The social dimensions of community delivery of intermittent preventive treatment of malaria in pregnancy in Madagascar, Mozambique, Nigeria and the Democratic Republic of the Congo.

INTRODUCTION: Intermittent preventive treatment in pregnancy with sulphadoxine pyrimethamine (IPTp) is a key malaria prevention strategy in sub-Saharan African countries. We conducted an anthropological study as part of a project aiming to evaluate a community-based approach to the delivery of IPTp (C-IPTp) through community health workers (CHWs) in four countries (the Democratic Republic of Congo, Madagascar, Mozambique and Nigeria), to understand the social context in order to identify key factors that could influence C-IPTp acceptability. METHODS: A total of 796 in-depth interviews and 265 focus group discussions were undertaken between 2018 and 2021 in the four countries with pregnant women, women of reproductive age, traditional and facility-based healthcare providers, community leaders, and relatives of pregnant women. These were combined with direct observations (388) including both community-based and facility-based IPTp delivery. Grounded theory guided the overall study design and data collection, and data were analysed following a combination of content and thematic analysis. RESULTS: A series of key factors were found to influence acceptability, delivery and uptake of C-IPTp in project countries. Cross-cutting findings include the alignment of the strategy with existing social norms surrounding pregnancy and maternal health-seeking practices, the active involvement of influential and trusted actors in implementation activities, existing and sustained trust in CHWs, the influence of husbands and other relatives in pregnant women's care-seeking decision-making, the working conditions of CHWs, pregnant women's perceptions of SP for IPTp and persistent barriers to facility-based antenatal care access. CONCLUSIONS: The findings provide evidence on the reported acceptability of C-IPTp among a wide range of actors, as well as the barriers and facilitators for delivery and uptake of the intervention. Overall, C-IPTp was accepted by the targeted communities, supporting the public health value of community-based interventions, although the barriers identified should be examined if large-scale implementation of the intervention is considered.

Using and improving the PHISICC paper-based tools in the health facility laboratories: Examples of Human Centered Design taking systems thinking into practice, in Côte d'Ivoire and Nigeria.

Background: Health workers in low- and middle-income countries are increasingly demanded to collect more and more data to report them to higher levels of the health information system (HIS), in detriment of useful data for clinical and public health decision-making, potentially compromising the quality of their health care provison. In order to support health workers' decision-making, we engaged with partners in Côte d'Ivoire, Mozambique and Nigeria in a research project to conceive, design, produce, implement and test paper-based health information tools: the PHISICC tools. Our aim was to understand the use of PHISICC tools by health workers and to improve them based on their feedback. Methods: The design Health Facility Laboratories (HF Labs) in Côte d'Ivoire and in Nigeria were set up after months of use of PHISICC tools. Activities were structured in three phases or 'sprints' of co-creative research. We used a transdisciplinary approach, including anthropology and Human Centered Design (HCD), observations, shadowing, structured interviews and co-creation. Results: Health workers appreciated the standardization of the tools across different health care areas, with a common visual language that optimized use. Several design issues were raised, in terms of formats and contents. They strongly appreciated how the PHISICC registers guided their clinical decision-making and how it facilitated tallying and counting for monthly reporting. However, adherence to new procedures was not universal. The co-creation sessions resulted in modifications to the PHISICC tools of out-patient care and postnatal care. Discussion: Although health systems and systemic thinking allowed the teams to embrace complexity, it was the HCD approach that actually produced a shift in researchers' mind-set: from HIS as data management tools to HIS as quality of care instruments. HCD allowed navigating the complexity of health systems interventions due to its capacity to operate change: it not only allowed us to understand how the PHISICC tools were used but also how to further improve them. In the absence of (or even with) an analytical health systems framework, HCD approaches can work in real-life situations for the ideation, testing and implementation of interventions to improve health systems and health status outcomes.

A qualitative inquiry of rural-urban inequalities in the distribution and retention of healthcare workers in southern Nigeria.

INTRODUCTION: Globally, the population in rural communities are disproportionately cared for by only 25% and 38% of the total physicians and nursing staff, respectively; hence, the poor health outcomes in these communities. This condition is worse in Nigeria by the critical shortage of skilled healthcare workforce. This study aimed to explore factors responsible for the uneven distribution of healthcare workers (physicians and nurses) to rural areas of Ebonyi State, Nigeria. METHODS: Qualitative data were obtained using semi-structured in-depth interviews and focus group discussions from purposively selected physicians, nurses, and policymakers in the state. Data was analysed for themes related to factors influencing the mal-distribution of healthcare workers (physicians and nurses) to rural areas. The qualitative analysis involved the use of both inductive and deductive reasoning in an iterative manner. RESULTS: This study showed that there were diverse reasons for the uneven distribution of skilled healthcare workers in Ebonyi State. This was broadly classified into three themes; socio-cultural, healthcare system, and personal healthcare workers' intrinsic factors. The socio-cultural factors include symbolic capital and stigma while healthcare system and governance issues include poor human resources for health policy and planning, work resources and environment, decentralization, salary differences, skewed distribution of tertiary health facilities to urban area and political interference. The intrinsic healthcare workers' factors include career progression and prospect, negative effect on family life, personal characteristics and background, isolation, personal perceptions and beliefs. CONCLUSIONS: There may be a need to implement both non-financial and financial actions to encourage more urban to rural migration of healthcare workers (physicians and nurses) and to provide incentives for the retention of rural-based health workers.

Cost-effectiveness analysis of an intervention project engaging Traditional and Religious Leaders to improve uptake of childhood immunization in southern Nigeria.

Vaccination is a cost-effective public health intervention, yet evidence abounds that vaccination uptake is still poor in many low- and middle-income countries. Traditional and Religious Leaders play a substantial role in improving the uptake of health services such as immunization. However, there is paucity of evidence on the cost-effectiveness of using such strategies. This study aimed to assess the cost-effectiveness of using a multi-faceted intervention that included traditional and religious leaders for community engagement to improve uptake of routine immunisation services in communities in Cross River State, Southern Nigeria. The target population for the intervention was traditional and religious leaders in randomly selected communities in Cross River State. The impact of the intervention on the uptake of routine vaccination among children 0 to 23 months was assessed using a cluster randomized trials. Outcome assessments were performed at the end of the project (36 months).The cost of the intervention was obtained from the accounting records for expenditures incurred in the course of implementing the intervention. Costs were assessed from the health provider perspective. The cost-effectiveness analysis showed that the incremental cost of the initial implementation of the intervention was US$19,357and that the incremental effect was 323 measles cases averted, resulting in an incremental cost-effectiveness ratio (ICER) of US$60/measles case averted. However, for subsequent scale-up of the interventions to new areas not requiring a repeat expenditure of some of the initial capital expenditure the ICER was estimated to be US$34 per measles case averted. Involving the traditional and religious leaders in vaccination is a cost-effective strategy for improving the uptake of childhood routine vaccinations.

Does an innovative paper-based health information system (PHISICC) improve data quality and use in primary healthcare? Protocol of a multicountry, cluster randomised controlled trial in sub-Saharan African rural settings.

INTRODUCTION: Front-line health workers in remote health facilities are the first contact of the formal health sector and are confronted with life-saving decisions. Health information systems (HIS) support the collection and use of health related data. However, HIS focus on reporting and are unfit to support decisions. Since data tools are paper-based in most primary healthcare settings, we have produced an innovative Paper-based Health Information System in Comprehensive Care (PHISICC) using a human-centred design approach. We are carrying out a cluster randomised controlled trial in three African countries to assess the effects of PHISICC compared with the current systems. METHODS AND ANALYSIS: Study areas are in rural zones of Côte d'Ivoire, Mozambique and Nigeria. Seventy health facilities in each country have been randomly allocated to using PHISICC tools or to continuing to use the regular HIS tools. We have randomly selected households in the catchment areas of each health facility to collect outcomes' data (household surveys have been carried out in two of the three countries and the end-line data collection is planned for mid-2021). Primary outcomes include data quality and use, coverage of health services and health workers satisfaction; secondary outcomes are additional data quality and use parameters, childhood mortality and additional health workers and clients experience with the system. Just prior to the implementation of the trial, we had to relocate the study site in Mozambique due to unforeseen logistical issues. The effects of the intervention will be estimated using regression models and accounting for clustering using random effects. ETHICS AND DISSEMINATION: Ethics committees in Côte d'Ivoire, Mozambique and Nigeria approved the trials. We plan to disseminate our findings, data and research materials among researchers and policy-makers. We aim at having our findings included in systematic reviews on health systems interventions and future guidance development on HIS. TRIAL REGISTRATION NUMBER: PACTR201904664660639; Pre-results.

Trust, community health workers and delivery of intermittent preventive treatment of malaria in pregnancy: a comparative qualitative analysis of four sub-Saharan countries.

This qualitative study is part of a project aiming to evaluate a community-based approach to the delivery of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) through community health workers (CHWs) in four sub-Saharan African countries: the Democratic Republic of Congo (DRC), Madagascar, Mozambique and Nigeria. The study aimed to understand the factors that influence the anticipated acceptability of this intervention. A total of 216 in-depth interviews and 62 focus group discussions were carried out in the four country sites with pregnant women, women of reproductive age, community leaders, pregnant women's relatives, CHWs, formal and informal health providers. Grounded theory guided the study design and data collection, and content and thematic analysis was performed through a comparative lens. This paper focuses on one crosscutting theme: trust-building. Two mechanisms that underpin communities' trust in delivery of IPTp via CHWs were identified: 'perceived competence' and 'community and healthcare system integration'. Communities' perception of CHWs' competence shapes their trust in them, which suggests that CHWs' credentials should be made public and that specialised training in maternal health is required for them. Integration depends on the promotion of socially embedded practices and the involvement of formal healthcare systems in CHWs' work.

The use of WhatsApp group messaging in the coordination of measles supplemental immunization activity in Cross Rivers State, Nigeria, 2018.

INTRODUCTION: Cross Rivers State, in southern Nigeria, conducted measles Supplemental Immunization Activities (SIAs) in 2 phases from 2 -15 March, 2018. The SIAs coordination was led by the State technical coordination committee. A total of 90 supervisors from the national and subnational levels, including consultants were deployed to support the SIAs. The instant messaging service - WhatsApp was utilized to help in the communication and coordination among the State and field teams. METHODS: We reviewed the chat logs from the WhatsApp group exchanges made between 28 February 2018 and 31 March 2018. Thematic content analysis was done. RESULTS: A total of 653 WhatsApp messages were posted among the 55 group members during the study period, including text messages and media content. Eleven percent of the posts related to monitoring processes and data sharing, while posts related to vaccine logistics and waste management made up about 6% of the total. Overall coordination and deployment was covered in 6% of the posts. Forty percent of the media content showed vaccination service delivery and SIAs launching events or monitoring meetings in various areas. The coordination team used WhatsApp to send reminders to the field staff about data sharing, vaccine and waste management, as well as feedback on coverage and completeness of data sharing. The WhatsApp group discussions did not include most of the logistical and hesitancy challenges documented in the State SIAs technical report. CONCLUSION: We recommend focusing group discussions on instant messaging platforms so that they can be used for problem solving and sharing best practices, integrating it with other supervisory processes and tools, as well as providing feedback based on processed data from the field.

Determinants of Choice of Place of Delivery among Women Attending Two Referral Hospitals in Kano North-West Nigeria.

BACKGROUND: Women are often unable to choose for themselves when, where, and from whom to seek care. This study was undertaken to determine factors that influence a woman's choice of place of delivery among women attending immunization clinics in two referral hospitals in Kano, Nigeria. MATERIALS AND METHODS: A hospital-based cross-sectional descriptive study conducted among 314 women who delivered in Kano, Nigeria. Stratified random sampling was done. Pretested, interviewer-administered questionnaires were used to obtain responses about sociodemographic characteristics, choice of place of delivery, and factors that influenced their choice of place of delivery. Ethical approval was obtained from an ethical committee. Women who gave birth within the past 12 months and gave informed consent were recruited. The data were analyzed using SPSS statistical software version 22. RESULTS: About 218 (69.4%) women had their previous delivery in the health facility, whereas 96 (30.6%) had theirs outside the health facilities. The level of satisfaction in health facility care was also high. For those who had their deliveries outside the health facility, 37 (38.5%) of the deliveries were monitored by a nurse/midwife. The respondents level of education (P ≤ 0.001), spouse level of education (P < 0.001), spouse occupation (P ≤ 0.015), human influence (P = 0.025), and total cost of each visit (P = 0.010) were associated with the choice of place of delivery; however, at multivariate logistic regression, only human influence and respondents level of education were determinants of the choice of place of delivery. CONCLUSION: Most of the respondents had their previous deliveries in the health facilities and had a high level of satisfaction with the health facilities where they delivered compared to other studies. Utilization of the health facilities for childbirth may increase if there is involvement of relations, especially husbands and mothers and if the clients' level of education is improved.

Knowledge, attitudes and beliefs about the health hazards of biomass smoke exposure amongst commercial food vendors in Nigeria.

BACKGROUND: Exposure to biomass smoke is a major cause of morbidity and mortality in Africa. Commercial food vendors in Nigeria and elsewhere in Africa are commonly exposed to biomass smoke from open fire cooking both at work and home. Little is known about the knowledge, attitudes and beliefs of food vendors about the health hazards of biomass smoke exposure in Nigeria. METHODS: We did a descriptive cross sectional survey of the knowledge, attitudes and beliefs of commercial food vendors in the cities of Benin and Calabar in Nigeria. We recruited respondents using a multi-stage approach. Structured interviewer-administered questionnaires were used for data collection. RESULTS: We recruited 308 participants (164, 53.2% female). The majority 185(60.2%) were married and had post-primary education 206(67.4%). The average monthly income was <30,000 Naira (US$150). Most 198(64.4%) were not aware that biomass smoke exposure is harmful to human health. About three-quarters (221; 71.8%) were unconcerned as to the effect of exposure to fumes from biomass fuels on their health. Less than half of respondents (110, 41.6%) believed biomass smoke was harmful to health. Male gender, being single, having post-primary education and preferring electricity or gas fuels were associated with good knowledge of the adverse health effects of biomass smoke exposure whilst female gender and having good knowledge of the adverse health effects of biomass smoke were associated with positive attitudes towards preventing exposure. CONCLUSION: Commercial food vendors in our study had limited knowledge about the adverse health effects of biomass smoke exposure and negative attitudes towards preventing these adverse health effects. We suggest an educational intervention is needed to improve this knowledge.

Providing information about the consequences of female genital mutilation to healthcare providers caring for women and girls living with female genital mutilation: A systematic review.

BACKGROUND: The persistence of female genital mutilation (FGM) in some countries, despite an overall decline in the prevalence of the practice, calls for improvement in the capacity of healthcare workers and institutions to provide optimal care for this population. OBJECTIVES: To determine the impact of providing information on FGM and its consequences to healthcare providers on their attitudes toward FGM, and quality of care and patient satisfaction. SEARCH STRATEGY: The following major databases were searched from inception to August 2015: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, SCOPUS, Web of Science, and ClinicalTrials.gov, without language restrictions. SELECTION CRITERIA: Controlled studies were included based on use of objective measures. DATA COLLECTION AND ANALYSIS: Two team members independently screened and collected data. Relative risks and proportions were calculated and evidence assessed using the GRADE (Grade of Recommendation, Assessment, Development and Evaluation) approach. RESULTS: One study was identified. Based on this study there was no evidence to suggest change in healthcare provider outcomes after the intervention. CONCLUSIONS: Despite a comprehensive search, only one study of low methodological quality was included. This precludes a definitive conclusion regarding the impact of providing information on FGM to healthcare providers. More research is needed. PROSPERO REGISTRATION: CRD42015024570.