Background: As the African Programme for Onchocerciasis Control (APOC) matured into its 10^th year of ensuring community involvement in mass annual treatment of onchocerciasis with ivermectin, there was recognition of a need to study not only annual coverage of ivermectin in villages but also the compliance of individual villagers with these annual treatments. This was based on the concern that while population coverage goals may be achieved each year, there might be segments of the population who systematically are not complying with the annual regimen, thus creating a reservoir of infection and threatening program gains. Methods: A multi-site study in five APOC sponsored projects in Nigeria and Cameroon was undertaken to identify the socio-demographic correlates of compliance with ivermectin treatment. A total of 8,480 villagers above 9 years of age selected through a systematic random sampling from 101 communities were surveyed to ascertain their levels of compliance, by adapting APOC's standard household ivermectin survey form. Community leaders, community directed distributors (CDDs) of ivermectin and health workers were interviewed with in-depth interview guides, while focus group discussions were held with community members to help explain how socio-demographic factors might affect compliance. Results: Eight-year compliance ranged from 0 to 8 times with 42.9% taking ivermectin between 6-8 times annually (high compliance). In bivariate analysis high compliance was positively associated with being male, over 24 years of age, having been married, not being Christian, having little or no formal education and being in the ethnic majority. These variables were also confirmed through regression analysis based on total times ivermectin was taken over the period. While these factors explained only 8% of the overall variation in compliance, ethnic status and education appeared to be the strongest factors. Those with higher education may be more mobile and harder to reach while neglect of ethnic minorities has also been documented in other programs. Conclusion: These findings can help managers of CDTI programmes to ensure ivermectin reaches all segments of the population equally.

Background: Despite massive anti-malaria campaigns across the subcontinent, effective access to intermittent preventive treatment (IPTp) and insecticide-treated nets (ITNs) among pregnant women remain low in large parts of sub-Saharan Africa. The slow uptake of malaria prevention products appears to reflect lack of knowledge and resistance to behavioural change, as well as poor access to resources, and limited support of programmes by local communities and authorities. Methods: A recent community-based programme in Akwa Ibom State, Nigeria, is analysed to determine the degree to which community-directed interventions can improve access to malaria prevention in pregnancy. Six local government areas in Southern Nigeria were selected for a malaria in pregnancy prevention intervention. Three of these local government areas were selected for a complementary community-directed intervention (CDI) programme. Under the CDI programme, volunteer community-directed distributors (CDDs) were appointed by each village and kindred in the treatment areas and trained to deliver ITNs and IPTp drugs as well as basic counseling services to pregnant women. Findings: Relative to women in the control area, an additional 7.4 percent of women slept under a net during pregnancy in the treatment areas (95% CI [0.035, 0.115], p-value < 0.01), and an additional 8.5 percent of women slept under an ITN after delivery and prior to the interview (95% CI [0.045, 0.122], p-value < 0.001). The effects of the CDI programme were largest for IPTp adherence, increasing the fraction of pregnant women taking at least two SP doses during pregnancy by 35.3 percentage points [95% CI: 0.280, 0.425], p-value < 0.001) relative to the control group. No effects on antenatal care attendance were found. Conclusion: The presented results suggest that the inclusion of community-based programmes can substantially increase effective access to malaria prevention, and also increase access to formal health care access in general, and antenatal care attendance in particular in combination with supply side interventions. Given the relatively modest financial commitments they require, community-directed programmes appear to be a cost-effective way to improve malaria prevention; the participatory approach underlying CDI programmes also promises to strengthen ties between the formal health sector and local communities.

Objective  To assess individual compliance with annual ivermectin treatment in onchocerciasis‐endemic villages.Methods  Multi‐site study in eight APOC‐sponsored projects in Cameroon, Nigeria and Uganda to identify the socio‐demographic correlates of compliance with ivermectin treatment. A structured questionnaire was administered on 2305 persons aged 10 years and above. Two categories of respondents were purposively selected to obtain both high and low compliers: people who took ivermectin 6–8 times and 0–2 times previously. Simple descriptive statistics were employed in characterizing the respondents into high and low compliers, while some socio‐demographic and key perceptual factors were employed in regression models constructed to explain levels of compliance among the respondents.Results  Some demographic and perceptual factors associated with compliance were identified. Compliance was more common among men (54.4%) (P < 0.001). Adults (54.6%) had greater rates of high compliance (P < 0.001. The mean age of high compliers (41.5 years) was significantly older (35.8 years) (t = 8.46, P < 0.001). Perception of onchocerciasis and effectiveness of ivermectin influenced compliance. 81.4% of respondents saw benefits in annual ivermectin treatment, high compliance among those who saw benefits was 59.3% compared to 13.3% of those who did not (P < 0.001).Conclusion  Efforts to increase compliance with ivermectin treatment should focus on providing health education to youth and women. Health education should also highlight the benefits of taking ivermectin.

Summary: Objectives  To document peoples’ perceptions of the benefits of taking ivermectin, as an important predictor of sustained compliance with long‐term ivermectin treatment, and to identify the socio‐demographic correlates of perceived benefits of ivermectin treatment.Methods  Multisite study in Cameroon, DRC, Nigeria and Uganda. A structured questionnaire was administered to 1600 persons randomly selected from household treatment records. Community leaders, community‐directed drug distributors (CDDs) and health workers were interviewed using in‐depth interview guides, while focus group discussions (FGDs) were held with community members to capture factors that reflected their perception of benefits of community‐directed treatment with ivermectin (CDTI). Case histories of persons with special experiences with onchocerciasis were collected.Results  In this study, 84.7% of respondents indicated that ivermectin treatment has many benefits. The social benefits of CDTI included improved ability to work, peer acceptance and improved school attendance. Other individual benefits included self‐respect/esteem, election to political office and improved relationship in the homes. The health benefits included improved skin texture and less ill health. Important demographic factors that influenced perception of the benefits of taking ivermectin, include marital status (P = 0.012), age (P = 0.029) and length of stay in onchocerciasis‐endemic communities (P < 0.001). Another factor was individual perception of susceptibility to onchocerciasis infection (P < 0.0001).Conclusion  A programmatic focus on the benefits of CDTI could provide a basis for motivating communities to comply with long‐term treatment with ivermectin. The results illustrate the importance of capturing beneficiaries’ perceptions towards CDTI as a resource for producing health education materials for increasing the sustainability ivermectin distribution in endemic countries.

The relationship between people’s perception and utilization of public health serviceswas investigated. A survey of 840 households across selected urban, peri urban and rural communities, in the Southeast of Nigeria, was conducted using the mixed methods approach. Of the nine (9) demographic variables, only the locality and status of the health system (strong or weak in terms of child immunization) was found to influence both the poor rating and utilization of public health services. Individuals from states with strong health system rated relatively higher and used public health services more (p < 0.001), than their counterparts from states with weak health care system. Similarly, those in the urban or peri-urban localities used public health services more (p = 0.013). The two perceptual variables significantly influence the rating and use of public health services. Those with a good perception of the quality of health service provided, rated and patronized them more (p < 0.001). Also, health centres that provide a high number of services enjoyed greater rating and patronage (p < 0.001 and p = 0.0524 respectively). The results of the structured questionnaire survey were confirmed by qualitative enquiry,based on in-depth interviews and focus group discussions. It will be necessary to create a more responsive atmosphere in the health facilities, with culturally-sensitive and friendly health workers, and provision of affordable drug to improve the perceptions of the primary health care system, for it to succeed in providing health services for all.