Joseph Okeibunor

Rural-urban differences in health-seeking for the treatment of childhood malaria in south-east Nigeria

OBJECTIVES To identify the differences in health-seeking for childhood malaria treatment, between urban and rural communities in Nigeria, with a view to providing information to policy makers that will be used to improve malaria control. METHODS Quantitative and qualitative research methods were employed in eliciting information. A pre-tested structured questionnaire was administered to 1200 caretakers of children under 5 years who had malaria 2 weeks prior to the survey period. Focus group discussions were held with mothers and in-depth interviews with health care providers. RESULTS Health-seeking for malaria, differed significantly between rural and urban mothers. While majority (64.7%) of urban caretakers patronized private/government health facilities, most (62%) of their rural counterparts resorted to self-treatment with drugs bought over-the-counter, from patent medicine vendors. Hospitals were geographically more accessibility to urban than rural dwellers. Rural mothers only go to hospital when the problem persists or becomes worse, which results in delay in seeking appropriate and timely care. CONCLUSION Urban and rural mothers differed in their responses to childhood fevers. Training drug vendors and caretakers are important measures to improve malaria control. Health facilities with good quality services and readily available drugs should be provided.

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

BackgroundDespite 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.MethodsA 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.FindingsRelative 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.ConclusionThe 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

BackgroundAs 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.MethodsA 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 APOCs 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.ResultsEight-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.ConclusionThese findings can help managers of CDTI programmes to ensure ivermectin reaches all segments of the population equally.

Additional health and development activities for community-directed distributors of ivermectin: threat or opportunity for onchocerciasis control?

We studied the involvement of community‐directed distributors (CDDs) of ivermectin for onchocerciasis control in other health and development activities in Nigeria, Togo and Cameroon. Most CDDs (82%) were involved in additional activities, especially EPI, water and sanitation and community development projects. These activities did not take up much time and were not considered an important burden. Ivermectin treatment coverage did not decline with increasing number of additional activities. Other health programmes are interested in building on the experiences and structures of community‐directed treatment with ivermectin and involving CDDs in their health programmes. Some, such as EPI, provide financial incentives. Incentives by other programmes may enhance the performance of CDDs when they are selected on the basis of their CDD status. CDDs, health personnel and community members have very positive attitudes towards greater involvement of CDDs in additional health and development activities. We conclude that additional activities for CDDs do not pose a threat to but rather provide an opportunity to strengthen sustainability and effectiveness of ivermectin treatment.

A school-based schistosomiasis and intestinal helminthiasis control programme in Nigeria: acceptability to community members.

In a population with high prevalences in schoolchildren of infection with hookworm (32.4%), Ascaris (22.9%) and Trichuris (2.5%), visible haematuria (17.9%), micro‐haematuria (17%) and proteinuria (47.3%), the knowledge about transmission of schistosomiasis and acceptability of a school‐based control programme were assessed. The community perceived schistosomiasis (80.6%) and intestinal helminthiasis (66.5%) as important health problems in school‐age children and most people would prefer placement of the control programme in school because it would eliminate transportation cost to the health facility. They welcomed the idea of using teachers for detection of infection and drug administration. The health staff, on the other hand, were willing to work with teachers, but emphasized that teachers should be limited to organizational and supervisory roles while they do tests and administer the drug. This view was also shared by the officials in the state ministries of health and education.

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.

Where would I be without ivermectin? Capturing the benefits of community-directed treatment with ivermectin in Africa.

Objectives  To document peoples’ perceptions of the benefits of taking ivermectin, as an important predictor of sustained compliance with long‐term ivermectin treatment, and to identify the socio‐demographic correlates of perceived benefits of ivermectin treatment.

Feasibility of measuring compliance to annual ivermectin treatment in the African Programme for Onchocerciasis Control.

The African Programme for Onchocerciasis Control (APOC) sponsors annual distribution of ivermectin to control onchocerciasis. Ivermectin should be taken annually by 65% of community members for a number of years to eliminate the disease as a public health problem. While many community coverage surveys have been undertaken during project monitoring, individual compliance could not be studied until several annual rounds of distribution had occurred. This paper reports on the efforts to determine whether adequate records could be found to enable a compliance study. A step‐down process from project to district to community level was used to identify project sites where continuous ivermectin distribution up through 2004 had occurred. The first step consisted of selecting 17 of 25 projects by APOC. The second step determined adequacy of districts where distribution had occurred on a regular annual basis. Among 121 districts 58.6% undertook distribution in all 7 years. A total 852 villages were visited and community level records were found in all but three. Records showed that distribution had occurred for a minimum of five consecutive times in 429 villages, and ultimately 10 projects. While the feasibility study found an adequate number of villages to study compliance, the large number of projects, districts and villages that did not qualify for the follow‐on compliance study should lead National Onchocerciasis Control Programme managers to strengthen the overall coverage and consistency of their efforts.

Barriers to care seeking in directly observed therapy short-course (DOTS) clinics and tuberculosis control in southern Nigeria: a qualitative analysis.

An understanding of the socioeconomic and cultural realities of persons infected with tuberculosis (TB) in communities is important to re-strategizing control programs because these realities often come as constraints to the use of the directly observed therapy short-course (DOTS) in Nigeria. In-depth interviews and focus group discussion were used to study barriers to attendance at DOTS clinics for both prompt diagnosis and treatment of smear positive cases in Nigerian communities. A number of common and interrelated factors form barriers to use of DOTS clinics. These include perceived causes of the infection, for example witchcraft, that mitigate against an orthodox solution to TB and thereby affect perceived efficacy of DOTS. Another factor is perceived high cost in resource poor settings. Facility staff were noted to have demanded money from patients in spite of the fact that DOTS is advertised as free treatment. Furthermore, community members complain of the hostile attitude of health staff toward poor people as a barrier to community use of the facilities. It follows, therefore, that the attitude of health workers must be addressed if community members will use the DOTS clinics.

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.