Background
Methods
Study setting
Study objectives
Study design and participants
Scope of enquiry
Thematic parameter | Questions to be answered from formative research |
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Health system context | What is the functionality and perceived quality of health care at the health facility level, specifically for the management of malaria? |
What is the scope of health services offered and perceived quality of care at the community level for the management of malaria, including referral? | |
How functional are the links between the community and health facility levels and how does this affect quality of care? | |
How could access to quality malaria treatment at the community level be improved, including for referred patients? | |
What is the existing precedence for financial or other support to CCGs? | |
What is the capacity for and existing level and quality of reporting by CCGs? Do they see reporting as important? | |
Socio-cultural context | What is the level of knowledge, range of attitudes and care-seeking patterns in the community with regards to malaria prevention and treatment? What are these affected by? |
What is the relationship between the CCGs and the community, including levels of support to and trust in CCGs? | |
What written and spoken languages are best understood? What are literacy levels like and how could this affect the development of communication materials or the feasibility of caretakers of children under five to keep simple diaries on fever cases and adverse events? | |
What information and communication channels could best support promotion and uptake? | |
How do community leaders or other figures influence health related behaviours? How could the project best collaborate with them in order to raise acceptability and uptake? | |
Are there other ways in which community support could be garnered? | |
SMC delivery approach | How feasible, acceptable and effective could different drug delivery methods be i.e. health facility, community fixed-point, or a household-to-household? What challenges could be anticipated and how could these be addressed? |
Data collection
Target group | Interviews conducted | Sampling |
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Katsina State Government | 4 IDIs | All personnel with key roles in malaria control delivery |
LGA leadership | 4 IDIs, I FGD | At least 1 representative from each LGA |
LGA primary health care and malaria focal staff | 5 IDIs | At least 1 representative from each LGA |
UN agencies, active international and local NGOs | 5 IDIs | All representatives with key roles in malaria control delivery |
Health facility representatives (committee chairpersons of HFMCs) or health facility in-charges | 8 IDIs | 2 representatives per LGA, from both primary and secondary levels |
Traditional and religious community leaders | 6 IDIs | Including both traditional and religious leaders. 2 informants per LGA were originally targeted. Specific wards were selected at random |
Village Health Committees (VHCs) | 2 IDIs, 5 FGDs | 2 villages were selected at random within the ward selected at random (same ward as for community leadership IDIs). All members of the VHC invited to participate |
CCGs | 2 IDIs, 3 FGDs | All CCGs in each LGA were invited to participate but selected at random if a large number. A target of 1 FGD/LGA. IDI if only 1 participant |
Health-orientated CBOs | 2 FGDs | All representatives with key roles in supporting community-level health interventions |
Household heads (male participants) | 3 FGDs | 2 villages were selected at random within the ward selected at random (same villages selected as for VHCs). Specific households were selected at random via the random walk method, with the interval selected dependent on village size. Original target of 2 FGDs/LGA |
Caregivers of children under five (female participants) | 4 FGDs | 2 villages were selected at random within the ward selected at random (same villages selected as for VHCs). Specific households were selected at random via the random walk method, with the interval selected dependent on village size. Original target of 2 FGDs/LGA |
Total | 36 IDIs, 18 FGDs (54) |
Data analysis
Intervention design process
Ethical considerations
Results
Study participants
FR findings
Health system context
Perceived quality of care
Because the government doesn’t provide the drugs, drugs are being purchased by the healthcare facility staff and sold to patients. If he (facility staff) has a patient, he will not care to refer him because he wants money he and does not like to release the patient. (State level respondent, IDI)
[The community] feel very happy for the service by us because they are even coming to our houses [to] collect medicine. Even when we go to their houses, they are very friendly and nice to us. (CCG, FGD, Mai’Adua)
The quality of care at the community level depends on their capacity. I think it is just satisfactory. (State level respondent, IDI)
Linkage with the health system
[The community health volunteers], they bring out the report, sometimes they do not and we used to tell them to be submitting reports. (Health facility in-charge, IDI Mai Adu’a)
They only supervise us as when they give us drugs—that is what it is about. (CCG, FGD, Baure)
There is very poor quality in referring. The system lacks proper and clear documentation across the board. [There is a need] to provide referral forms because they normally use exercise books which don’t provide feedback to either side within the referral system. (LGA leadership, IDI, Mai’Adua)
They can be saying why the incentive and they can begin to suspect. They may say ‘most likely now they have not succeeded with polio, now they want to start with malaria again’ and you may even find people sending message that ‘it contains this and that is why it is being given free of charge to the people’. The most important thing is that to educate the people let them understand, this malaria is there and everybody has experienced it. (State level respondent, IDI)
Socio-cultural context
Health-seeking behaviour
Interviewer: Like in this town, whom do you trust much and listen to?Caregiver 1: My husband.Caregiver2: District head.I: Why is this?C2: Because district heads are together with our husbands.C1: He is the one to grant the permission on everything. (Caregivers, FGD, Mai Adu’a)
Yes, we know the [nomadic] population here is about 1600 people. We have about ten settlements. Generally malaria affects nomadic population because they are living near the small ponds where they give their animals drinks. They access health care through mobile and outreach activities. (Health facility worker, IDI, Baure)
Mobilization and community support
You know, it is our tradition here that our people do not disrespect their leaders, and they are living in peace, that is why it is very difficult for them to disobey them, especially when they give them certain information about something…Honestly, they trust their leaders right from district head, village and ward heads. (Community leader, IDI, Baure)
The masses always believe in their traditional and religious institutions, because they are the ones that are always closer to the people and they know their problems and most people do solve their financial and social problems from their advice. (VHC, FGD, Mashi)
The majority of people listen to radio so it is important especially—the FM and state radio, it is good, a lot of jingles, a lot of message should be passed through these media houses and secondly, there is need when you see the community leaders, they should call their own village heads to have meeting so that they can disseminate information given to them, down to the grassroots. (State level respondent, IDI)
Support for the intervention
Malaria is a serious sickness, distorting the smooth running of our lives, and we are all sick and tired at the same time looking for a solution. (Household head, FGD, Dutsi)
The community leaders, policy makers should be involved—do you know why? This polio has spoiled everything, so any programme you have, people will suspect it.”(State level respondent, IDI)
Some people will think that it is just business as usual due to their previous experience of unfulfilled promises with other organizations. (VHC, FGD, Mai Adu’a)
So, we can encourage the community through telling them the importance of this project. They need to understand. You see, they have to live in a very good environment, no stagnant water, no refuse dumping, using the net. They need to understand all the ways of keeping malaria down. (LGA leadership, IDI, Mai’Adua)
SMC delivery approach
House to work will work because the one we are doing now is house to house. It is better. We will enlighten women that this medicine is very useful to them. (CCG, FGD Mai’Adua)
For me, it is house to house approach, because it has been tested and trusted during fighting for polio campaign. The secret here is that some view it that, if they go to the hospital, they have to buy this and that, so they may likely not go. (CBO, FGD, Dutsi)
They may think it is something else, just like the case of polio… So I will not suggest house to house unless [it is] with very good promotion. (State level respondent, IDI)
[Health facility staff] have the information on what the drugs are for; they will be able to dispense it out to the patients adequately. They will be able to monitor any problems that may arise as a result of dispensing the drug. (State level respondent, IDI)
When drugs are made available, hand them over to the head of personnel in the hospital, after which people should be made aware of the availability of the drugs in question. People should be told on the days and times they are supposed to be coming for such drugs. It is important they get used to going to the facilities. (VHC, FGD, Mashi)
I think from the experience two-way will help, one by delivering these drugs to the facilities, like in Dutsi LGA where they have quite a number of facilities that are closer and can take care of the communities. Secondly, where communities are far from the facilities, you make outreach, or select an area and a village head and supply them. (LGA leadership, IDI, Dutsi)
They have to go to CCGs and what is important is to make the community aware and sensitize them that something is coming and it is for their own good. So, if everybody is aware about the introduction of supply, the CCG will work it 100 %, free-minded inside the community. (LGA leadership, IDI, Baure)
You cannot work without the facilities at community level but, if I will advise, you have to use the traditional leader to monitor the facilities, for example, if you have drugs to be distributed for a given community, so that drugs should be channel through the facility because it is drugs and people know that anything that has to do with drugs is from the facilities they will value it most. Then use the community leaders to put an eye on what the facilities are doing…to ensure that what is meant for the community has really gotten to them. (NGO informant, IDI)
Involving the community will be one of the most important steps. The malaria control programme also has staff at [the] LGA and state level—they definitely need to be involved because they know the terrain, they know the people in the communities. They have different sources of advocacy groups. The community and the facilities all have development committees—I think it is a nice idea to strengthen those committees. (State level respondent, IDI)
Supportive factors | Potential challenges |
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Malaria is seen as a community priority | Role of CCGs and scope of services offered unclear across community and health facility levels |
Communities have a good understanding of the signs and symptoms of malaria, ways of preventing malaria, and the biological groups most at risk | A range in skills and experience in the management of malaria among CCGs |
Wide support for a community level distribution of drugs | Health facility staff perceive CCGs to provide low quality of care |
Community level support for and trust in CCGs | Weak referral linkage between community and health facility levels |
Close proximity of CCGs to beneficiaries which could enable high intervention coverage and facilitate effective follow-up and monitoring of adverse events | Community referral action potentially hindered by perception of inadequate skills among health facility staff, inconsistent ACT supply and potential cost of transport and malaria treatment |
High levels of community acceptability of ACT | Differing opinions on the most effective distribution approach—fixed-point or household-to-household |
Supportive supervision system between health facility and CCGs established (though weak in some areas) | A lack of consensus over the suggested management of the intervention and potential roles of the health facility and community leadership |
High levels of trust in community traditional and religious leadership, and general consensus that they should play a pivotal role in mobilization for the programme | Low storage capacity at the community level |
Community leadership frequently involved in disseminating health information to their communities and so have basic health knowledge and local information dissemination systems are established | Potential security issues relating to the distribution of drugs at the community level |
Simple, visual communication materials written in local languages could be well accepted | Varying levels of capacity for effective reporting among CCGs |
Low levels of community literacy (particularly among women) which may inhibit understanding of any written guidance or communication materials as well as record keeping capacity | |
Potential suspicions of ‘outside’ interventions, exacerbated by negative associations with the polio campaign |