What works best for ensuring treatment adherence. Lessons from a social support program for people treated for tuberculosis in Ukraine.

BACKGROUND: Worldwide, TB is one of the top 10 causes of death and the leading cause from a single infectious agent. Ukraine is one of 30 countries with the highest burden of multidrug-resistant tuberculosis. Global literature shows that social support (SS) is important in improving TB treatment adherence, reducing lost to follow up rates and improving treatment outcomes. There are several models of SS available, and the literature provides little information on what aspects of SS are most important to TB patients in improving their adherence. METHODS: We used qualitative data collected through in-depth interviews (IDI) with 21 TB patients and 15 SS providers and coordinators in Ukraine in August-September 2016 to understand how the SS program promoted treatment adherence among patients. We examined the aspects of outpatient TB treatment that made adherence particularly difficult for patients in at-risk groups and aspects of the SS programs that worked best for addressing those barriers. Interviews were transcribed and analysis was performed to derive emergent themes. RESULTS: Main barriers included side effects from medicine, the amount of time required daily for transportation and waiting in lines at the health facility, transportation expenses, risks of being identified when visiting a TB facility and lack of motivation to seek treatment. Features of the SS program most valued by patients were convenience of not having to visit facility and support provided by nurses. These two features directly addressed most of the barriers identified. The commitment and qualities of the nurses that provided the SS was an important element of the program. CONCLUSIONS: This qualitative study suggests that the SS program in Ukraine was successful in reducing treatment default among patients at high risk of default because it directly addressed most of the major barriers they faced to treatment adherence.

A case study of community-based distribution and use of Misoprostol and Chlorhexidine in Sokoto State, Nigeria.

The United States Agency for International Development/Targeted States High Impact Project supported Sokoto State, Nigeria government in the development of a community-based intervention aimed at preventing post-partum haemorrhage (PPH) and cord infection among women and children, respectively. This paper describes the innovative intervention within the Nigeria health delivery system. It then explains the case study approach to assessing this intervention and summarises findings. Ultimately, the intervention was received well in communities and both drugs were added to the procurement list of all health facilities providing maternity services in the State. Key factors leading to such success include early advocacy efforts at the state-level, broad stakeholder engagement in designing the distribution system, early community engagement about the value of the drugs and concerted efforts to monitor and ensure availability of the drugs. Implementation challenges occurred in some areas, including shortage of community-based health volunteers (CBHVs) and drug keepers, and socio-cultural barriers. To maximise and sustain the effectiveness of such interventions, state government needs to ensure constant drug supply and adequate human resources at the community level, enhance counselling and mobilisation efforts, establish effective quality improvement strategies and implement a strong M&E system.

Task Shifting Provision of Contraceptive Implants to Community Health Extension Workers: Results of Operations Research in Northern Nigeria.

BACKGROUND: Contraceptive use remains low in Nigeria, with only 11% of women reporting use of any modern method. Access to long-acting reversible contraceptives (LARCs) is constrained by a severe shortage of human resources. To assess feasibility of task shifting provision of implants, we trained community health extension workers (CHEWs) to insert and remove contraceptive implants in rural communities of Bauchi and Sokoto states in northern Nigeria. METHODS: We conducted 2- to 3-week training sessions for 166 selected CHEWs from 82 facilities in Sokoto state (September 2013) and 84 health facilities in Bauchi state (December 2013). To assess feasibility of the task shifting approach, we conducted operations research using a pretest-posttest design using multiple sources of information, including surveys with 151 trained CHEWs (9% were lost to follow-up) and with 150 family planning clients; facility observations using supply checklists (N = 149); direct observation of counseling provided by CHEWs (N = 144) and of their clinical (N = 113) skills; as well as a review of service statistics (N = 151 health facilities). The endline assessment was conducted 6 months after the training in each state. RESULTS: CHEWs inserted a total of 3,588 implants in 151 health facilities over a period of 6 months, generating 10,088 couple-years of protection (CYP). After practicing on anatomic arm models, most CHEWs achieved competency in implant insertions after insertions with 4-5 actual clients. Clinical observations revealed that CHEWs performed implant insertion tasks correctly 90% of the time or more for nearly all checklist items. The amount of information that CHEWs provided clients increased between baseline and endline, and over 95% of surveyed clients reported being satisfied with CHEWs' services in both surveys. The study found that supervisors not only observed and corrected insertion skills, as needed, during supervisory visits but also encouraged CHEWs to conduct more community mobilization to generate client demand, thereby promoting access to quality services. CHEWs identified a lack of demand in the communities as the major barrier for providing services. CONCLUSION: With adequate training and supportive supervision, CHEWs in northern Nigeria can provide high-quality implant insertion services. If more CHEWs are trained to provide implants and greater community outreach is conducted to generate demand, uptake of LARCs in Nigeria may increase.

Factors influencing the use of magnesium sulphate in pre-eclampsia/eclampsia management in health facilities in Northern Nigeria: a mixed methods study.

BACKGROUND: Eclampsia remains a major cause of perinatal and maternal morbidity and mortality worldwide. We examined facilitators and barriers to the use of magnesium sulphate (MgSO4) in the management of pre-eclampsia/eclampsia (PE/E) in health facilities in Bauchi and Sokoto States in Nigeria. METHODS: Data were collected from 80 health facilities using a cross-sectional, mixed method (quantitative and qualitative) design. We assessed health facility readiness to manage PE/E and use MgSO4 as the drug of choice, through provider interviews, in-depth interviews with facility managers and an inventory of equipment and supply in facilities. Bivariate and qualitative data analyses were performed to isolate the principal enabling factors and barriers to the management of PE/E and use of MgSO4. RESULTS: The majority of health facility providers correctly mentioned MgSO4 as the drug of choice for the prevention and termination of convulsions in severe PE/E (65 %). Sixty-four percent of the health facilities had service registers available. About 45 % of providers had been trained on the use of MgSO4 for the management of PE/E. Regarding providers' practices, 45 % of respondents indicated that MgSO4 was used to prevent and treat convulsions in severe PE/E in their facilities. Barriers to management of PE/E included inadequate numbers of skilled providers, frequent shortages of MgSO4, lack of essential equipment and supplies, irregular supply of electricity and water, and non-availability of guidelines and clinical protocols at the health facilities. Technical support to providers was inadequate. CONCLUSION: The study revealed that a constellation of factors adversely affect the management of PE/E and especially the use of MgSO4 by service providers. Efforts to improve the management of PE/E in facilities should include integrated programs that substantially improve provider and facility readiness to manage PE/E for better maternal and newborn health outcomes in Northern Nigeria.

Reducing the burden of diarrhea among children under five years old: lessons learned from oral rehydration therapy corner program implementation in Northern Nigeria.

BACKGROUND: In Nigeria, diarrhea remains one of the leading causes of death among children under five years old. Oral Rehydration Therapy (ORT) corners were introduced to health facilities in Bauchi and Sokoto states to serve as points of treatment for sick children and equip caregivers with necessary skills in case management of diarrhea and diarrhea prevention. OBJECTIVES: The operations research study examined the effect of facility-based ORT corners on caregivers' knowledge and skills in management of simple and moderate diarrhea at home, as well as caregivers' and service providers' perceived facilitators and barriers to utilization and delivering of ORT corner services. It also examined whether ORT activities were conducted according to the established protocols. METHODS: This quantitative study relied on multiple sources of information to provide a complete picture of the current status of ORT corner services, namely surveys with ORT corner providers (N = 21), health facility providers (N = 23) and caregivers (N = 229), as well as a review of service statistics and health facility observations. Frequency distribution and binary analysis were conducted. RESULTS: The study revealed that ORT corner users were more knowledgeable in diarrhea prevention and management and demonstrated better skills for managing diarrhea at home than ORT corner non-users. However, the percentage of knowledgeable ORT users is not optimal, and providers need to continue to work toward improving such knowledge. ORT corner providers identified a lack of supplies as the major barrier for providing services. Furthermore, the study revealed a lack of information, education and communication materials, supportive supervision, and protocols and guidelines for delivering ORT corner services, as well as inadequate documentation of services provided at ORT corners. RECOMMENDATIONS: Recommendations for ORT corners program planners and implementers include ensuring all ORT corners have oral rehydration salt (ORS) packages and salt, sugar, and zinc tablets in stock, a secured commodity supply chain to avoid stockouts, and adequate policies and procedures in place.