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Understanding the Factors Enabling and Blocking Sustained Implementation of Cholera Interventions in a Fragile Region Of F1000Research 2021, 10:85 Last updated: 04 AUG 2021 STUDY PROTOCOL Understanding the factors enabling and blocking sustained implementation of cholera interventions in a fragile region of Nigeria: a multi-phase group model building study protocol [version 1; peer review: 2 approved with reservations] Kelly Elimian 1, Carina King 1, Karin Diaconu2, John Ansah3, Sebastian Yennan4, Chinwe Ochu4, Emmanuel Pembi5, Gandi Benjamin6, Birger Forsberg1, Chikwe Ihekweazu4, Tobias Alfvén1 1Department of Global Public Health, Karolinska Institute, Stockholm, Sweden 2Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK 3Health Services and Systems Research, Duke-NUS Medical School Singapore, Singapore, Singapore 4Nigeria Centre for Disease Control, Nigeria Centre for Disease Control, Abuja, Nigeria 5Adamawa State Ministry of Health, Yola, Adamawa, Nigeria 6Bauchi State Ministry of Health, Bauchi, Bauchi State, Nigeria v1 First published: 09 Feb 2021, 10:85 Open Peer Review https://doi.org/10.12688/f1000research.50831.1 Latest published: 09 Feb 2021, 10:85 https://doi.org/10.12688/f1000research.50831.1 Reviewer Status Invited Reviewers Abstract Introduction: Adamawa and Bauchi are cholera endemic states in the 1 2 north-east region of Nigeria, each with local government areas classified as cholera hotspots. Ineffective implementation of multi- version 1 sectoral cholera interventions in both states could make obtaining the 09 Feb 2021 report report global target for cholera control in Nigeria out of reach. A major contributing factor to this challenge is fragility of the region due to 1. Kenny Moise , Université Quisqueya, Port- persistent Boko Haram insurgency activities, often characterised by the destruction of health infrastruture and displacement of au-Prince, Haiti communities to areas with suboptimal living conditions. Given the Aude Mélody Achille, Université Quisqueya, complexity of disease control in such a fragile setting, this study aims Port-au-Prince, Haiti to systematically examine the barriers and/or facilitators influencing the implementation of existing cholera interventions in these states. 2. Godfrey Bwire , Makerere University Methods: The study will use a systems dynamic approach. First, we will conduct a health facility survey to determine the current health College of Health Sciences, School of Public system capacity to support multi-sectoral cholera interventions, and Health, Kampala, Uganda conduct key informant interviews with purposely selected state and national cholera stakeholders to identify the context-specific Any reports and responses or comments on the facilitators and barriers to the implementation of cholera article can be found at the end of the article. interventions in these states. We will then conduct nine group model building workshops (four in both the Adamawa and Bauchi states and one in Abuja) among cholera stakeholders similar to those recruited for the interviews. Page 1 of 16 F1000Research 2021, 10:85 Last updated: 04 AUG 2021 Conclusion: By engaging diverse and relevant cholera stakeholders, including community members, this study has the potential to provide a rich understanding of context-specific factors influencing the implementation of multi-sectoral cholera interventions in a fragile region of Nigeria, with a view to achieve sustainable progress towards cholera control in the country. Moreover, this study could have an impact on the control of other water-borne diarrheagenic diseases in the country. Keywords Cholera; Fragility; Multi-sectoral; System dynamic; Group model building; Adamawa; Bauchi; Nigeria Corresponding author: Kelly Elimian ([email protected]) Author roles: Elimian K: Conceptualization, Funding Acquisition, Methodology, Resources, Software, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing; King C: Conceptualization, Funding Acquisition, Methodology, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing; Diaconu K: Investigation, Methodology, Validation, Writing – Original Draft Preparation, Writing – Review & Editing; Ansah J: Methodology, Supervision, Visualization, Writing – Review & Editing; Yennan S: Project Administration, Supervision, Validation, Writing – Review & Editing; Ochu C: Project Administration, Resources, Supervision, Visualization, Writing – Review & Editing; Pembi E: Investigation, Project Administration, Resources, Supervision, Writing – Review & Editing; Benjamin G: Investigation, Project Administration, Resources, Supervision, Writing – Review & Editing; Forsberg B: Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing; Ihekweazu C: Project Administration, Resources, Supervision, Visualization, Writing – Review & Editing; Alfvén T: Conceptualization, Funding Acquisition, Methodology, Project Administration, Resources, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests: No competing interests were disclosed. Grant information: This study is funded by Swedish Forte (registration number: 2020-00027). The grant was assigned to Kelly Elimian for his Postdoctoral International Fellowship. The funder had no involvement in the design or writing of this protocol. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2021 Elimian K et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Data associated with the article are available under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original data is properly cited. How to cite this article: Elimian K, King C, Diaconu K et al. Understanding the factors enabling and blocking sustained implementation of cholera interventions in a fragile region of Nigeria: a multi-phase group model building study protocol [version 1; peer review: 2 approved with reservations] F1000Research 2021, 10:85 https://doi.org/10.12688/f1000research.50831.1 First published: 09 Feb 2021, 10:85 https://doi.org/10.12688/f1000research.50831.1 Page 2 of 16 F1000Research 2021, 10:85 Last updated: 04 AUG 2021 Introduction Cholera endemic countries are required to contextualise and Despite the possible underestimation due to limited surveillance implement the GTFCC strategic roadmap; however a significant and reluctance to report cases for economic reasons, approxi- constraint—and a possible source of reversal to current gains— mately 2.9 million cholera cases and 95,000 cholera-related deaths is fragility. This can be the result of violence and prolonged are recorded annually worldwide1. These occur predominantly in conflict, political and economic instability, marginalisation and 47 endemic countries2. Notably, since 2017, the inequitable bur- inequality, weak and distorted national governance structures den of cholera has continued to increase, with the poorest and and processes, and significant environmental threats and natural most vulnerable populations in fragile settings with inadequate disasters12. Fragility can impact public health by limiting a portable water, sanitation and hygiene most at risk3. Cholera population’s capacity to respond and adapt to stressors and elimination as a target, sits across the United Nation’s (UN) shocks, such as a disease outbreak in a humanitarian setting. Sustainable Development Goals (SDG) agenda4, given its roots A 2020 WHO report indicates a decrease in progress in inequity, poverty, environmental threats and conflict. This is towards cholera control, with nearly double the number of chol- because public health measures targeting cholera have an explicit era cases during 2019 (923,037) than 2018 (499,447); the number implication for water-related diseases within SDG3 (ensur- of cholera-related deaths however decreased by 36% (from ing healthy lives and promoting wellbeing for all) and an 2,990 in 2018 to 1,911 in 2019)13. Notably, 93% of cases in implicit implication for tracking progress towards achieving 2019 were from Yemen, a country that has become extremely f SDG6 –universal and equitable access to safe and affordable drink- ragile by recurrent armed conflicts with frequent, widespread ing water, and access to adequate and equitable sanitation and cuts in water supplies13. A similar trend was also noted in hygiene for all. Additionally, cholera transmission is an impor- Mozambique, where—amidst successive cyclones with heavy rains tant motivation for the development of the 1952 World Health and population displacement in 2019—over 7,000 cholera cases Organization’s (WHO) International Sanitary Regulations5, given was recorded in comparison to 910 cases in the previous year13. its capacity to impact global health security and economic growth6. In Nigeria, the burden of diarrhoeagenic diseases is extremely While substantial progress has been made towards cholera high, having the second highest total of under-5 child deaths from control in the SDG era, a combination of climate change, natural pneumonia and diarrhoea in the world14. Nigeria has witnessed two and man-made disasters, and rapid unplanned urbanisation con- major cholera outbreaks in recent years, with over 40,000 cases 7 tinue to support transmission . The WHO’s Global Task
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