Co-implementing vitamin A supplementation with seasonal malaria chemoprevention in Sokoto State, Nigeria: a feasibility and acceptability study.

BACKGROUND: Bi-annual high dose vitamin A supplements administered to children aged 6-59 months can significantly reduce child mortality, but vitamin A supplementation (VAS) coverage is low in Nigeria. The World Health Organization recommends that VAS be integrated into other public health programmes which are aimed at improving child survival. Seasonal malaria chemoprevention (SMC) provides a ready platform for VAS integration to improve health outcomes. This study explored the feasibility and acceptability of integrating VAS with SMC in one local government area in Sokoto State. METHODS: A concurrent QUAN-QUAL mixed methods study was used to assess the feasibility and acceptability of co-implementing VAS with SMC in one LGA of Sokoto state. Existing SMC implementation tools and job aids were revised and SMC and VAS were delivered using a door-to-door approach. VAS and SMC coverage were subsequently assessed using questionnaires administered to 188 and 197 households at baseline and endline respectively. The qualitative component involved key informant interviews and focus group discussions with policymakers, programme officials and technical partners to explore feasibility and acceptability. Thematic analysis was carried out on the qualitative data. RESULTS: At endline, the proportion of children who received at least one dose of VAS in the last six months increased significantly from 2 to 59% (p < 0.001). There were no adverse effects on the coverage of SMC delivery with 70% eligible children reached at baseline, increasing to 76% (p = 0.412) at endline. There was no significant change (p = 0.264) in the quality of SMC, measured by proportion of children receiving their first dose as directly observed treatment (DOT), at baseline (54%) compared to endline (68%). The qualitative findings are presented as two overarching themes relating to feasibility and acceptability of the integrated VAS-SMC strategy, and within each, a series of sub-themes describe study participants' views of important considerations in implementing the strategy. CONCLUSION: This study showed that it is feasible and acceptable to integrate VAS with SMC delivery in areas of high seasonal malaria transmission such as northern Nigeria, where SMC campaigns are implemented. SMC-VAS integrated campaigns can significantly increase vitamin A coverage but more research is required to demonstrate the feasibility of this integration in different settings and on a larger scale.

The Equity Impact of Universal Home Visits to Pregnant Women and Their Spouses in Bauchi State, Nigeria: Secondary Analysis From a Cluster Randomised Controlled Trial.

BACKGROUND: Socio-economically disadvantaged women have poor maternal health outcomes. Maternal health interventions often fail to reach those who need them most and may exacerbate inequalities. In Bauchi State, Nigeria, a recent cluster randomised controlled trial (CRCT) showed an impressive impact on maternal health outcomes of universal home visits to pregnant women and their spouses. The home visitors shared evidence about local risk factors actionable by households themselves and the program included specific efforts to ensure all households in the intervention areas received visits. PURPOSE: To examine equity of the intervention implementation and its pro-equity impact. RESEARCH DESIGN AND STUDY SAMPLE: The overall study was a CRCT in a stepped wedge design, examining outcomes among 15,912 pregnant women. ANALYSIS: We examined coverage of the home visits (three or more visits) and their impact on maternal health outcomes according to equity factors at community, household, and individual levels. RESULTS: Disadvantaged pregnant women (living in rural communities, from the poorest households, and without education) were as likely as those less disadvantaged to receive three or more visits. Improvements in maternal knowledge of danger signs and spousal communication, and reductions in heavy work, pregnancy complications, and post-natal sepsis were significantly greater among disadvantaged women according to the same equity factors. CONCLUSIONS: The universal home visits had equitable coverage, reaching all pregnant women, including those who do not access facility-based services, and had an important pro-equity impact on maternal health.

Impact-Oriented Dialogue for Culturally Safe Adolescent Sexual and Reproductive Health in Bauchi State, Nigeria: Protocol for a Codesigned Pragmatic Cluster Randomized Controlled Trial.

BACKGROUND: Adolescents (10-19 years) are a big segment of the Nigerian population, and they face serious risks to their health and well-being. Maternal mortality is very high in Nigeria, and rates of pregnancy and maternal deaths are high among female adolescents. Rates of HIV infection are rising among adolescents, gender violence and sexual abuse are common, and knowledge about sexual and reproductive health risks is low. Adolescent sexual and reproductive health (ASRH) indicators are worse in the north of the country. OBJECTIVE: In Bauchi State, northern Nigeria, the project will document the nature and extent of ASRH outcomes and risks, discuss the findings and codesign solutions with local stakeholders, and measure the short-term impact of the discussions and proposed solutions. METHODS: The participatory research project is a sequential mixed-methods codesign of a pragmatic cluster randomized controlled trial. Focus groups of local stakeholders (female and male adolescents, parents, traditional and religious leaders, service providers, and planners) will identify local priority ASRH concerns. The same stakeholder groups will map their knowledge of factors causing these concerns using the fuzzy cognitive mapping (FCM) technique. Findings from the maps and a scoping review will inform the contextualization of survey instruments to collect information about ASRH from female and male adolescents and parents in households and from local service providers. The survey will take place in 60 Bauchi communities. Adolescents will cocreate materials to share the findings from the maps and survey. In 30 communities, randomly allocated, the project will engage adolescents and other stakeholders in households, communities, and services to discuss the evidence and to design and implement culturally acceptable actions to improve ASRH. A follow-up survey in communities with and without the intervention will measure the short-term impact of these discussions and actions. We will also evaluate the intervention process and use narrative techniques to assess its impact qualitatively. RESULTS: Focus groups to explore ASRH concerns of stakeholders began in October 2021. Baseline data collection in the household survey is expected to take place in mid-2022. The study was approved by the Bauchi State Health Research Ethics Committee, approval number NREC/03/11/19B/2021/03 (March 1, 2021), and by the Faculty of Medicine and Health Sciences Institutional Review Board McGill University (September 13, 2021). CONCLUSIONS: Evidence about factors related to ASRH outcomes in Nigeria and implementation and testing of a dialogic intervention to improve these outcomes will fill a gap in the literature. The project will document and test the effectiveness of a participatory approach to ASRH intervention research. TRIAL REGISTRATION: ISRCTN Registry ISRCTN18295275; https://www.isrctn.com/ISRCTN18295275. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/36060.

Universal home visits improve male knowledge and attitudes about maternal and child health in Bauchi State, Nigeria: Secondary outcome analysis of a stepped wedge cluster randomised controlled trial.

BACKGROUND: The World Health Organization recommends increased male involvement to improve maternal and newborn health in low- and middle-income countries, but few studies have measured the impact of male-engagement interventions on targeted men. A trial of universal home visits to pregnant women and their spouses in Nigeria improved maternal and child health outcomes. This analysis examines the impact of the visits on male spouses. METHODS: In Toro Local Government Area in Bauchi State, Nigeria, we randomly allocated eight wards into four waves, beginning the intervention at one-year intervals. The intervention comprised two-monthly evidence-based home visits to discuss local risk factors for maternal and child health with all pregnant women and their male spouses. Measured secondary outcomes of the intervention in the men included knowledge about danger signs in pregnancy and childbirth, beliefs about heavy work in pregnancy, discussion with their wives about pregnancy and childbirth, knowledge about causes and intentions about management of childhood diarrhoea, and views about childhood immunisation. The analysis compared outcomes between men in visited wards (intervention group) and pre-intervention wards (control group), using a cluster t test. Generalised linear mixed modelling accounted for the effect of socio-economic differences on the measured impact. RESULTS: The analysis included 6931 men in the intervention group and 9434 in the control group. More men in the intervention group knew four or more danger signs in pregnancy (risk difference (RD) = 0.186, 95% confidence interval (CI) = 0.044 to 0.327), and three danger signs in childbirth (RD = 0.091, 95%CI = 0.013 to 0.170), thought pregnant women should reduce heavy work before the third trimester (RD = 0.088, 95% CI = 0.015 to 0.162), and had discussed pregnancy and childbirth with their spouse (RD = 0.157, 95% CI = 0.026 to 0.288). More knew correct management of childhood diarrhoea with fluids and feeding (RD = 0.300, 95% CI = 0.203 to 0.397) and less would give a child medicine to stop diarrhoea (RD = 0.206, 95% CI = 0.125 to 0.287). Socio-economic differences did not explain the effect of the intervention on any of the outcomes. CONCLUSION: Universal home visits improved knowledge of male spouses about maternal and child health, which could contribute to improved maternal and child outcomes. TRIAL REGISTRATION: ISRCTN, ISRCTN82954580. 11 August 2017. Retrospectively registered. http://www.isrctn.com/ISRCTN82954580.