Social Innovation For Health Research: Development of the SIFHR Checklist.

BACKGROUND: Social innovations in health are inclusive solutions to address the healthcare delivery gap that meet the needs of end users through a multi-stakeholder, community-engaged process. While social innovations for health have shown promise in closing the healthcare delivery gap, more research is needed to evaluate, scale up, and sustain social innovation. Research checklists can standardize and improve reporting of research findings, promote transparency, and increase replicability of study results and findings. METHODS AND FINDINGS: The research checklist was developed through a 3-step community-engaged process, including a global open call for ideas, a scoping review, and a 3-round modified Delphi process. The call for entries solicited checklists and related items and was open between November 27, 2019 and February 1, 2020. In addition to the open call submissions and scoping review findings, a 17-item Social Innovation For Health Research (SIFHR) Checklist was developed based on the Template for Intervention Description and Replication (TIDieR) Checklist. The checklist was then refined during 3 rounds of Delphi surveys conducted between May and June 2020. The resulting checklist will facilitate more complete and transparent reporting, increase end-user engagement, and help assess social innovation projects. A limitation of the open call was requiring internet access, which likely discouraged participation of some subgroups. CONCLUSIONS: The SIFHR Checklist will strengthen the reporting of social innovation for health research studies. More research is needed on social innovation for health.

"Cross-border collaboration in onchocerciasis elimination in Uganda: progress, challenges and opportunities from 2008 to 2013".

BACKGROUND: Until recently onchocerciasis was prevalent in 37 out of 112 districts of Uganda with at least 3.8 million people at risk of contracting the disease, but following the launching of community-directed treatment with ivermectin (CDTI) in 1996 and the adoption of an onchocerciasis elimination policy in 2007, the country has made significant progress in combating the disease. By 2015, interruption of transmission had been achieved in ten of the 17 onchocerciasis foci, but cross-border foci remained particularly problematic, and therefore within the onchocerciasis elimination framework, Uganda embarked upon addressing these issues with its neighbouring countries, namely the Democratic Republic of Congo (DRC) and South Sudan. This paper summarises the experience of Uganda in addressing cross-border issues on onchocerciasis elimination with DRC. MAIN ACHIEVEMENTS AND LESSONS LEARNED: The key achievements comprise of the adoption of an elimination policy by the Government of Uganda, cross-border meetings, training DRC technical staff and entomological/ epidemiological surveys. The first strategy meeting was held in Kampala in 2008, but the second strategy meeting was not held in Kinshasa until 2013. The involvement of the high-level officials from the Ministry of Health of DRC was critical for the success of the second strategy meeting, and was precipitated by collaboration to control an outbreak of Ebola Virus. Both meetings demonstrated the political commitment of endemic countries and allowed the implementation of a joint action plan. Important steps in establishing a mutually respected elimination targets was agreed on during cross border meetings. The African Programme for Onchocerciasis Control facilitated and funded these initial meetings, thus overcoming some political and financial challenges faced by both countries. This highlighted the need for multilateral organisations such as the Expanded Special Project for the Elimination of Neglected Tropical Diseases in cross-border activities for other Neglected Tropical Diseases. The collaboration between both countries facilitated the training of technical staff from DRC in entomology which facilitated joint cross-border activities to update the epidemiological understanding of onchocerciasis in Beni and Mahagi districts in North Kivu and Ituri Provinces respectively. In Nebbi district, Uganda, 23.7% of crabs were infested by the vector Simulium neavei compared with 6.3% in Mahagi district, DRC. Rapid Epidemiological Assessment (REA) revealed nodule prevalence of 3.2% and onchodermatitis at 26.4% from five villages in DRC. CONCLUSION: Political commitment of both countries and the support from APOC allowed two cross-border meetings which were critical for the implementation of initial cross border activities for onchocerciasis elimination.

Perception and utilization of public health services in Southeast Nigeria: Implication for health care in communities with different degrees of urbanization.

BACKGROUND: The relationship between people's perception and utilization of public health services was investigated. METHODS: A survey of 840 households across selected urban, peri urban and rural communities, in the Southeast of Nigeria, was conducted using the mixed methods approach. RESULTS: Of the nine (9) demographic variables, only the locality and status of the health system (strong or weak in terms of child immunization) was found to influence both the poor rating and utilization of public health services. Individuals from states with strong health system rated relatively higher and used public health services more (p < 0.001), than their counterparts from states with weak health care system. Similarly, those in the urban or peri-urban localities used public health services more (p = 0.013). The two perceptual variables significantly influence the rating and use of public health services. Those with a good perception of the quality of health service provided, rated and patronized them more (p < 0.001). Also, health centres that provide a high number of services enjoyed greater rating and patronage (p < 0.001 and p = 0.0524 respectively). The results of the structured questionnaire survey were confirmed by qualitative enquiry,based on in-depth interviews and focus group discussions. CONCLUSIONS: It will be necessary to create a more responsive atmosphere in the health facilities, with culturally-sensitive and friendly health workers, and provision of affordable drug to improve the perceptions of the primary health care system, for it to succeed in providing health services for all.

Characteristics of persons who complied with and failed to comply with annual ivermectin treatment.

OBJECTIVE: To assess individual compliance with annual ivermectin treatment in onchocerciasis-endemic villages. METHODS: Multi-site study in eight APOC-sponsored projects in Cameroon, Nigeria and Uganda to identify the socio-demographic correlates of compliance with ivermectin treatment. A structured questionnaire was administered on 2305 persons aged 10 years and above. Two categories of respondents were purposively selected to obtain both high and low compliers: people who took ivermectin 6-8 times and 0-2 times previously. Simple descriptive statistics were employed in characterizing the respondents into high and low compliers, while some socio-demographic and key perceptual factors were employed in regression models constructed to explain levels of compliance among the respondents. RESULTS: Some demographic and perceptual factors associated with compliance were identified. Compliance was more common among men (54.4%) (P < 0.001). Adults (54.6%) had greater rates of high compliance (P < 0.001. The mean age of high compliers (41.5 years) was significantly older (35.8 years) (t = 8.46, P < 0.001). Perception of onchocerciasis and effectiveness of ivermectin influenced compliance. 81.4% of respondents saw benefits in annual ivermectin treatment, high compliance among those who saw benefits was 59.3% compared to 13.3% of those who did not (P < 0.001). CONCLUSION: Efforts to increase compliance with ivermectin treatment should focus on providing health education to youth and women. Health education should also highlight the benefits of taking ivermectin.

Empowering communities in combating river blindness and the role of NGOs: case studies from Cameroon, Mali, Nigeria, and Uganda.

The control of onchocerciasis is not only a major success story in global health, but also one of the best examples of the power of public-private partnership at the international level as well as at the national level. The onchocerciasis story is also a leading example of the contribution of a group of called Non-Governmental Development Organizations (NGDO) to operational research which resulted in important changes in treatment strategies and policies.The four case studies presented here illustrate some key contributions the NGDOs made to the development of "community directed treatment with ivermectin" -CDTI, in Africa, which became the approved methodology within the African Programme for Onchocerciasis Control (APOC). The partnership between the international, multilateral, government institutions and the NGDO Coordination Group was the backbone of the APOC programme's structure and facilitated progress and scale-up of treatment programmes. Contributions included piloting community-based methodology in Mali and Nigeria; research, collaboration and coordination on treatment strategies and policies, coalition building, capacity building of national health workforce and advocacy at the national and international level. While the Onchocerciasis Control Programme (OCP) and APOC provided leadership, the NGDOs working with the national health authorities played a major role in advocacy evolving the community methodology which led to achieving and maintaining- treatments with ivermectin for at least 20 years and strengthening community health systems.

A model for evaluating the sustainability of community-directed treatment with ivermectin in the African Program for Onchocerciasis Control.

Onchocerciasis is controlled by mass treatment of at-risk populations with ivermectin. Ivermectin is delivered through community-directed treatment (CDTI) approach. A model has been developed to evaluate the sustainability of the approach and has been tested at 35 projects in 10 countries of the African Program for Onchocerciasis Control (APOC). It incorporates quantitative and qualitative data collection and analysis, taking account of two factors identified as crucial to project sustainability. These are (i) the provision of project performance information to partners, and (ii) evidence-based support for project implementation. The model is designed to provide critical indicators of project performance of the model to implementing, coordinating, and funding partners. The model's participatory and flexible nature makes it culturally sensitive and usable by project management. This model is able to analyze the different levels involved in project implementation and arrive at a judgment for the whole project. It has inbuilt mechanisms for ensuring data reliability and validity. The model addresses the complex issue of sustainability with a cross-sectional design focusing on how and at which operational level of implementation to strengthen a CDTI project. The unique attributes and limitations of the model for evaluating the sustainability of projects were described.

Integrated transmission assessment surveys (iTAS) of lymphatic filariasis and onchocerciasis in Cross River, Taraba and Yobe States, Nigeria.

BACKGROUND: Integrated transmission assessment surveys (iTAS) have been recommended for evaluation of the transmission of both lymphatic filariasis (LF) and onchocerciasis as the prevalence of both diseases moves toward their respective elimination targets in Nigeria. Therefore, we conducted an iTAS between May and December 2017 in five local government areas (LGAs), also known as implementation units (IUs), in states of Cross River, Taraba and Yobe in Nigeria. METHODS: The TAS comprised two phases: the Pre-iTAS and the iTAS itself. Three states (Cross River, Taraba and Yobe), comprising five LGAs and 20 communities that have completed five rounds of combined treatment with ivermectin and albendazole for LF and 12 total rounds of ivermectin, were selected for inclusion in the study. All participants were tested with the Filariasis Test Strip (FTS; Alere Inc.) and the Biplex rapid Diagnostic Test (RDT; identifying filaria antigens Ov16/Wb123; Abbott diagnosctics Korea Inc.). Pre iTAS included 100 children ages 5-9 in each 4 communities and 300 individuals ages 10 and older in a subset of two communities.  For the iTAS, only LGAs where antigenemia prevalence in all sampled communities during the Pre-iTAS was < 2% for LF were selected. RESULTS: Of the five LGAs included in the study, four met the cutoff of the Pre-iTAS and were included in the iTAS; the Ikom LGA was excluded from the iTAS due to antigenemia prevalence. A total of 11,531 school-aged children from 148 schools were tested for LF and onchocerciasis across these four LGAs, including 2873 children in Bade, 2622 children in Bekwara, 3026 children in Gashaka and 3010 children in Karim Lamido. Using the FTS, all samples from Bade and Karim Lamido were negative, whereas 0.2% of the samples from Bekwara and Gashaka were positive. Using the Biplex RDT, LF prevalence in Bade, Bekwara, Gashaka and Karim Lamido was < 0.1%, 0.5%, 0.4% and < 0.1%, respectively. Moreover, all samples from Bade and Karim Lamido were negative for onchocerciasis, whereas 3.1% and 1.8% of the samples from Bekwara and Gashaka were positive, respectively. CONCLUSION: This study has provided additional information on the current burden of onchocerciasis and LF in the four IUs sampled where mass drug administration (MDA) for both infections has been ongoing for years. The study identifies that LF-MDA can be safely stopped in all four of the IUs studied, but that MDA for onchocerciasis needs to continue, even though this may pose a challenge for LF surveillance. Based on the preliminary results from all four sites, this study has fulfilled the primary objective of determining the programmatic feasibility of an iTAS as a tool to simultaneously assess onchocerciasis and LF prevalence in areas co-endemic for the two infections that have completed the recommended treatment for one or both infections, and to make decisions on how to proceed.

Identification of the onchocerciasis vector in the Kakoi-Koda focus of the Democratic Republic of Congo.

BACKGROUND: The objective of this study was to characterise the vector in a small hyper-endemic focus of onchocerciasis (the Kakoi-Koda focus) which has recently been discovered on the western slopes of the rift valley above Lake Albert. METHODOLOGY/PRINCIPAL FINDINGS: Aquatic stages of blackflies were collected by hand from streams and rivers, and anthropophilic adult females were collected by human landing catches. Using a combination of morphotaxonomy and DNA barcoding, the blackflies collected biting humans within the focus were identified as Simulium dentulosum and Simulium vorax, which were also found breeding in local streams and rivers. Simulium damnosum s.l., Simulium neavei and Simulium albivirgulatum were not found (except for a single site in 2009 where crabs were carrying S. neavei). Anthropophilic specimens from the focus were screened for Onchocerca DNA using discriminant qualitative real-time triplex PCR. One specimen of S. vorax was positive for Onchocerca volvulus in the body, and out of 155 S. dentulosum, 30% and 11% were infected and infective (respectively). CONCLUSIONS/SIGNIFICANCE: Simulium dentulosum currently appears to be the main vector of human onchocerciasis within the Kakoi-Koda focus, and S. vorax may be a secondary vector. It remains possible that S. neavei was the main (or only) vector in the past having now become rare as a result of the removal of tree-cover and land-use changes. Simulium vorax has previously been shown to support the development of O. volvulus in the laboratory, but this is the first time that S. dentulosum has been implicated as a probable vector of onchocerciasis, and this raises the possibility that other blackfly species which are not generally considered to be anthropophilic vectors might become vectors under suitable conditions. Because S. dentulosum is not a vector in endemic areas surrounding the Kakoi-Koda focus, it is probable that the Kakoi-Koda focus is significantly isolated.

SARS CoV-2 Seroprevalence in Selected States of High and Low Disease Burden in Nigeria.

Importance: The global impact of COVID-19 has led to an increased need to continuously assess disease surveillance tools. The utility of SARS-CoV-2 serologic tools in determining immunity levels across different age groups and locations in helping to quickly assess the burden of COVID-19 with significant health policy implications is unknown. Objective: To determine the prevalence of SARS-CoV-2 antibodies with respect to the age group and sex of participants. Design, Setting, and Participants: A cross-sectional survey of 4904 individuals across 12 states with high and low COVID-19 disease burden in Nigeria was carried out between June 29 and August 21, 2021. Main Outcomes and Measures: Enzyme-linked immunosorbent assay was used for the detection of specific SARS-CoV-2 immunoglobulin G and immunoglobulin M antibodies, such as the nucleocapsid protein-NCP and spike protein S1. Interviewer-administered questionnaires provided information on participants' history of disease and associated risk factors. Results: A total of 4904 individuals participated in the study (3033 were female [61.8%]; mean [SD] age, 26.7 [6.51] years). A high seroprevalence of SARS-CoV-2 (78.9%) was obtained. Seropositivity was consistent across the states surveyed, ranging from 69.8% in Lagos to 87.7% in Borno. There was no association between sex and seropositivity (female, 2414 [79.6%]; male, 1456 [77.8%]; P = .61); however, an association was noted between age and seropositivity, with the peak prevalence observed in participants aged 15 to 19 years (616 [83.6%]; P = .001). Similarly, loss of appetite (751 [82.3%]; P = .04) and smell (309 [84.4%]; P = .01) were associated with seropositivity. Conclusions and Relevance: In this cross-sectional study, a high SARS-CoV-2 seroprevalence was obtained among the study population during the low level of vaccination at the time of the survey. Thus, there is a need for both an efficacy and antibody neutralization test study to ascertain the efficacy of the antibody detected and the potential for herd immunity in Nigeria.

Onchocerciasis control in Ghana (1974-2016).

BACKGROUND: The control of onchocerciasis in Ghana started in 1974 under the auspices of the Onchocerciasis Control Programme (OCP). Between 1974 and 2002, a combination of approaches including vector control, mobile community ivermectin treatment, and community-directed treatment with ivermectin (CDTI) were employed. From 1997, CDTI became the main control strategy employed by the Ghana OCP (GOCP). This review was undertaken to assess the impact of the control interventions on onchocerciasis in Ghana between 1974 and 2016, since which time the focus has changed from control to elimination. METHODS: In this paper, we review programme data from 1974 to 2016 to assess the impact of control activities on prevalence indicators of onchocerciasis. This review includes an evaluation of CDTI implementation, microfilaria (Mf) prevalence assessments and rapid epidemiological mapping of onchocerciasis results. RESULTS: This review indicates that the control of onchocerciasis in Ghana has been very successful, with a significant decrease in the prevalence of infection from 69.13% [95% confidence interval) CI 60.24-78.01] in 1975 to 0.72% (95% CI 0.19-1.26) in 2015. Similarly, the mean community Mf load decreased from 14.48 MF/skin snip in 1975 to 0.07 MF/skin snip (95% CI 0.00-0.19) in 2015. Between 1997 and 2016, the therapeutic coverage increased from 58.50 to 83.80%, with nearly 100 million ivermectin tablets distributed. CONCLUSIONS: Despite the significant reduction in the prevalence of onchocerciasis in Ghana, there are still communities with MF prevalence above 1%. As the focus of the GOCP has changed from the control of onchocerciasis to its elimination, both guidance and financial support are required to ensure that the latter goal is met.

Community-directed distributors-The "foot soldiers" in the fight to control and eliminate neglected tropical diseases.

The neglected tropical diseases (NTDs) affect hundreds of millions of people, predominantly in rural, often difficult-to-access areas, poorly served by national health services. Here, we review the contributions of 4.8 million community-directed distributors (CDDs) of medicines over 2 decades in 146,000 communities in 27 sub-Saharan African countries to control or eliminate onchocerciasis and lymphatic filariasis (LF). We examine their role in the control of other NTDs, malaria, HIV/AIDS interventions, immunisation campaigns, and support to overstretched health service personnel. We are of the opinion that CDDs as community selected, trained, and experienced "foot soldiers," some of whom were involved in the Ebola outbreak responses at the community level in Liberia, if retrained, can assist community leaders and support health workers (HWs) in the ongoing Coronavirus Disease 2019 (COVID-19) crisis. The review highlights the improved treatment coverage where there are women CDDs, the benefits and lessons from the work of CDDs, their long-term engagement, and the challenges they face in healthcare delivery. It underscores the value of utilising the CDD model for strong community engagement and recommends the model, with some review, to hasten the achievement of the NTD 2030 goal and assist the health system cope with evolving epidemics and other challenges. We propose that, based on the unprecedented progress made in the control of NTDs directly linked to community engagement and contributions of CDDs "foot soldiers," they deserve regional and global recognition. We also suggest that the World Health Organization (WHO) and other international stakeholders promote policy and guidance for countries to adapt this model for the elimination of NTDs and to strengthen national health services. This will enhance the accomplishment of some Sustainable Development Goals (SDGs) by 2030 in sub-Saharan Africa.

Social innovation for health: engaging communities to address infectious diseases.

Universal health coverage emphasises the value of the community-based delivery of health services to ensure that underserved populations have access to care. In areas where infectious diseases are endemic, there are often few resources and limited capacity, and the introduction of effective and accessible strategies require innovation. In this special issue, the contributing authors emphasise the power of local responses to the circumstances that underpin diseases of poverty, and highlight the methodological and programme innovations necessary to support and sustain these responses. Through case studies, the authors illustrate how social innovations can address health inequities, and they identify the role of academics in the Social Innovation in Health Initiative to support this approach.

Social innovation research checklist: A crowdsourcing open call and digital hackathon to develop a checklist for research to advance social innovation in health.

While social innovations in health have shown promise in closing the healthcare delivery gap, especially in low- and middle-income countries (LMICs), more research is needed to evaluate, scale up, and sustain social innovations. Research checklists can standardize and improve reporting of research findings, promote transparency, and increase replicability of study results and findings. This article describes the development of a 17-item social innovation in health research checklist to assess and report social innovation projects and provides examples of good reporting. The checklist is adapted from the TIDieR checklist and will facilitate more complete and transparent reporting and increase end user engagement. SUMMARY POINTS: While many social innovations have been developed and shown promise in closing the healthcare delivery gap, more research is needed to evaluate social innovationThe Social Innovation in Health Research Checklist, the first of its kind, is a 17-item checklist to improve reporting completeness and promote transparency in the development, implementation, and evaluation of social innovations in healthThe research checklist was developed through a three-step process, including a global open call for ideas, a scoping review, and a three-round modified Delphi processUse of this research checklist will enable researchers, innovators and partners to learn more about the process and results of social innovation in health research.

The need for evidence-based strategies and tools for onchocerciasis elimination in Africa.

In a recent article we discussed the feasibility of onchocerciasis elimination in Africa by 2025. We expressed concern that elimination may be impeded by failure to build on the lessons learned in the African onchocerciasis control programmes and the introduction of strategies and tools from the Americas. Richards et al. and Cupp et al. wrote to refute our concern and described recent achievements with stopping treatment in some areas.In this response, we discuss their arguments which did not convince us. We point out several scientific flaws in the American conceptual framework of elimination which has led to longer periods of treatment than necessary, and in the use of an arbitrary threshold for stopping treatment. We show that recent achievements fall significantly short of what would be needed to achieve onchocerciasis elimination by 2025.We conclude our response by advocating for a more objective and inclusive debate on strategies and tools for onchocerciasis elimination.

Is onchocerciasis elimination in Africa feasible by 2025: a perspective based on lessons learnt from the African control programmes.

BACKGROUND: Onchocerciasis is found predominantly in Africa where large scale vector control started in 1974. Registration and donation of ivermectin by Merck & Co in 1987 enabled mass treatment with ivermectin in all endemic countries in Africa and the Americas. Although elimination of onchocerciasis with ivermectin was considered feasible only in the Americas, recently it has been shown possible in Africa too, necessitating fundamental changes in technical and operational approaches and procedures. MAIN BODY: The American programme(OEPA) operating in onchocerciasis epidemiological settings similar to the mild end of the complex epidemiology of onchocerciasis in Africa, has succeeded in eliminating onchocerciasis from 4 of its 6 endemic countries. This was achieved through biannual mass treatment with ivermectin of 85% of the eligible population, and monitoring and evaluation using serological tests in children and entomological tests. The first African programme(OCP) had a head start of nearly two decades. It employed vector control and accumulated lots of knowledge on the dynamics of onchocerciasis elimination over a wide range of epidemiological settings in the vast expanse of its core area. OCP made extensive use of modelling and operationalised elimination indicators for entomological evaluation and epidemiological evaluation using skin snip procedures. The successor African programme(APOC) employed mainly ivermectin treatment. Initially its objective was to control onchocerciasis as a public health problem but that objective was later expanded to include the elimination of onchocerciasis where feasible. Building on the experience with onchocerciasis elimination of the OCP, APOC has leveraged OCP's vast modelling experience and has developed operational procedures and indicators for evaluating progress towards elimination and stopping ivermectin mass treatment of onchocerciasis in the complex African setting. CONCLUSIONS: Following the closure of APOC in 2015, implementation of onchocerciasis elimination in Africa appears to overlook all the experience that has been accumulated by the African programmes. It is employing predominantly American processes that were developed in a dissimilar setting from the complex African onchocerciasis setting. This is impeding progress towards decisions to stop intervention in many areas that have reached the elimination point. This article summarizes lessons learned in Africa and their importance for achieving elimination in Africa by 2025.

Nutritional value of school meals and their contributions to energy and nutrient intakes of rural school children in Enugu and Anambra States, Nigeria.

BACKGROUND: Nutritional deficiencies among school children may hinge on inadequate nutrient intake. School meals should improve nutrient intakes by providing a third of recommended daily energy and nutrient intakes (RNI). The study aimed at evaluating school meals served in three rural schools to determine if they met one third of the RNI of the children. This will enhance meal planning. METHODS: Food samples (20 g) that constituted the school meals were collected for five consecutive days from three schools where school lunch programme was implemented. These were put in labelled small air tight plastic containers and stored in deep freezers in the Department of Home Science, Nutrition and Dietetics, University of Nigeria, Nsukka. The samples were analysed chemically using standard methods. Portion sizes of foods were obtained and the contributions made by these meals to the children's RNI were calculated. Results were presented in percentages and means ± standard deviations. RESULTS: The results showed that energy value of the meals ranged from 32.27 - 243.4 Kcal/100 g. The school meals contained carbohydrate (0.7 - 48.4 g), protein (0.69 - 12.6 g), vitamin C (0.7 - 8.22 mg), vitamin A (3.0 - 255.5 RE), iron (0.05 - 1.7 mg), calcium (3.0 -120 mg) and zinc (0.14 - 3.0 mg) per 100 g of food consumed. They contributed 16.4 - 25.5% energy, 53.4 - 116.9% protein, 66.0 - 159.5% vitamin A, 37.3 - 45.7% vitamin C, 13.2 - 28.5% calcium, 5.9 - 20.6% iron and 35.1 - 92.9% zinc to the children's daily requirements. CONCLUSION: The school meals provided over one third of the RNI for protein, vitamins A and C, and zinc but did not meet a third of the RNI for energy, calcium and iron.

Performance of predictors: evaluating sustainability in community-directed treatment projects of the African programme for onchocerciasis control.

The predictors of sustainability of community-directed treatment with ivermectin (CDTI) at four implementation levels were evaluated in 41 African Programme for Onchocerciasis Control (APOC) projects, encompassing 492 communities in 10 countries. A model protocol provided information on indicators corresponding to nine aspects of a project that is likely to be sustainable at community level after the cessation of external support. Six of the nine aspects had components of community ownership as predictors of project sustainability. Quantitative and qualitative assessments were used to obtain individual community scores and an overall sustainability score for each project graded on a scale of 0-4. Of the 41 projects evaluated, 70% scored "satisfactorily" to "highly sustainable" at the community level. We found variations among countries and that health system weaknesses could hamper community efforts in sustaining a project, such as when ivermectin was delivered late. Community ownership was of primary importance to the community score, and the community-level scores correlated with overall project sustainability. The therapeutic coverage achieved in each project correlated with the ratio of volunteer ivermectin distributors per population served. Surprisingly, the performance of these distributors was not affected by the direct incentives offered, and coverage appeared to be highest when cash or in-kind compensation was not given at all. Although further research is required, anecdotal evidence pointed to diverse indirect benefits for distributors-political goodwill, personal satisfaction and altruistic fulfillment. The results demonstrate that community ownership is among the important determining factors of sustainability of community-based programmes.

The Potential for Community-Directed Interventions: Reaching Underserved Populations in Africa.

Community-directed interventions (CDIs) have the potential for fulfilling the promise of primary health care by reaching underserved populations in various settings. CDI has been successfully tested by expanding access to additional health services like malaria case management through local effort in communities where ivermectin distribution is ongoing. The question remains whether the CDI approach has potential in communities that do not have a foundation of community-directed treatment with ivermectin. The UNICEF/UNDP/World Bank/WHO Special Program of Research and Training in Tropical Diseases commissioned three sets of formative studies to explore the potential for introducing CDI among nomads, urban poor, and rural areas with no community-directed treatment with ivermectin. This article reviews their findings. Community and health system respondents identified a set of mainly communicable diseases that could be adapted to CDI as well as participatory mechanisms like community-based organizations and leaders that could form a foundation for local organizing and participation. It is hoped that the results of these formative studies will spur further research on CDI among peoples with poor health-care access.