Background Described as the ‘backbone of health systems’, particularly in low- and middle-income countries, community health workers (CHWs) are a critical cadre on the frontline of any outbreak response. However, it is widely recognised that CHWs are frequently lacking in appropriate support from the health system due to inadequate physical, social and financial resources. Furthermore, despite their critical role in service delivery, the health and well-being of CHWs is seldom considered and the additional emotional and physical burdens that health systems shocks can present are frequently ignored. Thus a critical step in strengthening health systems to manage disease outbreaks or other system shocks is to ensure that CHWs are adequately supported. Within this study we document the experiences of CHWs within Nigeria during the coronavirus disease 2019 (COVID-19) outbreak to understand the impact of the pandemic on CHW well-being with a view to identifying strategies that could support CHWs during COVID-19 and subsequent health system shocks. Methods This study was based in Ogun, Kaduna and Kwara States, Nigeria. We used the creative participatory methodology of photovoice with 30 CHWs (10 in each state). Participants were asked to take photos documenting their experiences of working and living through the pandemic. Participants sent photos with captions to the research team via WhatsApp following one-on-one discussions. Photos were co-analysed among participants in focus group discussions using thematic analysis. Results Our findings reveal similar experiences of CHWs across Ogun, Kwara and Kaduna States in Nigeria, providing a unique insight into how the Nigerian health system was impacted and how this closely aligns to the performance and well-being of CHWs. CHW experiences related to three overarching themes: major stressors and challenges experienced due to COVID-19 (fear of contracting COVID-19, food insecurity, personal and gendered impacts), the impact of COVID-19 on providing routine care (stigma from community members, heavy workloads and inadequate equipment provision) and motivation and support from the community (pride in their roles and valued support from community leaders). The challenges highlighted through photovoice led to developing recommendations to address some of the challenges. This included training, adequate resource provision, routine supervision and peer support. Conclusions COVID-19 highlighted the burden health workers often face. Photovoice allowed a space for frontline health workers to come together to share common experiences, particularly the psychosocial impact of working during health system shocks and its impact on performance. This underlines the need to acknowledge mental health and prioritise the well-being of healthcare staff. Sharing stories from the perspectives of health workers provides a platform to share learning and strategies on how to best support health workers holistically, particularly during health system shocks.

Background The overall burden of neglected tropical diseases (NTDs) affecting the skin is undetermined. Skin conditions are among the top 10 causes of disability worldwide. Affected persons seek treatment at advanced stages of the disease, resulting in morbidity and disability. We developed and evaluated an integrated training intervention for early case detection, referral and management of skin NTDs in two states in Nigeria. Methods This was a mixed-methods study using participatory approaches to develop specific skin algorithms and training packages for community and primary level health workers. This supported the identification, referral and clinical diagnosis of suspected cases. We used Kirkpatrick's model to evaluate the training package. Results Participants’ knowledge improved after the 2-months intervention. Across both states, knowledge retention appeared more robust for cadres at all levels: state, local government area and primary healthcare. All (100%) participants mentioned that the training assisted them in detecting, referring and managing skin NTDs. Training was understood by participants and training materials were easy to understand. Materials were also effective in educating community members about the symptoms of NTDs and supported referral to facilities for appropriate management. Conclusions Community implementers can be trained and supervised to detect people affected by skin NTDs and support appropriate management within the existing patient care pathway.