Background: Nigeria has one of the highest child mortality rates in the world, with an estimated 750,000 deaths annually among children under age five. The majority of these deaths are due to pneumonia, malaria, or diarrhea. Many parents do not seek sick-child care from trained, biomedical providers, contributing to this high rate of mortality. Methods: This qualitative study explores factors enabling or preventing parents from seeking care for sick underfive children in Nigeria's Kogi and Ebonyi states, including gender-related roles and social norms. Interviews were conducted with parents of sick under-five children and service providers, and focus group discussions were held with community leaders to assess how care-seeking behavior was influenced by four modes from the Colvin et al. conceptual framework for household decision-making and pathways to care. These include (1) caregivers' recognition and response to illness, (2) seeking advice and negotiating access within the family, (3) making use of community-based treatment options, and (4) accessing biomedical services. Results: Parents were found to have a general understanding of illness symptoms but did not always attribute illness to biomedical causes. Intra-household decision-making processes were shaped by gender dynamics between men and women, and were found to have great effects on decisions to seek care. Use of traditional medicine and self-treatment were found to be common first steps in treatment before turning to the biomedical care system. Once the decision to seek biomedical care was taken, the route of seeking care varied between seeking care at chemists and then continuing to health facilities or starting with a health facility and then accessing prescriptions from a chemist. Conclusion: We conclude that care-seeking decisions do not follow a linear process; that intra-household decisionmaking processes particularly among parents should not be underestimated in addressing sick-child care seeking; and that, given the role of mothers as primary caregivers, their knowledge in illness recognition and agency in careseeking decision-making, and seeking biomedical care, is deserving of future study.

Background: The aim of this study was to compare health workers knowledge and skills competencies between those trained using the onsite simulation-based, low-dose, high frequency training plus mobile mentoring (LDHF/ m-mentoring) and the ones trained through traditional offsite, group-based training (TRAD) approach in Kogi and Ebonyi states, Nigeria, over a 12-month period. Methods: A prospective cluster randomized controlled trial was conducted by enrolling 299 health workers who provided healthcare to mothers and their babies on the day of birth in 60 health facilities in Kogi and Ebonyi states. These were randomized to either LDHF/m-mentoring (intervention, n = 30 facilities) or traditional group-based training (control, n = 30 facilities) control arm. They received Basic Emergency Obstetrics and Newborn Care (BEmONC) training with simulated practice using anatomic models and role-plays. The control arm was trained offsite while the intervention arm was trained onsite where they worked. Mentorship was done through telephone calls and reminder text messages. The multiple choice questions (MCQs) and objective structured clinical examinations (OSCEs) mean scores were compared; p-value < 0.05 was considered statistically significant. Qualitative data were also collected and content analysis was conducted.

Background This paper provides insights into design and implementation of a Conditional Cash Transfer (CCT) pilot programme under the Subsidy Reinvestment and Empowerment Programme on Maternal and Child Health (SURE-P MCH) in Nigeria. The CCT day to day operations were independently assessed, from design to enrollment and pay out, in order to inform future CCT designs and implementation. Methods This study combined a desk review of SURE-P MCH CCT operational documents and retrospective, descriptive cross-sectional survey of 314 primary beneficiaries of the CCT scheme from 29 SURE-P MCH CCT designated health facilities between June – July 2015. The programme implementation manual (PIM) and several CCT monthly reports and articles obtained from the project implementation unit (PIU) were reviewed while structured questionnaire of (16) questions was used for face-to-face interviews with (30–33) CCT beneficiaries drawn from each of eight (8) participating states of Anambra, Bauchi, Bayelsa, Ebonyi, Kaduna, Niger, Ogun, and Zamfara and the Federal Capital Territory (FCT)-Abuja. Findings were analyzed and reported using R* statistical package (version 3.1.2). Subsequently a strengths, weaknesses, opportunities and threats (SWOT) analysis was conducted to identify key challenges and possible recommendations. Results The SWOT analysis indicated a robust design for the CCT programme, which would have enhanced operational effectiveness if implemented as designed. However, the programme faced several implementation challenges. For instance, though 65% of beneficiaries perceived CCT pay-out events to be orderly and well-organized, in some of the pilot states the events were marred with inconsistencies resulting in large crowds and increased waiting time for some beneficiaries. Similarly, only 40% of beneficiaries received the complete N5,000 (USD30) cash incentive, 28% received N1,000 (USD6) while others received either N2000 (USD12), N3000 (USD18) or N4000 (USD24). Conclusion The CCT pilot had a robust design as a result of a successful proof of concept which preceded the pilot roll-out. However, its implementation was marred with several challenges ranging from untimely release of funds, limited monitoring and evaluation and other operational challenges. Future CCT programmes should understudy the SWOT analysis presented in this paper to improve the design and implementation of CCT programmes in Nigeria and other settings.

Background Poor reproductive, maternal, newborn, child, and adolescent health outcomes in Nigeria can be attributed to several factors, not limited to low health service coverage, a lack of quality care, and gender inequity. Providers’ gender-discriminatory attitudes, and men’s limited positive involvement correlate with poor utilization and quality of services. We conducted a study at the beginning of a large family planning (FP) and maternal, newborn, child, and adolescent health program in Kogi and Ebonyi States of Nigeria to assess whether or not gender plays a role in access to, use of, and delivery of health services. Methods We conducted a cross-sectional, observational, baseline quality of care assessment from April–July 2016 to inform a maternal and newborn health project in health facilities in Ebonyi and Kogi States. We observed 435 antenatal care consultations and 47 births, and interviewed 138 providers about their knowledge, training, experiences, working conditions, gender-sensitive and respectful care, and workplace gender dynamics. The United States Agency for International Development’s Gender Analysis Framework was used to analyze findings. Results Sixty percent of providers disagreed that a woman could choose a family planning method without a male partner’s involvement, and 23.2% of providers disagreed that unmarried clients should use family planning. Ninety-eight percent believed men should participate in health services, yet only 10% encouraged women to bring their partners. Harmful practices were observed in 59.6% of deliveries and disrespectful or abusive practices were observed in 34.0%. No providers offered clients information, services, or referrals for gender-based violence. Sixty-seven percent reported observing or hearing of an incident of violence against clients, and 7.9% of providers experienced violence in the workplace themselves. Over 78% of providers received no training on gender, gender-based violence, or human rights in the past 3 years. Conclusion Addressing gender inequalities that limit women’s access, choice, agency, and autonomy in health services as a quality of care issue is critical to reducing poor health outcomes in Nigeria. Inherent gender discrimination in health service delivery reinforces the critical need for gender analysis, gender responsive approaches, values clarification, and capacity building for service providers.

Background Nigeria has one of the highest child mortality rates in the world, with an estimated 750,000 deaths annually among children under age five. The majority of these deaths are due to pneumonia, malaria, or diarrhea. Many parents do not seek sick-child care from trained, biomedical providers, contributing to this high rate of mortality. Methods This qualitative study explores factors enabling or preventing parents from seeking care for sick under-five children in Nigeria’s Kogi and Ebonyi states, including gender-related roles and social norms. Interviews were conducted with parents of sick under-five children and service providers, and focus group discussions were held with community leaders to assess how care-seeking behavior was influenced by four modes from the Colvin et al conceptual framework for household decision-making and pathways to care. These include (1) caregivers’ recognition and response to illness, (2) seeking advice and negotiating access within the family, (3) making use of community-based treatment options, and (4) accessing biomedical services. Results Parents were found to have a general understanding of illness symptoms but did not always attribute illness to biomedical causes. Intra-household decision-making processes were shaped by gender dynamics between men and women, and were found to have great effects on decisions to seek care. Use of traditional medicine and self-treatment were found to be common first steps in treatment before turning to the biomedical care system. Once the decision to seek biomedical care was taken, the route of seeking care varied between seeking care at chemists and then continuing to health facilities or starting with a health facility and then accessing prescriptions from a chemist. Conclusion We conclude that care-seeking decisions do not follow a linear process; that intra-household decision-making processes particularly among parents should not be underestimated in addressing sick-child care seeking; and that, given the role of mothers as primary caregivers, their knowledge in illness recognition and agency in care-seeking decision-making, and seeking biomedical care, is deserving of future study.