Factors associated with an increase in tobacco use and alcohol drinking during the COVID-19 pandemic: A cross-sectional study of data from 105 countries.

INTRODUCTION: The COVID-19 pandemic has inevitably led to monumental challenges, and alcohol drinking and tobacco use have unlikely been spared. This cross-sectional survey reports on factors associated with an increase in alcohol drinking and tobacco use during the COVID-19 pandemic. METHODS: An online survey conducted in 2020, generated data from 14899 adults residing in 105 countries. Dependent variables were changes in alcohol drinking and tobacco use. Independent variables were age, sex, education level, job loss, lost or reduced wages, investment/retirement benefits, interrupted substance addiction care, and income level of the countries. Multilevel logistic regression analysis was computed to explore the associations between dependent and independent variables in adjusted models using the backward stepwise method. The probability of including or excluding a covariate was set at p(in)<0.05 and p(out)>0.1, respectively. RESULTS: Of the regular alcohol consumers (N=4401), 22.9% reported an increase in their alcohol drinking. Of the regular tobacco users (N=2718), 31% reported an increase in their tobacco use. Job loss (Alcohol: AOR=1.26; Tobacco: AOR=1.32) and lost/reduced wages (Alcohol: AOR=1.52; Tobacco: AOR=1.52) were associated with higher odds of increased alcohol drinking and tobacco use. Many interruptions to addiction care (AOR=1.75) were associated with higher odds of increased alcohol drinking. Whereas no interruption to addiction care was associated with lower odds of increased alcohol drinking (AOR=0.77). Also, none (AOR=0.66) or some (AOR=0.70) interruptions to addiction care were associated with lower odds of increased tobacco use. CONCLUSIONS: This global survey alludes to the unintended consequences of the current COVID-19 pandemic on alcohol drinking and tobacco use. It is critical that the strategies for emergency responses should include support to ameliorate the impact of financial distress and disruption in substance dependence treatment services.

Perceptions and Rumors About the Ebola Virus Disease Vaccine in the Ituri and Kivu Provinces of the Democratic Republic of Congo.

Perceptions and rumors about vaccinations can contribute to vaccine hesitancy. This study aimed to examine perceptions and rumors about the Ebola vaccine during the 10th Ebola Virus Disease outbreak in the Ituri and North Kivu provinces of the Democratic Republic of Congo. Eight hundred randomly selected respondents were surveyed with a uniform structured questionnaire. Further, we collected qualitative data through focus group discussions and using in-depth interview guides. Results revealed several misperceptions and rumors about the vaccine, which led to some level of vaccine hesitancy and refusal among the people. The acceptance rate of the vaccine was 67.3% (below the 80% threshold needed to create herd immunity in the population). More of the urban population (31.3%) than the rural population (10.4%) accepted the vaccine. Refusals were largely due to fear that the vaccine could activate other diseases in the body and could even kill. Some feared that it was a conspiracy of the government to reduce the population in the study area through forced fertility control and death, among other such concerns. In conclusion, these rumors increased mistrust, which challenged the efforts of the government and its partners to safeguard the health of the people.

eHealth or e-Chaos: The use of Digital Health Interventions for Health Systems Strengthening in sub-Saharan Africa over the last 10 years: A scoping review.

Background: Digital health solutions are a potent and complementary intervention in health system strengthening to accelerate universal access to health services. Implementing scalable, sustainable, and integrated digital solutions in a coordinated manner is necessary to experience the benefits of digital interventions in health systems. We sought to establish the breadth and scope of available digital health interventions (DHIs) and their functions in sub-Saharan Africa. Methods: We conducted a scoping review according to the Joanne Briggs Institute's reviewers manual and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Extension for Scoping Reviews (PRISMA-ScR) checklist and explanation. We retrieved data from the WHO Digital Health Atlas (DHA), the WHO e-Health country profiles report of 2015, and electronic databases. The protocol has been deposited in an open-source platform - the Open Science Framework at https://osf.io/5kzq7. Results: The researchers retrieved 983 digital tools used to strengthen health systems in sub-Saharan Africa over the past 10 years. We included 738 DHIs in the analysis while 245 were excluded for not meeting the inclusion criteria. We observed a disproportionate distribution of DHIs towards service delivery (81.7%, n = 603), health care providers (91.8%, n = 678), and access and use of information (84.1%, n = 621). Fifty-three percent (53.4%, n = 394) of the solutions are established and 47.5% (n = 582) were aligned to 20% (n = 5) of the system categories. Conclusions: Sub-Saharan Africa is endowed with digital health solutions in both numbers and distinct functions. It is lacking in coordination, integration, scalability, sustainability, and equitable distribution of investments in digital health. Digital health policymakers in sub-Saharan Africa need to urgently institute coordination mechanisms to terminate unending duplication and disjointed vertical implementations and manage solutions for scale. Central to this would be to build digital health leadership in countries within SSA, adopt standards and interoperability frameworks; advocate for more investments into lagging components, and promote multi-purpose solutions to halt the seeming "e-chaos" and progress to sustainable e-health solutions.

Coordination and Management of COVID-19 in Africa through Health Operations and Technical Expertise Pillar: A Case Study from WHO AFRO One Year into Response.

Background: following the importation of the first Coronavirus disease 2019 (COVID-19) case into Africa on 14 February 2020 in Egypt, the World Health Organisation (WHO) regional office for Africa (AFRO) activated a three-level incident management support team (IMST), with technical pillars, to coordinate planning, implementing, supervision, and monitoring of the situation and progress of implementation as well as response to the pandemic in the region. At WHO AFRO, one of the pillars was the health operations and technical expertise (HOTE) pillar with five sub-pillars: case management, infection prevention and control, risk communication and community engagement, laboratory, and emergency medical team (EMT). This paper documents the learnings (both positive and negative for consideration of change) from the activities of the HOTE pillar and recommends future actions for improving its coordination for future emergencies, especially for multi-country outbreaks or pandemic emergency responses. Method: we conducted a document review of the HOTE pillar coordination meetings' minutes, reports, policy and strategy documents of the activities, and outcomes and feedback on updates on the HOTE pillar given at regular intervals to the Regional IMST. In addition, key informant interviews were conducted with 14 members of the HOTE sub pillar. Key Learnings: the pandemic response revealed that shared decision making, collaborative coordination, and planning have been significant in the COVID-19 response in Africa. The HOTE pillar's response structure contributed to attaining the IMST objectives in the African region and translated to timely support for the WHO AFRO and the member states. However, while the coordination mechanism appeared robust, some challenges included duplication of coordination efforts, communication, documentation, and information management. Recommendations: we recommend streamlining the flow of information to better understand the challenges that countries face. There is a need to define the role and responsibilities of sub-pillar team members and provide new team members with information briefs to guide them on where and how to access internal information and work under the pillar. A unified documentation system is important and could help to strengthen intra-pillar collaboration and communication. Various indicators should be developed to constantly monitor the HOTE team's deliverables, performance and its members.

The Addis Declaration on Immunization: A binding reminder of the political support needed to achieve universal immunization in Africa.

While African countries have improved access to immunization since the start of the millennium, progress has stagnated in the last few years. One in five African children is not vaccinated with life-saving vaccines, and recent outbreaks of vaccine-preventable diseases (VPDs) including yellow fever, measles, and meningitis, among others point to gaps in immunization coverage as well as disease surveillance. In 2017, African Heads of State endorsed the Addis Declaration on Immunization (ADI) at the 28th African Union Summit and committed to ensuring universal access to immunization across the continent. Since then, countries have taken several steps to translate the ADI commitments into tangible progress. However, the continent continues to face challenges in delivering immunization services, including limited vaccine-related funding, inequitable access to immunization services and weak surveillance systems. In the absence of concerted political will, COVID-19 threatens to reverse progress made so far. This paper reflects on the effects of political will in shaping the immunization agenda on the continent and the continued need for political commitment to deliver on the ADI commitments in a post-COVID world. Data were gathered from the regular national immunization reports, WHO/UNICEF estimates of immunization coverage as well as case studies of country implementation on ADI.

Implementation research approaches to promoting universal health coverage in Africa: a scoping review.

BACKGROUND: Implementation research has emerged as part of evidence-based decision-making efforts to plug current gaps in the translation of research evidence into health policy and practice. While there has been a growing number of initiatives promoting the uptake of implementation research in Africa, its role and effectiveness remain unclear, particularly in the context of universal health coverage (UHC). Hence, this scoping review aimed to identify and characterise the use of implementation research initiatives for assessing UHC-related interventions or programmes in Africa. METHODS: The review protocol was developed based on the methodological framework proposed by Arksey and O'Malley, as enhanced by the Joanna Briggs Institute. The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). MEDLINE, Scopus and the Cochrane Library were searched. The search also included a hand search of relevant grey literature and reference lists. Literature sources involving the application of implementation research in the context of UHC in Africa were eligible for inclusion. RESULTS: The database search yielded 2153 records. We identified 12 additional records from hand search of reference lists. After the removal of duplicates, we had 2051 unique records, of which 26 studies were included in the review. Implementation research was used within ten distinct UHC-related contexts, including HIV; maternal and child health; voluntary male medical circumcision; healthcare financing; immunisation; healthcare data quality; malaria diagnosis; primary healthcare quality improvement; surgery and typhoid fever control. The consolidated framework for implementation research (CFIR) was the most frequently used framework. Qualitative and mixed-methods study designs were the commonest methods used. Implementation research was mostly used to guide post-implementation evaluation of health programmes and the contextualisation of findings to improve future implementation outcomes. The most commonly reported contextual facilitators were political support, funding, sustained collaboration and effective programme leadership. Reported barriers included inadequate human and other resources; lack of incentives; perception of implementation as additional work burden; and socio-cultural barriers. CONCLUSIONS: This review demonstrates that implementation research can be used to achieve UHC-related outcomes in Africa. It has identified important facilitators and barriers to the use of implementation research for promoting UHC in the region.

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.

Coping strategies of families of persons with learning disability in Imo state of Nigeria.

BACKGROUND: Coping with a relative with a learning disability could be a stressful experience for family members. The present study is aimed at exploring the coping strategies adopted by families in trying to make meaning of their situation. METHOD: A qualitative study design using focus group discussions (FGDs) was adopted. Ten FGD sessions were held with family members of persons with a learning disability. RESULTS: Findings revealed patterns of family coping to include problem-focused, emotion-focused, and spiritual/religious-focused. Also, coping responses to a learning disability varied based on the level of information available to families about the condition of their relative. In some cases, interspousal relationship was strained due to stress. CONCLUSION: It was recommended that families of persons with a learning disability need social support and professional help from social workers to facilitate the adoption of more positive-oriented coping strategies by family members.

Towards a Strategy for Reducing Missed Opportunities for Vaccination in Malawi: Implications of a Qualitative Health Facility Assessment.

BACKGROUND: Missed opportunities for vaccination (MOVs), estimated to be about 32-47% of child healthcare clinic visits in various settings globally, contribute to unfulfilled childhood vaccination coverage targets in the African region. OBJECTIVE: We assessed the extent of MOVs, identify local drivers and test interventions to reduce MOVs in Malawi. METHODS: We conducted in-depth and key informant interviews with administrators of district hospitals and officers in charge of community health facilities. Focus group discussions were held with health workers and caregivers of children under 24 months of age who received services from study health facilities in Malawi. Coverage rates were collected from the health facility records. RESULTS: Vaccination is appreciated in the communities, but coverage is generally below targets. In some facilities, reported coverage was less than 50%. Opportunities to provide up-to-date vaccination for children were missed due to lack of awareness and knowledge of health workers and caregivers, attitude and priority of health workers, long waiting time, poor coordination and referral of eligible children by clinicians and nurses and overall lack of a team approach to vaccination perceived as a responsibility of health surveillance assistants. Other notable issues included limited time of caregivers labouring on estate farms, unavailability of vaccines resulting from poorly functioning of cold chain equipment and limited transport and failure to appreciate the impact of MOV on poor immunization coverage. CONCLUSION: Simple, low-cost, pragmatic and community-driven interventions that may reduce MOVs and improve vaccine coverage.

A population-based national estimate of the prevalence and risk factors associated with hypertension in Rwanda: implications for prevention and control.

BACKGROUND: Hypertension is a leading cause of cardiovascular diseases and a growing public health problem in many developed and developing countries. However, population-based data to inform policy development are scarce in Rwanda. This nationally representative study aimed to determine population-based estimates of the prevalence and risk factors associated with hypertension in Rwanda. METHODS: We conducted secondary epidemiological analysis of data collected from a cross-sectional population-based study to assess the risk factors for NCDs using the WHO STEPwise approach to Surveillance of non-communicable diseases (STEPS). Adjusted odds ratios at 95% confidence interval were used to establish association between hypertension, socio-demographic characteristics and health risk behaviors. RESULTS: Of the 7116 study participants, 62.8% were females and 38.2% were males. The mean age of study participants was 35.3 years (SD 12.5). The overall prevalence of hypertension was 15.3% (16.4% for males and 14.4% for females). Twenty two percent of hypertensive participants were previously diagnosed. A logistic regression model revealed that age (AOR: 8.02, 95% CI: 5.63-11.42, p < 0.001), living in semi-urban area (AOR: 1.30, 95% CI: 1.01-1.67, p = 0.040) alcohol consumption (AOR: 1.24, 95% CI: 1.05-1.44, p = 0.009) and, raised BMI (AOR: 3.93, 95% CI: 2.54-6.08, p < 0.001) were significantly associated with hypertension. The risk of having hypertension was 2 times higher among obese respondents (AOR: 3.93, 95% CI: 2.54-6.08, p-value < 0.001) compared to those with normal BMI (AOR: 1.74, 95% CI: 1.30-2.32, p-value < 0.001). Females (AOR: 0.75, 95% CI: 0.63-0.88, p < 0.001) and students (AOR: 0.45, 95% CI: 0.25-0.80, p = 0.007) were less likely to be hypertensive. CONCLUSION: The findings of this study indicate that the prevalence of hypertension is high in Rwanda, suggesting the need for prevention and control interventions aimed at decreasing the incidence taking into consideration the risk factors documented in this and other similar studies.

Polio eradication in the African Region on course despite public health emergencies.

The World Health Organization, African Region is heading toward eradication of the three types of wild polio virus, from the Region. Cases of wild poliovirus (WPV) types 2 and 3 (WPV2 and WPV3) were last reported in 1998 and 2012, respectively, and WPV1 reported in Nigeria since July 2014 has been the last in the entire Region. This scenario in Nigeria, the only endemic country, marks a remarkable progress. This significant progress is as a result of commitment of key partners in providing the much needed resources, better implementation of strategies, accountability, and innovative approaches. This is taking place in the face of public emergencies and challenges, which overburden health systems of countries and threaten sustainability of health programmes. Outbreak of Ebola and other diseases, insecurity, civil strife and political instability led to displacement of populations and severely affected health service delivery. The goal of eradication is now within reach more than ever before and countries of the region should not relent in their efforts on polio eradication. WHO and partners will redouble their efforts and introduce better approaches to sustain the current momentum and to complete the job. The carefully planned withdrawal of oral polio vaccine type II (OPV2) with an earlier introduction of one dose of inactivated poliovirus vaccine (IPV), in routine immunization, will boost immunity of populations and stop cVDPVs. Environmental surveillance for polio viruses will supplement surveillance for AFP and improve sensitivity of detection of polio viruses.

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 Nigerian women taking sulfadoxine/pyrimethamine twice during pregnancy for the prevention of malaria.

OBJECTIVE: To investigate the characteristics of women in Nigeria who are likely to take sulfadoxine/pyrimethamine (SP) as recommended for the prevention of malaria in pregnancy to reduce maternal and child mortality rates. METHODS: A cross-sectional survey of 1380 women was conducted using a structured questionnaire. The women had given birth within 6months prior to the survey and were drawn from 6 local government areas in Nigeria. RESULTS: Several demographic factors-older age bracket, ever attended school, currently living with a partner, ever married, and wealth-were significantly associated with compliance. Compliance was higher among respondents who had ever been married than among those who had never been married (χ(2)=6.733; P=0.006). Compliance was also higher among those in paid employment (χ(2)=17.110; P<0.001) and those in a higher wealth quintile (χ(2)=34.861; P<0.001). Knowledge of malaria, which included prevention of malaria in pregnancy through use of IPTp with 2 doses of SP, showed a positive association with compliance. Compliance with 2 doses of SP among those with good knowledge was higher (63.9%) than among those with poor knowledge (46.9%) (χ(2)=26.981; P<0.001). CONCLUSION: The present findings could help in targeting health education programs to specific subgroups of women to increase compliance with the recommended 2 doses of SP for the prevention of malaria in pregnancy.

Prospects of using Community Directed Intervention strategy in delivering health services among Fulani Nomads in Enugu State, Nigeria.

BACKGROUND: The Community Directed Interventions (CDI) strategy has proven effective in increasing access to health services in sedentary populations. It remains to be seen if CDI strategy is feasible among nomads given the dearth of demographic and medical data on the nomads. This study thus characterized the nomadic populations in Enugu State, Nigeria and outlined the potentials of implementing CDI among nomads. STUDY DESIGN AND METHODS: This exploratory study adopted qualitative methods. Forty focus group discussions (FGD) were held with members of 10 nomadic camps in 2 LGAs in Enugu State, as well as their host communities. Thirty in-depth interviews (IDIs) were held with leaders of nomadic camps and sedentary populations. Ten IDIs with traditional healers in the nomadic camps and 14 key informant interviews with health workers and programme officers were also conducted. Documents and maps were reviewed to ascertain the grazing routes of the nomads as well as existing health interventions in the area. RESULTS: Like sedentary populations, nomads have definable community structures with leaders and followers, which is amenable to implementation of CDI. Nomads move their cattle, in a definite pattern, in search of grass and water. In this movement, the old and vulnerable are left in the camps. The nomads suffer from immunization preventable health problems as their host communities. The priority health problems in relation to CDI include malaria, measles, anemia, and other vaccine preventable infections. However, unlike the sedentary populations, the nomads lack access to health interventions, due to the mutual avoidance between the nomads and the sedentary populations in terms of health services. The later consider the services as mainly theirs. The nomads, however, are desirous of the modern health services and often task themselves to access these modern health services in private for profit health facilities when the need arises. CONCLUSION: Given the definable organizational structure of the nomads in Enugu State and their desire for modern health intervention, it is feasible to test the CDI strategy for equitable healthcare delivery among nomads. They are willing and capable to participate actively in their own health programmes with minimal support from professional health workers.

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.

Intention to continue with ivermectin treatment for onchocerciasis control after eight years of annual distribution in Cameroon, Nigeria, and Uganda.

This study identified the socio-demographic correlates of intention to comply with ivermectin treatment, from a structured interview of 2,306 persons aged 10 years and above, grouped into high and low compliers, who took ivermectin 6-8 times and 0-2 times respectively. 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. Demographic and perceptual factors associated with intention to comply with prolonged treatment with ivermectin were identified. Intention to comply was higher among married persons (91.8%, p < 0.001); local populations (89.8%, p < 0.001); and those with history of complying with treatment (98.2%, p < 0.001). Perception of onchocerciasis and effectiveness of ivermectin influenced intention to continue. The perceptual factors that drive the intention to comply should inform plans for health education at the project and village levels.

Preventing malaria in pregnancy through community-directed interventions: evidence from Akwa Ibom State, Nigeria.

BACKGROUND: Despite massive anti-malaria campaigns across the subcontinent, effective access to intermittent preventive treatment (IPTp) and insecticide-treated nets (ITNs) among pregnant women remain low in large parts of sub-Saharan Africa. The slow uptake of malaria prevention products appears to reflect lack of knowledge and resistance to behavioural change, as well as poor access to resources, and limited support of programmes by local communities and authorities. METHODS: A recent community-based programme in Akwa Ibom State, Nigeria, is analysed to determine the degree to which community-directed interventions can improve access to malaria prevention in pregnancy. Six local government areas in Southern Nigeria were selected for a malaria in pregnancy prevention intervention. Three of these local government areas were selected for a complementary community-directed intervention (CDI) programme. Under the CDI programme, volunteer community-directed distributors (CDDs) were appointed by each village and kindred in the treatment areas and trained to deliver ITNs and IPTp drugs as well as basic counseling services to pregnant women. FINDINGS: Relative to women in the control area, an additional 7.4 percent of women slept under a net during pregnancy in the treatment areas (95% CI [0.035, 0.115], p-value < 0.01), and an additional 8.5 percent of women slept under an ITN after delivery and prior to the interview (95% CI [0.045, 0.122], p-value < 0.001). The effects of the CDI programme were largest for IPTp adherence, increasing the fraction of pregnant women taking at least two SP doses during pregnancy by 35.3 percentage points [95% CI: 0.280, 0.425], p-value < 0.001) relative to the control group. No effects on antenatal care attendance were found. CONCLUSION: The presented results suggest that the inclusion of community-based programmes can substantially increase effective access to malaria prevention, and also increase access to formal health care access in general, and antenatal care attendance in particular in combination with supply side interventions. Given the relatively modest financial commitments they require, community-directed programmes appear to be a cost-effective way to improve malaria prevention; the participatory approach underlying CDI programmes also promises to strengthen ties between the formal health sector and local communities.

Compliance with eight years of annual ivermectin treatment of onchocerciasis in Cameroon and Nigeria.

BACKGROUND: As the African Programme for Onchocerciasis Control (APOC) matured into its 10th year of ensuring community involvement in mass annual treatment of onchocerciasis with ivermectin, there was recognition of a need to study not only annual coverage of ivermectin in villages but also the compliance of individual villagers with these annual treatments. This was based on the concern that while population coverage goals may be achieved each year, there might be segments of the population who systematically are not complying with the annual regimen, thus creating a reservoir of infection and threatening program gains. METHODS: A multi-site study in five APOC sponsored projects in Nigeria and Cameroon was undertaken to identify the socio-demographic correlates of compliance with ivermectin treatment. A total of 8,480 villagers above 9 years of age selected through a systematic random sampling from 101 communities were surveyed to ascertain their levels of compliance, by adapting APOC's standard household ivermectin survey form. Community leaders, community directed distributors (CDDs) of ivermectin and health workers were interviewed with in-depth interview guides, while focus group discussions were held with community members to help explain how socio-demographic factors might affect compliance. RESULTS: Eight-year compliance ranged from 0 to 8 times with 42.9% taking ivermectin between 6-8 times annually (high compliance). In bivariate analysis high compliance was positively associated with being male, over 24 years of age, having been married, not being Christian, having little or no formal education and being in the ethnic majority. These variables were also confirmed through regression analysis based on total times ivermectin was taken over the period. While these factors explained only 8% of the overall variation in compliance, ethnic status and education appeared to be the strongest factors. Those with higher education may be more mobile and harder to reach while neglect of ethnic minorities has also been documented in other programs. CONCLUSION: These findings can help managers of CDTI programmes to ensure ivermectin reaches all segments of the population equally.

Drawing and interpreting data: Children's impressions of onchocerciasis and community-directed treatment with ivermectin (CDTI) in four onchocerciasis endemic countries in Africa.

Although the depiction of a child leading a blind man is the most enduring image of onchocerciasis in Africa, research activities have hardly involved children. This paper aims at giving voice to children through drawings and their interpretation. The study was conducted in 2009 in Cameroon, Democratic Republic of Congo (DRC), Nigeria and Uganda. Children aged 6-16 years were asked to draw their perceptions of onchocerciasis and community-directed treatment with ivermectin (CDTI) in their communities. A total of 50 drawings were generated. The drawings depicted four main aspects of onchocerciasis: (1) the disease symptoms, (2) the negative consequences of onchocerciasis among children and in the community generally, (3) the ivermectin distribution process, and (4) the benefits or effects of taking ivermectin. Out of the 50 drawings, 30 were on symptoms, 7 on effects of the disease on children, 8 on distribution process, and 5 represented multiple perceptions on symptoms, drug distribution processes, benefits, and effects of treatment. The lack of clarity when treatment with ivermectin can be stopped in endemic areas requires working with children to ensure continued compliance with treatment into the future. Children's drawings should be incorporated into health education interventions.