Co-occurrence of non-communicable disease risk factors among adolescents in Jos, Nigeria.

BACKGROUND: The co-occurrence and clustering of risk factors for non-communicable disease (NCD) is a global public health concern. AIM: This study aimed to assess the co-occurrence and clustering of risk factors for NCDs among in-school and out-of-school adolescents in Jos North Local Government Area, Plateau State, Nigeria. SETTING: Secondary schools and markets in Jos North Local Government Area. METHODS: A comparative cross-sectional study was conducted among 377 in-school and 377 out-of-school adolescents, aged 10-19 years of age. An interviewer-administered questionnaire was used to collect information on behavioural and physical risk factors for NCDs. Chi-square and Mann-Whitney U tests were used for comparisons at a 5% level of significance. Statistical analysis was carried out using Statistical Product and Service Solutions (SPSS) version 23.0. RESULTS: Of the 754 sampled adolescents, 386 (51.2%) were females and 368 (48.8%) were males. Adolescents aged 10-14 years made up 37.8% of the participants, 15 to 17 years of age accounted for 46.9% and 18-19 years 15.3%. Risk factors with the highest prevalence were a sedentary lifestyle (94.2%) and an unhealthy diet (92.4%). Majority (97.2%) had two or more risk factors while 1.9% of adolescents had no risk factor. More in-school adolescents (24.1%) had two risk factors compared to 14.1% of out-of-school adolescents (p 0.001); 14.1% of out-of-school adolescents had five or more risk factors compared to 2.9% of those in school (p 0.001). CONCLUSION: Co-occurrence and clustering of behavioural and physical risk factors was found among both in-school and out-of-school adolescents.Contribution: This study highlighted the burden of risk factors for NCDs among both in-school and out-of-school adolescents in the North-Central part of Nigeria. This is especially useful in developing targeted interventions to tackle these risk factors.

Views of Nigerian civil servants about compulsory COVID-19 vaccination: A qualitative study.

BACKGROUND:  COVID-19 caused unforeseen global burden, although vaccine strategy rapidly stalled transmission and protected those at risk. Many governments made vaccination mandatory for public space access. AIM:  This study aimed to elucidate perception of Nigerian civil servants towards mandatory COVID-19 vaccination and elicited their recommendations. SETTING:  This study was conducted in twelve purposively selected states in the six geopolitical zones and the Federal Capital Territory (FCT), Nigeria. Relevant ministries, departments and agencies were selected within the study sites. METHODS:  It was a qualitative study that interviewed consenting civil servants. Ethical approval was obtained from the National Health Research Ethics Committee. Interviews were conducted in person, following a pre-test. Data was analysed using NVivo software version 12. RESULTS:  Most participants were willing to take the vaccine if their safety was assured. However, enforcement to do so was a hindrance. Most participants commended the government for the effort to curb COVID-19 transmission and create awareness but were displeased with planning and handling of misconceptions. They recommended a more committed approach to vaccine production and funding by the government. CONCLUSION:  Participants were willing to take the COVID-19 vaccines because the gains of protection outweighed the risks. They suggested a less involuntary approach through reinforcing awareness creation and avoiding threats.Contribution: There is limited qualitative research on perception of Nigerian civil servants regarding mandatory COVID-19 vaccination. Being the main driving force of Nigeria's public service, their views are invaluable. Findings could contribute to future policies in times of emergency.

Promoting equity through inclusive learning, planning and implementing: lessons from Nigeria's mass drug administration programme for neglected tropical diseases.

BACKGROUND: An inclusive, localised approach to planning and implementing equitable mass drug administration was developed through participatory action research (PAR). This new approach aligns with principles of learning health systems (LHS). Tools were co-developed to support scaling up the new approach across two Nigerian states. Lessons are distilled here to enable learning for other programmes. METHODS: Observations and reports by researchers (2019-2021) from 23 meetings and workshops, 8 in-depth interviews and 8 focus group discussions (FGDs) were used. RESULTS: Nine key steps of best practice were identified to promote inclusive LHS for participatory planning and implementing: utilise participatory research methodologies to facilitate community engagement and tailor interventions; develop tools and governance structures to support learning, teamwork and sustainability; strengthen capacity for participation and collaboration with space for dialogue and shared learning; undertake participatory planning to develop action plans; advocate for implementation; monitor action plans; review and act on successes and challenges; apply community evaluation to understand challenges and enablers and disseminate policy and programme changes. CONCLUSIONS: PAR in disease programmes can support health systems to embed cyclical and iterative learning to sustainably address localised equity challenges. However, it takes time, resources and political commitment.

Lessons from participatory community mapping to inform neglected tropical disease programmes in Nigeria.

BACKGROUND: Participatory research methods promote collaborations between researchers and communities to collectively overcome implementation challenges for sustainable social change. Programmes usually take a top-down approach to addressing such challenges. This study developed and piloted contextualised participatory methods to identify community structures that could improve the equity of medicine administration for neglected tropical diseases (NTDs) in northern and southern Nigeria. METHODS: Participants and researchers conducted transect walks and social mapping to understand which community-based structures could be used to maximise accessibility and acceptability of medicines for NTDs. RESULTS: Using visual participatory methods with a diverse set of stakeholders facilitated the identification of new structures within the community that could be used to improve the equity of medicine distribution and access. Available materials such as sticks, stones and leaves were appropriately used by respondents in the rural areas, which increased meaningful engagement irrespective of their literacy level. Structures identified included Qur'anic schools, football grounds, mechanics shops, shrines, village head's houses and worship centres. Challenges in using these structures for medicine distribution included resistance from school authorities and restrictions to women's access due to traditions and norms, particularly within palaces and mosques. CONCLUSIONS: This article highlights the importance of meaningful community engagement methods and engaging gatekeepers in visual participatory methods. It emphasizes the importance of including divergent views of various population groups in order to ensure that all communities are reached by NTDs programmes.

A mixed methods evaluation of an integrated training package for skin neglected tropical diseases in Kaduna and Ogun, Nigeria.

BACKGROUND: The overall burden of neglected tropical diseases (NTDs) affecting the skin is undetermined. Skin conditions are among the top 10 causes of disability worldwide. Affected persons seek treatment at advanced stages of the disease, resulting in morbidity and disability. We developed and evaluated an integrated training intervention for early case detection, referral and management of skin NTDs in two states in Nigeria. METHODS: This was a mixed-methods study using participatory approaches to develop specific skin algorithms and training packages for community and primary level health workers. This supported the identification, referral and clinical diagnosis of suspected cases. We used Kirkpatrick's model to evaluate the training package. RESULTS: Participants' knowledge improved after the 2-months intervention. Across both states, knowledge retention appeared more robust for cadres at all levels: state, local government area and primary healthcare. All (100%) participants mentioned that the training assisted them in detecting, referring and managing skin NTDs. Training was understood by participants and training materials were easy to understand. Materials were also effective in educating community members about the symptoms of NTDs and supported referral to facilities for appropriate management. CONCLUSIONS: Community implementers can be trained and supervised to detect people affected by skin NTDs and support appropriate management within the existing patient care pathway.

Does inter-border conflict influence the views of task sharing among community health volunteers in Nigeria? A qualitative study.

BACKGROUND: Volunteer community health workers are increasingly being engaged in Nigeria, through the World Health Organization's task sharing strategy. This strategy aims to address gaps in human resources for health, including inequitable distribution of health workers. Recent conflicts in rural and fragile border communities in northcentral Nigeria create challenges for volunteer community health workers to meet their community's increasing health needs. This study aimed to explore the perception of volunteers involved in task sharing to understand factors affecting performance and delivery in such contexts. METHODS: This was a qualitative study conducted in fragile border communities in north central Nigeria. Eighteen audio recorded, semi-structured interviews with volunteers and supervisors were performed. Their perceptions on how task sharing and allocation of tasks affect performance and delivery were elucidated. The transactional social framework was applied during the thematic analysis process to generate an explanatory account of the research data, which was analysed using NVivo software. RESULTS: Promotive and preventive tasks were shared among the predominantly agrarian respondents. There was a structured task allocation process that linked the community with the health system and mainly cordial relationships were in place. However, there were barriers related to ethnoreligious crises and current conflict, timing of task allocations, gender inequities in volunteerism, shortage of commodities, inadequate incentives, dwindling community support and negative attitudes of some volunteers. CONCLUSION: The perception of task sharing was mainly positive, despite the challenges, especially the current conflict. In this fragile context, reconsideration of non-seasonal task allocations within improved community-driven selection and security systems should be encouraged. Supportive supervision and providing adequate and timely renumeration will also be beneficial in this fragile setting.

'You want to deal with power while riding on power': global perspectives on power in participatory health research and co-production approaches.

INTRODUCTION: Power relations permeate research partnerships and compromise the ability of participatory research approaches to bring about transformational and sustainable change. This study aimed to explore how participatory health researchers engaged in co-production research perceive and experience 'power', and how it is discussed and addressed within the context of research partnerships. METHODS: Five online workshops were carried out with participatory health researchers working in different global contexts. Transcripts of the workshops were analysed thematically against the 'Social Ecology of Power' framework and mapped at the micro (individual), meso (interpersonal) or macro (structural) level. RESULTS: A total of 59 participants, with participatory experience in 24 different countries, attended the workshops. At the micro level, key findings included the rarity of explicit discussions on the meaning and impact of power, the use of reflexivity for examining assumptions and power differentials, and the perceived importance of strengthening co-researcher capacity to shift power. At the meso level, participants emphasised the need to manage co-researcher expectations, create spaces for trusted dialogue, and consider the potential risks faced by empowered community partners. Participants were divided over whether gatekeeper engagement aided the research process or acted to exclude marginalised groups from participating. At the macro level, colonial and 'traditional' research legacies were acknowledged to have generated and maintained power inequities within research partnerships. CONCLUSIONS: The 'Social Ecology of Power' framework is a useful tool for engaging with power inequities that cut across the social ecology, highlighting how they can operate at the micro, meso and macro level. This study reiterates that power is pervasive, and that while many researchers are intentional about engaging with power, actions and available tools must be used more systematically to identify and address power imbalances in participatory research partnerships, in order to contribute to improved equity and social justice outcomes.

Mass administration of medicines in changing contexts: Acceptability, adaptability and community directed approaches in Kaduna and Ogun States, Nigeria.

Nigeria has the highest burden of NTDs in sub-Saharan Africa. Commitments to reach the control and elimination of many Neglected Tropical Diseases (NTDs), particularly those amenable to preventive chemotherapy (onchocerciasis, schistosomiasis, soil transmitted helminths, lymphatic filariasis and trachoma) by 2020 are detailed in the London declaration. Strategies to reach targets build on existing approaches, one of which is the use of community directed intervention (CDI) methods to deliver the mass administration of medicines (MAM). However, treatment using this approach has been inconsistent and there are questions about the acceptability and adaptability of these interventions during periods of programmatic, social, and political change. This paper explores the current strengths and weaknesses of CDI approaches in MAM delivery. We consider the acceptability and adaptability of existing MAM approaches to ensure equity in access to essential treatments. Using qualitative methods, we explore implementer perspectives of MAM delivery. We purposively selected programme implementers to ensure good programmatic knowledge and representation from the different levels of health governance in Nigeria. Data collection took place across two States (Kaduna and Ogun). Our results indicate that CDI approaches have underpinned many historic successes in NTD programme acceptance in Nigeria, specifically in Kaduna and Ogun State. However, our results also show that in some contexts, factors that underpin the success of CDI have become disrupted presenting new challenges for programme implementers. Capturing the tacit knowledge of health implementers at varying levels of the health system, we present the current and changing context of MAM delivery in Kaduna and Ogun States and consolidate a platform of evidence to guide future programme delivery and research studies. We situate our findings within the broader NTD literature, specifically, in identifying how our findings align to existing reviews focused on factors that shape individual acceptance of MAM.

Guiding principles for quality, ethical standards and ongoing learning in implementation research: multicountry learnings from participatory action research to strengthen health systems.

Global health gains can be achieved through strengthening health systems to identify and address implementation challenges in low- and middle-income countries. Participatory research, that promotes joint problem and solution finding between communities and different health systems actors, supports policy implementation analysis at all levels. Within the neglected tropical disease programmes in Liberia and Nigeria, we applied participatory action research (PAR) to address programmatic and health system bottlenecks with health systems strengthening embedded. This paper shares learning from 20 interviews with co-researchers, from national and sub-national levels and academic researchers who worked collaboratively to understand challenges, co-create solutions and advocate for policy change. Through analysis and reflections of existing PAR principles, we inductively identified five additional guiding principles for quality, ethical standards and ongoing learning within PAR projects that aim to strengthen health systems. (1) Recognize communities as units of identity and define stakeholder participation to ensure equitable engagement of all actors; (2) enable flexible action planning that builds on existing structures whilst providing opportunities for embedding change; (3) address health systems and research power differentials that can impede co-production of knowledge and solution development; (4) embed relational practices that lead to new political forms of participation and inquiry within health systems and (5) develop structures for ongoing learning at multiple levels of the health system. PAR can strengthen health systems by connecting and co-creating potentially sustainable solutions to implementation challenges. Additional research to explore how these five additional principles can support the attainment of quality and ethical standards within implementation research using a PAR framework for health systems strengthening is needed.

Neglected Tropical Diseases as a 'litmus test' for Universal Health Coverage? Understanding who is left behind and why in Mass Drug Administration: Lessons from four country contexts.

INTRODUCTION: Individuals and communities affected by NTDs are often the poorest and most marginalised; ensuring a gender and equity lens is centre stage will be critical for the NTD community to reach elimination goals and inform Universal Health Coverage (UHC). NTDs amenable to preventive chemotherapy have been described as a 'litmus test' for UHC due to the high mass drug administration (MDA) coverage rates needed to be effective and their model of community engagement. However, until now highly aggregated coverage data may have masked inequities in availability, accessibility and acceptability of medicines, slowing down the equitable achievement of elimination goals. METHODS: We conducted qualitative programmatic analysis across different country contexts through the novel application of the Tanahashi Coverage Framework enhanced by gendered intersectional theory to interrogate different components of programme coverage: availability, accessibility, acceptability, contact and effective. Drawing on communities and health implementers perspectives (using focus groups, interviews, and participatory methods) from varying levels of the health system, across four African country contexts (Cameroon, Ghana, Liberia and Nigeria), we show who is left behind and provide recommendations for programmes to respond. FINDINGS: We have unmasked inequities in programme delivery that repeatedly leave vulnerable populations underserved in relation to the prevention and treatment of PC NTDs across all components of coverage explored within the Tanahashi framework. Inequities are influenced by health systems challenges and limitations, due to lack of consideration of gender, power and equity issues. Effective treatment for individuals and communities is shaped by individual identities and the intersecting axes of inequity that converge to shape these positions including gender, age, disability, and geography. Health systems are inherently social and gendered thus they become mediators in managing the impact that social and structural processes have on individual health outcomes. SIGNIFICANCE: To our knowledge this is the only paper which has combined a comprehensive equity framework with intersectional feminist theory, to establish a fuller understanding of who is left behind and why in MDA across countries and contexts. Ensuring the most vulnerable have continued access to future treatment options will contribute to the progressive realisation of UHC, allowing the NTD community to continue to support their vision of being a true 'litmus test'.

Optimising the performance of frontline implementers engaged in the NTD programme in Nigeria: lessons for strengthening community health systems for universal health coverage.

BACKGROUND: The control and elimination of Neglected Tropical Diseases (NTDs) is dependent on mass administration of medicines (MAM) in communities and schools by community drug distributers (CDDs) who are supported and supervised by health facility staff (FLHF) and teachers. Understanding how to motivate, retain and optimise their performance is essential to ensure communities accept medicines. This study aimed to capture and translate knowledge, problems and solutions, identified by implementers, to enhance NTD programme delivery at the community level in Nigeria. METHODS: Qualitative data was collected through participatory stakeholder workshops organised around two themes: (i) identification of problems and (ii) finding solutions. Eighteen problem-focused workshops and 20 solution-focussed workshops were held with FLHF, CDDs and teachers in 12 purposively selected local government areas (LGA) across two states in Nigeria, Ogun and Kaduna States. RESULT: The problems and solutions identified by frontline implementers were organised into three broad themes: technical support, social support and incentives. Areas identified for technical support included training, supervision, human resource management and workload, equipment and resources and timing of MAM implementation. Social support needs were for more equitable drug distributor selection processes, effective community sensitisation mechanisms and being associated with the health system. Incentives identified were both non-financial and financial including receiving positive community feedback and recognition and monetary remuneration. The results led to the development of the 'NTD frontline implementer's framework' which was adapted from the Community Health Worker (CHW) Generic Logic Model by Naimoli et al. (Hum Resour Health 12:56, 2014). CONCLUSION: Maximising performance of frontline implementers is key to successful attainment of NTD goals and other health interventions. As NTDs are viewed as a 'litmus test' for universal health coverage, the lessons shared here could cut across programmes aiming to achieve equitable coverage. It is critical to strengthen the collaboration between health systems and communities so that together they can jointly provide the necessary support for frontline implementers to deliver health for all. This research presents additional evidence that involving frontline implementers in the planning and implementation of health interventions through regular feedback before, during and after implementation has the potential to strengthen health outcomes.

Survival and nutritional status of children with severe acute malnutrition, six months post-discharge from outpatient treatment in Jigawa state, Nigeria.

BACKGROUND: The Outpatient Therapeutic Program (OTP) for treatment brings the management of Severe Acute Malnutrition (SAM) closer to the community. Many lives have been saved through this approach, but little data exists on the outcome of the children after discharge from such programmes. This study was aimed to determine the survival and nutritional status of children at six months after discharge from OTP for SAM. METHODOLOGY: This was a prospective study of children with SAM admitted into 10 OTPs in two local government areas of Jigawa state from June 2016 to July 2016. Home visits at six months after discharge enabled the collection of data on survival and nutritional status. The primary outcome measures were survival and nutritional status (Mid upper arm circumference and weight-for-height z-score). RESULT: Of 494 children with SAM, 410 were discharged and 379 were followed up. Of these, 354, (93.4%) were found alive while 25 (6.6%) died. Among the survivors 333 (94.1%) had MUAC ≥12.5cm and 64 (18.1%) had WHZ<-3. Mortality rates were higher 10 (8.4%) among the 6-11months old. Most deaths 16 (64%) occurred within the first 3months post-discharge. Those who died were significantly more stunted, p = 0.016 and had a smaller head circumference, p = 0.005 on entry to OTP programme. There was improvement from admission to six months follow up in the number of children with complete immunization (27.4% to 35.6%), and a decrease in the number of unimmunized children (34.8% vs 20.6%) at follow-up. CONCLUSION: The study demonstrates good post discharge survival rate and improved nutritional status for SAM patients managed in OTPs. There were, however considerable post discharge mortality, especially in the first three months and lower immunization uptake post discharge. A follow-up programme will improve these indices further.