The use of formative research to inform the design of a seasonal malaria chemoprevention intervention in northern Nigeria.

BACKGROUND: Experience of seasonal malaria chemoprevention (SMC) is growing in the Sahel sub-region of Africa, though there remains insufficient evidence to recommend a standard deployment strategy. In 2012, a project was initiated in Katsina state, northern Nigeria, to design an appropriate and effective community-based delivery approach for SMC, in consultation with local stakeholders. Formative research (FR) was conducted locally to explore the potential feasibility and acceptability of SMC and to highlight information gaps and practical considerations to inform the intervention design. METHODS: The FR adopted qualitative methods; 36 in-depth interviews and 18 focus group discussions were conducted across 13 target groups active across the health system and within the community. Analysis followed the 'framework' approach. The process for incorporating the FR results into the project design was iterative which was initiated by a week-long 'intervention design' workshop with relevant stakeholders. RESULTS: The FR highlighted both supportive and hindering factors to be considered in the intervention design. Malaria control was identified as a community priority, the community health workers were a trusted resource and the local leadership exerted strong influence over household decisions. However, there were perceived challenges with quality of care at both community and health facility levels, referral linkage and supportive supervision were weak, literacy levels lower than anticipated and there was the potential for suspicion of 'outside' interventions. There was broad consensus across target groups that community-based SMC drug delivery would better enable a high coverage of beneficiaries and potentially garner wider community support. A mixed approach was recommended, including both community fixed-point and household-to-household SMC delivery. The FR findings were used to inform the overall distribution strategy, mechanisms for integration into the health system, capacity building and training approaches, supportive interventions to strengthen the health system, and the social mobilization strategy. CONCLUSIONS: Formative research played a valuable role in exploring local socio-cultural contexts and health system realities. Both opportunities and challenges for the introduction of SMC delivery were highlighted, which were appropriately considered in the design of the project.

Health worker perspectives on the possible use of intramuscular artesunate for the treatment of severe malaria at lower-level health facilities in settings with poor access to referral facilities in Nigeria: a qualitative study.

BACKGROUND: Innovative strategies are needed to reduce malaria mortality in high burden countries like Nigeria. Given that one of the important reasons for this high malaria mortality is delay in receiving effective treatment, improved access to such treatment is critical. Intramuscular artesunate could be used at lower-level facilities given its proven efficacy, ease of use and excellent safety profile. The objective of this study was therefore to explore health workers' perspectives on the possible use of intramuscular artesunate as definitive treatment for severe malaria at lower-level facilities, especially when access to referral facilities is challenging. The study was to provide insight as a formative step into the conduct of future experimental studies to ascertain the feasibility of the use of intramuscular artesunate for definitive treatment of severe malaria in lower level facilities where access to referral care is limited. METHODS: This qualitative study was done across three southern States in Nigeria (Oyo, Cross River and Enugu). Key informant interviews were conducted over a period of three months between October and December 2014 among 90 purposively selected health workers with different roles in malaria case management from primary care to policy level. A thematic content analysis was used to analyse data. RESULTS: Overall, most of health workers and other key informant groups thought that the use of intramuscular artesunate for definitive treatment of severe malaria at lower-level facilities was possible. They however reported human resource and infrastructure constraints as factors affecting the feasibility of intramuscular artesunate use as definitive treatment for severe malaria in lower-level facilities.. Specifically identified barriers included limited numbers of skilled health workers available to manage potential complications of severe malaria and poorly equipped facilities for supportive treatment. Intramuscular artesunate was considered easy to administer and the proximity of lower-level facilities to communities was deemed important in considering the possibility of its use at lower-level facilities. Health workers also emphasised the important role of operational research to provide additional evidence to guide the implementation of existing policy recommendations and inform future policy revisions. CONCLUSIONS: From the perspective of health workers, use of intramuscular artesunate for definitive treatment of severe malaria at lower-level health facilities in Nigeria is possible but dependent on availability of skilled workers, well-equipped lower-level facilities to provide supportive treatment There is need for further operational research to establish feasibility and guide the implementation of such an intervention.

Community engagement and mobilisation of local resources to support integrated Community Case Management of childhood illnesses in Niger State, Nigeria.

BACKGROUND: Despite strong evidence of integrated community case management (iCCM) of childhood illnesses being a proven intervention for reducing childhood morbidity and mortality, sustainability remains a challenge in most settings. Community ownership and contribution are important factors in sustainability. The purpose of this study was to document the process and scale achieved for community engagement and mobilisation to foster ownership, service uptake and sustainability of iCCM activities. METHODS: A review of data collected by the RAcE project was conducted to describe the scale and achievement of leveraging community resources to support the community-oriented resource persons (CORPs). The Rapid Access Expansion (RAcE)-supported iCCM programme in Niger state (2014-2017), aimed at improving coverage of case management services for malaria, pneumonia, and diarrhoea, among children aged 2-59 months. Resources donated were documented and costed based on the market value of goods and services at the time of donation. These monetary valuations were validated at community dialogue meetings. Descriptive statistics were used to summarise quantitative variables. The mean of the number of CORPs in active service and the percentages of the mobilised resources received by CORPs were calculated. RESULTS: The community engagement activities included 143 engagement and advocacy visits, and meetings, 300 community dialogues, reactivation of 60 ward development committees, and 3000 radio messages in support of iCCM. 79.5% of 1659 trained CORPs were still in active iCCM service at the end of the project. We estimated the costs of all support provided by the community to CORPs in cash and kind as US$ 123 062. Types of support included cash; building materials; farming support; fuel for motorcycles, and transport fares. CONCLUSIONS: The achievements of community engagement, mobilisation, and the resources leveraged, demonstrated acceptability of the project to the beneficiaries and their willingness to contribute to uninterrupted service provision by CORPs.

Effect of community-based intervention on improving access to treatment for sick under-five children in hard-to-reach communities in Niger State, Nigeria.

BACKGROUND: Access to prompt and appropriate treatment is key to survival for children with malaria, pneumonia and diarrhoea. Community-based services are vital to extending care to remote populations. Malaria Consortium supported Niger state Ministry of Health, Nigeria, to introduce and implement an integrated community case management (iCCM) programme for four years in six local government areas (LGAs). The objective was to increase coverage of effective treatment for malaria, pneumonia and diarrhoea among children aged 2-59 months. METHODS: The programme involved training, equipping, ongoing support and supervision of 1320 community volunteers (CORPs) to provide iCCM services to their communities in all six LGAs. Demand creation activities were also conducted; these included community dialogues, household mobilization, sensitization and mass media campaigns targeted at programme communities. To assess the level of changes in care seeking and treatment, baseline and endline household surveys were conducted in 2014 and 2017 respectively. For both surveys, a 30×30 multi-stage cluster sampling method was used, the sampling frame being RAcE programme communities. RESULTS: Care-seeking from an appropriate provider increased overall and for each iCCM illness from 78% to 94% for children presenting with fever (P < 0.01), from 72% to 91% for diarrhoea cases (P < 0.01), and from 76% to 89% for cases of cough with difficult or fast breathing (P < 0.05). For diagnosis and treatment, the coverage of fevers tested for malaria increased from 34% to 77% (P < 0.001) and ACT treatments from 57% to 73% (<0.005); 56% of cases of cough or fast breathing who sought care from a CORP, had their respiratory rate counted and 61% with cough or fast breathing received amoxicillin. At endline caregivers sought care from CORPs in their communities for most cases of childhood illnesses (84%) compared to other providers at hospitals (1%) or health centres (9%).This aligns with caregivers' belief that CORPs are trusted providers (94%) who provide quality services (96%). CONCLUSION: Implementation of iCCM with focused demand creation activities can improve access to quality lifesaving interventions from frontline community providers in Nigeria. This can contribute towards achieving SDGs if iCCM is scaled up to hard-to-reach areas of all states in the country.

Sickle-Cell Disease in Nigerian Children: Parental Knowledge and Laboratory Results.

BACKGROUND: Sickle-cell disease (SCD) is the most common inherited genetic disorder in sub-Saharan Africa, and it is associated with early mortality and lifelong morbidity. Early diagnosis is essential for instituting appropriate care and preventive therapy. OBJECTIVE: To compare parental knowledge or perception of their offspring's hemoglobin phenotype prior to testing and actual validated laboratory test results. METHODS: In a prospective community-based survey, we assessed parental knowledge of their children's hemoglobin phenotype and corroborated this with the results from a laboratory confirmatory test determined by high-performance liquid chromatography. RESULTS: We screened 10,126 children aged less than 5 years. A total of 163 (1.6%) parents indicated that their offspring had been previously tested and had knowledge of the child's hemoglobin genotype. However, 51 (31.2%) of 163 parents of children who had been previously tested did not know the result of their offspring's test, and 18 (35.3%) of these 51 children were found to have SCD. Of those who claimed previous knowledge, 25 (15.3%) of 163 reported incorrect results. Overall, we identified 272 (2.76%) new cases from 9,963 children who had not been previously tested. CONCLUSION: There is the need to promote public awareness about SCD and the benefit of early diagnosis, quality assurance in laboratory diagnosis and institution of sustainable patient care pathways.

Comparison of five antimicrobial regimens for treatment of mild to moderate inflammatory facial acne vulgaris in the community: randomised controlled trial.

BACKGROUND: We investigated the efficacy and cost-effectiveness of five antimicrobial regimens for mild to moderate facial acne and whether propionibacterial antibiotic resistance affects treatment response. METHODS: In this randomised, observer-masked trial, 649 community participants were allocated one of five antibacterial regimens. Primary outcomes were patients' self-assessed improvement and reduction in inflamed lesions at 18 weeks. Analyses were by intention to treat. FINDINGS: Moderate or greater improvement at 18 weeks was reported in 72 (55%) of 131 participants assigned oral oxytetracycline plus topical placebo, 70 (54%) of 130 assigned oral minocycline plus topical placebo, 78 (60%) of 130 assigned topical benzoyl peroxide plus oral placebo, 84 (66%) of 127 assigned topical erythromycin and benzoyl peroxide in a combined formulation plus oral placebo, and 82 (63%) of 131 assigned topical erythromycin and benzoyl peroxide separately plus oral placebo. Most improvement occurred in the first 6 weeks. Treatment differences for the proportion of people with at least moderate improvement were: minocycline versus oxytetracycline -1.2% (unadjusted 95% CI -13.3 to 10.9); combined erythromycin and benzoyl peroxide versus oxytetracycline 11.1% (-0.7 to 22.9) and versus minocycline 12.3% (0.4 to 24.2); erythromycin and benzoyl peroxide separately versus combined formulation -3.5% (-15.2 to 8.2); benzoyl peroxide versus oxytetracycline 5.0% (-7.0 to 17.0), versus minocycline 6.2% (-5.8 to 18.2), and versus combined formulation -6.1% (-17.9 to 5.7). Benzoyl peroxide was the most cost-effective treatment. Efficacy of both tetracyclines was reduced by pre-existing tetracycline resistance. INTERPRETATION: Topical benzoyl peroxide and benzoyl peroxide/erythromycin combinations are similar in efficacy to oral oxytetracycline and minocycline and are not affected by propionibacterial antibiotic resistance.

Nurses in research: the treatment of acne.

Many nurses undertake research, either as part of a research team or independently as the research lead. Nurses are well placed to participate in research, using their clinical skills to the benefit of both the participants and the research objectives. This article focuses on the value of nurses in research. Using the example of their own experiences of a large NHS clinical trial, the authors demonstrate how nurses can become involved in research, what skills are needed, and how nursing skills and experience can contribute to the role of a clinical assessor/research nurse.

Capacity-building for public health: http://peoples-uni.org.

The development of educational context around free and open-source materials available on the Internet has the ability to help build public health capacity in low- to middle-income countries. Inspiration to develop such a programme comes from the free and open-source software movement, where many hundreds of individuals have collaborated in the development of high-quality software freely available on the Internet, and its education counterpart of Open Educational Resource development. These reflect societal developments, especially those associated with Web 2.0. In a partnership across the global and digital divides, the People's Open Access Education Initiative (http://peoples-uni.org) has been established to embrace three aspects. First, identifying open-access materials linked to the competences required to tackle public health problems, with subsequent modifications to the materials by teachers and students to reflect local issues. Second, teaching through online facilitation by volunteers in conjunction with members of local universities. Third, accrediting learned competences. Situation analyses already performed suggest that the need for this education is great and that this solution may be feasible in many countries. Several partners have already agreed to be involved and exemplar course modules are being prepared. We call for volunteers to help take this initiative further.