Provider and community perspectives of integrated COVID-19 and routine childhood immunisation programmes in Nigeria: a qualitative exploratory study (preprint)

Background In Nigeria, COVID-19 vaccines were delivered through outreach activities and integrated with routine immunisation. However, evaluations of integrated approaches for novel vaccines are scarce. We aimed to understand the perceived benefits and challenges of integrating the COVID-19 vaccine within routine- immunisation in Nigeria and identify ways to strengthen this approach.Methods We conducted 30 semi-structured interviews with community members and healthcare workers in primary healthcare (PHC) facilities in Jigawa (n = 16) and Oyo (n = 14) states, Nigeria in August 2022. Participants were selected purposively from PHC facilities. Healthcare worker and community interviews were analysed separately using thematic analysis.Results We identified four themes that describe the community response, perceived impact, and health system adaptions to the challenges associated with the integrated vaccine delivery approach. Community members expressed concern that children might be given COVID-19 vaccines instead of routine immunisations, while others appreciated the integrated approach due to their trust in the efficacy of COVID-19 vaccines, government, and healthcare providers. Healthcare providers perceived the integrated approach as improving vaccination coverage and awareness but noted additional problems of increased workload, vaccine scarcity, and prolonged clinic visits. Insufficient resources were subsisting barriers to effective integration in both states, but the provider’s gender was also a challenge in Jigawa state. Additionally, the use of incentives to generate demand had ambiguous effects in Jigawa state.Conclusion Taking an integrated approach to deliver COVID-19 vaccines was acceptable by health workers but resisted from the community. Addressing persistent challenges in existing vaccination programmes is pertinent to enhance effectiveness and acceptability of the integrated approach.

Community participatory learning and action cycle groups to reduce type 2 diabetes in Bangladesh (DClare): an updated study protocol for a parallel arm cluster randomised controlled trial (preprint)

The “Diabetes: Community-led Awareness, Response and Evaluation” (D:Clare) trial aims to scale-up and replicate an evidence-based participatory learning and action cycle intervention in Bangladesh, to inform policy on population-level T2DM prevention and control. The trial was originally designed as a stepped-wedge cluster randomised controlled trial, from March 2020 – September 2022. Twelve clusters were randomly allocated (1:1) to implement the intervention at project months 1 or 12 in two steps, and evaluated through three cross-sectional surveys at months 1, 12 and 24. However, due to the COVID-19 pandemic we suspended project activities on the 20 th March 2020. As a result of the changed risk landscape and the delays introduced by the COVID-19 pandemic, we changed from the stepped-wedge design to a wait-list parallel arm cluster RCT (cRCT) with baseline data. We had four key reasons for eventually agreeing to change designs: equipoise, temporal bias in exposure and outcomes, loss of power and time and funding considerations. Trial registration: ISRCTN42219712 (https://doi.org/10.1186/ISRCTN42219712). Registration date: 31/10/2019.

Incidence Rate of COVID-19 Mortality and its Associated Factors During the First and Second Waves in Nigeria: A Retrospective Cohort Study (preprint)

Background: COVID-19 mortality rate has not been formally assessed in Nigeria. We therefore aimed to address this gap and identify associated mortality risk factors during the first and second waves in Nigeria.Methods: We conducted a retrospective cohort study using the national surveillance database between February 27, 2020, and April 3, 2021. The outcome was deaths amongst persons with a laboratory diagnosis of COVID-19. Incidence rates of COVID-19 death per 100,000 person-days were estimated. Adjusted negative binomial regression was used to identify factors associated with COVID-19 death, and presented as adjusted Incidence Rate Ratios (aIRR) with 95% confidence intervals (CI). Results: The first wave included 65,790 COVID-19 patients, of whom 994 (1∙51%) died; the second wave included 91,089 patients, of whom 513 (0∙56%) died. The incidence rate of deaths related to COVID-19 was higher in the first wave [54∙25 (95% CI: 50∙98-57∙73)] than in the second wave [19∙19 (17∙60-20∙93)]. Factors independently associated with increased risk of death in both waves were: age ≥45 years, male gender [first wave aIRR 1∙65 (1∙35-2∙02) and second wave 1∙52 (1∙11-2∙06)], being symptomatic [aIRR 3∙17 (2∙59-3∙89) and 3∙04 (2∙20-4∙21)], and being hospitalised [aIRR 4∙19 (3∙26-5∙39) and 7∙84 (4∙90-12∙54)].Interpretation: The incidence rate of COVID-19 death in Nigeria was higher in the first wave, suggesting improved public health response and care during the second wave. Regional mortality differences suggest that policy makers focus on regional equity in access to testing and quality of care to mitigate the impact of another COVID-19 wave in Nigeria.Funding: None to declare. Declaration of Interest: None to declare. Ethical Approval: Ethical approval for the study was given by the Nigeria National Health Research Ethics Committee (NHREC/01/01/2007-22/06/2020).

Integrated Sustainable Childhood Pneumonia and Infectious Disease Reduction in Nigeria (INSPIRING) Through Whole System Strengthening in Jigawa, Nigeria: Study Protocol For a Cluster Randomised Controlled Trial (preprint)

BackgroundChild mortality remains unacceptably high, with Northern Nigeria reporting some of the highest rates globally (e.g. 192/1000 live births in Jigawa State). Coverage of key protect and prevent interventions, such as vaccination and clean cooking fuel use, are low. Additionally, knowledge, care-seeking and health system factors are poor. Therefore, a whole systems approach is needed for sustainable reductions in child mortality.MethodsThis is a cluster randomised controlled trial, with integrated process and economic evaluations, conducted from January 2021 – September 2022. The trial will be conducted in Kiyawa Local Government Area, Jigawa State, Nigeria, with an estimated population of 230,000. Clusters are defined as primary government health facility catchment areas (n=33). The 33 clusters will be randomly allocated (1:1) in a public ceremony, and 32 clusters included in the impact evaluation. The trial will evaluate a locally adapted ‘whole systems strengthening’ package of three evidence-based methods: community men’s and women’s groups; Partnership Defined Quality Scorecard; healthcare worker training, mentorship and provision of basic essential equipment and commodities. The primary outcome is mortality of children aged 7 days to 59 months. Mortality will be recorded prospectively using a cohort design, and secondary outcomes measured through baseline and endline cross-sectional surveys. Assuming the following, we will have a minimum detectable effect size of 30%: a) baseline mortality of 100 per 1000 livebirths; b) 4,480 compounds with 3 eligible children per compound; c) 80% power; d) 5% significance; e) intra-cluster correlation of 0.007; f) coefficient of variance of cluster size of 0.74. Analysis will be by intention-to-treat, comparing intervention and control clusters, adjusting for compound and trial clustering. DiscussionThis study will provide robust evidence of the effectiveness and cost-effectiveness of community-based participatory learning and action, with integrated health system strengthening and accountability mechanisms, to reduce child mortality. The ethnographic process evaluation will allow for a rich understanding of how the intervention works in this context. However, we encountered a key challenge in calculating the sample size, given the lack of timely and reliable mortality data, and the uncertain impacts of the COVID-19 pandemic. Trial registrationISRCTN 39213655, registered 11th December 2019

Measuring Oxygen Access: lessons from health facility assessments in Nigeria (preprint)

The COVID-19 pandemic has highlighted global oxygen system deficiencies and revealed gaps in how we understand and measure oxygen access. We present a case study on oxygen access from 58 health facilities in Lagos state, Nigeria. We found large differences in oxygen access between facilities (primary vs secondary, government vs private) and describe four key domains to consider when measuring oxygen access. Use: 8/58 (14%) of facilities had a functional pulse oximeter for detecting hypoxaemia (low blood oxygen level) and guiding oxygen care. Oximeters were typically located in outpatient clinics (12/27, 44%), paediatric ward (6/27, 22%), or operating theatre (4/27, 15%), not suitable for children, and infrequently used. Availability: 34/58 (59%) facilities had a functional source of oxygen available on the day of inspection, of which 31 (91%) facilities had it available in a single ward area, typically the operating theatre or maternity ward. Cost: Oxygen was free to patients at primary health centres, when available, but expensive in hospitals and private facilities, with the median cost for 2 days oxygen 13000 ($36 USD) and 27500 ($77 USD) naira, respectively. Patient access: No facilities were adequately equipped to meet minimum oxygen demands for patients. We were unable to determine the proportion of hypoxaemic patients who received oxygen therapy with available data. We highlight the importance of a multi-faceted approach to measuring oxygen access that assesses access at the point-of-care, and ideally at the patient-level. We propose standard metrics to report oxygen access and describe how these can be integrated into routine health information systems and existing health facility assessment tools.