Safety, Quality, and Acceptability of Contraceptive Subdermal Implant Provision by Community Health Extension Workers Versus Nurses and Midwives in Nigeria: Protocol for a Quasi-Experimental, Noninferiority Study.

BACKGROUND: As part of its Family Planning 2020 commitment, the Nigerian government is aiming for a contraceptive prevalence rate of 36% by 2018, and in 2014, approved a policy to allow community health extension workers (CHEWs), in addition to doctors, nurses, and midwives, to provide contraceptive subdermal implants. There is a lack of rigorous evidence on the safety of long-acting reversible contraceptive provision, such as implants, among lower cadres of health providers. OBJECTIVE: This study aimed to compare implant provision by CHEWs versus nurses and midwives up to 14 days post insertion. METHODS: The quasi-experimental, noninferiority study will take place in public sector facilities in Kaduna and Ondo States. In each state, we will select 60 facilities, and from these, we will select a total of 30 nurses and midwives and 30 CHEWs to participate. Selected providers will be trained to provide implant services. Once trained, providers will recruit a minimum of 8125 women aged between 18 and 49 years who request and are eligible for an implant, following comprehensive family planning counseling. During implant insertion, providers will record data about the process and any adverse events, and 14 days post insertion, providers will ask 4410 clients about adverse events arising from the implant. Supervisors will observe 792 implant insertions to assess service provision quality and ask clients about their satisfaction with the procedure. We will conclude noninferiority if the CI for the difference in the proportion of adverse events between CHEWs and nurses and midwives on the day of insertion or 14 days post insertion lies to the right of -2%. RESULTS: In September and October 2015, we trained 60 CHEWs and a total of 60 nurses and midwives from 12 local government areas (LGAs) in Kaduna and 23 LGAs in Ondo. Recruitment took place between November 2015 and December 2016. Data analysis is being finalized, and results are expected in March 2018. CONCLUSIONS: The strength of this study is having a standard care (nurse and midwife provision) group with which CHEW provision can be compared. The intervention builds on existing training and supervision procedures, which increases the sustainability and scalability of CHEW implant provision. Important limitations include the lack of randomization due to nurses and midwives in Nigeria working in separate types of health care facilities compared with CHEWs, and that providers self-assess their own practices. It is unfeasible to observe all procedures independently, and observation may change practice. Although providers will be trained to conduct implant removals, the study time will be too short to reach the sample size required to make noninferiority comparisons for removals. TRIAL REGISTRATION: ClinicalTrials.gov NCT03088722; https://clinicaltrials.gov/ct2/show/NCT03088722 (Archived by WebCite at http://www.webcitation.org/6xIHImWvu)

Misuse of Artemisinin Combination Therapies by Clients of Medicine Retailers Suspected to Have Malaria Without Prior Parasitological Confirmation in Nigeria

Abstract Background: Prompt and effective case detection and treatment are vital components of the malaria case management strategy as malaria-endemic countries implement the testing, treating and tracking policy. The implementation of this policy in public and formal private sectors continue to receive great attention while the informal private retail sector (mostly the patent and propriety medicine vendors [PPMVs]) where about 60% of patients with fever in Nigeria seek treatment is yet to be fully integrated. The PPMVs sell artemisinin combination therapies (ACTs) without prior testing and are highly patronized. Without prior testing, malaria is likely to be over-treated. The need to expand access to diagnosis in the huge informal private health sector among PPMVs is currently being explored to ensure that clients that patronize retail drug stores are tested before sales of ACTs. Methods: A cross-sectional multistage study was conducted among 1279 adult clients, 20 years and above, who purchased malaria medicines from 119 selected PPMVs in five administrative areas (States) of Nigeria, namely: Adamawa, Cross River, Enugu, Lagos and Kaduna, as well as the Federal Capital Territory, Abuja. Exit interviews using a standard case report questionnaire was conducted after the purchase of the antimalarial medicine and thick/thin blood smears from the clients’ finger-prick were prepared to confirm malaria by expert microscopy. Results: Of the 1279 clients who purchased malaria medicines from the PPMV outlets, 107 (8.4%) were confirmed to have malaria parasites. The malaria prevalence in the various study areas ranged from 3.5% to 16%. A high proportion of clients in the various study sites who had no need for malaria medicines (84%-96.5%) purchased and used antimalarial medicines from the PPMVs. This indicated a high level of over-treatment and misuse of antimalarials. Common symptoms that are widely used as indicators for malaria such as, fever, headache, and tiredness were not significantly associated with malaria. Nausea/vomiting, poor appetite, chills, bitter taste in the mouth and dark urine were symptoms that were significantly associated with malaria among the adult clients (P<.05) but not fever (P=.06). Conclusion: Misuse of ACTs following overtreatment of malaria based on clinical diagnosis occurs when suspected cases of malaria are not prior confirmed with a test. Non-testing before sales of malaria medicines by PPMVs will perpetuate ACT misuse with the patients not benefiting due to poor treatment outcomes, waste of medicines and financial loss from out-of-pocket payment for unneeded medicines

Evidence from epidemic appraisals in Nigeria

Although HIV prevalence has increased in most-at-risk populations (MARPs) across Nigeria, effective programming was difficult because Nigeria lacked information for prevention programmes to target interventions that maximise coverage and cost effectiveness. Epidemic appraisals (EA) were conducted in eight states to provide evidence for the planning, implementation and co-ordination of prevention interventions. Component 1: Mapping determined the size, typology and locations of MARPs. Component 2: Venue profiling identified and profiled venues where general populations engaged in high-risk behaviours. Component 3: Rural appraisals provided insights into risk behaviours and sexual networking in villages. States used mapping results to prioritise areas with a MARP coverage of 70% – 80% and then scale up interventions for non-brothel-based female sex workers (FSWs) instead of focusing on brothel-based FSWs. The eight states prioritisedf unding for the high-coverage areas to ensure a minimum coverage level of 70% – 80% of MARPs was reached. The refocused resources led to cost efficiencies. Applying venue profiling results, six states implemented interventions at bars and night clubs – previously not covered. States also maximised intervention coverage for high-risk general populations; this led to the use of resources for general population interventions in a focused way rather than across an entire state. States focused on condom programmes in rural areas. EA results provided the evidence for focusing interventions for high MARP coverage as well as forhigh-risk general populations. The states applied the results and rapidly refocused their interventions, increasing the likelihood of having an impact on HIV transmission in those states. Nigeria is now implementing EAs in the remaining 29 states to effect national-level impact

Does Pre-Survey Training Impact Knowledge of Survey Administrators and Survey Outcomes in Developing Countries? Evaluation Findings of a Training of Trainers Workshop for National AIDS and Reproductive Health Survey-Plus in Nigeria

Background: Although, Nigeria had conducted various national surveys followed by central and state level trainings for survey administrators, prior pre-survey trainings have not been systematically evaluated to assess their impact on knowledge gain and final outcome of the survey. A central training of trainers’ session was organized for master trainers on the conduct of the 2012 National AIDS and Reproductive Health Survey. Objectives: To evaluate the impact of training on the quality of conduct of a national research survey in the 36 states and the Federal Capital Territory in Nigeria. Method: A total of 185 participants consisting of State AIDS Program Coordinators, Reproductive Health Coordinators, State Laboratory Scientists, Lead Supervisors and Counselor Testers were invited from the 36 states in Nigeria and the FCT for the central training of trainers in Abuja. The training lasted 5 days and the trainees were grouped into two on the basis of behavioral epidemiology and laboratory components. Training tools such as the developed protocol, training power point slides, practical sessions such as role plays, and usage of HIV rapid test kits were utilized during the training. The facilitators were drawn from Federal Ministry of Health (FMoH), universities and research Institutions as well as Non-Governmental Organizations (NGOs). The facilitators prepared and administered 25 structured questions for the behavioral group and 28 questions for the laboratory group at the beginning of the training to assess the participants’ knowledge of HIV and the survey. The same questions answered by Trainees responded to the same questions prior to the commencement and at the end of the trainings. Scores were aggregated to 100 for each test. We conducted paired t-test to determine statistically significant differences between pre-test and post-test results at 0.05 significance level and ANOVA to determine if there were differences in knowledge level among different groups. Result: The overall mean pre-test and post-test scores were 64.0% and 77.4% respectively indicating a 13.4% knowledge gain above what it was at the beginning of the training. The mean pre-test score and post-test score for the Southern states (SN) were 64.7% and 80.3% while that of the Northern states (NN) were 63.5% and 75.3% representing a knowledge gain of 15.6% and 11.8% respectively. There was statistical significant difference in the post-test scores between the two regions (p=0.001) and in knowledge gained after the training (p=0.017). Conclusions and Public Health Implications: Comparison between the pre test and post test scores at the 5-day training showed a significant gain in knowledge of participants. The survey training contributed positively to the preparation and building of knowledge needed for the conduct of 2012 NARHS-plus

Does Pre-Survey Training Impact Knowledge of Survey Administrators and Survey Outcomes in Developing Countries? Evaluation Findings of a Training of Trainers Workshop for National AIDS and Reproductive Health Survey-Plus in Nigeria

Background: Although, Nigeria had conducted various national surveys followed by central and state level trainings for survey administrators, prior pre-survey trainings have not been systematically evaluated to assess their impact on knowledge gain and final outcome of the survey. A central training of trainers’ session was organized for master trainers on the conduct of the 2012 National AIDS and Reproductive Health Survey. Objectives: To evaluate the impact of training on the quality of conduct of a national research survey in the 36 states and the Federal Capital Territory in Nigeria. Method: A total of 185 participants consisting of State AIDS Program Coordinators, Reproductive Health Coordinators, State Laboratory Scientists, Lead Supervisors and Counselor Testers were invited from the 36 states in Nigeria and the FCT for the central training of trainers in Abuja. The training lasted 5 days and the trainees were grouped into two on the basis of behavioral epidemiology and laboratory components. Training tools such as the developed protocol, training power point slides, practical sessions such as role plays, and usage of HIV rapid test kits were utilized during the training. The facilitators were drawn from Federal Ministry of Health (FMoH), universities and research Institutions as well as Non-Governmental Organizations (NGOs). The facilitators prepared and administered 25 structured questions for the behavioral group and 28 questions for the laboratory group at the beginning of the training to assess the participants’ knowledge of HIV and the survey. The same questions answered by Trainees responded to the same questions prior to the commencement and at the end of the trainings. Scores were aggregated to 100 for each test. We conducted paired t-test to determine statistically significant differences between pre-test and post-test results at 0.05 significance level and ANOVA to determine if there were differences in knowledge level among different groups. Result: The overall mean pre-test and post-test scores were 64.0% and 77.4% respectively indicating a 13.4% knowledge gain above what it was at the beginning of the training. The mean pre-test score and post-test score for the Southern states (SN) were 64.7% and 80.3% while that of the Northern states (NN) were 63.5% and 75.3% representing a knowledge gain of 15.6% and 11.8% respectively. There was statistical significant difference in the post-test scores between the two regions (p=0.001) and in knowledge gained after the training (p=0.017). Conclusions and Public Health Implications: Comparison between the pre test and post test scores at the 5-day training showed a significant gain in knowledge of participants. The survey training contributed positively to the preparation and building of knowledge needed for the conduct of 2012 NARHS-plus. Keywords: Training • Survey • NARHS-Plus • State AIDS Program Coordinators • Reproductive Health Coordinators • State Laboratory Scientists • Lead Supervisors and Counselor Testers • Abuja • Nigeria Copyright © 2013 Oyedeji et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited