Exploring barriers to guideline implementation for prescription of surgical antibiotic prophylaxis in Nigeria.

Background: In Nigeria, the prescription of surgical antibiotic prophylaxis for prevention of surgical site infection tends to be driven by local policy rather than by published guidelines (e.g. WHO and Sanford). Objectives: To triangulate three datasets and understand key barriers to implementation using a behavioural science framework. Methods: Surgeons (N = 94) from three teaching hospitals in Nigeria participated in an online survey and in focus group discussions about barriers to implementation. The theoretical domains framework (TDF) was used to structure question items and interview schedules. A subgroup (N = 20) piloted a gamified decision support app over the course of 6 months and reported barriers at the point of care. Results: Knowledge of guidelines and intention to implement them in practice was high. Key barriers to implementation were related to environmental context and resources and concern over potential consequences of implementing recommendations within the Nigerian context applicable for similar settings in low-to-middle-income countries. Conclusions: The environmental context and limited resource setting of Nigerian hospitals currently presents a significant barrier to implementation of WHO and Sanford guidelines. Research and data collected from the local context must directly inform the writing of future international guidelines to increase rates of implementation

Using community theater to improve demand for vaccination services in the Niger Delta Region of Nigeria

Abstract Introduction Despite abundant evidence showing immunization as a lifesaving public health measure, a large proportion of Nigerian children are still not or fully vaccinated. Lack of awareness and distrust of the immunization process by caregivers are some of the reasons for poor immunization coverage which need to be addressed. This study aimed at improving vaccination demand, acceptance and uptake in Bayelsa and Rivers State, both in the Niger Delta Region (NDR) of Nigeria through a human-centered process of trust building, education and social support. Methods A quasi-experimental intervention christened Community Theater for Immunization (CT4I) was deployed in 18 selected communities between November 2019 and May 2021 in the two states. In the intervention localities, relevant stakeholders including the leadership of the health system, community leaders, health workers and community members were engaged and actively involved in the design and performance of the theaters. The content for the theater showcased real stories, using a human-centered design (HCD) of ideation, co-creation, rapid prototyping, feedback collection and iteration. Pre- and post-intervention data on the demand and utilization of vaccination services were collected using a mixed method. Results In the two states, 56 immunization managers and 59 traditional and religious leaders were engaged. Four broad themes implicating user and provider factors emerged from the 18 focus group discussions as responsible for low immunization uptake in the communities. Of the 217 caregivers trained on routine immunization and theater performances, 72% demonstrated a knowledge increase at the post-test. A total of 29 performances attended by 2,258 women were staged with 84.2% of the attendees feeling satisfied. At the performances, 270 children received vaccine shots (23% were zero-dose). There was a 38% increase in the proportion of fully immunized children in the communities and 9% decline in the proportion of zero-dose children from baseline. Conclusion Both demand- and supply-side factors were identified as responsible for poor vaccination in the intervention communities. Our intervention demonstrates that caregivers will demand immunization services if they are engaged through community theater using a human-centered design (HCD). We recommend a scaling up of HCD to address the challenge of vaccine hesitancy

Gamified antimicrobial decision support app (GADSA) changes antibiotics prescription behaviour in surgeons in Nigeria: a hospital-based pilot study

Abstract Aims Surgical Antibiotic Prophylaxis (SAP) in Nigeria is often not evidence based. The aim of this study is to test if the GADSA application can change prescription behaviour of surgeons in Nigeria. In addition, the study aims to identify AMS strategies and policies for the future. Methods The GADSA gamified decision support app uses WHO and Sanford prescribing guidelines to deliver real-time persuasive technology feedback to surgeons through an interactive mentor. The app can advise on whether clinician’s decisions align with SAP recommendations and provides the opportunity for clinicians to make adjustments. Twenty surgeons actively participated in a 6-month pilot study in three hospitals in Nigeria. The surgeons determined the risk of infection of a surgical procedure, and the need, type and duration of SAP. The study used a longitudinal approach to test whether the GADSA app significantly changed prescribing behaviour of participating surgeons by analysing the reported prescription decisions within the app. Results 321 SAP prescriptions were recorded. Concerning the surgical risk decision, 12% of surgeons changed their decision to be in line with guidelines after app feedback (p < 0.001) and 10% of surgeons changed their decision about the need for SAP (p = 0.0035) to align with guidelines. The change in decision making for SAP use in terms of “type” and “duration” to align with guidelines was similar with 6% and 5% respectively (both p-values < 0.001). Conclusion This study suggests that the GADSA app, with its game based and feedback feature, could significantly change prescribing behaviour at the point of care in an African setting, which could help tackle the global challenge of antibiotic resistance