'Let him die in peace': understanding caregiver's refusal of medical oxygen treatment for children in Nigeria.

INTRODUCTION: Efforts to improve oxygen access have focused mainly on the supply side, but it is important to understand demand barriers, such as oxygen refusal among caregivers. We therefore aimed to understand caregiver, community and healthcare provider (HCP) perspectives and experiences of medical oxygen treatments and how these shape oxygen acceptance among caregivers of sick children in Lagos and Jigawa states, which are two contrasting settings in Nigeria. METHODS: Between April 2022 and January 2023, we conducted an exploratory qualitative study using reflexive thematic analysis, involving semistructured interviews with caregivers (Jigawa=18 and Lagos=7), HCPs (Jigawa=7 and Lagos=6) and community group discussions (Jigawa=4 and Lagos=5). We used an inductive-deductive approach to identify codes and themes through an iterative process using the theoretical framework of acceptability and the normalisation process theory as the analytic lens. RESULTS: Medical oxygen prescription was associated with tension, characterised by fear of death, hopelessness about a child's survival and financial distress. These were driven by community narratives around oxygen, past negative experiences and contextual differences between both settings. Caregiver acceptance of medical oxygen was a sense-making process from apprehension and scepticism about their child's survival chances to positioning prescribed oxygen as an 'appropriate' or 'needed' intervention. Achieving this transition occurred through various means, such as trust in HCPs, a perceived sense of urgency for care, previous positive experience of oxygen use and a symbolic perception of oxygen as a technology. Misconceptions and pervasive negative narratives were acknowledged in Jigawa, while in Lagos, the cost was a major reason for oxygen refusal. CONCLUSION: Non-acceptance of medical oxygen treatment for sick children is modifiable in the Nigerian context, with the root causes of refusal being contextually specific. Therefore, a one-size-fits-all policy is unlikely to work. Financial constraints and community attitudes should be addressed in addition to improving client-provider interactions.

Factors associated with immunization status among children aged 12-59 months in Lagelu local government area, Ibadan: a cross-sectional study.

Introduction: childhood deaths from preventable causes remain high in Nigeria. Although vaccines are available to combat many of these diseases, vaccine coverage remains low in many at-risk communities. With this study, we aimed to determine factors that might have impacted the use of immunization services in Ibadan, the capital of Oyo State in southwest Nigeria. Methods: we conducted a community-based cross-sectional study in a peri-urban local government area in Ibadan using a multi-stage cluster sampling technique to identify respondents for this study. The interviewer-administered questionnaire was used to obtain information on respondents and child socio-demographic details. We reviewed the child´s vaccine card to determine vaccine status. Data were analyzed using STATA version 14 at a 5% level of significance. Results: of the 265 children aged 12 to 59 months who had their vaccine cards appropriately filled, only 65.3% (n=173) received all basic vaccines, while 90.2% (n=239) and 86.8% (n=230) received 3 doses of pentavalent vaccine (PENTA) and pneumococcal conjugate vaccines (PCV-10) respectively. We found a significant difference in the completion of basic vaccination according to the caregiver´s place of residence and the mother´s educational level. Access-related barriers were frequently reported (n=24, 54.5%) as reasons for missing a due vaccine. Conclusion: improvement in vaccine coverage in this setting is necessary. Targeted health information for mothers may be a cost-efficient and sustainable approach to improve vaccine coverage for under-five children.

Linking communities and health facilities to improve child health in low-resource settings: a systematic review.

Community-facility linkage interventions are gaining popularity as a way to improve community health in low-income settings. Their aim is to create/strengthen a relationship between community members and local healthcare providers. Representatives from both groups can address health issues together, overcome trust problems, potentially leading to participants' empowerment to be responsible for their own health. This can be achieved via different approaches. We conducted a systematic literature review to explore how this type of intervention has been implemented in rural and low or lower-middle-income countries, its various features and how/if it has helped to improve child health in these settings. Publications from three electronic databases (Web of Science, PubMed and Embase) up to 03 February 2022 were screened, with 14 papers meeting the inclusion criteria (rural setting in low/lower-middle-income countries, presence of a community-facility linkage component, outcomes of interest related to under-5 children's health, peer-reviewed articles containing original data written in English). We used Rosato's integrated conceptual framework for community participation to assess the transformative and community-empowering capacities of the interventions, and realist principles to synthesize the outcomes. The results of this analysis highlight which conditions can lead to the success of this type of intervention: active inclusion of hard-to-reach groups, involvement of community members in implementation's decisions, activities tailored to the actual needs of interventions' contexts and usage of mixed methods for a comprehensive evaluation. These lessons informed the design of a community-facility linkage intervention and offer a framework to inform the development of monitoring and evaluation plans for future implementations.

Community perceptions matter: a mixed-methods study using local knowledge to define features of success for a community intervention to improve quality of care for children under-5 in Jigawa, Nigeria.

OBJECTIVES: In this study, we used the information generated by community members during an intervention design process to understand the features needed for a successful community participatory intervention to improve child health. DESIGN: We conducted a concurrent mixed-methods study (November 2019-March 2020) to inform the design and evaluation of a community-facility linkage participatory intervention. SETTING: Kiyawa Local Government Area (Jigawa State, Nigeria)-population of 230 000 (n=425 villages). PARTICIPANTS: Qualitative data included 12 community conversations with caregivers of children under-5 (men, older and younger women; n=9 per group), 3 focus group discussions (n=10) with ward development committee members and interviews with facility heads (n=3). Quantitative data comprised household surveys (n=3464) with compound heads (n=1803) and women (n=1661). RESULTS: We analysed qualitative data with thematic network analysis and the surveys with linear regression-results were triangulated in the interpretation phase. Participants identified the following areas of focus: community health education; facility infrastructure, equipment and staff improvements; raising funds to make these changes. Community involvement, cooperation and empowerment were recognised as a strategy to improve child health, and the presence of intermediate bodies (development committees) was deemed important to improve communication and solve problems between community and facility members. The survey showed functional community relations' dynamics, with high levels of internal cohesion (78%), efficacy in solving problems together (79%) and fairness of the local leaders (82%). CONCLUSIONS: Combining the results from this study and critical theories on successful participation identified community-informed features for a contextually tailored community-facility link intervention. The need to promote a more inclusive approach to future child health interventions was highlighted. In addition to health education campaigns, the relationship between community and healthcare providers needs strengthening, and development committees were identified as an essential feature for successfully linking communities and facilities for child health. TRIAL REGISTRATION NUMBER: ISRCTN39213655.

Whose knowledge counts? Involving communities in intervention and trial design using community conversations.

BACKGROUND: Current debates in Global Health call for expanding methodologies to allow typically silenced voices to contribute to processes of knowledge production and intervention design. Within trial research, this has typically involved small-scale qualitative work, with limited opportunities for citizens to contribute to the structure and nature of the trial. This paper reports on efforts to move past typical formative trial work, through adaptation of community conversations (CCs) methodology, an action-oriented approach that engages large numbers of community members in dialogue. We applied the CC method to explore community perspectives about pneumonia and managing the health of children under-5 in Northern Nigeria to inform our pragmatic cluster randomised controlled trial evaluating a complex intervention to reduce under-5 mortality in Nigeria. METHODS: We conducted 12 rounds of community conversations with a total of 320 participants, in six administrative wards in Kiyawa Local Government Area, Jigawa state, our intervention site. Participants were male and female caregivers of children under five. Conversations were structured around participatory learning and action activities, using drawings and discussion to reduce barriers to entry. During activities participants were placed in subgroups: younger women (18-30 years of age), older women (31-49 years) and men (18 years above). Discussions were conducted over three 2-h sessions, facilitated by community researchers. Following an initial analysis to extract priority issues and perspectives on intervention structure, smaller focus group discussions were completed with participants in five new sites to ensure all 11 administrative wards in our study site contributed to the design. RESULTS: We identified enabling and limiting factors which could shape the future trial implementation, including complex power relationships within households and wider communities shaping women's health decision-making, and the gendered use of space. We also noted the positive engagement of participants during the CC process, with many participants valuing the opportunity to express themselves in ways they have not been able to in the past. CONCLUSIONS: CCs provide a structured approach to deep meaningful engagement of everyday citizens in intervention and trial designs, but require appropriate resources, and commitment to qualitative research in trials. TRIAL REGISTRATION: ISRCTN39213655. Registered on 11 December 2019.

Care seeking for under-five children and vaccine perceptions during the first two waves of the COVID-19 pandemic in Lagos State, Nigeria: a qualitative exploratory study.

OBJECTIVE: To explore healthcare seeking practices for children and the context-specific direct and indirect effects of public health interventions during the first two waves of COVID-19 in Lagos State, Nigeria. We also explored decision-making around vaccine acceptance at the start of COVID-19 vaccine roll-out in Nigeria. DESIGN, SETTING AND PARTICIPANTS: A qualitative explorative study involving 19 semistructured interviews with healthcare providers from public and private primary health facilities and 32 interviews with caregivers of under-five children in Lagos from December 2020 to March 2021. Participants were purposively selected from healthcare facilities to include community health workers, nurses and doctors, and interviews were conducted in quiet locations at facilities. A data-driven reflexive thematic analysis according to Braun and Clark was conducted. FINDINGS: Two themes were developed: appropriating COVID-19 in belief systems, and ambiguity about COVID-19 preventive measures. The interpretation of COVID-19 ranged from fearful to considering it as a 'scam' or 'falsification from the government'. Underlying distrust in government fuelled COVID-19 misperceptions. Care seeking for children under five was affected, as facilities were seen as contagious places for COVID-19. Caregivers resorted to alternative care and self-management of childhood illnesses. COVID-19 vaccine hesitancy was a major concern among healthcare providers compared with community members at the time of vaccine roll-out in Lagos, Nigeria. Indirect impacts of COVID-19 lockdown included diminished household income, worsening food insecurity, mental health challenges for caregivers and reduced clinic visits for immunisation. CONCLUSION: The first wave of the COVID-19 pandemic in Lagos was associated with reductions in care seeking for children, clinic attendance for childhood immunisations and household income. Strengthening health and social support systems with context-specific interventions and correcting misinformation is crucial to building adaptive capacity for response to future pandemics. TRIAL REGISTRATION NUMBER: ACTRN12621001071819.

Pulse oximetry and oxygen services for the care of children with pneumonia attending frontline health facilities in Lagos, Nigeria (INSPIRING-Lagos): study protocol for a mixed-methods evaluation.

INTRODUCTION: The aim of this evaluation is to understand whether introducing stabilisation rooms equipped with pulse oximetry and oxygen systems to frontline health facilities in Ikorodu, Lagos State, alongside healthcare worker (HCW) training improves the quality of care for children with pneumonia aged 0-59 months. We will explore to what extent, how, for whom and in what contexts the intervention works. METHODS AND ANALYSIS: Quasi-experimental time-series impact evaluation with embedded mixed-methods process and economic evaluation. SETTING: seven government primary care facilities, seven private health facilities, two government secondary care facilities. TARGET POPULATION: children aged 0-59 months with clinically diagnosed pneumonia and/or suspected or confirmed COVID-19. INTERVENTION: 'stabilisation rooms' within participating primary care facilities in Ikorodu local government area, designed to allow for short-term oxygen delivery for children with hypoxaemia prior to transfer to hospital, alongside HCW training on integrated management of childhood illness, pulse oximetry and oxygen therapy, immunisation and nutrition. Secondary facilities will also receive training and equipment for oxygen and pulse oximetry to ensure minimum standard of care is available for referred children. PRIMARY OUTCOME: correct management of hypoxaemic pneumonia including administration of oxygen therapy, referral and presentation to hospital. SECONDARY OUTCOME: 14-day pneumonia case fatality rate. Evaluation period: August 2020 to September 2022. ETHICS AND DISSEMINATION: Ethical approval from University of Ibadan, Lagos State and University College London. Ongoing engagement with government and other key stakeholders during the project. Local dissemination events will be held with the State Ministry of Health at the end of the project (December 2022). We will publish the main impact results, process evaluation and economic evaluation results as open-access academic publications in international journals. TRIAL REGISTRATION NUMBER: ACTRN12621001071819; Registered on the Australian and New Zealand Clinical Trials Registry.

Prevalence of pneumonia and malnutrition among children in Jigawa state, Nigeria: a community-based clinical screening study.

OBJECTIVE: To estimate the point prevalence of pneumonia and malnutrition and explore associations with household socioeconomic factors. DESIGN: Community-based cross-sectional study conducted in January-June 2021 among a random sample of households across all villages in the study area. SETTING: Kiyawa Local Government Area, Jigawa state, Nigeria. PARTICIPANTS: Children aged 0-59 months who were permanent residents in Kiyawa and present at home at the time of the survey. MAIN OUTCOME MEASURES: Pneumonia (non-severe and severe) defined using WHO criteria (2014 revision) in children aged 0-59 months. Malnutrition (moderate and severe) defined using mid-upper arm circumference in children aged 6-59 months. RESULTS: 9171 children were assessed, with a mean age of 24.8 months (SD=15.8); 48.7% were girls. Overall pneumonia (severe or non-severe) point prevalence was 1.3% (n=121/9171); 0.6% (n=55/9171) had severe pneumonia. Using an alternate definition that did not rely on caregiver-reported cough/difficult breathing revealed higher pneumonia prevalence (n=258, 2.8%, 0.6% severe, 2.2% non-severe). Access to any toilet facility was associated with lower odds of pneumonia (aOR: 0.56; 95% CI: 0.31 to 1.01). The prevalence of malnutrition (moderate or severe) was 15.6% (n=1239/7954) with 4.1% (n=329/7954) were severely malnourished. Being older (aOR: 0.22; 95% CI: 0.17 to 0.27), male (aOR: 0.77; 95% CI: 0.66 to 0.91) and having head of compound a business owner or professional (vs subsistence farmer, aOR 0.71; 95% CI: 0.56 to 0.90) were associated with lower odds of malnutrition. CONCLUSIONS: In this large, representative community-based survey, there was a considerable pneumonia and malnutrition morbidity burden. We noted challenges in the diagnosis of Integrated Management of Childhood Illness-defined pneumonia in this context.

Using intermittent pulse oximetry to guide neonatal oxygen therapy in a low-resource context.

OBJECTIVE: To evaluate the effectiveness of intermittent pulse oximetry in guiding oxygen therapy in neonates in a low-resource setting. DESIGN AND SETTING: Prospective validation study at three hospitals in southwest Nigeria. We performed concealed continuous pulse oximetry on participants to evaluate intermittent SpO2 monitoring. PATIENTS: We recruited all preterm or low birthweight neonates, and all term neonates who required oxygen therapy, who were admitted to the neonatal ward(s) of the study hospitals during the study period. MAIN OUTCOME MEASURES: Proportion of time preterm/low birthweight neonates on oxygen spent within, above and below the target SpO2 range of 90%-95%; and the proportion of time term neonates and neonates not on oxygen spent within and below the target range of 90%-100%. RESULTS: Preterm/low birthweight neonates receiving oxygen therapy (group A) spent 15.7% (95% CI 13.3 to 18.9) of time in the target SpO2 range of 90%-95%. They spent 75.0% (63.6-81.1) of time above 95%, and 2.7% (1.7-5.6) of time below 85%. Term neonates and all neonates not receiving oxygen (group B) spent 97.3% (95% CI 96.4 to 98.6) of time within the target range of 90%-100%, and 0.9% (0.3-1.4) of time below 85%. Guidelines recommended SpO2 monitoring 3 times per day for all patients, however neonates in groups A and B were monitored an average of 4.7 and 5.3 times per day, respectively. CONCLUSIONS: To better maintain SpO2 within the target range, preterm/low birthweight neonates on oxygen should have their SpO2 monitored more frequently than the current 4.7 times per day. In all other neonates, however, monitoring SpO2 5.3 times per day appears suitable.