In Nigeria, forty-one public health facilities were enrolled in Sokoto state, in urban (46.3%) and rural (53.7%) areas across Sokoto South (46.3%), Tangaza (26.8%) and Silame (26.8%) LGAs. Of 259 community distributors observed, the majority (89.6%) were females with a mean age of 28.7 years (SD=10.2). The majority (64.1%) had at least a secondary education and a mean of 3.2 (SD=1.7) years’ experience as a community distributor for SMC.
In Burkina Faso, forty-six public health facilities were enrolled in Bogodogo (47.8%), Dafra (23.9%) and Lena (28.3%) health districts, in rural (56.5%) and urban (43.5%) areas. Of 252 community distributors observed, just over half (51.6%) of CDs were male, with a mean age of 33.0 years (SD=9.8). A quarter (24.6%) of CDs had at least a secondary education and a mean of 2.8 (SD=1.7) years’ experience as a community distributor.
In Chad, 35 public (31.4%), private (11.4%), community (28.6%) and confessional (28.6%) health facilities were enrolled in N’Djamena Sud (51.4%), Massakory (31.4%) and Guelendeng (17.1%) health districts, in rural (48.6%) and urban (51.4%) areas. Of 266 community distributors observed, the majority (73.7%) were male, with a mean age of 28.8 years (SD=8.8). Under half (42.1%) of community distributors had completed secondary education or above and they had an average of 3.1 years’ (SD=1.8) experience as a community distributor.
Inter-rater reliability between data collectors and their supervisors was high in Nigeria (kappa: 0.77, standard error: 0.02) and Burkina Faso (kappa: 0.76, standard error: 0.03) and moderate in Chad (kappa: 0.64, standard error: 0.02).
In each country, eight focus group discussions (FGDs) were completed, across urban (n=4) and rural (n=4) areas with an equal number of male and female groups, with the exception of the rural areas in Burkina Faso, where four mixed male and female groups were formed.
Observation of infection prevention and control adherence
Case study 1: Nigeria
Equipment availability was variable between LGAs and for different types of equipment, with no distinct trends between rural and urban LGAs. Overall, 67.6% community distributors received hand sanitiser and 79.9% received at least one face mask, with a much lower proportion (25.1%) receiving the recommended two new face masks. Availability of disinfecting wipes and bio-waste bags was low (Additional file 2).
Adherence to mask use was high (506 [73.3%] of 690 indications). Community distributors rarely washed their hands for the recommended 30 seconds (56 [3.5%] of 1578 indications) but this increased when excluding length of time spent hand washing (578 [36.6%] of 1578 indications). Hand sanitiser was used more frequently than soap and water. Community distributors rarely practiced exclusive safe distancing in the compound (211 [16.4%] of 1279 indications) and community distributors’ temperature was checked for 117 [22.6%] of 518 indications. Due to low availability of disinfection wipes and biowaste bags, data on compliance with disinfection of SPAQ blister packs and waste management are inconclusive (Figure 2, Additional file 3).
Case study 2: Burkina Faso
Equipment availability varied by type of equipment and by health district. The majority of the community distributors received hand sanitiser across all three health districts (96% or above). For all other types of equipment, at least 10% more community distributors in the rural district of Lena were observed receiving equipment compared to the other two districts. Notably, 59.5% of community distributors received two or more new face masks, ranging from 44.1% in Dafra to 75.9% in Lena. Disinfecting wipes were available to at least a third of community distributors in all three health districts and bio-waste bags were available to over half of community distributors (Additional file 2).
Adherence to mask use was high (1168 [86.9%] of 1344 indications). Adherence to hand washing for the recommended 30 seconds was low (165 [10.3%] of 1606 indications) increasing substantially when excluding length of time spent hand washing (994 [61.4%] of 1619 indications). Hand sanitiser was used more frequently than soap and water. Among those receiving wipes and biowaste bags, there was evidence of some adherence to disinfection of SPAQ blister packs (51 [17.4%] of 294 indications) and waste management (102 [30.9%] of 330 indications). Community distributors rarely practiced exclusive safe distancing in the compound (99 [7.9%] of 1249 indications) and adherence to taking community distributors’ temperature was very low [2.6%] of 504 indications] (Figure 2, Additional file 3).
Case study 3: Chad
Equipment availability was variable between health districts and for different types of equipment, with no distinct trends between rural and urban districts. Overall, 89.8% community distributors received hand sanitiser and 92.9% received at least one face mask, with a much lower proportion (34.2%) receiving the recommended two new face masks. Around a half of community distributors received disinfecting wipes (50.4%) and bio-waste bags (45.9%) (Additional file 2).
Adherence to mask use was high (1983 [81.4%] of 2437 indications). Community distributors rarely washed their hands for the recommended 30 seconds (103 [3.4%] of 3045 indications), increasing when excluding length of time spent hand washing (1362 [55.5%] of 2453 indications). Hand sanitiser was used more frequently than soap and water. Among those receiving wipes and biowaste bags, there was evidence of some adherence to disinfection of SPAQ blister packs (68 [16.9%] of 402 indications) and waste management (124 [41.1%] of 302 indications). Community distributors rarely practiced exclusive safe distancing in the compound (135 [5.4%] of 2512 indications) and adherence to taking temperature was quite low (79 [15.0%] of 528 indications] (Figure 2, Additional file 3).
Table 1 Characteristics of community distributors enrolled in the study
|
Characteristics
|
Nigeria
(N=259)
|
Burkina Faso
(N=252)
|
Chad
(N=266*)
|
|
Age (years), mean [SD], min, max
|
28.7 (10.2), 18, 70
|
33.0 (9.8), 20, 63
|
28.8 (8.8), 20, 70
|
|
Age (years), n (%)
|
|
|
|
|
|
|
|
<30
|
168
|
64.9
|
101
|
40.1
|
162.0
|
60.9
|
|
30-49
|
73
|
28.2
|
134
|
53.2
|
92.0
|
34.6
|
|
≥50
|
18
|
6.9
|
17
|
6.8
|
11.0
|
4.1
|
|
Sex, n (%)
|
|
|
|
|
|
|
|
Female
|
232
|
89.6
|
122
|
48.4
|
69
|
25.9
|
|
Male
|
27
|
10.4
|
130
|
51.6
|
196
|
73.7
|
|
Education, n (%)
|
|
|
|
|
|
|
|
No education
|
21
|
8.1
|
0
|
0.0
|
13.0
|
4.9
|
|
Arabic/Islamic school
|
31
|
12.0
|
1
|
0.4
|
17.0
|
6.4
|
|
Primary
|
5
|
1.9
|
27
|
10.7
|
17.0
|
6.4
|
|
11
|
4.2
|
37
|
14.7
|
11.0
|
4.1
|
|
Some secondary
|
25
|
9.7
|
125
|
49.6
|
95.0
|
35.7
|
|
Completed secondary
|
87
|
33.6
|
21
|
8.3
|
39.0
|
14.7
|
|
Some tertiary
|
26
|
10.0
|
34
|
13.5
|
54.0
|
20.3
|
|
Completed tertiary
|
53
|
20.5
|
7
|
2.8
|
19.0
|
7.1
|
|
Years of experience as a community distributor, mean (SD) min, max
|
3.2 (1.7), 1, 7
|
2.8 (1.7), 0, 7
|
3.1 (1.8) 0, 7
|
|
*Descriptive data for one community distributor unavailable
|
Findings from focus group discussions with community distributors
Acceptability of COVID-19 infection prevention and control measures
Community distributors in urban and rural areas of Burkina Faso, Chad and Nigeria viewed the infection prevention and control measures favourably, expressing that the equipment gave them confidence and motivation to participate in the SMC campaign despite the pandemic, typically:
“Truly this prevention that they brought is proper and it has given us peace of mind, we know what to do because before, everyone was afraid of this sudden situation. This precaution has given us peace of mind, on top of that they added sanitizer and facemask, so we feel confident working with them… even if we get infected, we will not spread it or bring it home or to our environment” (Nigeria_Sokoto_ Urban Female _02).
“In any case…I come back to what she said. It's a good thing as it allows us to protect ourselves, we protect ourselves against Covid-19 and other diseases as well. And it makes us clean.” (Burkina Faso_FGD2_F_Trame D'Accueil)
“Which reassures us, during this ...at the time of the distribution, we had all the materials such as hydroalcoholic gel, gloves, and then the mask, we had all that, that's what reassures us…” (Chad_FDG2_M_ Kamerom)
However, many community distributors were still fearful. In Burkina Faso, although community distributors generally agreed with infection prevention and control measures, many still expressed ‘a lot of fear’ of being infected with COVID-19. In Nigeria, male distributors admitted being initially fearful of becoming infected but when they were trained and assured that infection prevention and control equipment would be provided, they were put at ease. In Chad, some distributors felt compelled to use the mask for fear of being reprimanded by the police. For additional quotes please see Additional File 4.
Feasibility of implementing infection prevention and control measures
Impact of infection prevention and control measures on community distributor’s workload
In Burkina Faso and Nigeria, community distributors acknowledged that the biggest impact on their workload was not implementing the infection prevention and control measures, rather the time taken to explain the changed circumstances of the SMC campaign, convince reluctant caregivers about the need for additional measures and address caregiver concerns about the campaign during COVID-19. In Burkina Faso and Nigeria, distributors found communicating the need for infection prevention and control measures to illiterate caregivers particularly challenging. In Burkina Faso, distributors indicated that some caregivers did not fully understand the practices, especially the need for hand washing; some caregivers thought community distributors asked them to wash their hands because they were dirty. In Chad, distributors mentioned that delivering SMC during the pandemic had led to some mistrust; some caregivers were afraid that distributors would bring COVID-19 into the household and refused compound entry on the pretext that everyone had been asked to stay at home.
“Most of them are aware that it is for their own protection. But for example, when you arrive in a compound where everybody is illiterate, it's a complicated matter…We explain them, they understand, but can't really comply with the rules.” (Burkina Faso_FGD2_F_ Trame D'Accueil)
“You arrive at someone's house and you have to wash your hands before giving medications; this can frustrate the person because it implies that their hands are not clean.” (Burkina Faso_FGD5_F_Secteur 24)
“The work you can finish in 30minutes for example when you come and do your introduction, it will add more minutes instead of maybe 30minutes, it will increase to 50minutes this is because you will have to go through the measures and tell them about it step by step” (Nigeria_Sokoto, Urban_female_02)
“Corona affected the distribution of CPS [SMC] a bit in that it caused a bit of mistrust […] parents are a little afraid that we are bringing this virus to them to distribute so they are afraid when we are approach to them for the distribution of drugs and others even outright refuse this contact. Even if we respect the distancing to give but they are afraid that corona is there so when we knock on the door many times, they respond violently, stuff like that, that's my opinion” (Chad_FGD8_M_Moursal)
As a result, distributors described working additional hours in order to reach their targets for drug administration, which they said was exhausting. Most mentioned the time taken for hand hygiene for themselves and the caregiver before administering the first dose, and time to put on face masks; but they did not seem concerned by this and mostly they regarded the tasks as necessary and feasible to do. In contrast, community distributors in Chad felt that having to adhere to the infection prevention and control measures had a negative impact on their work and encroached on work time to the extent they felt forced ‘to do a double job’; administering SMC and raising awareness about COVID-19.
“How coronavirus affected work, this is called, overwork. Because you have to start raising awareness first. It is already taking time. Then you have to take the hygiene measures before doing the actual work as it was told to do. This makes it an overload of work for us." (Burkina Faso_FGD1_Mixed_Peele)
“You will see a particular work that you are supposed to round up in 5minutes you will end up rounding up in 10minutes, seriously houses that you are expected to cover per day, because of all those issues you will be unable to complete it” (Nigeria_Sokoto_Rural_Female)
"... the work is heavier, that's what I was saying, it's that workload, because before, we were supposed to simply administer only the drugs, but here now it's as if we have a double mission like that, it is necessary and, to do the CPS [SMC] and it is also necessary to make the awareness of covid so that it weighs down a little and it plays on time. Yes, it is a challenge” (Chad_FGD7_F_Moursal)
Distributors in rural Sokoto, Nigeria explained that the state media and local town criers played a vital role in imparting information about COVID-19 prevention, creating awareness before the SMC campaign and allaying caregivers’ fears. Despite this, community distributors reported that some caregivers refused to greet them, or requested they wait outside the compound as they did not understand the rationale for the infection prevention and control measures or were worried that the visit to their home posed a threat to their safety.
Community distributors found face masks uncomfortable to wear
In all three countries, community distributors reported that wearing face masks throughout the working day was challenging. In Burkina Faso and Nigeria, many pointed out they had already been wearing masks for health reasons or to prevent inhalation of dust in arid regions; however, having to wear masks continuously throughout the day was their main concern. Typical discomforts community distributors experienced included:
“There are several difficulties such as breathing problems associated with wearing masks. It happens that often you do not manage to get oxygenated air properly...” (Burkina Faso_FGD6_Mixed_ Yegueresso)
“yes, honestly we somehow faced challenge because…using the face mask for the fact that we were not used to it before, even though we were using it in the past but now we use it often, we put it on during work, even after until we go back to the house before they say we can remove it, we need to have it on like 6 to 7 hours, we are not used to this duration” (Sokoto, Urban_female_04).
“Because coronavirus is there, that's how we wear the mask to distribute SMC. It squeezes and it hurts our ears. We can't breathe, even it was coronavirus that brought it all. Wearing the mask there is annoying” (Chad_FDG1_F_Kamerom)
Some distributors mentioned that supervisors conducting spot checks facilitated consistent and continuous mask-wearing throughout the day.
“Some, we leave from the house with. So it's already (whispers) from the house as soon as you leave at 6am sometime before you get there. It wasn’t easy, why, because we’re not used to it a few times it’s like it suffocates us, it’s a reflex by the way. We used to want to shoot like that first ... and when we see the supervisors behind us first we try to pull that out. It wasn't easy because the time is long and to stay like that with there, suddenly it suffocates us so it was not easy for me” (Chad_FDG5_F_Abena)
“Some people demanded that it be taken off because they didn't understand what we were saying. In order for them to understand us and for the work to go well we had to take off the mask. So we had to take it off while being careful not to be seen by a supervisor. So it complicated the work a lot because we were doing it in secret, so we had to do it quickly”. (Burkina Faso_FGD5_F_Secteur 24)
Barriers to consistent mask-wearing included complaints from community members about not being able to hear them clearly when speaking, being unrecognisable from a distance, and children being afraid of them. In all countries, distributors reported deliberately lowering or removing their mask when giving instructions for the drug administration but keeping the mask on to administer SMC drugs. Further to this, in Nigeria, distributors mentioned that caregivers demanded to see their face when administering SMC to their children; masks were thought to be a deliberate disguise to protect distributors if adverse events occurred.
“Well, we had challenges especially entering the houses, some parents once you knock on their door and greet them, they will start saying “you just come to give our children drugs without us knowing who you are?” So you see we will have to remove our facemask for recognition, they will even ask to know if we are the people that came the last month and we reply them, you see it is also a challenge” (Nigeria_Sokoto, Urban_female_04).
In Chad and Nigeria, community distributors were harassed when wearing masks – some recounted children running after them chanting, ‘the corona people’, which attracted a lot of attention and made them feel uncomfortable. In Chad, children reportedly shouted at community distributors wearing masks, as they were not familiar with face coverings.
Cultural norms made it difficult to adhere to safe distancing
In all three countries, cultural norms and traditions mean people are accustomed to greeting each other with physical contact and often spend time together in close proximity. As a result, community distributors described distancing as the most difficult measure to adhere to:
“We were uncomfortable because we said not to greet by shaking hands with people we are already used to, as we chat and laugh together, without realizing. But if we are prevented from doing this, will we be able to be comfortable? Obviously, we won't be comfortable. ((Laughter)) This is the aspect that is complicated”. (Burkina Faso_FGD6_Mixed_Yegueresso)
“Like that of social distancing, since you know the person and they know us, it is hard not to come, sit and discuss and even shake [hands]” (Nigeria_Sokoto_Rural_male)
"It is not easy as she says there true because as a good Chadian there you have to shake hands, because when you only greet like that, the person tells you… so you have to shake hands and given the illness, in doing this some people find that you may be neglecting them…” (Chad_FDG5_F_Abena)
In Nigeria, community distributors mentioned that it was difficult to observe safe distancing because they sometimes forgot, were influenced by caregivers or community members’ perceptions, and in a few instances space constraints in households precluded it. In rural Sokoto state, caregivers seemed to interpret safe distancing as community distributors’ irritation or anxiety about contracting COVID-19 from them.
Some community distributors found ways to work around the safe distancing measures. For example, in Nigeria, female distributors explained how a 1-metre distance was more comfortable and feasible, so long as a face mask is worn and proper hand hygiene observed. In Burkina Faso, distributors occasionally felt obliged to shake the hands of the elderly to appear respectful, although they emphasised that they sanitised their hands immediately after. In addition, distributors in Burkina Faso were tasked with measuring nutritional status of children alongside administering SMC; using upper arm circumference in under-5s necessitated touching the child’s arm, but distributors were keen to emphasize that they disinfected the Shakir (measurement) strip before and after each use.
Hand hygiene adherence was sub-optimal
Community distributors recognised the importance of hand hygiene and considered hands an easy source of COVID-19 infection and transmission from touching the mouth and nose with contaminated hands. However, distributors in all three countries admitted that hand hygiene was not done as frequently or for as long as stipulated in guidelines. In Burkina Faso and Chad, distributors talked about forming a habit, although many admitted that early in the campaign they often forgot. In rural Sokoto state, Nigeria, distributors mentioned that unannounced visits by supervisors motivated them to adhere to the guidelines; some also regarded hand hygiene as a mandatory instruction and so kept to this.
"At the beginning, it was not easy at first. But in everything, the more you do it, the more you get used to it. So it was like that.” (Burkina Faso_FGD1_Mixed_Peele)
"Well, it's a matter of habit eh, these are not the measures that we are used to doing but given the arrival of this disease we knew that it is really annoying, it is really worrisome then is to enable us to protect against disease. But most, most of the population does not want to apply these measures at all” (Chad_FDG6_M_Abena)
“Yes ma since it’s a promise you have taken upon yourself, you have to follow it diligently because they were appropriate and if you don’t want any problem, you just have to adhere to the directives” (Nigeria_Sokoto_Rural_female_05)
In Nigeria, distributors explained that although they were happy to practice hand hygiene, they found it difficult to adhere to 30 seconds each time. A few also reported that alcohol-based sanitisers caused unpleasant skin irritations and frequent application made their hands dry. A minority expressed concern that alcohol-based sanitiser went against religious rulings that forbid use of alcohol, and they were more likely to use soap and water.
“I can only say I did my best with the hand hygiene, but I am not certain about adhering to the 30 seconds rule” (Nigeria_Sokoto_South_female_02).
“Some Community distributor do not use the hand sanitizer. They do say it contains alcohol and so on and that because of that, their prayer is affected” (Nigeria_Sokoto, Urban_male_01)
Availability of soap and water in households was an important challenge in all three countries. Distributors in Burkina Faso recounted having to share soap and sanitiser with households as caregivers often did not have any, and in Chad distributors found it easier to use hand gel in communities as it ‘is difficult to find soap in some homes’.
SMC administration by caregivers during the coronavirus pandemic
In all three countries community distributors reported having to assist caregivers to administer the first doses of SP and AQ. In Burkina Faso, some caregivers recognized that their children would not accept the medicine if they had to administer it and preferred the distributor do it.
"There it is not easy, that is to say, she does not follow exactly what she is asked to do. We might ask to bring, how shall I put it, take the medicine and, take two pills out for the first dose, sometimes she doesn't do exactly what she's asked to do -there, maybe she even removes three. Effectively we keep saying that no, no it should have been two and not three…” (Chad_FGD8_M_Moursal)
“As they know that it's to help them that we respect the barrier measures, so some children would refuse to drink the medication if their own parents had to give them the medication. So this new method that has been adopted is a bit complicated! Unless we tease them to say we're going to give them a shot or something else, they will not take the medication with their parents!” (Burkina Faso_FGD2_F_Trame D'Accueil)
In Burkina Faso and Nigeria, distributors also mentioned coaxing children to take the drug by singing to them or teasing them. Although some children were happy to receive the drugs from caregivers, community distributors had to step in when children cried or ran away from parents; distributors felt that this tendency was more prevalent among older children who recalled polio immunisation campaigns. In both countries, community distributors carried sweets to persuade children to swallow the drugs, although this resulted in children refusing the drugs from their caregivers.