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Background: Experience of seasonal malaria chemoprevention (SMC) is growing in the Sahel sub-region of Africa, though there remains insufficient evidence to recommend a standard deployment strategy. In 2012, a project was initiated in Katsina state, northern Nigeria, to design an appropriate and effective community-based delivery approach for SMC, in consultation with local stakeholders. Formative research (FR) was conducted locally to explore the potential feasibility and acceptability of SMC and to highlight information gaps and practical considerations to inform the intervention design. Methods: The FR adopted qualitative methods; 36 in-depth interviews and 18 focus group discussions were conducted across 13 target groups active across the health system and within the community. Analysis followed the ‘framework’ approach. The process for incorporating the FR results into the project design was iterative which was initiated by a week-long ‘intervention design’ workshop with relevant stakeholders. Results: The FR highlighted both supportive and hindering factors to be considered in the intervention design. Malaria control was identified as a community priority, the community health workers were a trusted resource and the local leadership exerted strong influence over household decisions. However, there were perceived challenges with quality of care at both community and health facility levels, referral linkage and supportive supervision were weak, literacy levels lower than anticipated and there was the potential for suspicion of ‘outside’ interventions. There was broad consensus across target groups that community-based SMC drug delivery would better enable a high coverage of beneficiaries and potentially garner wider community support. A mixed approach was recommended, including both community fixed-point and household-to-household SMC delivery. The FR findings were used to inform the overall distribution strategy, mechanisms for integration into the health system, capacity building and training approaches, supportive interventions to strengthen the health system, and the social mobilization strategy. Conclusions: Formative research played a valuable role in exploring local socio-cultural contexts and health system realities. Both opportunities and challenges for the introduction of SMC delivery were highlighted, which were appropriately considered in the design of the project.
Katsina, located in far northern Nigeria and bordering Niger to its north, has an estimated population of 6.5 million people (national census projections, 2015). As in other northern Nigerian states, malaria is endemic in Katsina with all year round transmission at levels below national averages, with a seasonal peak (60 % of annual malaria cases) between the months of August and November, coinciding with the raining season (unpublished health system data). Project implementation planned to target four of the 34 Local Government Areas (LGAs) within Katsina state; Baure, Dutsi, Mai Adu’a and Mashi. The LGAs have a collective population of 868,752 (national census projections, 2015) and are found on the northern fringe of the state where malaria prevalence is reportedly higher. In total, there are 1427 health facilities in the state, constituting primary health centres, maternal and child health centres, health clinics and dispensaries [23]. The population is largely engaged with subsistence farming, living predominantly in widely dispersed settlement clusters. Islam is the dominant religion in the area and Hausa and Fulani are the predominantly spoken languages. The aim of the FR was to explore the local socio-cultural and health system context and to highlight information gaps and practical considerations to inform the design of an effective SMC delivery approach, inclusive of supportive interventions. Specifically, the objectives were to explore; (1) existing services, including scope and perceived quality, available for managing malaria at the health facility and community level, to which the SMC intervention could be linked, (2) community level health-seeking behaviour patterns, related attitudes, beliefs and other influencing factors, (3) the feasibility of different SMC delivery approaches, including at health facility level, community fixed point, or household-to-household, and (4) any socio-cultural or health system related factors which could either support or hinder the delivery of SMC. The study was qualitative in design and involved a series of in-depth interviews (IDIs) and focus group discussions (FGDs) among 13 pre-identified target groups. All groups were considered active participants in project planning, delivery or evaluation, and/or were direct beneficiaries of the project, and together were expected to represent an optimum range of opinions and perspectives. At the state level, the groups included government policymakers, LGA management and health officials, and United Nations (UN) agencies or non-governmental organizations (NGOs) who were engaged in work of a relevant scope. Health facility representatives included either committee chairpersons of Health Facility Management Committees (HFMCs) or health facility in-charges. At the community level, targeted groups included community leaders, Village Health Committee (VHC) representatives, male household heads, mothers and female caregivers, health-orientated Community Based Organizations (CBOs), as well as ‘Community Caregivers’ (CCGs). As already discussed, a range of community health volunteers exist in Nigeria with varying names, including role model caregivers, community drug distributors and health mobilizers, depending on the scope of donor support and focus of public health interventions being delivered i.e. health promotion, malaria treatment for children, mass drug administration for neglected tropical diseases or immunization campaigns. During early discussions with the Katsina authorities, it was decided that the community members to be involved in supporting SMC delivery would be called ‘Community Caregivers’ so as to distinguish them from other community level health workers. Specific CCG participants in the FR were selected at random. Finally, nomadic groups were not specifically targeted for enquiry; according to Katsina state informants, approximately 1 % of the state population are expected to be nomadic, mostly arable farmers entering Katsina from other states or Niger during the rainy season and moving largely without their families (and thus children who could be targeted for SMC), or pastoral farmers largely moving in the dry season. However, opportunities and challenges for including nomadic populations within the SMC target population were discussed as part of the research. The scope of enquiry was developed through a landscape review of relevant published and grey literature and through discussion with experts, including project staff and Katsina state stakeholders. Linked to the FR objectives, three thematic parameters were identified against which specific research questions were developed (Table 1). Technical scope of enquiry Data was collected during March 2013, four months ahead of the first cycle of SMC delivery. IDIs or FGDs were selected as appropriate for each target group; informants were grouped together where it was considered this would likely enhance the quality of opinion provided across respondents, whilst not adversely influencing respondent candour. All interviews were semi-structured in nature and guided by pre-tested topic guides, ensuring a focus was retained on the pre-agreed scope of enquiry (specific questions as relevant for each target group) while enabling new and potentially unexpected perspectives or ideas to be raised. The sample size was set at between 50 and 60 IDIs/FGDs a priori, considered appropriate for enabling deep-case orientated enquiry across target groups whilst remaining manageable within the time and budget available. Sampling within target groups was largely purposive, with specific wards, village and households selected at random for target groups active at these levels (Table 2). At village level, the random walk approach was used given no updated household lists were available. Target groups, data collection and sampling The research team included two field teams of researchers with supervisors, one overall field investigator (MK) and two research advisors (EB, CS). The field level team was comprised of equal numbers of men and women, considered important in a patriarchal setting such as northern Nigeria to facilitate both access to households and the disclosure of personal views by women. All field level team members had prior experience in qualitative data collection in a rural Nigerian setting, possessed relevant language skills and were familiar with the specific socio-cultural setting. They all attended a four-day training workshop on the study aims, process and tools, based in Katsina. All interviews were conducted where possible in quiet places, where the likelihood of interruptions or overhearing was considered minimal. All participants in each FGD were comprised of one sex only so as to reduce inhibitions in the sharing of opinions. Interviews were conducted in English or Hausa depending on the target group. For those conducted in Hausa, the transcripts were written in Hausa and then translated into English, with regular spot checking on clarity and meaning by field supervisors for quality control. All interviews were conducted by two researchers, one conducting the interview and the other writing notes of key points raised for back-up. All interviews were audio-recorded and verbatim transcriptions were developed preferably the same or the following day in order to enhance data validity, and the consideration and capture of interview context, as well as to enable the point of data saturation to be more effectively determined whilst in the field. Thematic analysis followed the ‘framework’ approach [24] whereby a pre-existing coding frame was developed based on the scope of enquiry (deductive approach) to which codes were added on review of the data (inductive approach). All data were coded and indexed in Excel (Microsoft). The FR preliminary findings were presented at a one-week long ‘intervention design’ workshop held in Abuja during April 2013. Attendees included key representatives from the national level (political and health leadership and the National Malaria Elimination Programme) and state level (political leadership, malaria focal people, primary health coordinators, health educators and management staff), as well as key NGO and SMC project specific staff. The representation of key health system stakeholders was important for building a sense of local ownership and ensuring consistency with national policy and guidelines. Plenary discussions and group work were used to build consensus on key decisions and the next steps in the design process in four agreed technical areas; (1) design of delivery system (including case management and pharmacovigilance), (2) capacity building, (3) advocacy, communication and social mobilization, and (4) monitoring and evaluation. The process for incorporating the FR results into the project design was iterative in that further questions arose both during and after the workshop, with further clarifications sought from the detailed findings once analysis was complete or through discussion with key stakeholders. The Katsina State Health Research Committee granted ethical clearance for the study in March 2013 (linked to system by date: letter dated 5 March 2013). Informed oral consent was acquired from all IDI and FGD participants. The consent form included information on the broad aims of the study, confidentiality, respondent rights and uses of the data, and was translated into Hausa. No interviewees refused to participate in the study. Participant identifiers were removed from documentation at the interpretation stage of the data analysis.
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