STUDY DESIGN AND METHODS

adaptation of the profile

We adapted the Health Capability Profile to the epidemiological context of CHB in rural Senegal, creating a measurable profile and index that we operationalized through quantitative surveys and qualitative interviews collecting both objective and subjective data. Each of the Profile’s 15 health capability domains were reframed to capture the cumulative CHB-related abilities and conditions for individuals in this specific context, such as CHB-related health knowledge and health services access in rural Senegal. This included adapting the domains to CHB infection (e.g., CHB-related risk factors and behaviors), to rural Senegal (e.g., social norms and cultural beliefs related to traditional medicine), and to stakeholders involved in CHB care and policy in Senegal (e.g., national stakeholders such as the Saafara Hépatites Patients Association and local stakeholders such as community-based healthcare workers).

Study design

The study follows a social justice mixed-methods design. The Health Capability Profile is the operationalized theoretical framework, which guides the design and conduct of the research. A full understanding of the various health capabilities and the overall health capability of a person requires data on objective abilities and situations (e.g., CHB status, CHB knowledge, economic circumstances, etc.), as well as information on subjective experiences (including, but not limited to, perceived competency, motivation, expectations, group membership influences, perception of a need to seek health services etc.). This need for objective and subjective quantitative and qualitative data from the individual and institutional and community perspectives necessitates a mixed-methods design that combines quantitative and qualitative data collection at the individual level.

quantitative data collection

The quantitative survey provides an overview of gaps and optima in health capabilities associated CHB-morbidity and mortality in the study area (objective data). A specific module was designed based on the health capability profile, in conjunction with a review of empirical studies, to identify items that could document health capability domains given the study area and participants. For example, health status and health functioning was assessed using self-reported health (SF12v2 health survey), CHB status and BMI in all participants. In addition, a clinical and biological check-up (to identify liver disease stage) and CHB-risk factors were explored for participants who tested positive for CHB. The quantitative health capability module was embedded in the demographic and socio-economic quantitative data collection of the 12356 ANRS AmBASS survey and administered to all 725 adult participants included after January 2019 (exhaustive sampling).

qualitative data collection

Guided by preliminary results from the quantitative survey, we then conducted one-on-one semi-structured interviews with patients, healthcare practitioners, community health counselors, and other stakeholders to gain individual, institutional, and community perspectives. Our qualitative data collection aimed at developing in-depth, dynamic, and comprehensive health capability profiles, including information on personal experiences (subjective data) as well as interactions between health capabilities at the individual level, both of which cannot be properly documented with standardized questionnaires.

All health capabilities of the profile were clarified, expressed in the context of rural Senegal, translated into French (official language of Senegal), and reworded as an open-ended question that is accessible and meaningful to all study participants in order to build the interview guide. The interview guide also includes an extensive list of clarification questions meant to guide interviewers in covering all 49 domains comprised in the profile. Selected survey participants were invited for interviews following a purposeful sampling strategy to interview individuals that represent the population’s diversity (both in terms of socioeconomic and demographic characteristics and in terms of CHB-related health capability profiles). Participants were contacted for interviews until data saturation was reached.

additional data collection

Individual level data collection is complemented with institutional and community-based data to account for all stakeholders and elements of the Profile (in particular healthcare professionals and community representatives). The additional data collection includes a health facility survey of CHB resources in the healthcare system and in-depth interviews with local CHB stakeholders—with a specific focus on physicians, nurses, and community healthcare workers.

Qualitative data: key stakeholders interviews

Additional interviews were conducted with healthcare staff involved with hepatitis B prevention or care for patients living in the Niakhar area and community health counselors of the Niakhar area to complement information on CHB-related external health capabilities. More specifically, these interviews were used to collect objective, community level data on CHB-related social and cultural norms, social networks and group membership influences, the political, economic and social security and the availability, safety, efficiency and accountability of health services, and of the overall healthcare system (including health and cultural beliefs and behaviors).

Quantitative data: health facilities survey

The survey makes an inventory of resources available in all the health facilities involved with CHB patients living in the Niakhar area, from the local dispensaries offering CHB testing up to the reference hospital in Dakar in charge of serious CHB cases (exhaustive sampling). The survey drew from a micro-costing methodology to document the availability and use of resources mobilized or mobilizable for CHB care, specifically human resources (headcount, general as well as specific CHB training, workload and salary base of physicians, healthcare workers, and administrative staff), equipment and facilities, medical imaging, biological exams (laboratory facility, staff, and machinery), and medication.