REACH initiative and was 34 35 441 funded by the Government of Canada. Ian Passe receives financial support from the Stony Brook 36 37 442 University Undergraduate Research & Creative Activities Award program. AMK is supported by 38 39 443 the Rudolf Geigy Foundation, Swiss Tropical and Public Health Institute, Basel, Switzerland. 40 41 42 444 Elysée Nouvet receives financial support from the Western University Faculty Development 43 44 445 Fund Grant program. SGL is supported by the Canadian Association for Microbiology and 45 46 446 Infectious Diseases. 47 48 49 447 50 51 52 53 54 55 56 57 58 59 22 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 46 BMJ Open
1 2 3 4 448 COMPETING INTEREST 5 6 7 449 Authors declare no financial or personal relationships with other people or organizations 8 9 10 11 450 that could inappropriately influence this work. The authors have no relationship and 12 13 14 451 obtained no funding for this study from the developers of evriMEDTM. The first and 15 16 For peer review only 17 18 452 corresponding author had full access to all the data in the study and had final 19 20 21 453 responsibility for the decision to submit this work for publication. 22 23 24 454 25 26 455 ACKNOWLEDGEMENTS 27 28 29 456 We are grateful to the DrOTS project Malagasy team including community healthcare workers 30 31 457 involved in patient and data management. We also thank the Madagascar’s National 32 33 458 Tuberculosis Control Program personnel for their collaboration, reviewers Kevin Schwartzman 34 35 36 459 and Dennis Falzon for their careful review and feedback on this protocol paper, and Dr. Mamy 37 38 460 Fiononana Ratofotera Raelison for his feedback on the study tools. 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 23 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 46
1 2 3 4 461 REFERENCES 5 6 7 462 1. WHO. Global TB Report. 2018. 8 9 463 2. WHO. WHO end TB strategy. 2016. WHO, Geneva, Switzerland. 2016. 10 11 464 3. Chimbatata NBW, Zhou CM, Chimbatata CM, Xu B. Post-2015, why delay to seek healthcare? 12 13 14 465 Perceptions and field experiences from TB healthcare providers in northern Malawi: a qualitative 15 16 466 study. Infect Dis PovertyFor 2017;6(1):60. peer review only 17 18 467 4. Cramm JM, Finkenflugel HJ, Moller V, Nieboer AP. TB treatment initiation and adherence in a 19 20 21 468 South African community influenced more by perceptions than by knowledge of tuberculosis. 22 23 469 BMC Public Health 2010;10:72. 24 25 470 5. Yates TA, Khan PY, Knight GM, et al. The transmission of Mycobacterium tuberculosis in high 26 27 471 burden settings. Lancet Infect Dis 2016;16(2):227-38. 28 29 30 472 6. WHO. Country Tuberculosis Profile - Madagascar. 2017. 31 32 473 7. MSANP, DGS, DLT. Plan stratégique national de lutte contre la tuberculose à Madagascar 33 34 474 2015-2019. Antananarivo: Ministère de la Santé Publique, Direction Générale de la Santé, 35 36 37 475 Direction de Luttre contre la Tuberculose 2015. 38 39 476 8. Ratovonirina NH, Rakotosamimanana N, Razafimahatratra SL, et al. Assessment of tuberculosis 40 41 477 spatial hotspot areas in Antananarivo, Madagascar, by combining spatial analysis and genotyping. 42 43 44 478 BMC Infect Dis 2017;17(1):562. 45 46 479 9. Barmania S. Madagascar's health challenges. Lancet 2015;386(9995):729-30. 47 48 480 10. INSTAT, ICF Macro. Enquête démographique et de santé 2008-2009. Antananarivo: Institut 49 50 481 National de la Statistique and ICF Macro; 2010. 51 52 53 482 11.UNAIDS. HIV Country Profile - Madagascar 2016. 2016. 54 55 483 12.Miller AC, Ramananjato RH, Garchitorena A, et al. Baseline population health conditions 56 57 58 59 24 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 46 BMJ Open
1 2 3 484 ahead of a health system strengthening program in rural Madagascar. Glob Health Action 4 5 6 485 2017;10(1):1329961. 7 8 486 13. Claesson A, Fredman D, Svensson L, et al. Unmanned aerial vehicles (drones) in out-of- 9 10 487 hospital-cardiac-arrest. Scand J Trauma Resusc Emerg Med;24(1):124. Published 2016 Oct 12. 11 12 488 doi:10.1186/s13049-016-0313-5 13 14 15 489 14. Harnett BM; Doarn CR; Rosen J; Hannaford B; Broderick TJ 2008. Evaluation of unmanned 16 For peer review only 17 490 airborne vehicles and mobile robotic telesurgery in an extreme environment. Telemedicine 18 19 491 journal and e-health 2008 14:539-544. 20 21 22 492 15. Katariya M, Chung DCK, Minifie T, et al. Drone inflight mixing of biochemical samples. 23 24 493 Analytical Biochemistry 2018;545(15):1-3. 25 26 494 16. McCall B. Sub-Saharan Africa leads the way in medical drones. The Lancet 2019;393: 27 28 29 495 (10166):17-18. DOI: 10.1016/S0140-6736(18)33253-7. 30 31 496 17. Médecins Sans Frontières. Innovating to reach remote TB patients and improve access to 32 33 497 treatment. MSF 2014 https://www.msf.org/papua-new-guinea-innovating-reach-remote-tb- 34 35 498 patients-and-improve-access-treatment (accessed October 02 2017). 36 37 38 499 18. UNICEF. Vanuatu announces drone trial participants to assess vaccine delivery in remote 39 40 500 islands. UNICEF 2017. https://reliefweb.int/report/vanuatu/vanuatu-announces-drone-trial- 41 42 501 participants-assess-vaccine-delivery-remote-islands (accessed October 02 2017). 43 44 45 502 19. Broomhead S, Mars M. Retrospective return on investment analysis of an electronic 46 47 503 treatment adherence device piloted in the Northern Cape Province. Telemed J E Health 2012; 48 49 504 18(1): 24-31. 50 51 52 53 54 55 56 57 58 59 25 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 46
1 2 3 505 20. Liu X, Lewis JJ, Zhang H, et al. Effectiveness of Electronic Reminders to Improve 4 5 6 506 Medication Adherence in Tuberculosis Patients: A Cluster-Randomised Trial. PLoS Med 2015; 7 8 507 12(9): e1001876. 9 10 508 21. Subbaraman R, de Mondesert L, Musiimenta A, et al. Digital adherence technologies for the 11 12 509 management of tuberculosis therapy: mapping the landscape and research priorities. BMJ Global 13 14 15 510 Health 2018;3:e001018. 16 For peer review only 17 511 22. WHO. Handbook for the use of digital technologies to support tuberculosis medication 18 19 512 adherence 2018. 20 21 22 513 23. Chikovore J, Hart G, Kumwenda M, Chipungu G, Desmond N, Corbett EL. TB and HIV 23 24 514 stigma compounded by threatened masculinity: implications for TB health-care seeking in 25 26 515 Malawi. Int J Tuberc Lung Dis. 2017;21(11):26–33. 27 28 29 516 24. Amo-Adjei J. Individual, household and community level factors associated with keeping 30 31 517 tuberculosis status secret in Ghana. BMC Public Health 2016;16(1):1196. 32 33 518 25. Deribew A, Abebe G, Apers L, et al. Prejudice and misconceptions about tuberculosis and 34 35 519 HIV in rural and urban communities in Ethiopia: a challenge for the TB/HIV control program. 36 37 38 520 BMC Public Health 2010;10:400. 39 40 521 26. Cazabon D, Suresh A, Oghor C, Qin ZZ, Kik SV, Denkinger CM, et al. Implementation of 41 42 522 Xpert MTB/RIF in 22 high tuberculosis burden countries: are we making progress? Eur Respir J 43 44 45 523 2017;50(2). 46 47 524 27. Campbell, JI, Eyal N, Musiimenta A, & Haberer, JE. Ethical Questions in Medical Electronic 48 49 525 Adherence Monitoring. Journal of general internal medicine 2015;31(3):338-42. 50 51 52 526 28. Soesilo D, Sandvik K. Drones in Humanitarian Action – A survey on perceptions and 53 54 527 applications 2016. Geneva: The Swiss Foundation for Mine Action (FSD). 55 56 57 58 59 26 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 46 BMJ Open
1 2 3 528 https://drones.fsd.ch/wp-content/uploads/2016/09/Drones-in-Humanitarian-Acion-Survey- 4 5 6 529 Analysis-FINAL21.pdf (accessed January 12 2018). 7 8 530 29. Peckham R, Sinha R. Anarchitectures of health: Futures for the biomedical drone. 9 10 11 531 Global Public Health 2018;15:1-16. 12 13 14 532 30. Eichleay M, Mercer S, Murashani J, Evens E. Using Unmanned Aerial Vehicles for 15 16 533 Development: PerspectivesFor from peer Citizens andreview Government Officials only in Tanzania 2016. ICT 17 18 534 Works: Durham, USA. https://www.ictworks.org/wp-content/uploads/2016/02/UAV-public- 19 20 21 535 perceptions-tanzania.pdf (accessed Jan 12 2018). 22 23 536 31. Nouvet E, Abu-Sada C, de Laat S, Wang C, Schwartz L. Opportunities, limits and challenges 24 25 537 of perceptions studies for humanitarian contexts. Canadian Jl of Development Studies. 26 27 538 2016;37(3). 28 29 30 539 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 27 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 46
1 2 3 541 4 5 6 542 7 543 8 544 TABLES 9 10 11 545 Table 1 - Focus group discussion recruitment plan, DrOTS perception study, Madagascar, 12 13 14 546 2017-2019 15 16 Location ForStakeholder peer group review onlyTarget # groups Participants/group 17 Village 1 Unmarried women 1 4 18 19 Unmarried men 1 4 20 Married women 1 4 21 Married men 1 4 22 23 Elderly women 1 4 24 Elderly men 1 4 25 Village 2 Unmarried women 1 4 26 27 Unmarried men 1 4 28 Married women 1 4 29 Married men 1 4 30 31 Elderly women 1 4 32 Elderly men 1 4 33 Village 3 Unmarried women 1 4 34 35 Unmarried men 1 4 36 Married women 1 4 37 Married men 1 4 38 39 Elderly women 1 4 40 Elderly men 1 4 41 National TB Program Mobile health unit team members 1 5 42 43 TOTAL 19 77 44 547 45 46 548 47 48 49 50 51 52 53 54 55 56 57 58 59 28 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 46 BMJ Open
1 2 3 549 Table 2 – Semi-structured interview recruitment plan, DrOTS perception study, 4 5 6 550 Madagascar, 2017-2019 7 8 Location Stakeholder group Participants 9 Sample village DrOTS enrolled patient 2 10 11 Villagers who tested negative for TB 2 12 Villagers hesitant, unable or who have declined DrOTS participation 2 13 Community health worker 1 14 15 Village leaders 1 16 TOTAL For peer review only 8 17 18 551 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 29 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 46
1 2 3 4 552 FIGURES 5 6 7 553 Figure 1 – Timelines, approaches and tools, DrOTS perception study, Madagascar, 2017-2019 8 9 554 10 11 555 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 30 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 31 of 46 BMJ Open
1 2 3 4 556 SUPPLEMENTARY MATERIAL 5 6 7 557 Supplementary material 1 – DrOTS Perception Study Baseline Questionnaire 8 9 558 10 11 559 Supplementary material 2 – DrOTS Perception Study End of Treatment Questionnaire 12 13 560 14 561 Supplementary material 3 – DrOTS Perception Study Focus Group Discussion Guide 15 16 For peer review only 17 562 18 563 Supplementary material 4 – DrOTS Perception Study Semi-Structured Interview Guide 19 20 21 564 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 31 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 46
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 249x170mm (300 x 300 DPI) 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 33 of 46 BMJ Open
1 2 3 DrOTS-Project: Baseline questionnaire 4 A. Basic socio-demographic information 5 Name of interviewer: 6 Interview date and start time: 7 Scan participant barcode (unique identifyer). 8 Name of commune: 9 10 Name of fokontany: 11 Name of village: 12 Is the participant considered a (1) TB suspect, (2) a non-suspect or (3) another community member? 13 Name of participant: 14 Gender of participant: 15 Date of birth of participant: 16 Age of participant: 17 What ethic group(s) do you belong to? 18 What is/are your religion(s)?For peer review only 19 What is your highest level of education? 20 What is/are your occupational activity/activities? 21 How many people live in your houshold?* (*Regular household members that usually/regularly live and sleep 22 in the household.) 23 How many children under the age of 5 years does your household have? 24 How many children aged 5-14 years does your household have? 25 How many children aged 5-14 years frequent school? 26 How many adults aged 15 years and older does your household have? 27 28 How many rooms does your household have? 29 How many rooms are used for sleeping? 30 How many people usually sleep in the same room with you? 31 Which of the following assets does your household or any of the regular household members possess? 32 Agricultural land 33 Livestock: zebu 34 Livestock: other 35 Bicycle 36 Generator 37 Radio 38 TV 39 Watch, wristwatch, clock 40 Toilet only for household members 41 Solar panel 42 Motorcycle 43 Bank account 44 Cell phone, telephone 45 Canoe, pirogue 46 Carpet 47 Internet access 48 Electricity 49 B. Travel history 50 Were you born in this village? 51 Since when do you live in this village? (year) 52 Where did you live before? 53 Do you ever travel outside of this village into other villages or towns? 54 To which locations do you travel? 55 How long have you been away on your last trip? 56 Number of days: 57 Number of weeks: 58 C. Risk factors 59 60 Do you currently smoke?
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1 2 3 On average, how many cigarettes (or other tobacco) do you smoke per day? 4 Do other members of your household smoke? 5 Where is the cooking done in your household? 6 What type of fuel does your household mainly use for cooking? 7 What type of cooking stove is used in your house? 8 D. TB-related health seeking behaviour 9 10 Which of the following symptoms do you currently have? 11 Cough 12 Cough with sputum or phlegm 13 Cough with blood 14 Difficulties breathing, shortness of breath 15 Chest pain 16 Episodes of fever 17 Night sweats 18 Weight loss For peer review only 19 The last time you were sick, where did you medical advice or treatment for your symptom(s)? 20 If not having sought treatment: Why did you not seek medical advice or treatment? 21 If not having sought treatment: What else did you do? 22 What care or treatment did you receive? 23 Where you satisfied with the care or treatment received? 24 If not satisfied: Why were you not satisfied? 25 If not having sought treatment at a health facility: Why did you not visit a health facility? 26 If having sought treatment at a health facility: Which health facility have you visited? 27 How long after your symptoms started did you seek medical advice or treatment? 28 Number of days: 29 Number of weeks: 30 How much time did it take you to get this care and/or treatment? 31 Number of hours: 32 Number of days: 33 How much ariary did you spend in total to get this care and/or treatment? 34 Do you currently take medication on a regular basis? 35 If yes, what medication do you currently take? 36 37 E. Knowledge on TB 38 Have you ever heard of an illness called tuberculosis? 39 Where have you heard about tuberculosis? 40 What do you think is the cause of tuberculosis? 41 When a person has tuberculosis, what could be the signs and symptoms the person has? 42 Do you think that tuberculosis can be transmitted from one person to another? 43 How can tuberculosis be transmitted from one person to another? 44 Do you think that the transmission of tuberculosis can be prevented/stopped? 45 How can the transmission from one person to another be prevented/stopped? 46 Do you think that tuberculosis can be healed? 47 How can tuberculosis be healed? 48 F. Medical history related to TB 49 Have you ever been tested for tuberculosis? 50 Have you ever been in contact with someone that had tuberculosis? 51 What relationship(s) did you have to that person or those persons? 52 Has anyone in your household been treated for tuberculosis in the past 2 years? 53 Have you personally, in the past, ever had tuberculosis or been treated for tuberculosis? 54 55 If yes, did you complete treatment (6 months)? 56 G. Behaviour towards TB 57 Please indicate, whether you agree or disagree with the following statements: 58 I believe that anyone/everybody can get TB 59 I would share food or drink with someone who has TB 60 I would sleep in the same room with someone who has TB
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1 2 3 If a member of my family gets TB, I would like to keep it a secret 4 I would keep distance from someone who has TB 5 I am afraid of someone who has TB 6 I believe that someone who has TB is disgusting 7 I believe that community members behave differently to someone who has TB 8 I believe that someone who has TB is isolated/alone in our community 9 I believe tuberculosis is a big problem in our community 10 H. End of the interview 11 Do you have any questions for me? 12 Coordinates: 13 14 Other comments or observations by the interviewer: 15 Time end of interview: 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 DrOTS-Project: End of treatment questionnaire 4 A. Basic socio-demographic information 5 Name of interviewer: 6 Interview date and start time: 7 Scan barcode of patient (unique identifyer). 8 Name of commune: 9 10 Name of fokontany: 11 Name of village: 12 Name of patient: 13 Gender of patient: 14 Weight of the patient: 15 B. Treatment follow-up 16 evriMED: 17 Discuss with the patient: 18 1. If everything went wellFor with the peer evriMED. review only 19 2. If applicable, discuss results from the last evriMED output. 20 3. Record number of daily doses (i.e. pills) remaining: 21 The patient has been shown all relevant videos. 22 Which DrOTS technologies have you been exposed to? 23 (1) Drones 24 (2) evriMED 25 (3) Videos 26 C. Drones 27 Did you know that a drone was coming to your village before you saw it? 28 If yes, how did you find out about the drone coming to your village? 29 Were you afraid when you first saw the drone flying? 30 Were you surprised when you first saw the drone flying? 31 Were you happy when you first saw the drone flying? 32 33 Do you know why a drone came to your village? 34 Do you know where the drone goes to? 35 Do you think that the drones bring something positive to your community? 36 Do you think that the drones bring something negative to your community? 37 Do yoy think that the drones can help you receive health care in your village? 38 What do you think that the drones could transport? 39 Do you think that the drones could hurt somebody? 40 Is there anything you do not like about the drones? 41 Do you want the drones to continue coming to your village? 42 If not, why not? 43 D. evriMED / boaty 44 In your opinion, what are the advantages of the evriMED and taking the pills with the evriMED? 45 In your opinion, what are the disadvantages of the evriMED and taking the pills with the evriMED? 46 What difficulties did you experience while using the evriMED? 47 Did the audio signal (reminding sound) help you taking your pills? 48 Did the visual signal (colour) help you taking your pills? 49 Overall, did the evriMED help you take your pills? 50 51 Do you think you could have forgotten taking your mediation if the evriMED didn’t remind you? 52 Did any problems/challenges influence you in using the evriMED? 53 What influenced you using the evriMED? 54 How did your family (or the people you live with) perceive the evriMED? What did they think or say about 55 evriMED? 56 Did you like to size of the evriMED? Was it too small or too big? 57 Would you recommend using evriMED to others that need to take pills regularly? 58 If you could change something about the evriMED, what would you change? 59 E. Videos 60 What did you like about the educational videos shown to you?
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1 2 3 What did you not like about the educational videos shown to you? 4 Do you feel like you could understand the message(s) presented in the video? 5 6 Do you think you have learnt about TB from the videos shown to you? 7 Do you think that other people could benefit from seeing the video/s that you did? 8 Would you like to see more videos? 9 If yes, what would you like to learn about? 10 H. End of the interview 11 Do you have any questions for me? 12 Coordinates of the household of the patient: 13 Other comments or observations by the interviewer: 14 Time end of interview: 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 4 5 Supplementary material 3: DrOTS Acceptability and Perceptions Study 6 7 Focus Group Discussion Guides 8 9 10 FGD For DrOTS enrolled villagers 11 12 Part 1: General context for The TB Project perceptions and experiences 13 1.1 What are the most common sicknesses here in the village? 14 15 1.2 What do you think are the main causes of sickness here in the village? 16 1.3 What do people inFor your household peer do usually review when they get sick? only 17 1.4 Do some people still like to visit traditional healers? 18 1.5 In what situations would you go to the healthcare center? 19 1.6 What if somebody is too sick to get to the healthcare center? What then? 20 1.7 Is there a village health coordinator or a community health worker for this village? What is their role 21 in the community? 22 23 24 1.8 Have other foreigners ever come to this village before this The TB Project program? 25 1.9 Have any medical teams ever come to the village before this TB project? 26 Probes: (If answer yes): 27 When? What services did those other teams offer? 28 Did someone in your community invite them so that they come or they just arrive? 29 Is the TB project team doing something pretty similar to what those earlier teams did, in your 30 view then? 31 Do the projects seem organized and run in a similar way? Are you involved in a similar way with 32 these visiting teams? Do you find interactions between the medical teams and the villagers 33 34 similar to those you have observed in the past between villagers and visiting medical teams? Is 35 it unusual to have the same group of people coming back? 36 37 PART II: PERCEPTIONS AND ENGAGEMENT WITH DROTS 38 2: Understanding of and first contact with The TB Project/TB Project 39 2.1 Have you told anyone outside the village about the TB project? What did you tell them? 40 Rephrase: How would you explain what the TB team is doing here to a friend or cousin in another 41 village? 42 43 2.2 What is the TB Project team trying to do, in your understanding? Who, in your understanding, is 44 organizing this Project? 45 2.3 How did you first find out about (or hear or learn: whichever most contextually appropriate) The TB 46 Project? 47 Probes: Was that the first time you learnt about TB? 48 2.4 Did you attend an information meeting? Why/why not? 49 2.5 When you first found out/heard/learnt about The TB Project, what went through your mind? 50 Rephrase/Probes: What did you think? Were you excited? Did you have any concerns? Did you ask any 51 52 questions? 53 2.6 Are there some in the village who have different ideas or feelings about the TB Project? 54 55 3: Perceptions and experiences of TB testing by The TB Project team 56 57 58 59 1 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 39 of 46 BMJ Open
1 2 3 3.1 The TB Project medical team does tests to see who might have TB. How did you feel about getting 4 tested by the team? 5 Probes: Did you want to get tested? Did you feel obligated in any way? Had you been tested before? 6 7 3.2 Was anything about the testing process difficult for you? 8 Probes: Did anything surprise you about the testing? Please explain. 9 3.3 Did you discuss with anyone in your house, or with neighbors, before getting tested by the team? 10 Probe: (If yes) : What did you discuss with them? What did they think about this testing? 11 (If did not discuss with anyone) Why did you not discuss the testing with anyone before deciding to do 12 it? 13 3.4 Did the healthcare team use a tablet? If yes: what did they use it for? Did you see a video on it? Was 14 it helpful? 15 16 3.5 Is there anything aboutFor the testingpeer process review you wished had been only done differently? 17 Probe: Please explain why that is important to you. 18 3.6 If you have to get a TB test: Do you prefer getting a TB test in a healthcare centre outside 19 the village, or being tested by a team that comes to your village? Why? 20 21 4: Perceptions and experiences of the drones 22 4.1 What did you think when you first saw the drones? 23 24 4.2 Do you like this idea of using drones/this flying bus to transport medications and test results in and 25 out of the community? Why/why not? 26 4.3 Does anything about these flying in and out of your community bother you? 27 Probes: Have you had any unpleasant experiences with the drones? Have the drones scared any one 28 here in the village? 29 4.4 If you had TB, how would you feel about receiving your medications through a drone? 30 Probe: Do you think medications for TB coming in on a drone will make it easier to know who has TB in 31 the village? Is that a concern for you? 32 33 4.5 Do you think you would feel the same way about receiving medications for another disease? 34 4.6 You spoke of a number of health problems at the beginning: do you imagine these drones could 35 help with other problems in the village, health-related or others? 36 Rephrase: What other uses might drones have in villages such as yours in the future? 37 38 5: Perceptions and experiences of the tablets and Evrimeds 39 5.1 Who here had a chance to watch any videos about TB? Which one(s)? 40 Probes (For each): What did you think of it How many times did you watch it? Who showed it to you? 41 42 5.2 What was the message of this video, as you remember it? 43 Probe: Do you think that what it talks about is important? Did you feel differently about TB after 44 watching the video? 45 5.3 Do you think sharing information about health and treatments for sicknesses through tablets is a 46 good strategy for getting people in the village to learn about these things? Why or why not? 47 48 6: Closing reflections on The TB Project and technologies for health 49 6.1 Has anything surprised you in your experience with the The TB Project team so far? 50 6.2 What do you think could be improved in the The TB Project program? 51 52 Rephrase: Has anything about this program been a little difficult for some in the village? 53 6.3 Do you think The TB Project will change how people think about TB or healthcare in the village? 54 6.4 Is the TB Project visiting the village something you want to see continued in the future? Why or why 55 not? 56 57 58 59 2 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 40 of 46
1 2 3 4 Conclusion 5 Thank you. We have learnt so much. Is there anything you would like to add? Is there anything we 6 7 missed? 8 9 10 11 12 FGD guide for Mobile Health Unit Focus Group Discussion Guide 13 14 Thank you agreeing to take part in this interview. In our discussion today, I am going to ask you 15 16 some questions aboutFor your experiencepeer with review The TB Project. Youonly are one of the first people in 17 Madagascar and the world to participate in such a program. It is very important we learn from 18 you what it has been like to introduce this program here at the village-level in Madagascar. 19 20 21 Introduction 22 Could you please share with me what your roles are within The TB Project? 23 24 Part 1: Understanding and experiences of DrOTS/The TB Project 25 1.1 How did you first find out about The TB Project? 26 27 1.2 Had you heard about TB before this? 28 1.3 When you first found out/heard/learnt about DrOTS/ The TB Project, what went through 29 your mind? 30 Probes: What did you think? Were you excited? Did you have any concerns? Did you ask any 31 32 questions? 33 1.4 Tell me what it is like to work in the villages with this project. 34 1.5 Have you encountered a village or a group of individuals or an individual that does not seem 35 happy with your presence in the village? 36 1.6 Do people in the villages ask you many questions? What sorts of questions do they ask? 37 38 1.7 Has a community member in a village – a patient, a community health worker, a king, 39 anyone - ever expressed any concerns/worry with you about The TB Project? 40 1.8 Do you find it easy or difficult to work with the community health worker? 41 Probe: What makes it easy? What makes it difficult? 42 43 1.9 Has anything changed in the way you work with villages since the start of the Project? 44 Rephrase: Have you learnt anything in the course of working in the villages that has helped you 45 improve your communication or process of testing with villagers? 46 47 Part 2: Experiences and perceptions of TB testing and patient enrollment 48 49 2.1 The The TB Project mobile health unit provides testing in villages to see who might have TB. 50 In many parts of the world, people do not like to talk about illness or about TB. Are you 51 observing any attitudes or ideas about TB in the villages that might be acting as barriers to 52 testing or treatment for TB? 53 54 2.2 Are there any other cultural ideas, beliefs, or practices that you have observed that seem to 55 make it difficult for people to get tested for TB or accept treatment? (if yes Has your team 56 developed any strategies to address those?) 57 58 59 3 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 41 of 46 BMJ Open
1 2 3 2.3 What happens once a patient tests positive for TB? 4 5 Probe: How are test results shared with patients (to the best of your knowledge)? 6 Could you describe what that involves? Were you involved at all in disclosing or discussing the 7 treatment plan with the patient? If yes, did you feel well prepared for that? 8 2.4 Do people comply with the treatment normally in your experience? If not, why not? 9 2.5 In your experience, what motivates some to seek testing? 10 11 12 Part 3 – Perceptions and experiences of the Tablets and education videos 13 3.1 How have you used the tablets and educational videos put out by The TB Project? 14 3.2 How does the community respond when you show them the videos? 15 3.3 Have you observed any challenges related to the use of these tablets? 16 For peer review only 17 3.4 Did you get a chance to actually operate the tablet? If yes, was it easy to use or difficult? 18 19 Part 4 – Perceptions and experiences of Evrimeds 20 4.1 You show the Evrimeds to the entire community during sensitization. Do people ask any 21 22 questions? 23 4.2 What is the process for giving the Evrimeds? What do you tell the patient? 24 Probe: Why is important things to say those things? 25 4.3 Have you observed any challenges related to Evrimeds? 26 27 Probe: Has anyone ever rejected the Evrimed? 28 4.4 Have you made any changes to the way in which you present the Evrimeds to the patient 29 over time? 30 31 Part 5 - Closing reflections on The TB Project and technologies for health 32 33 5.1 What has been the best part of working with The TB Project? 34 5.2 What challenges have you encountered? 35 5.3 Has anything surprised you in your experience with The TB Project? 36 5.4 Do you worry what will happen when The TB Project ends? 37 38 5.5 Do you think The TB Project will change how people think about TB? 39 5.6 Do you think anything about the The TB Project program could be improved? 40 Rephrase: Has anything about this program been a little difficult for some in the village? 41 42 Close 43 44 Thank you. We have learnt so much. Is there anything you would like to add? Is there anything 45 we missed? 46 47 48 49 50 51 52 53 54 55 56 57 58 59 4 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 42 of 46
1 2 3 4 5 Supplementary material 4 - DrOTS Perception Study Semi-Structured 6 7 Interview Guides 8 9 Interview guide for DrOTS enrolled patient 10 (can be pared down for villagers who have tested negative for TB through The TB Project, and 11 12 for villagers hesitant, unable or who have declined The TB Project participation) 13 14 Introduction 15 Thank you agreeing to take part in this interview. In our discussion today, I am going to ask you 16 some questions aboutFor your experiencepeer with review The TB Project. Youonly are one of the first people in 17 18 Madagascar and the world to engage with this new tuberculosis elimination program that 19 involves these new technologies – drones, tablets, and medical event reminder boxes. It is very 20 important we learn about your experience. 21 22 23 Part 1: First contact with The TB Project 24 1.1 How did you first find out about (or hear or learn: whichever most contextually appropriate) 25 The TB Project? 26 1.2 Can you remember how you felt when you first found out/heard/learnt about The TB 27 Project? What did you think?? Did you ask any questions? 28 29 1.3 Did you (also) attend an information meeting in the village? Why/why not? 30 1.4 Had you ever heard of TB before? 31 32 Part 2: Perception and experience of TB testing 33 34 2.1 The TB Project medical team does tests to see who might have TB. What motivated you to 35 get tested? 36 2.2 When and where did you get tested? 37 2.3 Did you consult anyone in making your decision about whether or not to be tested? 38 Probe: Why/why not? If yes, what did they think/say? How did that impact on your decision? 39 40 2.4 Was that the first time you had ever been tested for TB? 41 2.5 Was anything about getting tested difficult for you? 42 2.6 Did the healthcare team use a tablet? 43 Probe: What was your understanding of what they were using the tablet for? 44 2.7 Did you watch a video on the tablet? 45 If yes: what was the message of that video? 46 47 2.8 (If tested) When and how did you receive the results? 48 2.9 How did you feel and what went through your mind when you got the results? (If positive 49 result: Did you worry about people finding out about the results? What worried you about people 50 finding out (if the case)?) 51 2.91 What happened next? 52 53 2.92 Did you share the results with anyone? Why/why not? If yes, what was their reaction? 54 How did that make you feel? 55 2.93 Do you think people outside those in your family know you have TB? 56 57 58 59 1 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 43 of 46 BMJ Open
1 2 3 Probe: Was it your choice to tell them? If not your choice, how did they find out? 4 5 2.94 Is there anything the medical team or healthcare workers could do to that would make it 6 easier for people with TB to stop their neighbors or other villagers finding out about their TB 7 status if they want to keep this secret? 8 9 Part 3: Experience of The TB Project as a patient 10 11 Note: Skip section 3 for villagers who have tested negative for TB 12 3.1 What is involved in receiving TB treatment through this project? 13 3.2 Who is the CHW that you see for your treatment? How often do you see them? Where do 14 you see them (do they come to your house)? 15 3.3 Is this the first time you are speaking regularly with the Community Health Worker about a 16 For peer review only 17 health problem? 18 3.4 Tell me about the medicines: What has it been like for you, taking the medicine? 19 Probe: Have you experienced any side effects? 20 3.5 Has it been difficult or easy for you to follow the treatment? 21 22 3.6 What do you think of the little boxes / MERMS? 23 3.7 Have you ever had to travel with the MERM? If so: Is that difficult? 24 3.8 What is hardest thing about being a The TB Project patient, in your experience? 25 26 27 Part 4: Enrolled Patient general reflection on their experience 28 4.1 Are you happy you became a patient in this program? Why/why not? 29 4.2 What do you think is the most important thing for someone to know or consider before 30 they decide whether or not to accept receiving treatment through this program? 31 4.3 Is there anything about the testing or treatment process you wished had happened 32 33 differently? 34 Probe: Please explain why that is important to you. 35 36 37 38 Part 5: General reflections on The TB Project in the village 39 5.1 Have you recommend to anyone else in your house or village to get tested for TB with this 40 team? Why/why not? 41 5.2 In your view, are there any advantages or disadvantages to getting tested through The TB 42 Project as opposed to at a healthcare centre outside the village? 43 44 5.3 You are one of the few Malagasy with The TB Project experience. Has anything in this 45 experience really marked you or surprised you? 46 5.4 Is there anything you had trouble understanding when you first heard about The TB Project, 47 that those running the program might explain more clearly to future patients? 48 49 5.5 Do you think anything about the The TB Project program could be improved? 50 Rephrase: Has anything about this program been a little difficult for some in the village 51 5.6 What will be the impact here in the village if funding for The TB Project ends? 52 5.7 Would you like to see drones used for more things in your village in the future? 53 Rephrase: Do you envision drones being useful in other ways for your village in the future? 54 55 56 Conclusion 57 58 59 2 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 44 of 46
1 2 3 Thank you. I have learnt so much. Is there anything you would like to add? Is there anything we 4 5 missed? 6 7 8 9 10 Semi-Structured Interview Guide for leaders (Community health 11 12 worker, King, Chief Fokontany) 13 14 Part 1: General context for The TB Project 15 1.1 What are your responsibilities related to health in the village? 16 For peer review only 17 1.2 What do people in the villages for which you are responsible usually do if they get sick? 18 Probe: Do people use home remedies? Go to the pharmacy? What if somebody is too sick to 19 get to the healthcare center? What then? 20 1.1 Have other groups of foreigners come to this area/or village in the past? 21 22 Probe: What were they doing here? 23 1.2 Have other projects with medical teams come to these villages before this The TB Project 24 program? 25 Probes: When? What services did those other teams offer? (Or, why do you think no one has 26 27 come before?) Did you invite these medical teams? How did they decide to come to this/these 28 villages in particular, in your understanding? 29 1.5 Is the The TB Project team doing something pretty similar to what those earlier teams did, 30 in your view then? 31 Probes: Do the projects seem organized and run in a similar way? Are you involved in a similar 32 33 way with these visiting teams? Do you find interactions between the medical teams and the 34 villagers similar to those you have observed in the past between villagers and visiting medical 35 teams? Is it unusual to have the same group of people coming back? 36 37 38 Part 2: Understanding of and first contact with the TB project of Centre ValBio 39 2.1 How did you first find out about (or hear or learn: whichever most contextually appropriate) 40 the TB project of Centre ValBio? 41 Probes: Did you ask any questions that first time you heard about it? 42 2.2 When you first found out/heard/learnt about this TB project, what went through your 43 44 mind? 45 Rephrase/Probes: What did you think? Were you excited? Did you have any concerns? 46 2.3 Do you still see TB project in this way? 47 Probe: What made you change your mind? Are there some in the village who think differently 48 49 about the project? 50 2.4 How has this experience been for you? Does the TB project create more work for you? 51 Probe: Why? How? 52 How do you make time for this project? 53 2.5 How do you explain what the TB project/The TB Project is to the villagers? (for example, 54 55 when you called them to attend the first meeting, what did you tell them?) 56 57 58 59 3 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 45 of 46 BMJ Open
1 2 3 Probe: Do you explain it in the same way to all villagers, regardless of their education level? 4 5 What do you say exactly? 6 2.6 Have you encountered any challenges in terms of mobilizing support for The TB Project in 7 these villages? 8 Probe: How did they react? What did they say? If yes, why do you think? If there is an 9 exception, ask for details: Could you tell me more? What do you think that caused that? What 10 11 did you do? Did that help? 12 2.7 Have people in the village(s) asked you any questions about the project? 13 2.8 Has a The TB Project patient or their family ever shared any concerns with you about The TB 14 Project? 15 Probes: What is that concern about? What was your response? Is that common in your 16 For peer review only 17 experience? 18 19 Part 3: Perceptions and experiences of TB testing and patient enrollment 20 3.1 The The TB Project medical team provides testing in villages to see who might have TB. In 21 22 many parts of the world, people do not like to talk about illness or about T. Did you have any 23 concerns about their plan to test for TB in the villages with whom you work? 24 3.2 Was it difficult to ask villagers to get tested for TB? 25 Probe: How/why? What was your role when it comes to mobilizing villagers for testing? Do you 26 27 help explain the testing to villagers? 28 3.3 What response have you observed when villagers are invited to get tested for TB? 29 Probe: Has that been the same in all villages where you work? What do you think accounts for 30 that response? 31 3.4 Are there any cultural ideas, beliefs, or practices that might make it difficult for people to 32 33 get tested? 34 Probe: Have you observed such things? 35 3.5 How are test results shared with patients (to the best of your knowledge)? 36 3.6 What happens once a patient tests positive for TB, now that The TB Project is here? 37 38 Probe: Could you describe what that involves? Were you involved at all in discussing the 39 treatment plan with the patient? If yes, did you feel well prepared for that? 40 3.7 Did the patient or their family have any concerns about joining the The TB Project program 41 that they shared with you? 42 Probe: Do you understand those concerns? What did you tell them? 43 44 3.8 Is there anything about the way the The TB Project team goes about testing or informing 45 patients of their results that you might recommend be done differently? 46 3.9 In your view, are there any advantages or disadvantages to getting tested through this TB 47 project as opposed to at a healthcare centre outside the village? 48 49 50 Part 4: Perceptions and experiences of the Drones 51 4.1 What did you think when you first saw the drones? 52 4.2 Do you like this idea of using drones to transport medications and test results in and out of 53 the community? Why/why not? 54 55 Probe: Why is the The TB Project team using drones? Would you prefer a person going by 56 ground to transport medications in and out of the village? 57 58 59 4 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 46 of 46
1 2 3 4.3 Does anything about these flying in and out of your community bother you? 4 5 Probe: Have you experienced any challenges related to the use of these technologies in the 6 village? Have you had any unpleasant experiences with the drones? Have the drones scared any 7 one here in the village? 8 4.4 If you had TB, how would you feel about receiving your medications through a drone? 9 Probes: Would you feel the same way about receiving medications for other conditions? Do you 10 11 think medications for TB coming in on a drone will make it easier to know who has TB in the 12 village? Is that a concern for you? Do you think some patients and families might not want to 13 receive medicines through drones? 14 4.5 You spoke of a number of health problems at the beginning: do you imagine these drones 15 could help with other problems in the village, health-related or others? 16 For peer review only 17 Rephrase: Do you envision drones being useful in other ways for your village in the future? 18 19 Part 5: Perceptions and experiences of the tablets and education videos 20 5.1 How have you used the tablets and educational videos put out by The TB Project? 21 22 5.2 Do you feel these are an effective strategy for sharing information about TB and The TB 23 Project? 24 Probes: Why/why not? Have you observed any challenges related to the use of these tablets? 25 5.3 Did you get a chance to actually operate the tablet? If yes, was it easy to use or difficult? 26 27 Probe: for specifics of what was easy or difficult and why. 28 5.4 Do you think sharing information about health and treatments for sicknesses through tablets is a 29 good strategy for getting people in the village to learn about these things? Why or why not? 30 31 Part 6 – Perceptions and experiences of Evrimeds 32 6.1 The entire community gets to see the Evrimeds/little boxes during sensitization. Did people 33 34 ask any questions when they saw those? 35 6.2 Have you heard of any challenges related to Evrimeds? 36 37 Part 7: Closing reflections on The TB Project and technologies for health 38 39 7.1 What has been the best part of working with The TB Project? 40 7.2 What challenges have you encountered? 41 7.3 You have experience with The TB Project now. What health problems can technologies 42 solve, and which ones can they not solve, in your view? 43 7.4 What about the The TB Project program could be improved? 44 45 Rephrase: Has anything about this program been a little difficult for some in the village? 46 47 Conclusion 48 Thank you. We have learnt so much. Is there anything you would like to add? Is there anything 49 50 we missed? 51 52 53 54 55 56 57 58 59 5 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml