Evaluation of a capacity building intervention on malaria treatment for under-fives in rural health facilities in Niger State, Nigeria

Between 2008 and 2015, the Nigerian National Malaria Control Programme was supported to conduct a phased capacity building programme on malaria case management in 10 of the 37 States of Nigeria. These States included: Lagos, Kano, Anambra, Katsina, Niger, Ogun, Jigawa, Enugu, Kaduna and Yobe. Training materials were developed and a system of cascade training from State to local government area (LGA) level (i.e. district equivalent level) was implemented for health care workers.

The malaria case management capacity building intervention consisted of: (1) revised case management manuals including adult learning exercises; (2) cascade training where national level facilitators, including content and adult learning experts, supported the State to train State level facilitators or trainers, who then conducted 3 day training sessions; and (3) on the job capacity development through integrated supportive supervision, with the State level facilitators/trainers acting as supervisors.

This study was carried out from October 2011 to March 2013, in two local government areas, Katcha and Gbako of Niger State. Niger State is located in the North Central geopolitical zone of Nigeria and has a total of 25 local government areas, with an overall population of approximately 4.3 million people. The State has high infant and under-five mortality rates of 85 and 106 per 1000 live births, respectively, compared with the national average of 75 and 106 per 1000, respectively [3, 11]. Like many other parts of Nigeria, malaria is endemic in Niger State, with year-round transmission. In 2010, 45% of febrile under-fives tested in the North Central zone were RDT-positive [12] and malaria constituted the highest proportion of childhood febrile illnesses presenting to health facilities [3, 11].

At the time of this study, there were 1323 primary health care facilities (PHCs), 18 secondary health facilities and two tertiary health facilities in Niger State. Services, including diagnostics and prescribed treatment were provided free of charge by primary health care facilities to pregnant women and children under-5 years of age. In addition to the government owned health care facilities, there were also 446 registered private health facilities (hospitals, clinics, maternities, and laboratories) and 1200 licensed Patent Medicine Vendors.

The two LGAs were purposively selected on the basis of similarity in socio-economic characteristics and the ratio of public to private sector facilities. Sample size calculation was based on the proportion of under-fives receiving appropriate treatment for febrile illness (i.e. proportion of febrile children treated for malaria or tested for malaria and treated if positive) estimated at 10% in the comparison LGA. Assuming a coefficient of variation k = 0.4, and recruitment of 30 under-fives per facility, a minimum of 28 health facilities (14 per LGA) were required in order to detect an absolute difference in appropriate treatment prevalence between LGAs of 10%, at a power of 80%, and a 5% level of significance (two-sided).

Two stage stratified sampling strategy was used. In the first stage, a full list of all public and private facilities in Katcha and Gbako LGAs was compiled and they were classified as public or private and then into secondary or primary health facilities. Health facilities were selected proportional to the total number of facilities in each LGA. In total 28 facilities were selected, 14 in each LGA. In the second stage 840 febrile under-fives, 30 per facility, were selected from included health facilities. Recruitment of children from facilities continued over subsequent data collection visit days until required sample sizes were achieved.

Surveys were undertaken in Katcha and in Gbako 1 year after implementation of the case management training programme. All health workers involved in management of febrile under-fives on the day of the survey were invited to take part, and following consent, data on demographic characteristics of these staff were collected from the participating health workers and the health facility staff person in charge, using a structured questionnaire. Characteristics of the health facility were collected using a structured questionnaire and health facility stock records were consulted to record availability of supplies and equipment necessary for malaria diagnosis and treatment on the day of the survey. All health facility attendees aged under-5 years presenting with fever or a history of fever on each day of the survey were invited to take part, and following provision of informed consent, participant characteristics for presenting under-fives and their accompanying caregiver were collected and all consultation processes observed and recorded using a structured checklist.

Data were collected using paper questionnaires and subsequently double-entered using EpiData version 3.1 (EpiData Association, Odense, Denmark). Data were analysed using STATA version 13.0 (STATA Corporation, College Station, Texas). Sample weights for observations were estimated as the reciprocal of the probability of selection of each health facility for analyses conducted at the health facility level. Additionally, for analyses conducted at the individual under-five patient level, sample weights were estimated based on the product of the sampling weights of each selected health facility and those of individual patients. The probability of selection of individual under-five patients within each study health facility was calculated as 30/mean outpatient attendance for 2010. Descriptive and logistic regression analyses were carried out using svy commands.

Due to the change in national guidelines for malaria diagnosis and the introduction of confirmatory parasitology during the implementation of this intervention, the original primary outcome of appropriate treatment defined as febrile children being presumptively treated for malaria or tested and treated if positive, was no longer considered appropriate. Alternative outcomes of the prevalence of RDT use among febrile under-fives, and appropriate management of RDT-positives and RDT-negatives were generated [13]. Appropriate management was defined as prescription of artemether–lumefantrine (AL) or artesunate–amodiaquine (ASAQ) to RDT-positive under-fives and no AL or ASAQ prescribed to RDT-negative under-fives. As description of the sample showed that many of the RDT-negative under-fives who were not receiving AL or ASAQ were receiving another anti-malarial, appropriate management of RDT-negative was also defined as those RDT-negative under-fives who were not prescribed any anti-malarial.

Comparison of outcomes of clinical malaria diagnosis with rapid diagnostic tests and appropriate management of RDT-positive or RDT–negative under-fives was made between intervention and comparison areas in 2013, following 1 year of implementation of the intervention. Facilities and staff in the intervention LGA received the package of interventions included in the NMCP’s capacity development programme, while the comparison LGA received none of the specified components and experienced only Federal level initiatives (including changes in national policy such as the adoption of the WHO guidelines for the introduction of confirmatory parasitology).

Univariate logistic regression analyses calculated odds ratios (ORs) and confidence intervals (CIs) comparing the odds of these outcomes among under-fives from facilities in intervention and comparison LGAs. In multivariate logistic regression analyses, these associations were investigated controlling for the following a priori defined potential confounders: age and gender of the child; gender and education level of the carer; age and gender of the health worker; as well as RDT availability and either AL or ASAQ availability from health facility stock records [14].

Approval for the study was obtained from the Ethics Committees of the Niger State Ministry of Health, the University of Ibadan/University College Hospital Ethical Review Committee and the Ethics Committee of the London School of Tropical Medicine and Hygiene, UK.

The implementation of this programme in Niger State began in 2011 at which time surveys with health facility staff caring for febrile under-fives showed that 27% of health workers in intervention area health facilities had reported recent malaria training (in the 6 months before the survey), while 16% had reported recent training in the integrated management of childhood illness (IMCI). Similar levels of training were reported by staff from facilities in the comparison area- 29% for recent malaria training and 23% for recent IMCI training.

By 2013, all 14 facilities in the intervention LGA reported that at least one staff member had attended malaria training, while 13 of the 14 had done so for IMCI training. This contrasted to facilities in the comparison LGA where 12 of 14 facilities reported that at least one staff member had attended malaria training, but 7 of the 14 facilities reported that none of the staff interviewed had recently attended IMCI training. Table 2 shows that a higher proportion (54% versus 34%; p = 0.09) of health workers from health facilities in the intervention LGA reported recent malaria training. In addition, significantly more health workers from facilities in the intervention LGA reported attending IMCI training in the last 6 months (45%), in comparison to 20% from facilities in the comparison LGA. These results suggest that although the training component of the programme reached facilities, cascade training did not fully reach all staff members within intervention facilities. Furthermore, Table 1 shows that in 2013 similar mean numbers of supervision visits were recorded between intervention and comparison LGAs, suggesting that this component of the capacity development programme did not result in more frequent supervision visits in intervention LGAs.

A total of 28 health facilities were sampled, 14 in each LGA. The large majority were government-owned in both LGAs, with only 3% and 8% of included facilities from the private sector (Table 1). Facilities in both LGAs had similar catchment sizes.

In total, 171 health workers across these 28 health facilities were interviewed and observed during consultations with febrile under-fives during the period of data collection, with 65% of these health workers based in intervention facilities. About 60% of health workers in selected facilities from both LGAs were male, and about 95% from the Nupe ethnic group. Health workers from facilities in both LGAs had a mean age of about 35 years, and about 70% of health workers had worked at that facility for at least 3 years. The majority of staff managing febrile under-fives in this setting were Community Health Officers (CHO) and community health extension workers (CHEWs) (or junior community health extension workers (JCHEWs)), with fewer than 7% of staff managing under-fives in either LGA defined as clinically trained (Table 2).

In total, 840 febrile under-fives were recruited, 420 from facilities in the intervention LGA and likewise in the comparison LGA. Under-fives in both areas were similar in age, with a mean age of 1.9 years, and similar proportions of boys and girls were recruited. Fewer than 1% of children recruited were covered by the National Health Insurance Scheme. The carers accompanying the under-fives were principally female, the majority the child’s mother. Almost half of carers reported no formal education, and between 22% and 31% reported Islamic education (Table 3).

Over the study period, facilities were visited on average 25 times (range 11–32), and stock availability was assessed. On the days of visits, stock availability of RDTs and recommended ACT medicines (AL and ASAQ) were low in facilities from both LGAs. In total, 43% and 15% of included facilities in intervention and comparison LGAs respectively, reported that they had neither AL nor ASAQ available for 10% of the visit days. Stock-out problems for these ACT medicines in the intervention facilities appeared especially binary, with half of facilities reporting no stock on any of the visit days, and the other half reporting availability for over 80% of visit days. On average, over all visit days, AL or ASAQ were only available for about 50% of visit days in both intervention and comparison facilities but, as described above, this was not evenly distributed between all facilities, in particular for those located in the intervention LGA. Problems with RDT stock-outs were also recorded for facilities in both LGAs with 24% and 46% of facilities in intervention and comparison LGAs respectively reporting stock outs of RDTs at every visit day. On average, over all visit days, RDTs were available during 67% of visit days in facilities from the intervention LGA, and during 42% of visits in facilities from the comparison LGA (p = 0.136) (Table 4).

A higher proportion of febrile under-fives were tested with an RDT in facilities from the intervention LGA (56% vs. 36%), but these differences and the effect of the intervention on RDT testing were not statistically significant (adjusted odds ratio (AOR) = 1.41; 95% confidence interval (CI) 0.30, 6.52) (Table 5). Appropriate management of RDT-positive under-fives was high in both areas, with 85% and 90% of RDT-positive under-fives receiving AL or ASAQ in comparison and intervention LGAs, respectively. Multivariate models indicate no difference between the areas (AOR = 1.91; 95% CI 0.36, 10.04) (Table 5).

Appropriate management of RDT-negative under-fives was also high in both areas. In total 96% and 89% of RDT-negative under-fives did not receive AL or ASAQ in comparison and intervention LGAs, respectively, and no effect of the intervention on this outcome was detected (AOR = 0.68; 95% CI 0.11, 4.36). However, Fig. 1 shows that, in the intervention LGA, of the 66 RDT-negative under-fives who did not receive the first-line recommended ACTs, 23 (58%) received any anti-malarial, in comparison to 3/67 (4%) in the comparison LGA. When appropriate management of RDT-negative under-fives was defined by those who did not receive any anti-malarial, prevalence of appropriate treatment was 37% in the intervention LGA and 93% in comparison areas. On adjustment for a priori confounders, the odds of appropriate management of RDT-negative under-fives who did not receive any anti-malarial were substantially lower among those children treated at intervention health facilities (AOR 0.12; 95% CI 0.02, 0.77) (Table 5).

In both areas, a small number of RDT-positives (15 in intervention LGA and 7 in comparison LGA) were not given AL or ASAQ, and Fig. 1 shows that these children were given another anti-malarial, frequently artesunate monotherapy or chloroquine. Overall 10% (95% CI 3.8–25.7%) of febrile under-fives in intervention facilities, and 14% (95% CI 5.1–33.5%) in comparison facilities were prescribed artesunate as monotherapy (p = 0.632). Among RDT-positives in both the intervention and comparison facilities, 10% were prescribed artesunate as monotherapy (p = 0.981). However, among RDT-negatives, no under-fives were prescribed artesunate as monotherapy.