Iterative evaluation of mobile computer-assisted digital chest x-ray screening for TB improves efficiency, yield, and outcomes in Nigeria.

Wellness on Wheels (WoW) is a model of mobile systematic tuberculosis (TB) screening of high-risk populations combining digital chest radiography with computer-aided automated detection (CAD) and chronic cough screening to identify presumptive TB clients in communities, health facilities, and prisons in Nigeria. The model evolves to address technical, political, and sustainability challenges. Screening methods were iteratively refined to balance TB yield and feasibility across heterogeneous populations. Performance metrics were compared over time. Screening volumes, risk mix, number needed to screen (NNS), number needed to test (NNT), sample loss, TB treatment initiation and outcomes. Efforts to mitigate losses along the diagnostic cascade were tracked. Persons with high CAD4TB score (≥80), who tested negative on a single spot GeneXpert were followed-up to assess TB status at six months. An experimental calibration method achieved a viable CAD threshold for testing. High risk groups and key stakeholders were engaged. Operations evolved in real time to fix problems. Incremental improvements in mean client volumes (128 to 140/day), target group inclusion (92% to 93%), on-site testing (84% to 86%), TB treatment initiation (87% to 91%), and TB treatment success (71% to 85%) were recorded. Attention to those as highest risk boosted efficiency (the NNT declined from 8.2 ± SD8.2 to 7.6 ± SD7.7). Clinical diagnosis was added after follow-up among those with ≥ 80 CAD scores and initially spot -sputum negative found 11 additional TB cases (6.3%) after 121 person-years of follow-up. Iterative adaptation in response to performance metrics foster feasible, acceptable, and efficient TB case-finding in Nigeria. High CAD scores can identify subclinical TB and those at risk of progression to bacteriologically-confirmed TB disease in the near term.

Challenges in engaging the private sector for tuberculosis prevention and care in Nigeria: a mixed methods study.

OBJECTIVES: This study aimed to assess the practices of private practitioners regarding tuberculosis (TB), and to ascertain factors related to the low contribution of private healthcare providers to TB prevention and care in Nigeria. DESIGN: This is a mixed methods study comprising a quantitative retrospective review and qualitative study. SETTING: Private health facilities (HF) in Oyo State and the Federal Capital Territory (FCT), Nigeria. PARTICIPANTS: We used routinely collected data on patients with tuberculosis (TB) notified between 1 January 2017 and 31 December 2018. In-depth interviews were also conducted with the clinical staff of the facilities. PRIMARY AND SECONDARY OUTCOME MEASURES: The study outcomes are practices of TB case notification and treatment outcome, as well as the barriers and enablers of TB notification. RESULTS: A total of 13 (11.0%) out of 118 private HF were designated as 'engaged' TB care facilities in Oyo State and none (0%) of the 198 private HF in the FCT held this designation. From the 214 patients with presumptive TB, 75 (35%) were diagnosed with TB, 42 (56%) had a bacteriological test done, 12 (16%) had an X-ray of the chest alone and 21 (28%) had other non-specific investigations. Most patients diagnosed were referred to a public HF, while 19 (25%) patients were managed at the private HF. Among them, 2 (10.5%) patients were treated with unconventional regimens, 4 (21%) were cured, 2 (11%) died, 3 (16%) lost to follow-up and 10 (53%) were not evaluated. The general practitioners did not have up-to-date knowledge of TB with a majority not trained on TB. Most referred patients with presumptive and confirmed TB to the public sector without feedback and were unclear regarding diagnostic algorithm and relevant tests to confirm TB. CONCLUSION: Most private facilities were not engaged to provide TB services although with knowledge and practice gaps. The study has been used to develop plans for strategic engagement of the private sector in Nigeria.

Leveraging Innovative Financing Strategy to Increase Coverage and Resources Among Informal Sector for Social Health Insurance Within the Nigerian Context of Devolution: Evidence From Adoption Model Implementation.

Background: Enrollment in sub-national social health insurance schemes (SSHIS) can be challenging in developing countries like Nigeria, particularly among people in the informal sector. This could be due to a lack of knowledge on its mode of operation and benefits, distrust in government, inimical religious and traditional beliefs, as well as constraining economic factors. A complementary and innovative financing strategy such as the philanthropist adoption model (ADM) could be beneficial in improving SSHIS coverage and financial resources among persons in the informal sector. The study provides new evidence on how ADM influenced health insurance coverage and resources within SSHIS among informal settings in Nigeria. It also highlights contextual factors influencing the implementation of ADM. Methods: This study employed a mixed-methods case-study approach undertaken in Anambra State, Southeast Nigeria. Data were collected through in-depth interviews (n = 14), document review (n = 12), and quantitative (enrollment data) methods. The respondents were purposively selected based on their involvement with the implementation of the SSHIS. Data analysis for qualitative data was done using the manual thematic framework approach while descriptive analysis was performed for the quantitative data. Results: The implementation of ADM was a valuable and effective strategy for improving knowledge, coverage, and resource mobilization (annual premium pool) within the SSHIS in the informal sector. The main enablers of the implementation of ADM include strong political will and commitment, wider stakeholders' consultation and collaboration, numerous public-spirited philanthropists, and legal institutionalization of health insurance. Other enablers include organizational factors like good teamwork among Anambra State Health Insurance Agency (ASHIA) staff, enabling work environment (incentives, supervision, office space), and experienced marketers in the agency. However, ADM had several barriers that affected its implementation-acceptability issues due to distrust for government and the health system, health systems barriers including substandard health facilities and equipment, and inimical cultural and religious beliefs about health insurance. Conclusion: The study demonstrates a case for the implementation of innovative ADM as a strategy for enhancing SSHIS financial sustainability and coverage of persons in the informal sector. Hence, the strategy should be adopted in settings where philanthropy abounds for increasing access to quality healthcare delivery to poor beneficiaries toward achieving universal health coverage in developing countries.

Influence of sub-national social health insurance scheme on enrollees' health seeking behaviour in Anambra state, Nigeria: a pre and post study.

BACKGROUND: Appropriate health-seeking behaviour (HSB) is crucial for improving health outcomes and achieving universal health coverage (UHC). Accessing healthcare through the state social health insurance scheme (SSHIS) could lead to improved HSB. The study explores the influence of access to healthcare through health insurance on the HSB of the enrollees of the SSHIS in southeast, Nigeria. METHODS: A descriptive cross-sectional study undertaken in twelve health facilities in Anambra state using quantitative and qualitative research methods. Data were collected through a facility-based survey (n = 447) and sex-disaggregated focus group discussions (n = 12) of health insurance enrollees. Univariate and bivariate analyses were performed for quantitative data, while qualitative data were analyzed using a manual content approach. RESULT: The findings revealed a positive change in enrollee's HSB post-health insurance enrollment. Majority (83%) of the respondents reported that they immediately take action when ill post-health insurance enrollment as against 34% (pre-health insurance) resulting in a 49% increase, with a statistically significant difference (p < 0.02). There was a statistically significant association between positive HSB and marital status (p < 0.04); educational level (p < 0.00); occupation (p < 0.03) and ownership of health facility (p < 0.00). There was an increase in the percentage of enrollees who use the hospital as their first choice of provider during an illness episode post-health insurance enrollment. This increased from 37.4% to 90.2% (post-health insurance enrollment), representing a 52.8% increase, which is statistically significant (p < 0.03), in seeking care in hospitals. Similarly, the percentage (46%) of enrollees using patent medicine vendors (PMVs) as their first choice of provider when ill prior to enrollment in health insurance decreased to 8.1% post-health insurance enrollment, representing a 38% decline with a statistically significant (p < 0.00) drop in PMV patronage. Reasons for positive HSB include low cost of services and availability of quality care such as quality drugs, presence of doctors, and other skilled health workers by the health insurance facilities. CONCLUSION: Health insurance has been established as an effective strategy for improving appropriate HSB. Hence, increasing coverage of health insurance among the uninsured is crucial in improving access to quality and affordable health care towards achieving UHC, particularly in developing countries.

Population seroprevalence of SARS-CoV-2 antibodies in Anambra State, South-East, Nigeria.

OBJECTIVE: The objective of this study was to determine the proportion of the Anambra State population that had been infected by the SARS-CoV-2 virus and developed antibodies before the second wave. METHODS: The WHO-recommended health facility-based cross-sectional approach was adapted for this survey. Between 8th and 15th December 2020, 3142 participants across the 21 local government areas (LGAs) of the State, aged one year and over, attending randomly selected health facilities, were recruited. Demographic and symptom-related information were collected from the participants as well as whole peripheral blood, which was tested for SARS-CoV-2 IgG and IgM with rapid test kits. RESULTS: 425 participants tested positive for IgG only, 74 for IgM only, while 54 were positive for both IgG and IgM. Overall, 553 positives were recorded, giving a crude seroprevalence of 17.6% (95% CI = 16.26 - 18.98). It ranged widely from 31.9% (95% CI = 24.43 - 40.22) in Onitsha North LGA to 5.4% (95% CI = 2.19 - 10.78) in Awka north. Bayesian Adjustments yielded a state seroprevalence of 16.1%. CONCLUSION: One in six state residents had been infected by SARS-CoV-2 and developed antibodies before the second wave. All LGAs, age groups, sexes, and settlement types were affected by COVID-19. A large proportion of the population remained susceptible to SARS-CoV-2.