Methodological issues in HIV-related social research in Nigeria.

This paper is about methodological issues in a community-wide study in Nigeria on an infectious disease, namely HIV/AIDS. The study was designed to ascertain the risk factors that contribute to the spread of HIV/AIDS and how that can be tackled in order to bring about behavioural change. The research team believed at the onset that a study on the interplay between HIV/AIDS and sensitive issues like sexual mores and sexuality requires much more than a straightjacket social science method, such as simply doing a cross-section study and/or using interview schedule. This paper reviews the essence of cross-disciplinary approach; team building; as well as the use of a non-participatory observational approach in data collection. It also shows why ample consideration was given to ethical issues which are often glossed over in social research in developing countries. The lessons from the study underscore the methodological imperatives in social research that focus on sensitive issues in largely non-literate context like Nigeria. Although there are formidable challenges in community-based studies in largely non-literate societies, nevertheless they could easily be surmounted if there are ample time and resources to navigate the various sticking points.

Persistence of risky sexual behaviours and HIV/AIDS: evidence from qualitative data in three Nigerian communities.

The behavioural factors that are driving HIV/AIDS remain largely elusive despite vast number of quantitative studies. It is widely acknowledged that sensitive issues like sexual mores are better studied, using the qualitative methods. An ethnographic semi-longitudinal study was conducted in three of Nigeria's communities with high and/or low HIV/AIDS prevalence rates in order to ascertain the risky behavioural factors that are still driving the epidemic despite colossal investment in preventative programmes. The focus group discussion, in-depth interview and key informant methods were utilized to gather data from members of the communities, opinion leaders, policymakers, healthcare practitioners and religious leaders. The nine factors that appear to be driving the infection are: transactional sex, age of sexual debut and lack of parental care, misconceptions about HIV and AIDS, sexual partnership beyond spouses and primary partners, mismatched sexual desire, fatalism, syndrome of denial, condom use, and alcohol. The outcomes of the study have implications for the prevention of the HIV/AIDS epidemic in the country.

Informal payments for healthcare: differences in expenditures from consumers and providers perspectives for treatment of malaria in Nigeria.

OBJECTIVES: To examine differences in malaria treatment expenditures from the perspectives of consumers and providers in southeast Nigeria. METHODS: The study was conducted using household surveys, provider surveys and exit poll interviews. The amount of money that the providers claimed to charge their patients for malaria treatment services was compared with the expenditures that the respondents actually incurred for malaria treatment services from the same providers. RESULTS: The average expenditure for malaria treatment from the consumers as elicited from both the household survey and exit poll interviews was $6.30, while it was $2.20 for the providers from information from the provider survey. The widest gaps between expenditures for consumers and amounts purportedly charged by providers were found in public healthcare facilities. All socio-economic status groups and residents of urban and rural areas were exposed to informal payments. CONCLUSION: The differences in malaria treatment expenditures from consumers' and providers' perspectives point to high levels of informal payments, which worsen the economic burden of the disease and may predispose to catastrophic health spending. The informal payments are personal gains to the individual providers but represent a loss to the society, in terms of higher healthcare costs. Such payments should be addressed by policy makers so as to make treatment of malaria less costly to patients.

Geographic inequities in provision and utilization of malaria treatment services in southeast Nigeria: diagnosis, providers and drugs.

OBJECTIVES: To examine the levels of geographic inequities in households' choice of providers, mode of diagnosis and drugs for the treatment of malaria. METHODS: Interviewer-administered questionnaire was used to collect information from 2250 randomly selected respondents from six malaria-endemic communities in southeast Nigeria. A comparison of data between urban and rural areas was used to examine geographic inequities in treatment seeking. FINDINGS: There were geographic inequities in the use of different providers and drugs for the treatment of malaria. The urbanites used more of private hospitals/clinics and specialist hospital, while the rural dwellers used more of drug sellers (patent medicine dealers (PMD) and pharmacy shops (PS)). The rural dwellers were prescribed the cheaper drugs whilst the urbanites were prescribed the more costly drugs. CONCLUSION: The geographic inequities in malaria treatment are skewed against the rural people. Everybody is seeking care from the private sector for treatment of malaria but the rural dwellers are using mostly the informal healthcare providers.

Are there geographic and socio-economic differences in incidence, burden and prevention of malaria? A study in southeast Nigeria.

RATIONALE: It is not clearly evident whether malaria affects the poor more although it has been argued that the poor bear a very high burden of the disease. This study explored the socioeconomic and geographic differences in incidence and burden of malaria as well as ownership of mosquito nets. METHODS: Structured questionnaires were used to collect information from 1657 respondents from rural and urban communities in southeast Nigeria on: incidence of malaria, number of days lost to malaria; actions to treat malaria and household ownership of insecticide treated and untreated mosquito nets. Data was compared across socio-economic status (SES) quartiles and between urban and rural dwellers. RESULTS: There was statistically significant urban-rural difference in malaria occurrence with malaria occurring more amongst urban dwellers. There was more reported occurrence of malaria amongst children and other adult household members in better-off SES groups compared to worse-off SES groups, but not amongst respondents. The average number of days that people delayed before seeking treatment was two days, and both adults and children were ill with malaria for about six days. Better-off SES quartile and urban dwellers owned more mosquito nets (p < 0.05) (treated and untreated). CONCLUSION: Malaria occurs more amongst better-off SES groups and urban dwellers in southeast Nigeria. Deployment of malaria control interventions should ensure universal access since targeting the poor and other supposedly vulnerable groups may exclude people that really require malaria control services.

Malaria treatment perceptions, practices and influences on provider behaviour: comparing hospitals and non-hospitals in south-east Nigeria.

BACKGROUND: People seek treatment for malaria from a wide range of providers ranging from itinerant drug sellers to hospitals. However, there are lots of problems with treatment provision. Hence, factors influencing treatment provision in hospitals and non-hospitals require further investigation in order to remedy the situation. OBJECTIVES: To examine the knowledge, pattern of treatment provision and factors influencing the behaviour of hospitals and non-hospitals in the treatment of malaria, so as to identify loci for interventions to improve treatment of the disease. METHODS: A pre-tested structured questionnaire was used to collect data from 225 providers from hospitals and non-hospitals about their malaria treatment practices and factors that influence their provision of malaria treatment services in south-east Nigeria. The data from hospitals and other providers were compared for systematic differences. RESULTS: 73.5% of hospitals used microscopy to diagnose malaria and only 34.5.1% of non-hospitals did (p < 0.05). Majority of the respondents considered ability to pay bills (35.2%), already existing relationship (9.4%) and body mechanism (35.2%) of the patient before they provided malaria treatment services. Pressure from wholesalers to providers to repay the cost of supplied drugs was the major influence of the type of drugs provided to patients. CONCLUSION: There are many challenges to appropriate provision of malaria treatment services, although challenges are less in hospitals compared to other types of non-hospitals. Improving proper diagnosis of malaria and improving the knowledge of providers about malaria are interventions that could be used to improve malaria treatment provision.

Quality of anti-malarial drugs provided by public and private healthcare providers in south-east Nigeria.

BACKGROUND: There is little existing knowledge about actual quality of drugs provided by different providers in Nigeria and in many sub-Saharan African countries. Such information is important for improving malaria treatment that will help in the development and implementation of actions designed to improve the quality of treatment. The objective of the study was to determine the quality of drugs used for the treatment of malaria in a broad spectrum of public and private healthcare providers. METHODS: The study was undertaken in six towns (three urban and three rural) in Anambra state, south-east Nigeria. Anti-malarials (225 samples), which included artesunate, dihydroartemisinin, sulphadoxine-pyrimethamine (SP), quinine, and chloroquine, were either purchased or collected from randomly selected providers. The quality of these drugs was assessed by laboratory analysis of the dissolution profile using published pharmacopoeial monograms and measuring the amount of active ingredient using high performance liquid chromatography (HPLC). FINDINGS: It was found that 60 (37%) of the anti-malarials tested did not meet the United States Pharmacopoeia (USP) specifications for the amount of active ingredients, with the suspect drugs either lacking the active ingredients or containing suboptimal quantities of the active ingredients. Quinine (46%) and SP formulations (39%) were among drugs that did not satisfy the tolerance limits published in USP monograms. A total of 78% of the suspect drugs were from private facilities, mostly low-level providers, such as patent medicine dealers (vendors). CONCLUSION: This study found that there was a high prevalence of poor quality drugs. The findings provide areas for public intervention to improve the quality of malaria treatment services. There should be enforced checks and regulation of drug supply management as well as stiffer penalties for people stocking substandard and counterfeit drugs.

Examining catastrophic costs and benefit incidence of subsidized antiretroviral treatment (ART) programme in south-east Nigeria.

OBJECTIVES: To examine the extent to which costs of subsidized antiretrovirals treatment (ART) programmes are catastrophic and the benefit incidence that accrues to different population groups. METHODS: Data on expenditures to patients for receiving treatment from a government subsidized ART clinic was collected using a questionnaire. The patient costs excluded time and other indirect costs. Catastrophic cost was determined as the percentage of total expenditure on ART treatment as a proportion of household non-food expenditures on essential items. RESULTS: On average, patients spent 990 Naira (US$ 8.3) on antiretroviral (ARV) drugs per month. They also spent an average of $8.2 on other drugs per month. However, people that bought ARV drugs from elsewhere other than the ART clinic spent an average of $88.8 per month. Patients spent an average of $95.1 on laboratory tests per month. Subsidized ARV drugs depleted 9.8% of total household expenditure, other drugs (e.g. for opportunistic infections) depleted 9.7%, ARV drugs from elsewhere depleted 105%, investigations depleted 112.9% and total expenditure depleted 243.2%. The level of catastrophe was generally more with females, rural dwellers and most poor patients. Females and urbanites had more benefit incidence than males and rural dwellers. CONCLUSION: Subsidized ART programme lowers the cost of ARV drugs but other major costs are still incurred, which make the overall cost of accessing and consuming ART treatment to be excessive and catastrophic. The costs of laboratory tests and other drugs should be subsidized and there should also be targeting of ART programme to ensure that more rural dwellers and the most-poor people have increased benefit incidence.

Feasibility of a community health worker strategy for providing near and appropriate treatment of malaria in southeast Nigeria: an analysis of activities, costs and outcomes.

RATIONALE: Community health workers (CHWs) could be used to bring appropriate and timely treatment of malaria closer to home and there is the need to increase the body of knowledge about the feasibility of implementing the strategy. OBJECTIVE: To determine the processes, costs and outcomes of design and implementation of a strategy based on use of CHWs for near and appropriate treatment of malaria. METHODS: The CHW strategy was implemented in two villages (Adu and Ahani) in Enugu state, southeast Nigeria. Adu and Ahani have a population of approximately 3500 and 5000 residents, respectively. The study was conducted in four phases: (1) baseline survey; (2) design; (3) implementation, supervision and monitoring; and (4) evaluation. Interactive meeting with all the stakeholders were used to fine-tune the design of the CHW strategy. Community members that were selected by the project team with the help of community leaders were trained to become CHWs and their remuneration was through commissions on their drug sales. Community and provider's financial and non-financial costs of the startegy were computed. RESULTS: Non-financial costs were the highest contributor to consumer costs, while financial costs constituted more than 90% of provider costs. The total consumer cost in Ahani was US$2548, while the consumer cost in Adu was US$1585. The total provider cost in Ahani was US$4515, while in Adu it was US$4302. The unit cost cost per villager was US$1.40 in Ahani and US$1.70 in Adu, while the unit financial consumer cost per treated patient was $0.05 in both villages, respectively. The CHWs were acceptable to the people and had an increased market share out of existing malaria treatment provision strategies. CONCLUSION: The cost of starting up the CHW strategy is low and should be affordable to malaria control programs and communities. The CHW strategy is also economically viable and a potential cost-effective source for providing timely, and appropriate treatment of malaria in rural areas. It should be fine-tuned and added to malaria control armamenterium in Nigeria and other parts of sub-Saharan Africa.

Consumers stated and revealed preferences for community health workers and other strategies for the provision of timely and appropriate treatment of malaria in southeast Nigeria.

BACKGROUND: The African Heads of State meeting in Abuja, Nigeria on Roll Back Malaria adopted effective treatment of malaria nearer the home as one of the strategies for malaria control in Africa. A potentially effective strategy for bringing early, appropriate and low cost treatment of malaria closer to the home is through the use of community health workers (CHWs). There is paucity of information about people's actual preferences for CHWs and how stated preferences relates to revealed preferences for both the CHW strategy and other strategies for improving the timeliness of malaria treatment in not only Nigeria but in many malaria endemic countries. OBJECTIVES: To determine peoples' stated and actual preferences for different strategies for improving the timeliness and appropriateness of treatment of malaria before and after the implementation of a community health workers (CHW) strategy in their community. METHODS: A prospective study was undertaken in a rural malaria holo-endemic Nigerian community. A questionnaire was used to collect information on health-seeking from householders before (first survey) and after (second survey) implementation of a CHW malaria treatment strategy. RESULTS: The consumers mostly preferred the CHW strategy over self-treatment in the homes and other strategies of treatment. The use of community health workers (CHWs) increased from 0% to 26.1% (p < 0.05), while self-treatment in the homes decreased from 9.4% to 0% (p < 0.05) after the implementation of the CHW strategy. Use of patent medicine dealers also decreased from 44.8% to 17.9% (p < 0.05) after CHW strategy was implemented. CONCLUSION: Community health workers can be used to improve and ensure timely and appropriate treatment of malaria. The CHW strategy could also be sustained since it was preferred and used by consumers over self-treatment in the homes as well as other strategies for improving treatment. Hence, the CHW strategy is a feasible and promising method of improving home-management of uncomplicated malaria.

Socio-economic differences in preferences and willingness to pay for different providers of malaria treatment in southeast Nigeria.

This article determined whether there are links between socio-economic status (SES) and preferences of consumers for different strategies for improving timely and appropriate management of malaria. Ranking of preferences and willingness to pay (WTP) for 5 different strategies for improving the management of malaria in Enugu State, southeast Nigeria were elicited from randomly selected respondents. The results showed that the people were also willing to pay for improved management of malaria, though the levels of WTP was dependent on the SES of the respondents, with the poorest SES group willing to pay the least amount of money. Also, the respondents generally mostly preferred timely and appropriate management of malaria through formal public healthcare system. Hence, to decrease the inequity in malaria management and ensure the ready availability of appropriate treatment to the poorest households, the government should increase the availability and accessibility of publicly owned healthcare services, complemented by community-based health services.

Influence of education and knowledge on perceptions and practices to control malaria in Southeast Nigeria.

The study was undertaken in southeastern Nigeria to investigate whether the people's level of education and what they know about malaria affects how they seek treatment and prevention for the disease. Pre-tested questionnaires were used to collect data from randomly selected householders and analysed using logistic regression. Higher levels of education were associated with improved knowledge and practice about the appropriate strategies for the prevention and treatment of malaria. The results thus indicate that education can have a positive impact on the malaria burden and medium/long-term improvement of overall literacy rates. As well as this, short-term health education campaigns about the causes, manifestations and control of malaria will have a positive impact on its control.

Issues of measuring and improving the treatment of malaria in sub-Saharan Africa.

This paper, using focus group discussions and questionnaires in Enugu State, Southeast Nigeria, examines the implications of consumer malaria perceptions and behaviour for measuring the disease burden and improving its treatment. The results show that, because peoples' understanding of the disease was related to its symptoms, this could lead to overestimation of the economic burden of malaria, based only on surveys without diagnostic confirmation. Survey-based estimations of the burden of malaria should control for the different local terminologies of malaria, and health personnel should be aware of these in order to improve the appropriate use of antimalarial drugs in presumptive treatment of malaria.