Table 1.
Codes, themes and exemplar quotes.
| 2nd order themes | 1st order categories | Representative codes | Quotes |
|---|---|---|---|
| GOVERNANCE | Institutional impact | Political instability | "Just the uncertainty of governments. Right now, Burkina Faso is in a good place as far as their regulatory structure not being too affected by what has happened over the last few years politically. It seems like Burkina Faso has managed to keep going despite some political upheaval, but if things should change drastically, I think that could cause a problem." Regulatory affairs specialist |
| Maturity of regulatory process for GM | "The ability of the NBA (regulatory body) to conduct the assessment of the application and the evaluation of the application in a way that gives them the confidence that they've done their job properly … includes the confidence that they conducted a proper risk assessment to take the decision." Regulatory affairs specialist | ||
| Willingness of government to enforce regulations | "The problem we have today with the implementation of the measures is the leadership at the central level. The power of the central level is very low; the DRS (Direction Régionale de la Santé) and MCD (Médecin-Chef de District) think they can do what they want regardless of the decisions of the central level. And they do so without sanctions. Unfortunately, there is virtually no sense of accountability." Founder and leader of national NGO "Even if you have a sound legislation [… you may…] have no resources to implement it." Regulatory affairs specialist |
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| Strength of organized opposition groups | "They have a lot of money to spend, and a lot of effort that they can use to oppose and that's been a problem all along, especially in countries in Africa where you have well-funded opposition groups going up against these regulatory agencies … Anybody who is ideologically opposed to a genetic modification may support local people on the ground and have done frequently." Regulatory affairs specialist | ||
| Fatigue | "… if you're still trapped in the villages or still trying to get data out to those villages, then there's a sort of fatigue element that sets in and they say 'oh go away, you're never going to bring me this stuff. I don't want you here in my village anymore'.” Regulatory affairs specialist "[W]e're building up credibility and information with the committee, but they are three separate products. Normally you'd have the same product that you take through each of the steps, but … the product that you want release at the end, the gene-drive product, isn't the same as the product that you are seeing now, which is male sterile. And so what we're trying to do is to make sure they recognize elements from the male sterile that are equally applicable to gene-drive, such as the marker gene, for example." Regulatory affairs specialist |
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| RESILIENCE, AWARENESS AND KNOWLEDGE | Understanding of own health, including malaria | Patterns of disease & health | "We have the same epidemiological profile as in other regions; above all malaria which is a public health concern." Regional director within the Ministry of Health "In most healthcare documents, malaria is listed as the leading cause of death in Burkina Faso." Project Manager within the Ministry of Health at national level |
| Attitudes to malaria | "In terms of malaria, the population perceives this almost as a normal disease which is regrettable. All the protective measures that we are implementing are still not always being followed … With regards to mortality, they do not necessarily make the connection with malaria, except maybe with fetishes or sorcerers." Executive manager within the Ministry of Health | ||
| Experience of health system and healthcare | Socio-economic resilience | "But above all, the essential, the biggest issue: poverty … As far as the Imam is concerned, people are seeing him because of a range of problems, with poverty being the biggest issue. Out of 10 people, 8 are coming because of poverty." Religious leader from a rural village "The basic problems, the priority needs are education, healthcare, sanitation, road infrastructure. Those are the main problems: health, education, roads … There you go." General Secretary of a governmental administration at regional user level |
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| Religious and cultural context | "Cultural acceptability counts as much as the perception that needs to be overcome." Regional director within the Ministry of Health at regional managerial level "There is no universal criterion [for acceptance]. It all depends on the communities, on innovation and on many factors that can influence and vary from one community to another. The things that are appreciated are not always the same. This depends on the range of values of the communities; there are different values between the communities." Communication officer of a national NGO at national managerial level |
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| Education | "Grosso modo, it's the illiteracy… people are not informed. The people do not know or don't understand what is proposed to them. In the healthcare sector, the problem is the same." Retired mayor of a mid-sized village "The Burkinabé consider [malaria] as unnatural or sometimes like a spell. Thus, [the people] invest in supernatural measures before realising that it would be enough to simply follow the health advice so that it doesn't get worse or settle in completely. This problem is part of the battle … to change the mind-set." Public Health professional within the PNLP at national policy maker level |
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| Access to health facilities | "There is no impetus to visit a healthcare facility if one is ill because one expects costs that could not be covered. The impetus would be to manage one's illness as good as possible which will lead to a significant delay before visiting the healthcare facilities. When the people get there, it is already too late." Communication officer of a national NGO at national managerial level | ||
| Approaches to communicating information | Informal leaders | "The village chief has his advisors, his confidantes with whom he discusses and gives information to the population. He summons the family council and shares information. Generally, he will not be much challenged. He decides. No, no the chief will not be challenged." Retired health professional at regional level " … all innovations in the health sector involve the 'leaders of tradition', religious leaders, village chiefs and land chiefs; they pass on the information because people listen to them. The Imam and the 'leader of tradition' will transmit [the messages]. Our correspondents in the villages help us to pass on the information concerning innovation that must be introduced in the health sector." Health professional in a regional CMA "If I take a decision with the chief of the village, the entire populations follows. We organise ourselves by forming a group with the Imam and the Elders. We see what needs to be done and we take a decision to initiate what needs to be done in the neighbourhood." Chair of CVD of a rural village |
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| Local village system | "The village is organised based on groups and cooperatives. Essentially, there are three people with power: firstly, the CVD, then the Jeunesse (a group of young people) has a say and the Imam […] also has an incontestable power in the village." Local user level "We involve the local leaders: village chiefs, deputies, envoys, the CVD of the village, as well as the 'leader of tradition'. So people come because they participate. We need their technical help. The people say: 'there are the traditional leaders'… and then they come." Retired mayor of a mid-sized village |
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| EVIDENCE AND TRUST | Perceived benefits and acceptance of the evidence | Legitimacy of government robustness of health system | "When a population rebels against its prefect, there is a problem: the population does not trust its prefect. Otherwise, they would have communicated. Thus, the social distance was large." Representative of a civil society group at regional level "… it is important to reform and innovate but this needs to come from the base. Until now, we have seen reforms that are coming from the top. But they implement reforms that are removed from reality. This means that we do the planning and the innovations based on the concerns of the decision makers and not based on those of the population." Founder and leader of national NGO at national managerial level |
| Experience of malaria focused innovations | "When it's new people don't understand. They need to understand and generally any new activity that you introduce requires long preparations in order to sensitize the community; otherwise, your will find yourself alone and are bringing in an activity that does not work. For everything that is new you need to take the time to explain; it is necessary to start preparations early if you want to have an impact with the project. You need to be sure of this in the short-and mid-term." Member of an international NGO at international user level “[T]he suspicion is mainly cultural. [it remains] until the innovators prove it to us. We need to take into account the cultural aspects, the perception of the product, accessibility and also the support of the population." General Secretary of a network of NGOs at national technical level |
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| Experience of non-malaria innovations (medical and non-medical) | "In the beginning it was difficult. The women did not to vaccinate their children. But one day, the measles attacked the neighbourhood and we knew that everyone who was not vaccinated got the measles … afterwards, everyone got vaccinated. Now, all children are vaccinated." Chief of a rural village at local user level "They [the population] have habits that they are asked to change and they have difficulties adopting new behaviours. … If they don't understand this they will be reluctant. It's the level of understanding that leads to reluctance." Health professional in a regional CMA "If this [health innovation] seems easy and if you are convinced of the positive contribution to your daily practice, it works. But if it is complicated … " Manager within the drug allocation department of the Ministry of Health at national managerial level |
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| Familiarity and knowledge of technology | "The perception of what this technology is going to bring to you is crucial." Regulatory affairs specialist "I remember the editor of the Observer had brought up this topic at a conference. He tried to open a page for articles in Mòoré [local language]. But since the people have an 'academic logic', they wanted to build a morophone academy and tried to use too complicated words. At that point nobody understood anything any longer." Founder and leader of national NGO |
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| Familiarity and knowledge of GM technologies (agriculture and health) | "Those are new approaches to step back and find appropriate words and reduce them to an understandable language." Member of an international NGO "There is also the fact that in the communities, men are often reluctant to respond to certain interventions." Interim international consultant for Ministry of Health |
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| Peer pressure groups | "Some say that if doctors flattered them to get vaccinated, that shows it's because they want to inject diseases in their bodies so that they go and pay more money at the CSPS (Centre de santé et de promotion sociale). The doctors would get them ill so that they would go to the CSPS and pay a lot of money there. That is the idea of some of them." Member of an all-women focus group from a rural village |