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Objectives: This study aimed to assess communities' perception and adoption of the evidenced-based malaria diagnosis and case management intervention targeted at under-five children. The effectiveness of trained Volunteer Community Health Workers (VCHWs) to diagnose malaria among under-five children using rapid diagnostic testing kit, provide treatment using Artemisinin Combination Therapy and rectal Artesunate were assessed., Design: A qualitative evaluation study was conducted in October 2015., Setting: Communities in the 6 rural wards in Ona-Ara Local Government Area, Oyo State Nigeria., Participants: Caregivers of under-five children, community-based frontline health workers, and community leaders selected using purposively sampling., Methods: Nine Focus Group Discussions and 15 Key Informant Interviews were conducted using a pre-tested guide. Data were subjected to thematic analysis., Results: It was disclosed that VCHWs promoted people's access to prompt and appropriate malaria treatment. The communities accepted the VCHWs; the reasons given for this included the following: effectiveness of VCHWs in case management of malaria; good inter-personal relationship with caregivers; and the positive health outcomes associated with services provided by them. In addition, community members expressed satisfaction with the VCHWs and provided them with all the support needed to function throughout the malaria case management intervention. The VCHWs considered the support as a great source of encouragement., Conclusions: The use of VCHWs to treat malaria was adjudged to be effective and considered acceptable to the communities. The adoption of the intervention and its integration into the primary health system by the government is advocated for in medically underserved rural communities., Funding: This work was supported by UNICEF/UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland (project ID: A80550 [Nigeria] through funds made available by the European Commission (FP7) for research to improve community access to health interventions in Africa., Competing Interests: Conflict of interest: None declared, (Copyright © The Author(s).)

Background: In the context of task shifting, a promoted approach to healthcare delivery in resource-poor settings, trained community health workers (CHWs) have been shown to be effective in delivering quality care of malaria for febrile under-5 children. While their effectiveness has been documented, the fidelity of implementation (FOI) has not been adequately studied. By understanding and measuring whether an intervention has been performed with fidelity, researchers and practitioners gain a better understanding of how and why an intervention works, and the extent to which outcomes can be improved. The objective of this study was to assess the FOI of a recommended protocol for malaria care by CHWs in a resource-poor setting in Nigeria., Methods: Thirty-five female CHWs who participated in a 3-day training on home management of malaria among under-5 children were studied. They managed 1,646 children over the implementation period and then underwent evaluation via a one-time hospital-based observation by the trainers. During the evaluation, a pre-tested standard checklist was used to compute performance scores for CHWs; doctors and nurses were selected to serve as the gold standard for comparison. Performance scores (PS) recorded during the evaluation were used to assess adherence and compliance with the recommended treatment protocol., Results: Of the 4 skill domains assessed, adherence was greatest for compliance with malaria treatment recommendations (94%) and lowest for post-treatment initiation counseling of home-based caregivers (69%). The average overall adherence of 83% was comparable to adherence by gold standard comparators. Mean PS was not found to be significantly associated with CHW demographics. Scores for clinical evaluation among those whose occupation was not healthcare-related were significantly lowered by 0.52 [95% CI (1.05-0.01), p = 0.05]. Compliance with the treatment protocol increased by 23% for every unit increase in total PS (p = 0.07) and doubled for every unit increase in scores for post-treatment initiation counseling of caregivers (p = 0.002)., Conclusions: Studying intervention fidelity stands to identify the shortcomings of implementation and specific areas to target for improvement in future adoption or implementation. This study concludes that future trainings should emphasize clinical evaluation and post-treatment counseling of caregivers by CHWs to ensure the best outcome for children.

Background:  Malaria-endemic countries are encouraged to increase, expedite, and standardize care based on parasite diagnosis and treat confirmed malaria using oral artemisinin-based combination therapy (ACT) or rectal artesunate plus referral when patients are unable to take oral medication., Methods:  In 172 villages in 3 African countries, trained community health workers (CHWs) assessed and diagnosed children aged between 6 months and 6 years using rapid histidine-rich protein 2 (HRP2)-based diagnostic tests (RDTs). Patients coming for care who could take oral medication were treated with ACTs, and those who could not were treated with rectal artesunate and referred to hospital. The full combined intervention package lasted 12 months. Changes in access and speed of care and clinical course were determined through 1746 random household interviews before and 3199 during the intervention., Results:  A total of 15 932 children were assessed: 6394 in Burkina Faso, 2148 in Nigeria, and 7390 in Uganda. Most children assessed (97.3% [15 495/15 932]) were febrile and most febrile cases (82.1% [12 725/15 495]) tested were RDT positive. Almost half of afebrile episodes (47.6% [204/429]) were RDT positive. Children eligible for rectal artesunate contributed 1.1% of episodes. The odds of using CHWs as the first point of care doubled (odds ratio [OR], 2.15; 95% confidence interval [CI], 1.9-2.4; P < .0001). RDT use changed from 3.2% to 72.9% (OR, 80.8; 95% CI, 51.2-127.3; P < .0001). The mean duration of uncomplicated episodes reduced from 3.69 ± 2.06 days to 3.47 ± 1.61 days, Degrees of freedom (df) = 2960, Student's t (t) = 3.2 (P = .0014), and mean duration of severe episodes reduced from 4.24 ± 2.26 days to 3.7 ± 1.57 days, df = 749, t = 3.8, P = .0001. There was a reduction in children with danger signs from 24.7% before to 18.1% during the intervention (OR, 0.68; 95% CI, .59-.78; P < .0001)., Conclusions:  Provision of diagnosis and treatment via trained CHWs increases access to diagnosis and treatment, shortens clinical episode duration, and reduces the number of severe cases. This approach, recommended by the World Health Organization, improves malaria case management., Clinical Trials Registration:  ISRCTN13858170., (© 2016 World Health Organization; licensee Oxford Journals.)

Background:  Use of community health workers (CHWs) to increase access to diagnosis and treatment of malaria is recommended by the World Health Organization. The present article reports on training and performance of CHWs in applying these recommendations., Methods:  Two hundred seventy-nine CHWs were trained for 3-5 days in Burkina Faso, Nigeria, and Uganda, and 19 were certified to diagnose and treat only uncomplicated malaria and 235 to diagnose and treat both uncomplicated and severe malaria. Almost 1 year after training, 220 CHWs were assessed using standard checklists using facility staff responses as the reference standard., Results:  Training models were slightly different in the 3 countries, but the same topics were covered. The main challenges noticed were the low level of education in rural areas and the involvement of health staff in the supervision process. Overall performance was 98% (with 99% in taking history, 95% in measuring temperature, 85% for measuring respiratory rates, 98% for diagnosis, 98% for classification, and 99% for prescribing treatment). Young, single, new CHWs performed better than their older, married, more experienced counterparts., Conclusions:  Training CHWs for community-based diagnosis and treatment of uncomplicated and severe malaria is possible with basic and refresher training and close supervision of CHWs' performance., Clinical Trials Registration:  ISRCTRS13858170., (© 2016 World Health Organization; licensee Oxford Journals.)

Background:  The efficacy of artemisinin-based combination therapy (ACT) and rectal artesunate for severe malaria in children is proven. However, acceptability of a package of interventions that included use of malaria rapid diagnostic tests (RDTs), ACTs, and rectal artesunate when provided by community health workers (CHWs) is uncertain. This study assessed acceptability of use of CHWs for case management of malaria using RDTs, ACTs, and rectal artesunate., Methods:  The study was carried out in Burkina Faso, Nigeria, and Uganda in 2015 toward the end of an intervention using CHWs to provide diagnosis and treatment. Focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with parents of sick children, community leaders, and health workers to understand whether they accepted the package for case management of malaria using CHWs. Transcripts from FGDs and KII recordings were analyzed using content analysis. The findings were described, interpreted, and reported in the form of narratives., Results:  Treatment of malaria using the CHWs was acceptable to caregivers and communities. The CHWs were perceived to be accessible, diligent, and effective. There were no physical, social, or cultural barriers to accessing the CHWs' services. Respondents were extremely positive about the intervention and were concerned that CHWs had limited financial and nonfinancial incentives that would reduce their motivation and willingness to continue., Conclusions:  Treatment of malaria using CHWs was fully accepted. CHWs should be compensated, trained, and well supervised., Clinical Trials Registration:  ISRCTN13858170., (© 2016 World Health Organization; licensee Oxford Journals.)

Background: Agricultural practices such as the use of irrigation during rice cultivation, the use of ponds for fish farming and the storage of water in tanks for livestock provide suitable breeding grounds for anthropophylic mosquitoes. The most common anthropophylic mosquito in Nigeria which causes much of the morbidity and mortality associated with malaria is the anopheles mosquito. Farmers are therefore at high risk of malaria - a disease which seriously impacts on agricultural productivity. Unfortunately information relating to agricultural practices and farmers' behavioural antecedent factors that could assist malaria programmers plan and implement interventions to reduce risk of infections among farmers is scanty. Farmers' knowledge about malaria and agricultural practices which favour the breeding of mosquitoes in Fashola and Soku, two rural farming communities in Oyo State were therefore assessed in two rural farming communities in Oyo State., Methods: This descriptive cross-sectional study involved the collection of data through the use of eight Focus Group Discussions (FGDs) and the interview of 403 randomly selected farmers using semi-structured questionnaires. These sets of information were supplemented with observations of agricultural practices made in 40 randomly selected farms. The FGD data were recorded on audio-tapes, transcribed and subjected to content analysis while the quantitative data were analyzed using descriptive and inferential statistics., Results: Most respondents in the two communities had low level of knowledge of malaria causation as only 12.4% stated that mosquito bite could transmit the disease. Less than half (46.7%) correctly mentioned the signs and symptoms of malaria as high body temperature, body pains, headache, body weakness and cold/fever. The reported main methods for preventing mosquito bites in the farming communities included removal of heaps of cassava tuber peelings (62.3%), bush burning/clearing (54.6%) and clearing of ditches (33.7%). The dumping of cassava tuber peelings which allows the collection of pools of water in the farms storage of peeled cassava tubers soaked in water in uncovered plastic containers, digging of trenches, irrigation of farms and the presence of fish ponds were the observed major agricultural practices that favoured mosquito breeding on the farms. A significant association was observed between respondents' knowledge about malaria and agricultural practices which promote mosquito breeding. Respondents' wealth quintile level was also seen to be associated with respondents' knowledge about malaria and agricultural practices which promote mosquito breeding., Conclusion: Farmers' knowledge of malaria causation and signs and symptoms was low, while agricultural practices which favour mosquito breeding in the farming communities were common. There is an urgent need to engage farmers in meaningful dialogue on malaria reduction initiatives including the modification of agricultural practices which favour mosquito breeding. Multiple intervention strategies are needed to tackle the factors related to malaria prevalence and mosquito abundance in the communities.

Abstract: Background: Color is commonly used for branding and coding consumer products including medications. People associate certain colors in tablets and capsules with the effect of the drug and the illness for which it is meant. Color coding was introduced in age-specific prepacked antimalarial drugs for preschool aged children in Nigeria by the National Malaria Control Committee. Yellow was designated for the younger ages and blue for the older. The National Malaria Control Committee did not perform market research to learn how their color codes would be perceived by consumers. Objective: The study aimed at determining perceptions of both consumers and sellers of medicines at the community level to learn about color likes and dislikes that might influence acceptance of new color-coded child prepacks of antimalarial drugs. Methods: Qualitative methods were used to determine perceptions of drug colors. A series of focus group interviews were conducted with male and female community members, and in-depth interviews were held with medicine sellers in the Igbo-Ora community in southwestern Nigeria. Results: Respondents clearly associated medicines with their effects and purpose, for example white drugs for pain relief, red for building blood, blue to aid sleep, and yellow for malaria treatment. Medicine vendors had a low opinion of white colored medicines, but community members were ultimately more concerned about efficacy. The perceived association between yellow and malaria, because of local symptom perceptions of eyes turning yellowish during malaria, yielded a favorable response when consumers were shown the yellow prepacks. The response to blue was noncommittal but consumers indicated that if they were properly educated on the efficacy and function of the new drugs they would likely buy them. Conclusions: Community members will accept yellow as an antimalarial drug but health education will be needed for promoting the idea of blue for malaria and the notion of age-specific packets. Therefore, the strong medicine vendor–training component that accompanied roll out of these prepacks in the pilot states needs to be replicated nationally. [Copyright &y& Elsevier]