Facilitators and Barriers to SMC Uptake in Nigeria: A Qualitative Approach

Abstract

Nigeria adopted Seasonal Malaria Chemoprevention (SMC) for children under 5 years of age as part of national malaria control policies, in 2014. By 2021 the intervention was being implemented in 18 states, delivered over 4 months between June and October by 143,000 community drug distributors (CDDs) to a target population of 23.1million children. Further expansion of SMC is planned, extending to 21 states in 2022 with a target population of 27.1 million children, and an increased number of monthly cycles, from 4 to 5, may be needed in some states. In view of this massive scale-up of SMC, the National Malaria Elimination Programme conducted a qualitative research study shortly after the 2021 campaign to understand community attitudes to SMC, and to identify barriers to uptake and facilitating factors, in order to ensure that community perspectives inform future planning of SMC delivery in Nigeria. In each of five states (Kano, Kwara, Nasarawa, Yobe and Kebbi), Local Government Areas (LGAs) were ranked based on administrative coverage of SMC in 2021, and one LGA with high coverage and one with low coverage selected. In two wards (one urban and one rural) in each LGA, focus group discussions (FGDs) were held with caregivers, and in-depth interviews (IDIs) were conducted with community leaders and with community drug distributors. State-level and LGA malaria focal persons were also interviewed. At national level, key-informant interviews (KIIs) were held with the NMEP coordinator, and representatives of partners working on SMC in Nigeria. Interviews were recorded and transcribed, and those in local languages translated into English, and the transcripts were analysed using NVivo software. A total of 190 FGDs, KIIs and IDIs were undertaken. In all study areas malaria was seen as a major health concern and SMC was widely accepted as a key preventive measure, and community drug distributors (CDDs) were generally trusted. Caregivers preferred SMC delivered door-to-door to the fixed-point approach, because in addition to allowing them to continue daily tasks, door-to-door delivery allowed more time for the CDD to explain how to administer the treatments and advise about adverse reactions and to answer questions. Barriers identified included perceived side effects of SMC drugs, a lack of understanding of the purpose of SMC, mistrust and suspicions that medicines provided free may be unsafe or ineffective. Key informants and caregivers reported SMC distributions limited by drug shortages, supplies running out before all children in the community had been treated. Key findings from this study were shared with delivery teams during national and state level training in 2022 and through cascade training to all community drug distributors and others involved in SMC campaigns. Other steps to act on the findings will include updating the training curriculum to show SMC teams how to strengthen communication to caregivers on the importance, safety and effectiveness of SMC, during campaigns; more involvement of state and national level pharmacovigilance coordinators during implementation to improve completion and submission of individual case safety reports and investigation of suspected adverse drug reactions. To avoid local shortages of SMC drugs, NMEP will ensure stricter adherence to the planned medicine allocations for each facility based on microplanning estimates. Study findings were shared with donors and implementing partners, to reinforce the importance of retaining primarily door-to-door delivery of SMC in Nigeria.

Results from phase one of a hybrid effectiveness-implementation study to assess the feasibility, acceptability and effectiveness of implementing seasonal malaria chemoprevention in Nampula province, Mozambique

“…This multi-source approach in spreading the information about SMC and its objectives in this context worked effectively. The involvement of community members has been identi ed as a key advantage in delivering SMC and malaria messages at community level by other studies [29][30][31]. Bene ts of SMC have been already…”

Understanding the effective reproduction number ofPlasmodium falciparummalaria with seasonal variation at sub-national level in Nigeria

“…Across the incredibly diverse ecological zones, there are significant differences in the transmission’s seasonality and intensity. In the savanna ecological zones of Derived Savannah, Guinea Savannah, Sudan Savannah, and Sahel Savannah, highly seasonal malaria occurs during and shortly after the time of strong rainfall (three to four months) [30]. According to the time series plots 6, it can be observed that the spread of malaria in Nigeria is seasonal.…”

Malaria prevention in children: an update

“…A qualitative study in Burkina Faso highlighted the importance of studying SMC feasibility and acceptability before rolling out additional interventions, though, as a fifth cycle of SMC overlapped with farming activities, so timing of distribution required optimization for good uptake [16 ▪ ]. Caregiver education and engagement is also important to ensure completion of the entire three-day SMC regimen [17 ▪ ,18 ▪ ,19]. SMC visits also offer an opportunity to successfully deliver other healthcare services, as demonstrated in a study in Guinea that integrated mid-upper arm circumference assessment, and in a separate study in Nigeria that integrated vitamin A supplementation, both documenting no decrease in SMC coverage when additional interventions were added [20,21].…”