“It is the Will of God:" Religion’s Influence on Minimally Invasive Tissue Sampling (MITS) through the CHAMPS Network in Bangladesh and Sierra Leone Open Access

Abstract

Eighty-five percent of under-five deaths occur in African and South Asian countries and causes of these deaths are often misreported. Minimally Invasive Tissue Sampling (MITS) procedures were developed to collect body fluid and tissue with minimal damage to the body. The Child Health and Mortality Prevention Surveillance (CHAMPS) Network seeks to improve cause of death determination and reporting through the use of MITS. CHAMPS conducted formative research to understand community beliefs and practices surrounding death and burial in the sites where they planned to implement MITS. Secondary qualitative data analysis was conducted on interview and focus group data from Bangladesh and Sierra Leone to understand the influence of religion on the acceptability, practicality, and implementation of MITS. Religion was found to influence beliefs about causes of death, practices related to burial preparation, and desires to learn the cause of death, all of which had implications for the feasibility framework developed by CHAMPS, which assessed feasibility according to three factors: acceptability, practicality, and implementation. Participants in both countries hold spiritual and non-spiritual beliefs about causes of death, with the most prominent belief that death is “the will of God.” In Bangladesh, Shariah justified burial preparation and funeral rituals, but was not referenced by participants in Sierra Leone. Participants desired to learn the cause of death if it meant future death could be prevented in Bangladesh, but they did not find the MITS procedure to be acceptable due to Islamic doctrine related to harming or causing pain to the body. In Sierra Leone, there was less desire to learn causes of death because of the belief that death was God’s will, but more acceptance towards the MITS procedure. Timing of the MITS procedure and tissue extraction was the most notable consideration for practicality in both countries, and the use of community leaders is essential for the implementation of MITS in Sierra Leone.

Table of Contents

CHAPTER 1: INTRODUCTION 1

GLOBAL CHILD MORTALITY 1

ESTIMATIONS OF AND ERRORS IN REPORTING CHILD MORTALITY 1

The Gold Standard: Complete Diagnostic Autopsy  2

VERBAL AUTOPSIES 2

Limitations of Verbal Autopsies  3

IMPROVING CAUSE OF DEATH DETERMINATION AND REPORTING 4

Minimally Invasive Autopsies (MIAs) 4

The CHAMPS Network  5

THE IMPORTANCE OF AND NEED FOR COMPARING CULTURAL AND RELIGIOUS CONTEXTS IN BANGLADESH AND SIERRA LEONE 6

CONCEPTUALIZING RELIGION 8

PROBLEM STATEMENT 8

PURPOSE STATEMENT 9

RESEARCH OBJECTIVE AND AIMS 9

SIGNIFICANCE STATEMENT 9

CHAPTER 2: LITERATURE REVIEW 10

INTRODUCTION 10

EXPANDING OUR UNDERSTANDING OF RELIGION 10

RELIGION AS A SOCIAL DETERMINANT OF HEALTH 12

RELIGION IN CONTEXT 14

Religion in Bangladesh  15

Religion in Sierra Leone 18

BURIAL, AUTOPSIES, AND RELIGION 21

Burial Customs in Islam 21

Burial Customs in Hinduism 21

Objections to Autopsies 22

CHAPTER 3: MATERIALS AND METHODS 26

INTRODUCTION 26

DATA 27

DATA ANALYSIS 29

Conceptual Framework 30

INSTITUTIONAL REVIEW BOARD (IRB) AND ETHICAL CONSIDERATIONS 31

LIMITATIONS AND DELIMITATIONS 32

CHAPTER 4: FINDINGS 33

INTRODUCTION  33

FINDINGS 34

Theme 1. Beliefs about Causes of Life and Death 34

1a. God 35

1b. Other Spiritual Causes 37

1c. Biological 40

Theme 2. Practices Surrounding Death and Burial  43

2a. Preparation of the Body 43

2b. Preparation for Burial  51

2c. Funeral Rites 59

Theme 3. Learning the causes of death and attitudes towards MITS  66

OTHER FINDINGS 75

SUMMARY 76

CHAPTER 5: CONCLUSION AND DISCUSSION 77

INTRODUCTION 77

DISCUSSION OF THEMES 78

Beliefs about causes of life and death 78

Practices surrounding death and burial 80

Preparation of the body 80

Burial 81

Timing of Burial 83

Desire to Learn Cause of Death and Acceptance Towards MITS 84

Other Findings 86

IMPORTANCE AND IMPLICATIONS 87

Conceptual Framework 87

Acceptability 88

Practicality 90

Implementation 91

RELATION TO PREVIOUS RESEARCH 92

LIMITATIONS 93

SUGGESTIONS FOR FUTURE RESEARCH 94

CONCLUSION 95

REFERENCES 97

APPENDICES 115

APPENDIX A: IRB DETERMINATION 115

APPENDIX B: VERBAL CONSENT SCRIPT 116

APPENDIX C: KEY INFORMANT INTERVIEW GUIDE 118

APPENDIX D: SEMI-STRUCTURED INTERVIEW GUIDE 125

APPENDIX E: FOCUS GROUP DISCUSSION GUIDE 130

APPENDIX F: CODEBOOK 135

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Religion, General Health Sciences, Public Health
Keyword	spirituality religion Bangladesh autopsies cause of death CHAMPS MITS global health Sierra Leone child mortality
Committee Chair / Thesis Advisor	Blevins, John, Emory University
Committee Members	Kone, Ahoua, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs

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