Assessment of integrated Community Case Management of Childhood illness (iCCM) practices by trained Patent and Proprietary Medicine Vendors (PPMVs) in Ebonyi and Kaduna States, Nigeria

doi:10.21203/rs.3.rs-1618922/v1

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Research Article

Assessment of integrated Community Case Management of Childhood illness (iCCM) practices by trained Patent and Proprietary Medicine Vendors (PPMVs) in Ebonyi and Kaduna States, Nigeria

https://doi.org/10.21203/rs.3.rs-1618922/v1

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published 20 Jan, 2023

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Introduction

Malaria, Pneumonia and diarrhea has remained the leading cause of high mortality among children under the age of five years in Nigeria despite government responses in form of policies and programs. The most identifiable cause of these deaths has been attributed to service delivery gaps that limits access to quality child health services in the rural and hard to reach communities were most of these deaths occur at the household level.

Patent and proprietary medicine vendors have remained a good resource to addressing the service delivery gaps that lead to the unacceptable high mortality, however little has been done by the government, agencies and organizations to strengthen their capacity and improve their skill to provide quality health services in their various communities.

Methods

In Ebonyi and Kaduna States, 387 registered PPMVs were selected and trained on integrated community case management of childhood illness, out of which 165 with consistent and accurate data reporting practice were selected for study. The 165 PPMVs selected for this study were assessed on the first and last quarter of the intervention to measure the quality-of-service delivery of child health services in their various communities.

Results

The study revealed a significant improvement in the quality of treatment provided by the PPMVs across the three disease areas. 21.8% trained PPMVs could not appropriately treat malaria in the first quarter of the intervention, however, there was a significant decrease to 1.8% in second quarter in the number of those that cannot appropriate diagnose and treat malaria. There was also a decrease in the number of those who could not treat cough and fast breathing from 47(28.5%) to 14(8.5%) in the second quarter and for diarrhea from 33.3% in the first quarter to 2.4% in the second quarter.

Conclusion

Due to the ubiquitous nature of the PPMVs and their outnumbering presence in the hard-to-reach communities, they serve as valuable resource in addressing the health care delivery gap that has led to the continuous rise in the unacceptable high mortality rate of children under the age of five years in Nigeria.

Trial registration: Project No: IRB/20/099 dated 12th Jan 2021

Mortality

Under – 5

Caregiver

Community

Intervention

Illnesses

Malaria

Child mortality records show that in 2017 1 in every 13 children die before age five in Sub Saharan Africa [2]. In Nigeria, under five mortality rate is 132 per 1,000 live births meaning that 1 in 8 Nigerian children never reach the age of 5 [13]. Malaria, Pneumonia and diarrhea are the leading cause of deaths among children under the age of five years especially in the rural and underserved setting in Nigeria. These diseases are responsible for approximately one third of global deaths among children under five in 2018 totaling an estimated 1.6 million deaths in this age group [11]. Nigeria accounts for almost 15% of global under-5 mortality [6].

In spite of being preventable and treatable with low-cost public health intervention Malaria, Pneumonia and diarrhea still remains the major killer disease for children under the age of 5 years with 23%, 3%, and 13% [13] as prevalence respectively. However, UNICEF reported pneumonia to be the highest killer of children under the age of five years in Nigeria with 162,000 estimated deaths calculated at 19% in 2018

The trio are diseases of inequity – one concentrated within the poorest populations around the globe with disproportionate among the poor and the rich. More so, every 2 minutes a child dies of Malaria and pneumonia in every 39 seconds [17].

Fever is the most common symptoms of illnesses seen in under - fives in Africa [12]. Other common symptoms that have been reported in under-fives are cough and loose water stool [12].

The most immediate identifiable cause of Nigeria’s high number of under 5 deaths is a service delivery gap that limits access to health services. Research has shown that infant mortality is a major problem in Nigeria and has been linked to factors such as inadequate health facilities, lack of financial capacity, and lack of access to appropriate medical care [3]. Problems such as cost for treatment, deplorable state of the health facilities, distance to health facility, lack of awareness and knowledge for informed decisions and referral are some of the many difficulties stated by caregivers in describing difficulty with accessing healthcare [18]. These problems are particularly worrisome in the rural areas of developing countries where the density of modern health care facilities is low [1]

The improvement made towards child mortality reduction in Nigeria has witnessed a widening gap; inequity as well as a concentration of under-five deaths in the hard-to-reach communities. One of the reasons given for this inequality in childhood mortality reduction is the growing inequality in access to health care across communities and regions [1]. There is also an uneven distribution of healthcare facility and shortage of human resource for health. More so, the poor health seeking behavior of caregivers of children under the age of five years also contributes significantly to the high infant and under-five mortality [10]. Although households and communities have a major responsibility in recognizing when children need treatment outside the home, a recent national survey found that this has not been the case due to poor health seeking knowledge and practices in households [4].

In response to the unacceptable high mortality rate of children under five years in Nigeria, the Federal Government developed several policies and programs to improve health and address the identified Gaps. Some of them include National Child Health Policy, the National Malaria Policy, the Integrated Management of Childhood Illness Strategy and more recently the Integrated Maternal, Newborn and Child Health Strategy which is in line with the National Strategic Health Development Plan (FMOH, 2013). Integrated Management of Childhood Illness (IMCI) and iCCM are the key child survival thrust being used by the Nigerian Government to address the unacceptably high under-5 morbidity and mortality indices [18].

A recent systematic review of PPMV practices shows that PPMVs provide medicines and services for a wide variety of health needs, including malaria, respiratory infections, diarrhea [16]. The study also noted that an estimated 200,000 PPMVs operating in Nigeria are the first source of care for up to 55% of under-five child illnesses, such as malaria and diarrhea” [16]. Given the number of PPMVs, their presence in the rural communities, market share and their importance in improving primary health care in Nigeria, evidences are still limited on the quality of services they provide in the community if trained mentored and supervised to provide child health services.

Consequently, an iCCM focused intervention which encompassed a large scale of PPMVs was conducted by a Nigeria based public health organization, SFH to improve management of childhood, Malaria, pneumonia and diarrhea with an intervention approach focused on knowledge and skill improvement through training and feedback and support through mentorship. This study seeks to demonstrate the effectiveness of interventions such as ICCM training, supervision and linkage to quality iCCM commodities, among PPMVs to achieve high levels of knowledge and performance in diagnosing and treating common childhood illnesses.

2.1 Approach

Delivering Health to all Children is a social and behavior change communication intervention funded by NORVATIS foundation and implemented by Society for Family Health (SFH). The intervention was designed to address equity gaps and expand access to life saving efforts which will lead to reduction in the unacceptable high mortality rate in children under the age of 5 years in the implementing states. The project was committed to building the capacity of Patent and proprietary Medicine Vendors (PPMVs) in the implementing States to provides timely treatment for common childhood illness (pneumonia, malaria and diarrhea) which causes largest child mortality in Nigeria at the community level using life-saving curative interventions where normally, access would have been a challenge thereby ensuring equity.

The intervention was implemented in Ebonyi and Kaduna States. Ebonyi state is located in the South Eastern regions of Nigeria with over 3 million inhabitants spread across 13 administrative units referred to as Local Government Areas (LGAs) while Kaduna is a State in the North Western region of Nigeria serving as a home for more than 6 million residents with 23 LGAs. The intervention was implemented in 4 LGAs across the two states. In Ebonyi, the study was conducted in Ezza North and Ohaukwu LGAs while in Kaduna Igabi and Sabongari LGAs.

2.2 Study Design

At the inception of this study, fifteen (15) interpersonal communication agents (IPCA) were engaged in each State and trained on Integrated Community management of Childhood illness (ICCM). PPMVs operating in 150 communities across the two focus LGAs in each State where also mobilized and trained to provide iCCM services. The PPMVs trained were tier 2 PPMVs (health trained PPMVs). A total of 194 registered PPMVs were trained in Ebonyi State while 193 were trained in Kaduna State. The selected communities were shared among the 15 IPCAs with each being responsible for 10 communities and the PPMVs within the communities. The IPCA mobilized caregivers to take their children under the age of 2 months to 5 years to PPMVs on account of Malaria, Diarrhea, and Pneumonia; while the IPCAs in return monitor the quality-of-service delivery. At the first quarter of the intervention, the quality-of-service delivery was assessed using a designed checklist. The assessment was repeated towards the end of the second quarter and the two data sets were compared to obtain the level of improvement in quality service delivery.

2.3 Sample Size and Estimation

The study participants were PPMVs trained under Delivering Health to all Children program of the Society for family health. Out of the 387 trained PPMVs, 165 with consistent and accurate data reporting practice were selected for the purpose of this study.

2.4 Study tool

Data was collected using structured questionnaires and observation checklists containing close ended questions which explored quality treatment practices and knowledge of integrated management of early childhood illnesses among the PPMVs. Information from the observation and completed questionnaires was analyzed using SPSS version 22. The results were presented using frequencies and proportions while associations between categorical variables were tested using Chi-square test (Test of Independence) at significance level of 0.05.

3.1 Background Characteristics

Among the 165 PPMVs assessed for this study as shown in Table 1, majority were female participants (93, 56.4%). More than a quarter of the PPMVs (29%) were in Ezza North LGA while 15% have their outlets located at Ohaukwu LGA of Ebonyi State. Similarly, most of the PPMV outlets in Kaduna were located at Igabi LGA (34%) while 22% were from Sabon Gari LGA of Kaduna State. All the PPMVs assessed had been exposed to some level of health training. More than a quarter of the PPMVs were trained nurses (26%), 27% were Senior Community Health Extension Workers (S. CHEW), 12% were midwifes and 35% were Junior Community Health Extension Workers (JCHEW).

Table 1

Background Characteristics
Variable (N = 165)	Frequency	Percentage
LGA
Ezza North	47	29%
Igabi	56	34%
Ohaukwu	25	15%
Sabon Gari	37	22%
Gender
Male	72	43.6%
Female	93	56.4%
Qualification
Junior CHEW	57	35%
Senior CHEW	45	27%
Registered Nurse	43	26%
Midwife	20	12%

3.2 Assessment of the quality of child health services offered among trained PPMVs.

The capacity and willingness of the trained PPMVs to take respiratory rate was tested. In Table 2, about 39.4% of trained PPMV could not accurately take respiratory rate nor frequently measure respiratory rate each time a kid was brought in the first quarter. After the intervention period, majority of the PPMVs (93.3%) were able to reliably measure the respiratory rate of a sick child (ꭓ² (1) = 49.85, p-value = 0.000).

In the first quarter, 46.1% among the trained PPMVs were unable to detect fast breathing in a sick child and frequently fail to measure respiratory rate. In the second quarter, this number plummeted dramatically to 8.5%. Nearly all of the PPMVs could accurately diagnose fast breathing in sick children by the end of the intervention (ꭓ² (1) = 58.73, p-value = 0.000). The number of PPMVs that check for chest in-drawing in unwell children before delivering treatment increased significantly (ꭓ² (1) = 56.02, p-value = 0.000). At least 4 out of 5 PPMVs (83%) do not check for chest in-drawing in a sick child in the first quarter; after six months of skill reinforcement and supervision, 87.9% of PPMVs frequently check for chest in-drawing before therapy is given.

Table 2

The quality of child health services offering among trained PPMVs
Variable (N = 165)	Observation	Quarter 1	Quarter 2	df	ꭓ² (p-value)
Taking respiratory rate	Yes	100_a (60.6% )	154_a (93.3% )	1	49.85 (0.000)
Taking respiratory rate	No	65_b (39.4%)	11_b (6.7% )	1	49.85 (0.000)
How to determine fast breathing	Yes	89_a (53.9%)	151_a (91.5%)	1	58.73 (0.000)
How to determine fast breathing	No	76_b (46.1%)	14_b (8.5%)	1	58.73 (0.000)
Chest in drawing	Yes	82_a (49.7%)	145_a (87.9%)	1	56.02 (0.000)
Chest in drawing	No	83_b (50.3%)	20_b (12.1%)	1	56.02 (0.000)

3.3 Assessment of the quality of diagnosis for fever, cough, diarrhea

When the two quarters were compared in Table 3 to examine the quality of diagnosis for fever, cough, and diarrhea, it was discovered that there was an established gap in the number of PPMVs that assess cough. In the first quarter, 18.2% of the PPMVs failed to ask for or assess cough in sick children, while only 7.3% failed to do so before treatment at the end of the intervention (ꭓ² = 8.84, p-value = 0.003). In the first quarter, 17.6% of those who assess or ask for cough did not take the respiratory rate; this number reduced to 12.7% in the second quarter (ꭓ² = 1.51, p-value = 0.219). In addition, only 30 (18.2%) of the PPMVs in this study were able to correctly count respiratory rate in the first quarter. In quarter 2, the result improved to 100(60.6%) (ꭓ² = 64.60, p-value = 0.000). 126 (76.4%) tested for diarrhea during the first phase of the assessment, but in the second phase, 154 (93.3%) adopted the correct practice of assessing under-5 children for diarrhea before treatment (ꭓ² = 18.48, p-value = 0.000). There was also a considerable improvement in the accuracy of fever diagnosis. In the first quarter of the trial, 24 (14.5%) of the PPMVs did not screen for temperature before treating the child. According to the second quarter's assessment, 159 (96.4%) of PPMVs examine if the child has a temperature before treating them (ꭓ² = 11.88, p-value = 0.001). This finding also shows that in the first quarter, 40.6% of PPMVs did not perform RDT tests on children under the age of five who had a fever. In the second quarter, 87.3 percent of PPMVs were seen doing RDT tests before treatment (ꭓ² = 64.60, p-value = 0.000), indicating an improvement in diagnostic practice. At the start of the study, 71.5% of the PPMVs could not read the test result; by the second quarter, all (100%) of the PPMVs in the study could competently interpret the test result (ꭓ² = 183.68, p-value = 0.000). They were tested on their capacity to accurately identify all difficulties, and there was a substantial increase in the proportion of PPMVs who were unable to do so (ꭓ² = 0.34, p-value = 0.563).

Table 3

The quality of diagnosis for fever, cough, diarrhea
Variable (N = 165)	Observation	Quarter 1	Quarter 2	ꭓ² (p-value)
Does the CORP ask for or assess Cough?	Asked	135_a (81.8%)	153_a (92.7%)	8.84 (0.003)
Does the CORP ask for or assess Cough?	Not Checked	30_b (18.2%)	12_b (7.3%)	8.84 (0.003)
Does the CORP assess or take respiratory rate? (for cough only)	Yes	136_a (82.4%)	144_a (87.3%)	1.51 (0.219)
	No	29_a (17.6%)	21_a (12.7% )	1.51 (0.219)
Counted correctly	Yes	30_a (18.2%)	100_a (60.6%)	64.60(0.000)
	No	106_b (64.2%)	44_b (26.7%)
	Not applicable	29_b (17.6%)	21_b (12.7%)
Does the CORP ask for or assess Diarrhea?	Asked	126_a (76.4%)	154_a (93.3%)	18.48 (0.000)
Does the CORP ask for or assess Diarrhea?	Not Checked	39_b (23.6%)	11_b (6.7%)	18.48 (0.000)
Does the CORP ask for or assess Fever?	Asked	141_a (85.5%)	159_a (96.4%)	11.88 (0.001 )
Does the CORP ask for or assess Fever?	Not Checked	24_b (14.5%)	6_b (3.6%)	11.88 (0.001 )
Does the CORP assess or take RDT? (for fever only)	Yes	98_a (59.4%)	144_a (87.3%)	32.79 (0.000 )
Does the CORP assess or take RDT? (for fever only)	No	67_b (40.6%)	21_b (12.7%)	32.79 (0.000 )
Interpreted correctly?	Yes	47_a (28.5%)	165_a (100%)	183.68 (0.000)
Interpreted correctly?	No	118_b (71.5%)	0_b (0.0%)	183.68 (0.000)
Does the CORP identify all problems correctly?	Yes	134_a (81.2%)	138_a (83.6%)	0.34 (0.563)
Does the CORP identify all problems correctly?	No	31_a (18.8%)	27_a (16.4%)	0.34 (0.563)

3.4 Assessment of the quality of treatment for fever, cough, diarrhea

During the intervention time, the PPMVs' treatment quality in all three illness areas vastly improved according to the information on Table 4. In the first quarter, 21.8% of people did not know how to cure malaria; however, the percentage fell to 1.8% in the second quarter (ꭓ² = 31.67, p-value = 0.000). In the second quarter, the number of people who couldn't treat cough and quick breathing dropped from 47 (28.5%) to 14 (8.5%) (ꭓ² = 21.90, p-value = 0.000). In the second quarter, the number of PPMVs that were unable to treat diarrhea after following the proper treatment protocol fell from 33.3–2.4% (ꭓ² = 53.68, p-value = 0.000). In the first quarter, 43.6% of PPMVs didn't know what pre-referral treatment to administer, but this reduced to 14% in the second quarter (ꭓ² = 35.49, p-value = 0.000).

Table 4

The quality of treatment for fever, cough, and diarrhea
Variable (N = 165)		Quarter 1	Quarter 2	ꭓ² (p-value)
How to treat malaria?	Yes	129_a (78.2%)	162_a (98.2%)	31.67 (0.000)
How to treat malaria?	No	36_b (21.8%)	3_b (1.8%)	31.67 (0.000)
How to treat cough and fast breathing?	Yes	118_a (71.5%)	151_a (91.5%)	21.90 (0.000)
How to treat cough and fast breathing?	No	47_b (28.5%)	14_b (8.5%)	21.90 (0.000)
How to treat diarrhea?	Yes	110_a (66.7%)	161_a (97.6%)	53.68(0.000)
How to treat diarrhea?	No	55_b (33.3%)	4_b (2.4%)	53.68(0.000)
What pre-referral treatment to give?	Yes	93_a (56.4%)	142_a (86.0%)	35.49 (0.000)
What pre-referral treatment to give?	No	72_b (43.6%)	23_b (14%)	35.49 (0.000)

3.5 Comparing trends in case management for common childhood illnesses among PPMVs

When the case management trends for common childhood illnesses among PPMVs were examined between the two quarters, there was a significant shift as shown in Table 5. When a sick child is brought to their facility, the PPMVs have been habituated to looking for danger indications (ꭓ2 = 2.59, p-value = 0.274). There was also an improvement in the practice of referring a youngster who showed signs of danger. In the second quarter, the number of PPMVs who would outright refer a child with a danger indication jumped from 92(55.8%) to 156(94.5%) (ꭓ2 = 66.47, p-value = 0.000). Improved referral facilitation and follow-up have also been documented. In the second quarter, the percentage of improved referral facilitation and follow-up increased from 50.3–84.2% (ꭓ2 = 43.16, p-value = 0.000).

Table 5

Comparing trends in case management for common childhood illnesses among PPMVs
Variable (N = 165)		Quarter 1	Quarter 2	ꭓ² (p-value)
Does the CORP ask or assess for danger signs?	Checked	94_a (57%)	100_a (60.6%)	2.59 (0.274)
	Not Checked	22_a (13.3%)	13_a (7.9%)
	Partially Checked	49_a (29.7%)	52_a (31.5%)
Refers if child has a danger sign or condition he/she cannot treat?	Yes	92_a (55.8%)	156_a (94.5%)	66.47 (0.000)
	No	73_b (44.2%)	9_b (5.5%)	66.47 (0.000)
Facilitate referral (provide referral note and first dose of drugs) and counsel for follow-up correctly	Yes	83_a (50.3%)	139_a (84.2%)	43.16 (0.000)
	No	82_b (49.7%)	26_b (15.8%)	43.16 (0.000)

3.6 Assessment of Improvement in Data Quality

There was an overall improvement in data gathering and record keeping. In Table 6, more PPMVs learned how to accurately fill out the daily corps register. During the study period, the number of PPMVs who could fill daily corps registers increased from 144 (87.3%) to 156 (94.5%) (ꭓ² = 5.65, p-value = 0.059). Other than the 110(66.7%) documented in the first quarter, 132(80.0%) learned how to do their page summaries for the last full sheet (ꭓ² = 8.07, p-value = 0.018). They also made it a habit to preserve copies of the prior three ICCM HMIS forms. Only 125 (75.8%) possessed copies of their prior three ICCM HMIS forms in the first quarter, but 141 (85.5%) did in the second (ꭓ² = 29.39, p-value = 0.000). The importance of sending their ICCM HMIS forms to health facilities has also been recognized by PPMVs. Only 73 (44.2%) of PPMVs submitted an ICCM HMIS form to the health institution in the first quarter, but following months of skill reinforcement, 115 (69.7%) of PPMVs submitted an ICCM HMIS form to the health facility ((ꭓ² = 22.63, p-value = 0.000).

Table 6

Data Quality
Variable (N = 165)	Yes N = 165
Variable (N = 165)	Quarter 1	Quarter 2	ꭓ² (p-value)
Daily CORPs register filled correctly	144_a (87.3%)	156_a (94.5%)	5.65 (0.059)
Page Summaries done correctly for last full sheet	110_a (66.7%)	132_a (80.0%)	8.07 (0.018 )
Copies of at least previous 3 ICCM HMIS forms kept	125_a (75.8%)	141_a (85.5%)	29.39 (0.000 )
ICCM HMIS form submitted to health facility last month	73_a (44.2%)	115_a (69.7%)	22.63 (0.000)

3.7 Assessment of the Availability of Commodities

According to Table 7, as a result of the intervention's demand creation activities, commodity demand increased. As a result, the availability of several products, such as amoxicillin (77.6% − 63.0%), low osmolar ORS (92.1% − 91.5%), and antimalarials, has decreased (89.1% − 81.2%). The PPMVs' connection to local medication manufacturers increased product availability. In the second quarter, the number of products available expanded dramatically. The number of PPMVs with at least 10 packs of 25mg Arthemether – 67.5mg Amodiaquine/Lumefantrine (AL/AA) increased by 32.1% (ꭓ² = 44.85, p-value = 0.000), 50mg Arthemether – 135mg Amodiaquine/Lumefantrine increased from 41.8–66.1% (ꭓ² = 36.60, p-value = 0.000), While the number of PPMVs with roughly 60 Zinc pills increased from 88.5–90% (ꭓ² = 0.29, p-value = 0.592). The number of PPMVs with a timer and a continuous supply of AL/AA, Amoxicillin, and Low Osmolar ORS for 7 days or more without any stock-out of this product increased from 8.5–90.9% (ꭓ² = 1.81, p-value = 0.404).

Table 7

Availability of Commodities
Variable (N = 165)	Yes N = 165
Variable (N = 165)	Quarter 1	Quarter 2	ꭓ² (p-value)
Did you have dispersible amoxicillin everyday last month? If No For how many days were you without dispersible amoxicillin?	128_a (77.6%)	104_a (63.0%)	8.48(0.014 )
Arthemether Lumefantrine (AL) at least 20 full dose	134_a (81.2%)	135_a (81.8%)	0.34 (0.845)
25mg Arthemether – 67.5mg Amodiaquine (at least 10 packs)?	63_a (38.2%)	116_a (70.3%)	44.85 (0.000)
50mg Arthemether- 135mg Amodiaquine (at least 10 packs)?	69_a (41.8%)	109_a (66.1%)	36.60 (0.000 )
Low osmolar ORS (at least 10 sachets)	152_a (92.1%)	151_a (91.5%)	0.04 (0.841)
Did you have antimalarial every day last month? If No. for about How many days were you without antimalarial?	147_a (89.1%)	134_a (81.2%)	4.05 (0.044)
Did you have low osmolar ORS everyday last Month? If No For about how long were you without Low Osmolar ORS	148_a (89.7%)	143_a (86.7%)	0.73(0.394 )
Zinc tablet (approximately 60 tablets)	146_a (88.5%)	149_a (90.3%)	0.29 (0.592)
Chlorhexidene gel 4% (at least 10 tubes)	14_a (8.5%)	23_a (13.9%)	62.64 (0.000 )
Did you have continuous supply of AI/AA,Amoxicillin and Low Osmolar ORS? For the last 3 months without any stock out of this product?	106_a (64.3%)	58_a (35.2%)	1.18 (0.555)
Did you have a timer and a continuous supply of AI/AA, Amoxicillin and Low Osmolar ORS For 7 Days or more without any stock-out of this product	14_a (8.5%)	150_a (90.9%)	1.81 ( 0.404)

This research focuses on reducing under-5 mortality rate resulting from malaria, pneumonia, and diarrhea in Nigeria by improving the skill of PPMVs to offer high-quality, cost-effective health care to under-5 children with malaria, pneumonia, or diarrhea. Our findings demonstrate that PPMVs are an important source of care for children with illnesses and, if properly educated and supported, could give a chance to enhance children's health in the community. At the outset, the quality of the services was subpar, however the training and implementation of the DEL2ALL interventions increased service quality. This is in line with prior research, which showed that increasing iCCM for uncomplicated pneumonia with the help of PPMVs can help to lower disease burden [14].

Late detection of childhood illnesses is a leading cause of death in underdeveloped nations, according to recent studies. Early detection and treatment of illnesses will reduce the severity of cases and fatality. The capacity-building exercise resulted in earlier case detection and improved rapid treatment, reducing severe cases and death. This study shows that if PPMVs are given diagnostic supplies and pediatric formulations, instances will be identified earlier and diseases in children will be better handled. In a recent study in Uganda, drug retailers who were taught in iCCM and given diagnostic supplies as well as pre-packaged kid versions of ACT, amoxicillin, ORS, and zinc successfully managed childhood infections in 87.7% of cases [5].

To engage PPMVs in delivering iCCM, more training is required to improve fundamental health awareness and stocking and selling standards. The WHO recommends continuing education and promotion of iCCM through PPMVs in an evidence-based guideline for the management of diseases in children under the age of five. Through teaching and support of PPMVs, promotion of iCCM for the treatment of uncomplicated cases of malaria, pneumonia, and diarrhea in children under the age of five years offers promise.

PPMVs are qualified to train and certify as community-based resource persons to deliver iCCM. The training provided before enlisting PPMVs to deliver iCCM, as well as the ongoing assistance, improved PPMVs' case management patterns for common childhood illnesses. In some places, iCCM activities have been successful owing to the participation of trained community health workers. In Ghana and Uganda, lay community health workers who had been trained in dosage and referral for fever and pneumonia treatment were able to treat the majority of cases among children under the age of five [8].

PPMVs also have a number of attributes that appeal to community members, including as longer opening hours, friendliness, and more consistent availability than public facilities, which are prone to service outages [7, 15]. Because of their broad presence, well-regulated and well-trained PPMVs could help Nigeria achieve Universal Health Coverage by becoming increasingly involved in innovative health initiatives like integrated community case management (iCCM). There was a general improvement in record keeping and data collecting as a result of this research. More PPMVs learned how to accurately fill out the daily corps register. If properly trained, PPMVs could function as an efficient lay cadre of iCCM providers in Nigeria. During the intervention period of this study, the quality of therapy provided by the PPMVs in all three disease areas significantly improved, due to the trainings and support.

Our findings show that PPMV trainings are still an effective way to help PPMVs enhance their capacity to provide better healthcare to their communities. Increasing the frequency of training can help improve product distribution accessibility and coverage [9]. The assistance offered through the DEL2ALL method enhanced commodity access and availability. PPMVs are an excellent platform for optimum healthcare delivery since they stock and sell products and have appropriate understanding of the necessary therapy, and this is dependent on their ongoing training.

Refresher trainings for PPMVs have the impact of enhancing the level of knowledge and practices in specific areas, such as acceptable prescription procedures for the treatment of diarrhea, malaria, and pneumonia. Drug stores play an essential role in delivering basic healthcare services in Nigeria, and interventions to reduce disease and death must take this into account.

Because of the huge presence of PPMVs in rural and Sub-urban communities, this cadre of health care providers will be valuable in improving national statistics on under-5 mortality. Training PPMVs and reinforcing their skills will greatly improve service delivery and minimize mortality. The problem of commodity access and availability can be solved by assisting PPMVs by way of connecting them with local drug manufacturers and developing a mechanism for them to stock commodities through the government.

There is a need for continuous education for the PPMVs to enable this cadre of health providers understand their limits and improve their understanding and practice of early referral. Capacity building for PPMVs should focus on enhancing their services so that they can do more in the areas of minor disease diagnosis and pharmaceutical product knowledge. More research is needed to determine the best training strategies for increasing PPMV knowledge.

AA = Arthemether- Amodiaquine

ACT = Artemisinin- base Combination Therapy

AL = Arthemether Lumefantrine

CORPs = Community Resource Persons

DEL2ALL = Delivering Health to All Children

FMOH = Federal Ministry of Health

HMIS = Health Management Information System

ICCM = Integrated Community Case Management

IMCI = Integrated Management of Childhood Illnesses

IPCA = Interpersonal Communication Agents

JCHEW = Junior Community Health Extension Workers

LGA = Local Government Area

NDHS = National Health Demographic Survey

ORS = Oral Rehydration Solution

PPMV = Patent and Proprietary Medical Vendors

RDT = Rapid Diagnostic Test

SFH = Society for Family Health

SPSS = Statistical Package for Social Sciences

SCHEW = Senior Community Health Extension Worker

UNICEF = United Nation International Children Emergency Fund

WHO = World Health Organization

Ethics approval and consent to participate

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board, Nigerian Institute of Medical Research (Project No: IRB/20/099 dated 12^th Jan 2021). Informed consent was obtained from all the respondents involved in the study.

Consent for publication

Not applicable

Availability of data and materials

The data that support the findings of this study are available from Society for family Health Nigeria but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Society for Family Health Nigeria.

Competing interests

The authors declare no competing interest

Funding

The project was funded by NORVATIS Foundation while this particular study was fully funded by the authors’ affiliated organization (Society for Family Health).

Authors' contributions

Affiliations

All the authors are affiliated to the Society for Family Health, Nigeria

Akpu Blessing Oko¹ - Society for Family Health, Nigeria,

Anyanti Jennifer²- Society for Family Health, Nigeria,

Adizue Jane Chinyere³ - Society for Family Health, Nigeria,

Nwankwo Nelson^{4 -}Society for Family Health, Nigeria,

Idogho Omokhudu⁵ - Society for Family Health, Nigeria,

Onyezobi Chinedu Edward⁶ - Society for Family Health, Nigeria,

Aizobu Dennis⁷ - Society for Family Health, Nigeria.

Contributions

ABO, AJ, AJC, IO, and AD were responsible for conception of the study and initiated the design; ABO, AJ, AJC, and AD implemented the program. The manuscript text was written by NN and ABO. NN was in charge of data acquisition, data analysis, and data interpretation; OCE was in charge of data analysis review; and all authors were involved in the manuscript review and approval.

Acknowledgements

We would like to thank the patent and proprietary medical vendors that contributed to this study.

Authors' information

Akpu Blessing Oko: Programs Department, Society for Family Health, <[email protected]>
Anyanti Jennifer: Programs Department, Society for Family Health, <[email protected]>
Adizue Jane Chinyere: Project support Unit, Society for Family Health, <[email protected]>
Nwankwo Nelson: Research, Monitoring and Evaluation Department, Society for Family Health, [email protected]
Idogho Omokhudu: Programs and Operation Department, Society for Family Health, <[email protected]>
Onyezobi Chinedu Edward: Maternal and Reproductive Health Department, Society for Family Health, <[email protected]>
Aizobu Dennis: International Operation Department, Society for Family Health, <[email protected]>

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No competing interests reported.

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Assessment of integrated Community Case Management of Childhood illness (iCCM) practices by trained Patent and Proprietary Medicine Vendors (PPMVs) in Ebonyi and Kaduna States, Nigeria

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Abstract

I. Introduction

Ii. Materials And Methods

Iii. Results

Iv. Discussion

V. Conclusion

Vi. Recommendations

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References

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