'Government don't know me and if I stop, they won't know': A qualitative study on the lived experiences of volunteer health workers in the Nigerian health system and their implications for the sustainable development goals.

BACKGROUND: Volunteer health workers play an important, but poorly understood role in the Nigerian health system. We report a study of their lived experiences, enabling us to understand their motivations, the nature of their work, and their relationships with formally employed health workers in Primary Healthcare Centres (PHCs) in Nigeria, the role of institutional incentives, and the implications for attaining the health-related sustainable development goals (SDGs) targets. METHODS: The study used ethnographic observation of PHCs in Enugu State, supplemented with in-depth interviews with volunteers, formally employed health workers and health managers. The analysis employed a combination of narrative and reflexive thematic approaches. FINDINGS: The lived experiences of most volunteers unfold in four stages as they move into and out of their volunteering status. The first stage signifies hope, arising from the ease with which they are accepted and integrated into the PHC space. The anger stage emerges when volunteers confront the marked disparity in their treatment compared to formal staff, despite their substantial contributions to healthcare. Then, the bargaining stage sets in, where they strive for recognition and respect by pursuing formal employment and advocating for fair treatment and improved stipends. A positive response, such as improved stipends, can reignite hope among volunteers. If not, most volunteers transition to the acceptance stage - the acknowledgement that their status may never be formalised, prompting many to lose hope and disengage. CONCLUSION: There should be a clear policy on recruitment, compensation, and protection of volunteers in the health systems, to enhance the contribution they can make to the achievement of the health-related SDG targets.

The nature, drivers and equity consequences of informal payments for maternal and child health care in primary health centres in Enugu, Nigeria.

In Nigeria, most basic maternal and child health services in public primary health-care facilities should be either free of charge or subsidized. In practice, additional informal payments made in cash or in kind are common. We examined the nature, drivers and equity consequences of informal payments in primary health centres (PHC) in Enugu State. We used three interlinked qualitative methods: participant observation in six PHC facilities and two local government area (LGA) headquarters; in-depth interviews with frontline health workers (n = 19), managers (n = 4) and policy makers (n = 10); and focus group discussions (n = 2) with female service users. Data were analysed thematically using NVivo 12. Across all groups, informal payments were described as routine for immunization, deliveries, family planning consultations and birth certificate registration. Health workers, managers and policy makers identified limited supervision, insufficient financing of facilities, and lack of receipts for formal payments as enabling this practice. Informal payments were seen by managers and health workers as a mechanism to generate discretionary revenue to cover operational costs of the facility but, in practice, were frequently taken as extra income by health workers. Health workers rationalized informal payments as being of small value, and not a burden to users. However, informal payments were reported to be inequitable and exclusionary. Although they tended to be lower in rural PHCs than in wealthier urban facilities, participant observation revealed how, within a PHC, the lowest earners paid the same as others and were often left unattended if they failed to pay. Some female patients reported that extra payments excluded them from services, driving them to seek help from retail outlets or unlicensed health providers. As a result, informal payments reduced equity of access to essential services. Targeted policies are needed to improve financial risk protection for the poorest groups and address drivers of informal payments and unfairness in the health system.

People's willingness to use COVID-19 self-testing in Nigeria: a cross-sectional survey.

OBJECTIVES: Nigeria has been badly affected by the COVID-19 pandemic, and the poor testing coverage in the country may make controlling the spread of COVID-19 challenging. The aim of this study was to assess the general public's acceptability of SARS-CoV-2 self-testing as an approach which could help to address this gap. SETTING: A household-based survey was conducted in five urban and five rural local government areas in the states of Akwa Ibom, Anambra, Benue, Kaduna and Lagos, in mid-2021. PARTICIPANTS: 2126 respondents (969 were female) participated. A five-pronged, probabilistic sampling approach was used to recruit individuals older than 17 years and available to participate when randomly approached in their households by the surveyors. A 35-item questionnaire was used to collect data on their values towards SARS-CoV-2 self-testing. Primary outcomes were: likelihood to use a self-test; willingness to pay for a self-test; and likely actions following a reactive self-test result. RESULTS: Of the total 2126 respondents, 14 (0.66%) were aware of COVID-19 self-testing, 1738 (81.80%) agreed with the idea of people being able to self-test for COVID-19, 1786 (84.05%) were likely/very likely to use self-tests if available, 1931 (90.87%) would report a positive result and 1875 (88.28%) would isolate if they self-tested positive. Factors significantly associated with the use of a self-test were having a college education or higher (adjusted Odds Ratio (AOR): 1.55; 95% CI: 1.03 to 2.33), full-time employment (AOR: 1.67; 95% CI: 1.06 to 2.63), feeling at moderate/high risk of COVID-19 (AOR: 2.43; 95% CI: 1.70 to 3.47) and presence of individuals at risk of COVID-19 within the household (AOR: 1.38; 95% CI: 1.06 to 1.78). CONCLUSION: A majority of Nigerians agree with the concept of COVID-19 self-testing and would act to protect public health on self-testing positive. Self-test implementation research is necessary to frame how acceptability impacts uptake of preventive behaviours following a positive and a negative self-test result.

The effects of COVID-19 on food insecurity, financial vulnerability and housing insecurity among women and girls living with or at risk of HIV in Nigeria.

Aim: Women and girls living with or at high risk of acquiring HIV (WGL&RHIV) in Africa are economically vulnerable. This study aims to advance understanding of the economic impact of COVID-19 on WGL&RHIV and to identify the factors associated with this insecurity.Methods: Data were collected from a cross-sectional survey conducted among a convenience sample of WGL&RHIV in Nigeria between May and September 2021. Logistic regressions enabled the study of the role of HIV status, mental health and macrosocial characteristics (people with disability, transgender women, sex workers, persons engaged in transactional sex, substance users, and people on the move) on economic vulnerability, measured by food, financial and housing insecurity, since the COVID-19 pandemic began. The model accounted for the possible interactions between the macrosocial characteristics and controlled for confounders.Results: There were 3 313 (76.1%) of 4 355 respondents facing food insecurity, 3 664 (83.6%) of 4 385 with financial vulnerability and 1 282 (36.2%) of 3 544 with housing insecurity. Being a member of the key and vulnerable groups was strongly associated with food insecurity, financial vulnerability and housing insecurity, regardless of HIV serostatus. For example, WGL&RHIV engaging in transactional sex were more than four times more likely (aOR 4.42; 95% CI 2.57-7.59) to face housing insecurity and more than twice more likely to face food insecurity (aOR 2.47, 95% CI 1.35-4.52) and financial vulnerability (aOR 2.87, 95% CI 1.39-5.93). This economic vulnerability may reduce their negotiating power for safer sex or the use of HIV prevention methods, exposing them to increased risks of HIV infection. Poor mental health was also associated with the three forms of economic vulnerability.Conclusions: As the long-term impact of the COVID-19 crisis on African economies unfolds, HIV programmes at the country level must include economic vulnerability and mental unwellness mitigation activities for WGL&RHIV.

Factors associated with poor access to HIV and sexual and reproductive health services in Nigeria for women and girls living with HIV during the COVID-19 pandemic.

Aim: To determine the proportion of women and girls living with HIV (WGLHIV) who had poor access to HIV, tuberculosis and sexual and reproductive health (SRH) services in Nigeria during the COVID-19 pandemic and associated factors.Methods: This was a cross-sectional study that recruited WGLHIV with six categories of vulnerability (sex work, transactional sex, injecting or using illegal drugs, people on the move, transgender women and people with a disability) through an online survey conducted in ten Nigerian states between june and October 2021. The associations between the limited access to HIV, tuberculosis and SRH services due to COVID-19, the categories of vulnerability and the financial and non-financial barriers to these services were determined using multivariable logistics regression analysis.Results: Over 6 in 10, almost 2 in 10, and almost 4 in 10 WGLHIV had limited access to HIV, tuberculosis and SRH services respectively during the COVID-19 pandemic. Transgender women had 3.59 (95% CI 2.19-5.91) higher odds, women who engaged in sex work had 4.51 (95% CI 2.28-8.42) higher odds, and women who inject or use illegal drugs had 2.39 (95% CI 1.47-32.90) higher odds of facing limited access to sexual and reproductive health services when it was needed. In addition, the direct consequences of the COVID-19 crisis, such as the closure of HIV services and SRH service points, exacerbated pre-existing barriers significantly. Having no money, having to pay additional unofficial fees and the lack of security on the road to the health facility were the barriers with the greatest impact on access to health services.Conclusions: The COVID-19 pandemic had a negative impact on the access of WGLHIV to essential health services. This impact was disproportionately higher for marginalised groups. WGLHIV need non-discriminatory and affordable access to essential health services during the pandemic.

The effects of COVID-19 on food insecurity, financial vulnerability and housing insecurity among women and girls living with or at risk of HIV in Nigeria

Aim: Women and girls living with or at high risk of acquiring HIV (WGL&RHIV) in Africa are economically vulnerable. This study aims to advance understanding of the economic impact of COVID-19 on WGL&RHIV and to identify the factors associated with this insecurity.Methods: Data were collected from a cross-sectional survey conducted among a convenience sample of WGL&RHIV in Nigeria between May and September 2021. Logistic regressions enabled the study of the role of HIV status, mental health and macrosocial characteristics (people with disability, transgender women, sex workers, persons engaged in transactional sex, substance users, and people on the move) on economic vulnerability, measured by food, financial and housing insecurity, since the COVID-19 pandemic began. The model accounted for the possible interactions between the macrosocial characteristics and controlled for confounders.Results: There were 3 313 (76.1%) of 4 355 respondents facing food insecurity, 3 664 (83.6%) of 4 385 with financial vulnerability and 1 282 (36.2%) of 3 544 with housing insecurity. Being a member of the key and vulnerable groups was strongly associated with food insecurity, financial vulnerability and housing insecurity, regardless of HIV serostatus. For example, WGL&RHIV engaging in transactional sex were more than four times more likely (aOR 4.42; 95% CI 2.57­7.59) to face housing insecurity and more than twice more likely to face food insecurity (aOR 2.47, 95% CI 1.35­4.52) and financial vulnerability (aOR 2.87, 95% CI 1.39­5.93). This economic vulnerability may reduce their negotiating power for safer sex or the use of HIV prevention methods, exposing them to increased risks of HIV infection. Poor mental health was also associated with the three forms of economic vulnerability.Conclusions: As the long-term impact of the COVID-19 crisis on African economies unfolds, HIV programmes at the country level must include economic vulnerability and mental unwellness mitigation activities for WGL&RHIV