Integration of Hiv/Aids Prevention Into

INTEGRATION OF HIV/AIDS PREVENTION INTO ONCHOCERCIASIS CONTROI., PROGRAMME IN ANINRI AND OII-RIVER I,OCAI, GOVERNMENTAREAS, ENUGU STATE, NIGERIA USING THE COMMUNITY DIRECTED APPROACH OF APOC

KAP Study Report

ENUGU STATE MINISTRY OF HEALTH

In Collaboration With

GLOBAL HEALTH AWARENESS RESEARCH FOUNDATION (GHARF) ENUGU

Submitted to

African Programme for Onchocerciasis Contol Ouagadougou, Burkina Faso

September,2005

HECU t I srP. zooF APoclsft ll

ACKNOWLEDGEMENT

The African Programme for Onchocerciasis Control (APOC) provided the funds and logistic supports for this study. We owe the success of this exercise to cooperation received from APOC and National Onchocerciasis Control Programme (NOCP), Nigeria. We would like to thank specifically the following persons for their contributions and assistance towards the successful execution of this assignment:

Dr A. Seketeli, Director APOC and his staff for making available the necessary financial and logistic requirements for the success of this assignment. Dr Jonathan Jiya, National Coordinator, NOCP, Nigeria and his staff for facilitating execution of the study. The cooperation of the community members and their leaders interviewed is also recognised Our special thanks go to the Commissioner of Health and staff of the Ministry of Health Enugu for the kind reception and encouragement accorded the study team. The cooperation of the community members and their leaders interviewed is also recognised. The invaluable contribution of staff of GHARF and Onchocerciasis control offices in Enugu in collecting, coding and computer processing the data for this study is also lll

LIST OF ACRYNOMS

APOC African Programme for Onchocerciasis Control BCC Behavioral Change Communication CBIT Community Based Ivermectin Treatment CDDs Community Directed Distributors CDTI Community Directed treatment with Ivermectin CSM Community Self Monitoring CSO Civil Society Organization ESBS Enugu State Broadcasting Service FGD Focus Group Discussion FLHF First Line Health Facility FMOH Federal Ministry of Health FRCN Federal Radio Corporation of Nigeria GHARF Global Health Awareness Research Foundation GRBP Global 2000 River Blindness Programme HFS Health Facility Staff HIV Human Immuno- Deficiency Syndrome IDP Ivermectin Distribution Programme IEC Information, Education and Communication KAP Knowledge, Attitude and Practice LACA Local Government Action Committee on HIV/AIDS LGA Local Government Area LOCT Local Government Onchocerciasis Control Team M&E Monitoring and Evaluation MF Microfilaria MOH Ministry of Health MOU Memorandum of Understanding NASCP National AIDS/STL Control Programme NGDO Non-Governmental Development Organization NGOs Non-Governmental Organizations NOCPs National Onchocerciasis Control Programme NTA Nigerian Television Authority ovc Orphaned and Vulnerable Children PABA People Affected with HIV/AIDS PHC Primary Health Care PHCC Primary Health Care Coordinator PLWHA People Living with HIV/ AIDS REMO Rapid Epidemiological Mapping of Onchocerciasis SACA State Action Committee on HIV/AIDS SMoH State Ministry of Health SOCT State Onchocerciasis Control Team STDs Sexually Transmitted Diseases STIs Sexually Transmitted Infection 1V

EXECUTIVE SUMMARY

Knowledge, Attitude and Practice survey on the view of community members on the integration of HIV/AIDS prevention programme with an already existing successful Onchocerciasis Control programme was undertaken in 2 LGAs, Aninri and Oji River in Enugu State in August 2005. The integration is aimed at strengthening the sustainability of the Onchocerciasis programme and contribute to the reduction of the HIV/AIDS prevalence among adolescents and other at risk individuals in the State. In Enugu State, HIV/AIDS exerts tremendous effect on the socio-economic status of the populace. Information on AIDS prevention is grossly inadequate especially in most rural communities. Moreover the provision of care and support to families of PLWHAs and PABAs has been more demanding on the haditional extended family, which is gradually disappearing, Hence the HIV/AIDS sero- prevalence of 4.9o/o in urban areas and 13.7o/o in rural areas. There is therefore need to reverse this trend.

The CDTI strategy in the control of Onchocerciasis has remained a successful intervention programme, having achieved more than 80% therapeutic and 100% geographical coverage in Enugu State.

The goal of the Knowledge, Attitude and Practice (KAP) survey is to document community knowledge, attitude and practice on the already existing CDTI strategy for use in providing appropriate and correct information, education and communication on HIV/AIDS prevention and also on how to ensure the sustainability of CDTI activities in Enugu State. A planning meeting was arranged by the research team comprising the principal investigator, the social scientist, the Director, Diseases Control at the Ministry of Health, the State CDTI project coordinator and a representative from the reproductive health unit before the survey started. At this meeting, modality for selection of target villages, number of individuals to be involved in both the qualitative and quantitative surveys and other activities were decided.

An important finding is that the respondents are very familiar with the CDTI strategy, where community takes major decision. All the respondents (91.7%) think that the CDTI process has recorded success in providing health services with special reference to onchocerciasis control. Also 94.4o/o of these categories of respondents think it would be a good idea if the CDTI system could be adopted for control of other health problems in the study communities.

On the other hand, the success of the CDTI prograrnme is acknowledged by a majority of the people in the communities and this recognition cuts across sex, age and social class. The people demonstrated remarkable knowledge of the CDTI process, which sees the community members making the major decisions on the implementation of onchocerciasis control as well as supporting the processes. Both the qualitative and quantitative data highlighted the advantages of taking the drug without prompting. This v included improvement in and protection of sight (48.3%) improvement in general health of community members (54.4%), de-worms (20.5%) and enhancement of strength for farm work (3.9%).It also highlighted the recognition and acceptance of community role in CDTI process among community members. The community members support, select and support the CDDs as well as collect their Mectizan@ from agreed points.

The results show that HIV/AIDS is a major source of concern to the people in the two LGAs selected for the study. However, collective efforts are put in place to control the spread of the disease as well as manage its impacts in the communities. HIV/AIDS as a problem was considered the first most important problem in the communitiesby 6.20/o of the respondents, the 2nd and 3'd most important health problem by 7.7% and7.3o/o of the respondents respectively.

Without prompting the respondents listed HIV/AIDS control, schistosomasis and ARI apart from Onchocerciasis as health problems that should be better delivered using the CDTI system. The ranking of the unprompted list of health problems to be integrated into CDTI process gave ARI as number one followed by HIV/AIDS after Onchocerciasis. This cuts across concern different age groups and sexes. There is statistical significant difference by sex among the respondents on the preferred health problem for inclusion in the CDTI process. This finding is corroborated with qualitative data on the type of health programme community members would want CDTI strategy to be used for its implementation.

The investigation therefore reveals that HIV/AIDS is a major problem of concern for the people with more that fwo thirds (76.2%) of the respondents indicating the existence of persons infected with HIV or affected with AIDS in their community. More than eight in every ten persons (88.2%) interviewed who were asked about the adoption of CDTI strategy for delivery of HIV/AIDS control opting for its use.

Previous efforts to control the spread of HIV/AIDS have been mainly in the area of awareness creation (99.2%), referral of infected persons for testing (100%) and counseling (100%). These activities as reported by 6.1% of the respondents are managed by community members and another 6.1%o indicated that it is managed by the non- governmental or ganizati ons operating in their communiti e s.

However these efforts have not been very successful as attested by 51.8% of the respondents. About 88% of the respondents support the integration of the HIV/AIDS control programme into CDTI process, where the community members would take the major decision.

For almost half (48.4%) of the respondents, the CDTI process is 'easy'. Other reasons for opting for the inclusion of HIV/AIDS control activities in the CDTI process include the involvement of community members (21.8%o), higher coverage (5.6%) and the sustainability of the prograrnme (3.6%). vl

In the qualitative study, members of the communities studied as well as their leaders called for the inclusion of HIV/AIDS control programme in the CDTI process. They argued that the CDTI has been successful and it is good because the CDDs know all the nooks and corners of the village and will ensure everybody is reached with HIV/AIDS message (Adolescent female, Amudo). To others it is a means of ensuring that those who are unable to be reached due to stigmatization and discrimination are also reached through house to house health education.

The people requested the delivery of the HIV/AIDS control programme using the structure of the well-established CDTI in the communities. The members of the communities, including the community leaders demonstrated optimism on the CDDs accepting the additional role of delivering HIViAIDS services, as part of their CDTI functions.

The CDDs were very clear on their roles in the CDTI process with86.7Yo mentioning treatment of community members;73.3oh health education in the communities,23.3%o drug collection and 333% record keeping. Almost all the CDDs (93.3%) interviewed indicated their willingness to take on additional task of HIV/AIDS control. Twenty percent of the CDDs prioritized HIViAIDS as a health problem to be included in CDTI process while 72.7% of the CDDs recognized HIV as a major health problem in their communities. On aspect of HIV/AIDS prevention to be included with CDTI process, 60.1,% of the CDDs mentioned awareness creation.

The CDDs also declared their willingness to deliver HIV/AIDS services in addition to their CDTI functions. The strategies including simultaneous delivery of HIV/AIDS health education and onchocerciasis control services. The CDDs indicated interest in creating awareness and delivering HIV/AIDS services. The CDDs (3.3%) indicated the need for adequate training as a means of ensuring that they are able to take on this additional role. They however requested for deliberate training and provision of the materials for the services.

The key recommendations therefore include

1 Training of CDDs to take on the Delivery of HIV/AIDS services in the communities

2. Sensitization of community members on the new roles of CDDs

J Provision of the necessary materials such as health education materials on HIV/AIDS, and other materials that would facilitate the delivery of the services in the State. vll

TABLE OF CONTENTS

ACKNOWLEDGEMENT ,.ll

LIST OF ACRYNOMS , iii

EXECUTIVE SUMMARY ,iv

TABLE OF CONTENTS vii

LIST OF MAP AND FIGURES.... ix

1.0 INTRODUCTION..... 1

1. 1 Situational Analysis ..... 1 1.2 Rationale of the Study.. J^ 1.3 Objectives of the Study 5 1.3. 1 Main Objective...... 5 1.3.2 Specific Objectives 5

2.0 METHODOLOGY ...... 6 2.1 Study Design...... 6 2.2 Study Area and Population ...,,.6 2.3 Sample Size and Sampling Technique...... 9 2.4Data Collection .10 2.5 Method of Data Analysis .10

3.0 RESULTS I2 3.1 Distribution of Data t2 3.2 Socio-demographic Characteri stics of Respondents...... L2 3.3 KAP on Health Problems in the Community and CDTI Strategy t4

4.0 CONCLUSIONS. 29

5.0 RECOMENDATION 31

APPENDICES 32 I STUDY INSTRUMENTS 33 II SCHEDULE OF KAP SURVEY IN NENWE EMULEMOKE CoMrr,rur.rii; 53 III SCHEDULE OF KAP SURVEY IN ACHI COMMTINITY ... 54 vlll

LIST OF TABLES

Tables Page

1 Distribution of Respondents by their Socio-demographic Characteristics 10

2 Distribution of Respondents by Prioritization of Health Problems (oh in parenthesis) 11

3 Distribution of Respondents by Knowledge of the Mectizan@ and the CDTI Strategy for Controlling the Disease t2

4 Distribution of Respondents by Opinion on Using Community Member for Health Care Provisioning 18

5 Distribution of Respondents on Issues about HMAIDS 20

6 Distribution of CDDs by Selected Characteristics 23

7 Distribution of CDDs on Attitudes to Additional Health Tasks 24 1X

LIST OF MAP AND FIGURES Page

Map 1: Showing the two pilot LGAs (Aninri and Oji-River) in Enugu State 5

Fig. 1: Distribution of Respondents on Dosage Determination and Source of Information by LGA t7

Fig. 2: Distribution of Respondents on Perceived Most Important Health Problem for Inclusion in CDTI Process by LGA, Sex and Agegroup t9 I

1.0 INTRODUCTION

1.1 Situational Analysis

1.1.1. HMAIDS situation in Enugu State

Since 1986, when HIV/AIDS was discovered in a 13 -year female hawker, it has continued to decimate society, extending beyond the normal high risk groups to achieve saturation and generalization. This trend has continued in-spite of multi-sectoral and multi- disciplinary mitigation strategies enumerated by government, through the Enugu State Action Committee on HIV/AIDS (ENSACA). This body was created through a Presidential mandate to co-ordinate, facilitate, monitor and evaluate all HIV/AIDS prograrnmes in the state. It is also expected that they will mobilize human, material, and financial resources, as well as evolve the highest advocacy to ensure programme implementation. The health sector which is a strategic stakeholder within the multi-sectoral response, has been acknowledged to have central, pivotal and crucial roles to play. Within the last year, aggressive reform of the health sector is going on, both at federal and state levels. The sentinel surveillance reports for Enugu State show a steady rise from l:3% (1991), 2.7% (1993), l0:2 (1995), 4.7% (1999) 5:2% (2001) to 4.9% (2003), infecting over 76,000 people. It was observed during the survey, that rural sites have higher prevalence rates only in the south eastern part of Nigeria. For instance in Achi, a rural site in the state, the rate was 13.7% in 2003. Age -specific prevalence of HIV in south east zone in 2003 affirm that youths are most affected. Thus rates ranging from 4.7o/o (15-19), 5.2% (20-25 years), 3.6% (25-29years),3.7o/o (30-34years), 4.8o/o (35-39years) to 0.9% in (40-49 years) were found. Youths aged 20-26 years are worst hit. Further analysis of the data by level of education showed the highest prevalence among people with primary education (5.9%) and the secondary education (5.4%). From the general population, HIV/AIDS and Reproductive Health Survey (NARHS) of 2003, there are correlations between HIV prevalence and risk taking, by level of education and age. The NARHS report showed that younger women (15-19 years) and (20-24years) reported higher rates of multiple non-marital sex partnership of 12.9o/o and I 1.5% respectively, compared with to 2.7o/o among 30-39 years group. This was further collaborated by the finding that younger women between 15-19 years and 20-24 years, reported higher rates of sexual relationship of 12.6%o and l5o/o respectively, compared to 3.O%o.among those 30-39 years old. Women with only primary or secorrdary education had much higher rates of non-marital sex partnerships of 6.60/o and 14.0% respectively than these with 'no formal' or Quranic education of l.6oh respectively. The primary and secondary level groups also reported higher rates of sexual relationships of 7.2o/o and I6.2Yo respectively compared to the'no formal'and Quaranic education groups of l.7o/o and I.6Yo respectively. Thus results from the survey show 2 that younger age groups, primary and secondary education levels were associated with higher risk of HIV infection. Achi community, in Oji fuver local government area, with the highest HIV prevalence rate of 13.7% in Nigeria, is perhaps one of the few communities in Enugu State where girls could have children before marriage, without fear of marriage in future, or lost of integrity and status. This factor is perhaps the major catalyst, and it is further enhanced by location of many schools and institutions in the area - the School of Health Technology, Police College, School of Cooperative Studies, Police Station, Medium-sized Prison. Nenwe community on the other hand is located in the lowlands of Awgu local government area has high population of youths because of its proximity to Enugu, the state capital. It takes only 45 minutes drive from the community to the state capital. In both places, however, whereas 97.2% of the youths are aware of HIV/AIDS, up to 71.7% of them do not believe that sexual relationship has relevance to HIV/AIDS infection. And where 76.7% of them are aware of risk reduction measures including use of condoms, only 12.7% of the females and 35.5o/o of the males are willing to apply them. Furthermore, whereas 54.2% of females and 64.70/o of males respectively know, where HIV test could be carried out, only 18.1% and 18.8% respectively have actually done the test.

HMAIDS control activities in the state been in the following areas a. The Ministry of Health has organized sensitization of Health Care workers of all the secondary health facilities in the state. b. The ministry has also undertaken training of Health Workers on Voluntary Counselling and Testing (VCT) for prevention of Mother to Child Transmission (PMTCT) in 5 District Hospitals. c. Anti-retroviral drugs is available only at one site at the University of Nigeria Teaching Hospital in Enugu. The media, women groups and NGOS have ensured adequate information dissemination to evolve better knowledge attitudes and practices through youth and community sensitization and involvement. The Ministry of Health through its health education unit has tried to reach out to the communities through the local governments, but the impacts are yet to be seen. The state limited activities are informed by the fact that the Ministry of Health appointed a State HIV/AIDS Programme Coordinator was only this year. Also Enugu State Action Committee on HIV/AIDS (ENSACA) is trying to evolve a costed work-plan from all multi-sectoral stakeholders .This is to enable it access financial support. Meanwhile, the impact of the epidemic continues unabated.It appears therefore, that the key to more enduring and endearing intervention still remains with the health education through peer groups that can be trained at community level to ensure people-oriented, mass-driven, frontal confrontation with HIV/AIDS preventions strategies in our communities, particularly in Aninri and Oji River Local Government Area of Enugu State. l.l.2.Community Directed Treatment on lvermectin (CDTI) strategy

Community Directed Treatment on Ivermectin (CDTI) strategy has been in place in Enugu since 1998 and this project is in its seventh year of implementation of the CDTI strategy. It has provided an opporlunity for community members to take decisions on issues related to their health. CDTI activities commence annually in the state with advocacy visits to State and J

Local Government Policy makers to elicit their response towards supporting various implementation aspects of the prograrnme. Advocacy visits are simultaneously carried out with targeted mobilization at State, LGA and Community levels.

The partners involved in CDTI Implementation are the State Ministry of Health, Local Government Areas and CommunitiesA/illages. This includes APOC, NGDO's with Global 2000 as the supporting NGDO. The popular and successful implementation of the CDTI provides a window of opportunity to improve upon the HIV/AIDS prevention prograrnme apart from reduction in the level of prevalence of the diseases in various communities in Enugu State. We are therefore proposing to pilot a knowledge attirude and practice survey on the use of the successful CDTI strategy to carry out an information, education and communication activities on the prevent of HIV/AIDS in 2 selected LGAs in Enugu State.

1.2 Rationale of the Study

HIV/AIDS has impacted negatively on the lives of the populace in Enugu State. The epidemicity has exponentially moved from the known high-risk groups, to assume a generalized status where all community members are now at risk. This exerts tremendous effect on socio- economic development of the populace. Information on appropriate preventive measures by community members are still grossly inadequate. Moreover the provision of care and support to people living with HIV/AIDS (PLWHA) and people affected by HIV/AIDS (PABAs) has become more demanding as the traditional extended family system is gradually disappearing.

Accurate information on HIV/AIDS is not always readily available to adolescents in Nigeria, most especially in rural areas. In view of the rising number of adolescents infected by HIV/AIDS, there is need to provide services that will reverse this trend. In Enugu state, community members are not involved in any decision-making as it relates to HIV/AIDS prevention and control due to lack of appropriate structures for information dissemination. However, APOC in partnership with the Communities, National, State and Local health services as well as NGDOs has established a functional CDTI structure that is already on ground in most of the communities in Enugu state.

The HIV/AIDS control programme in Enugu State like in most parts of Nigeria moved from an initial stage of denial to health sector response and now to mult-sectoral response. This has brought on board government and non-governmental organizations, including FBO's and CSO's plus support from International Agencies and private sector even though response from the private sector has been minimal.

The sero- prevalence situation in the State (4.9Yo in urban areas and 13.7% in rural areas) with over 70,000 people affected, the steadily increasing population of OVCs, PLWHAs, PABAS and increase in mortality calls for increased advocacy, community sensitization and massive awareness campaign to improve STIs and HIV/AIDS prevention especially among the high risk groups. There is also need for capacity building of health service providers at all levels. 4

Integration of CDTI with HIV/AIDS prevention activities will help to provide this since the CDTI strategy already in place.

Integrating access to accurate information on the prevention of HIV/AIDS into CDTI strategy will therefore go a long way in improving HIV/AIDS control using the CDTI strategy. This will enable the community members to participate in the process and hence reduce mortality due to HIV/AIDS. Care and support of victims who are usually transported to the communities will augment self-esteem, improve nutrition, and improve referrals. Use of culturally appropriate information, education and communication materials will increase the acceptability of preventive measures and reduce rising STIs including HIV/AIDS and unwanted pregnancies and thereby effect rapid behavioral change. Finally, studies carried out in different countries; Bangladesh, Turkey, Mali, Malawi, Tanzania and Zimbabwe have shown the success of integrating other disease control strategies with reproductive health (RH) activities thus re-emphasizing the feasibility, replicability and sustainability of integration through CDTI strategy.

The benefits of the integration of HIV/AIDS with CDTI will include the following namely: i. Maintenance of long-term compliance to treatment with Ivermectin. Long term treatment of Onchocerciasis with Mectizanin the last 8 years has produced a sense of well being through reduction in itching, blindness and better skin appearance. Reduction of compliance to treatment may therefore evolve and this could lead to recrudescence of the disease. Integration may be one of the ways for ensuring sustainability of mectizan treatment for a long time. Furthermore, integration will correct areas of weakness identified during the 2003 evaluation in Enugu State. 5

1.3 Objectives of the Study

1.3.1 Main Objective To document community Knowledge, Attitude and Practice on the use of the already existing CDTI strategy to provide information, education and communication on HIV/AIDS prevention in communities and also ensure sustainability of CDTI activities in Enugu State

1.3.2 Specific Objectives

1. To determine community level of knowledge and attitude on CDTI strategy, the health system method and HIV/AIDS prevention activities in the community.

2. To assess community perception and views on the feasibility of using the CDTI strategy for the provision of HIV/AIDS prevention messages to adolescents and other at risk community members.

3. To determine community members view on the advantages and disadvantages of combining the distribution of Mectizan@ with HIV/AIDS prevention activities by CDDs and its effect on CDDs workload.

4. To determine the nature of HIV/AIDS prevention strategy community members consider appropriate for combination with CDTI strategy

5. To determine communities perception on how to improve HIV/AIDS prevention in their community and their role and responsibility in ensuring the success of the progralnme. 6

2.0 METHODOLOGY

2.1 Study Design A planning meeting was arranged by the research team comprising the principal investigator, the social scientist, the Director, Diseases Control at the Ministry of Health, the State CDTI project coordinator and a representative from the reproductive health unit. At this meeting, modality for selection of target villages, number of individuals to be involved in both the qualitative and quantitative surveys and other activities were decided.

A cross sectional design was adopted for the study. Put differently, the study followed a single- round survey design. This has been found useful in descriptive and exploratory studies such as this. It provided a valid cross-sectional picture of the demographic characteristics and issues, among other advantages. The study is not evaluative. It is aimed at the exploration and description of the health services the community members would like delivered through the CDTI process in Enugu state. In this study, a cross-sectional data set was collected from the study subjects using a uniform set of questionnaires, which was supplemented with qualitative methods of focus group discussions and in-depth interviews.

2.2 Study Area and Population

Enugu State is located in the Southeastern zone of Nigeria between 7 o 10' N and 7 o 45'N of the equator. The population of the State is about 2,680,439 people. It is made up of 17 Local Government Areas (LGAs). The people are of Igbo ethnicity. The State has a land area of 7, 617.82 Square Kilometers. The bioclimatic Zone is rainforest in nature with annual rainfall between l52cm and 203cm. The climate is comparatively equable and the temperature ranges between 22.2' C and 36' C. It is the humidity, which between 78% & 95Yo rather than the temperature that causes discomfort to newcomers. It is generally cool during the rainy season, while the mean temperature in the hottest periods of February and April is about 36 C. The topography has two marked zones, hilly or mountainous and flat zones. At least TlYo of the populations of Enugu State dwell in the rural areas. Agriculture therefore is the mainstay of their preoccupation (See Map 1.)

Fifteen out of seventeen LGAs in the state are implementing CDTI strategy. Aninri LGA with population of 67,500 people, with a geographical coverage of l00Yo in the last three years and therapeutic coverage of 83.25 in 2004 (7 5 .3% in 2003; 86.9% in 2002) and Oj i River LGA with population of 42,8857 with a geographical coverage of l00o/o in the last three years and therapeutic coverage of 79.360/o in 2004 were chosen as the pilot LGAs (see the pink portions in Map 1). Both Aninri and Oji River LGAs gave the highest support to their CDDs. Aninri LGA 7 had the overall CDTI performance in the state and hence was invited to the GRBP annual review meeting in Jos. 5

Map 1: Showing the two pilot LGAs (Aninri and Oji-River) in Enugu State

Aninri LGA is located in southern part of Enugu state bounded by Awgu LGA in the East and Nkanu East by the West. It comprises of 5 communities with 86 villages and 7 front line health facilities. All the 86 villages are endemic for Onchocerciasis and have been receiving Mectizan since 1998. There are a total of 215 community directed distributors (CDDs) in this LGA.

Oji River is demarcated by Oji River, which encourages breeding of the Simulium fly. This LGA has 147 CDDs and a high prevalence for Onchocerciasis and highest sero-prevalence for HIV/AIDS in Enugu State (13. 7o/o). There are 62 villages in Oji-River and 23 frontline health centers.

Persons aged 15 years and above, which is 57 per cent of the total population constituted the target population for this study. 9

2.3 Sample Size and Sampling Technique

Two hundred and sixty-two respondents, one hundred and thirty-seven and one hundred and twenty-five from Aninri and Oji-River LGAs respectively, constituted the sample for the quantitative study. This number was considered sufficient to support the simple descriptive statistics required for this situation analysis study.

A multi-stage sampling technique, which involved successive random sampling to pick villages and individual respondents, was adopted in drawing the sample. First the villages were listed. Five and four villages were selected through balloting from from Oji-River and Aninri LGAs respectively. The villages selected include Adu, Agbada, Ahani, Amaetiti, Amorji, Emudo, Enugu-Agu, Enugu-Ukwu and Uhueze. Each sampled village was assigned between 14 and 39 respondents, depending on the size of the population. In other words, the allocation of sample size was based on the probability of proportionality to size (PPS).

To get the respondents in each sampled village, the existing CDD registers for the distribution of ivermectin was employed. From the register, systematic sampling of households was carried out for each village. From the sampled household one person, one male or one female aged 15 years and above was randomly selected. Efforts were however made to ensure a balanced representation of the sexes in the sample by alternating the sexes of persons selected from the households. That is, in the sampled households, lists were compiled of the female members different from those of the males in the households. Where there is only one person with the required attribute, that is aged 15 years and above, the qualified person was purposively selected.

The Selection followed the Process below:

l. Determine a systematic sampling interval. Where, for example, we had are26 households in the village and we were selecting 5 adult males, the sampling interval would be 2615 or 5 (rounded off). We then balloted for the first household in the register by picking a number between one and 5. Where we chose, for example household #3 then the subsequent ones were #8,#13,#L8 and#23. 2. After selecting the households from the register, where we found more than one adult male listed, we selected one by balloting. 3. For subsequent categories (adult female), we picked a new household number from among the first five and continue as above. 4. If a selected person is unavailable, we chose another person in the same category within the selected household, or go to the next household in sequence.

In addition to this, some members of the community, who were not involved in the quantitative study, were purposively selected for the qualitative study. The criteria for selection varied with the nature of the qualitative study. For instance, the communityitraditional leaders and health facility personnel were purposively selected for in-depth interviews. Some members of the community, who were not involved in the quantitative study, were selected on the basis of availability for the focus group discussions. 10

2.4 Data Collection

The major instrument for the purpose of collecting data for the study was the semi structured questionnaire. This is because of the need for measurable statistical conclusions, which lend themselves to easy quantitative comparison and basis for evaluation of the control programme efforts. However, some qualitative data were ensured through the use of focus group discussions (FGDs) and in-depth interviews (IDIs). This was considered necessary to give some contextual meaning to the quantitative findings in the study.

For the quantitative data, a uniform set of questionnaire was administered to all the respondents irrespective of sex and location. The questionnaire sought information on the socio- demographic (background) characteristics of the respondents, knowledge, attitude and practice on common health problems and services in the communities.

The FGDs and in-depth interviews were conducted with carefully developed FGD/in- depth interview guide, which contained diagnostic questions on some of the issues raised in the questionnaire study. This provided in-depth understanding on the socio-cultural risk factors of the people with respect to health problems in the communities.

To ensure uniformity in the interpretation of concepts and recording of responses, the questionnaire was administered in face-to-face (other-administered) interviews with all the respondents. For this purpose, field assistants were recruited and trained on the objectives and methods of the study. Same sex interviews were conducted to prevent any cultural barriers and ensure free discussion ofissues.

For the qualitative data, FGDs were conducted with 6-8 persons in a group. The discussions were held with adult males and females, aged 25-35 and adult males and females aged 36 years and above. Discussions were also held with young males and females aged 15-24 years as well as with young persons of school age in the communities. A total of twelve FGDs were conducted in each LGA. This gave at least two per category of discussants and ensured collaborative information.

The participants in the FGDs were purposively selected from persons within the age and sex groups described above, who were not interviewed in the questionnaire study. To ensure this, new villages within the communities were randomly selected for the FGDs. Same sex discussion groups were ensured. A note-taker was also on hand to record important non-verbal expressions and reactions to issues raised by the facilitators of the FGDs.

2.5 Method of Data Analysis

The questionnaire data were computer processed and analyzed using the EPI6 and SPSS software packages for data analysis. Percentages and other descriptive statistics as well as graphic illustrations were used to describe the main characteristics of the study subjects. The chi- square (X2) statistics was used to test the association of the characteristics of the respondents with preferences of health problems to be integrated in the CDTI process. 1l

The data from the in-depth interviews and FGDs were analyzed with the inductive techniques with emphasis on interpretation and description of what was actually said. Some of the instructive statements were pulled out as illustrative quotes to support or give contextual meaning to the statistical data. t2

3.0 RESULTS

3.1 Distribution of Data

This section deals with the analysis of the data collected in August 2005. Three hundred copies of the survey instrument were administered to the study subjects randomly enlisted in the study in two LGA, namely Aninri and Oji-River. Responses from all 262 persons interviewed are included in the analysis that follows below.

Of the 262 valid questionnaires used in this analysis, about half (52.3%) came from Aninri LGA. Also included in the present analysis are qualitative data collected through FGDs with different segments of the population of the study area as well as in-depth interviews with community leaders, health workers and CDDs.

The presentation of the analysis and results of the study follows a definite sequence to make for easy comprehension. That is, the section is structured in different parts, namely, the socio-demographic information of the study subject as well as knowledge attitude and practice (KAP) on health problems of the community and the CDTI strategy. The other sections present data on the health system as well as the HIV/AIDS issues in the communities. Finally, there is a section on attitude of the respondents towards the use of the CDD for health care provisioning in the communities. The first section, however, presents the socio-demographic information on the respondents.

3.2 Socio-demographicCharacteristicsofRespondents

More than fifty per cent (53.4o/o) are males. The age ranged from <19 to 85 years with a mean age of 36.3 years and a standard deviation of +/- 16.84 years. The modal and median ages were 30 years and32 years respectively. The ages were categorized into intervals of ten years giving a total of six intervals. The age interval <19-24 years provided the highest proportion (29.4%) of respondents.

More than half (57.3%) of the respondents were married. About four in every ten respondents (38.5%) were single. Two (0.8%) were divorce/separated (1.3%) while 9 (3.4%) were widowed (2.3%). See Table 1 for details. 13

Table 1: Distribution of Respondents by their Socio-demographic Characteristics

Socio-demographic characteristics Frequency Percentages Age 15-24 years 77 29.4 25-34 years 58 22.r 35-44 years 44 16.8 45-54 years 37 14.1 55-64 years 25 9.5 65+ years 2l 8.0 Marital Status Single l0l 38.5 Married 150 57.3 Divorced/Separated 2 0.8 Widowed 9 3.4 Religious Affiliation Christianity 243 92.7 African Traditional Religion 19 7.3 Educational level Primary 93 35.5

Secondary 10 1 38.5 Post Secondary 20 7.6 No Formal Education 48 18.3 Occupational Group Farmer 95 36.3 Petty-Trader 35 13.4 Housewi felUnemployed/student 24 9.2 Professional 1l 4.2 Artisan 32 t2.2 Businessmen/women 65 24.8 Income Group (Weekly in Naira) < 500.00 96 36.6 500.00-1000.00 t02 38.9 1001.00+ 64 24.4

Table I also shows that the population was predominantly Christian (92.7%). The farmers dominated sample. The farmers constituted more than one-third of the sample (36.3%). Others were made up of professional (teachers, nurses and civil servants, among others), traders, artisans and the unemployed populations with 4 .2 per cent, 13 .4 per cent, 12.2 per cent and 9 .2 per cent respectively. The businessmen and women constituted almost a quarter (24.8%) of the sample.

A majority (38.9%) of the respondents earned between I+500.00 and N1000.00 weekly. Less than a quarter of the respondents more than N1000 weekly, while more than a third (36.6%) eamed less than I+500.00 weekly. This translates to 3.6 US Dollars a week or five cents a day. t4

This is far the below the poverty line of 1.00 US Dollar per day. This is typical of most onchocerciasis endemic communities in Africa.

3.3 KAP on Health Problems in the Community and CDTI Strategy

Without any prompting, respondents listed a number of health problems in the communities. The respondents indicated health problems they consider most pressing and deserving immediate attention and later prioritized these. See Table 2.

Table 2z Distribution of Respondents by Prioritization of Health Problems (% in parenthesis)

Health Problems Prioritization First Second Third HIV/AIDS 16 (6.2) t8 (7.7) t2 (7.3) Malaria 101 (3e.0) 47 (20.0) 30 (18.2) Maternal Health 4 (1.s) Schistosomiasis 2 (0.8) 1 (0.4) Onchocerciasis 37 (r4.3) 27 (Lr.s) 2s (1^s.2) Acute Respiratory Infections 2e (rt.2) 42 (17.9) 36 (2r.8) Child Health 6 (2.3) t7 (7.2) t6 (e.7) Others (Rheumatism, Stomach pain, etc) 64 (24.7) 83 (3s.3) 46 (27.e) Total 2s9 (100.0) 23s (100.0) 16s (100.0)

Table 2 shows that only 259 of the respondents listed the problems they considered of number one importance, while 253 and 165 gave their second and third most important problems respectively. In the column of the first most important health problems listed by the respondents, malaria came tops with 39.0 per cent of the respondents pointing at it. The group of health problems classified as 'others' came next with 24.7 per cent. HIV/AIDS as a problem was considered the first most important problem in the communities by 6.2 per cent of the respondents. It was however considered the second and third most important health problem by 7 .7 per cent and 7 .3 per cent of the respondents.

Other health problems recorded very little mention among the respondents. Problems like maternal health problems and Schistosomiasis did not only get small mentions by 1.5 per cent and 0.8 per cent of the respondents respectively, as the first most important problem that deserve priority attention, they were excluded from further listings. Other problems like child health acute respiratory infections and onchocerciasis were mentioned in all the categories of ranking. (See Table 2). l5

Table 3: Distribution of Respondents by Knowledge of the Mectizan@ and the CDTI Strategy for Controlline the Disease About Mectizan@ and CDTI Strategy Frequency Percentage Heard of Mectizan@ Yes 251 96.2 No 10 3.8 When Respondent Started taking Mectizan@ in the community 1-2 years ago 40 t5.7 3-4 years 69 27.1 5-6 years 38 t4.9 7+ 92 36.t Don't Know t6 6.3 Advantages of taking Mectizan@ Improves sight r25 48.3 Improve health r4r 54.4 Deworms 53 20.s Enhances strength for work 10 3.9 Enhances alertness 13 5.0 Proportion of Community members accepting Few l8 7.0 Half 100 38.8 Everybody r28 49.6 Do not know t2 4.7 Reasons for Accepting Mectizan@ Improvement in sight 6l 23.7 Enhancement in the health of the people t77 68.9 We were asked to take it 11 4.3 Enhances strength for farm work 42 16.3 Distributors Community Directed Distributor (CDD) t67 65.s Health Worker 43 16.9 Village committee 2t 8.2 Village members t7 6.7 Do not Know 7 2.7 Who Selected CDD Village Head 32 12.5 Health staff 42 16.s Village Committee 109 42.7 Village members 47 18.4 Do not know 25 9.8 Mode of Distribution House to House t32 51.8 Central Place 94 36.9 Combination of both 23 9.0 Do not know 1 0.4 16

About Mectizan@ and CDTI Strategy Frequency Percentage Does Community Compensate CDDs? Yes 60 23.4 No 105 41.0 Do not know 9l 35.5 Community Compensation of CDDs Money 38 63.3 Transport t6 26.7 Prayers 3 5.0 Do not know 3 5.0 Treated during Last Distribution Yes 1,69 69 8 No 73 30 2 How many Tablet I tablet 11 4.8 2 tablets 57 24.7 3 tablets 26 1 1.3 4 tablets 125 54.1 Do not know t2 5.2 Determination of Tablets Age 155 61.8 Measurement by weight 34 13.5 Measurement by height 50 19.9 Do not know t2 4.8 Availability of Mectizan@ Through village announcement t96 77.s Through CDD 42 16.6 Through health service 6 2.4 Village head 2 0.8 Do not know 7 2.8

Almost all the (96.2%) respondents to the inquiry on awareness about Mectizan@ indicated that they have heard about the drug Mectizan@. However, there were variations on when the respondents commenced treatment with Mectiza@ in the community. All the same the largest proportion (36.1%) indicated that they have taken the drug for the past f,rve years or more. A few (6.3%) could not tell for how long they have taken the drug in the community.

Similarly, another small proportion (6.6Yo) of the respondents could not tell the frequency of the distribution in the community. A majority (53.7%) of the respondents indicated that the drug is distributed only once ayear.

The respondents mentioned a number of advantages of taking the drug without prompting. Some of the advantages include improvement in, and protection of the sight (48.3%), improves the general health of the members of the community (54.4oh), de-worms (20.5%) and enhances strength for farm work (3.9%). It might be necessary to mention at this point that each t7 respondent was allowed to mention as many advantages as s/he could remember during the survey.

About half (49.6%) of the respondents indicated that every body in the communities accepts the drug. However, some smaller proportions (38.8% or 7.0o/o) indicated that half or a few of the members of the communities respectively accept it. Two-thirds (68.9%) of the respondents indicated that the drug is accepted in the communities because of the salutary effects it has on their health. However, a small proportion (4.3%) indicated that they take the drug because they were asked to take it in the community.

The reasons and advantages of taking the drug by the people were also captured in the qualitative segment of the study. Here are samples of expressions that point to the perceived benefits of taking the drug in the communities.

Mectizan@ is well accepted in the community. Many people take it for blindness prevention (Village Head, Emudo, Enugu State).

It is fully accepted because the drugs are effective for eyes and clearing of worm and rashes on the skin (Village head,IhueTe, Enugu State).

The advantages of taking the drug include expulsion of worms. It clears and cures rashes and eye problems. It can also revert menses and cure infertility leading to 'miracle baby' (Village head, Emudo, Enugu State.

The drug is ffictively accepted in the communities (CBO leader, Amaetiti, Enugu State).

This drug brtngs out hidden diseases in the body. If you have any disease hiding in your body, the drug will bring it out. There is someone who got swollen after taking it. It means that there was a disease in the person's body and so it was cured and the person became well again (Female Adolescents, Enugu-Agu, Enugu State)

It also brings out something that loola like ringworm (Female Adolescent, Enugu-Agu, Enugu State).

I have taken it and I lcnow that it prevents all these killer diseases that are prevalent in our community (Adult males, Umunba, Enugu State).

There is a woman whose child took this drug and expelled worms. The drug has cured many people in this village. You will see that the one he (the CDD) brought today will not last two weel

The qualitative data also highlight the recognition and acceptance of community roles in the CDTI process among the community members. This is typified in the following states made during FGD or in-depth interview sessions.

We were told that our role is to support the CDDs. We l

The community does not do much since we do not compensate the CDDs now even though we used to in the past (Village head, Umunba, Enugu State).

tle help with the mobilization of community members through announcement in village meetings and in churches (Village head, Enugu Akwu, Enugu State).

Community disseminates information when the drug is available (Village head, Amaetiti, Enugu State).

Yes, we are aware of our responsibility in the CDTI process. So we give the CDDs money, and also pick their transport expenses for the collection of the drugs from the health center (Village head, Ihueze, Enugu State).

Table 3 above also indicates that in 65.5 per cent of the cases, the community directed distributors (CDDs) were mentioned as the responsible persons for the distribution of the drug. And in 73.6 per cent of the cases, it was mentioned that these CDDs are selected and enlisted by members of the communities or the village head or village health committee. About half (51.8%) of the respondents indicated that the strategy for distribution is house to house. However, in 9.0 per cent of the cases, CDDs combined the house to house and the central place strategy.

During the focus group discussions, the community members elaborated on this. The FGD with men in Amudo community for instance noted that the

Main strategt is that when the drug arrives the Igwe summons the health committee to notify them, then the announcement is made and a date is fixed for the distribution of the drug at the Igwe's palace. Those that were absent are later treated by the CDD visiting their houses.

The community announces the arrival of the drugs through the town criers, churches etc. (Adult Females, Ihueze)

This was corroborated by the young females FGD sessions in the community. However, in some other communities, the principal strategy is the house-to-house distribution. This was confirmed by the male youth in Amaetiti when they stated that,

The CDDs go from house-to-house to give the drug. The reason is that this is a farming community and not many people will turn out when you ask them to come t9

for the drug at a central place, which is likely to come during their work hours. So the CDDs go to their houses when they are backfrom theirfarms.

However the data show that compensation of CDDs for distributing Mectizan@ is not a common feature of the communities studied. For instance, majority (41.0%) of the respondents indicated that the CDDs were not compensated while more than a third of the respondents could not say if the CDDs were compensated. Less than a quarter of the respondents (B.a%) indicated that the CDDs were compensated.

More than half (63.3%) of those who indicated that the CDDs were compensated indicated that it was done with money. About a quarter (26.7%) of this category of respondents indicated that it is by supporting the transportation cost incurred in the process of the distribution of Mectizan@. However, five per cent indicated that it is through prayers while another 5.0% could not tell the nature of the compensation given to the CDDs. These were also mentioned in the qualitative data collected during the survey. For instance, a community leader during an in- depth interview, noted that,

Yes, CDDs are compensated. Each family contributes N5.00 initially. Now it is NI0.00 (Village head, Emudo, Enugu State)

We give the CDD N1000.00 at the end of each distribution season (Village head, Amaorji, Enugu State).

In the FGD session with young females in Amudo village of Aninri LGA, it was noted that,

The people give him money when he gives them drug. That is each family gives N10.00 for each treatment of the family. It was the amount agreed by the community leaders (Adolescent Females, Amudo, Enugu State).

The adult male group corroborated this when they stressed that,

The community agreed that they should collect a fixed amount from each family treated as a way of offsetting the cost of their service to the community (Adult males, Amudo, Enugu State).

More than two-thirds (69.8%) of the persons interviewed indicated that they received drug during the last distribution period. These people also indicated various numbers of tablets they received from the CDDs (see Table 3 for details). It will suffice, however, to note that a majority (61.8%) of the respondents indicated that the number of tablets they were given in each treatment period was determined on the basis of age. Less than a fifth (19.9%) of the respondents indicated that dosage was determined with a height-measuring device.

On their source of information about the availability of the drug on the community, a majority (77.5%) of the respondents indicated that they know about the availability of the drug through the announcement made by the town crier and directed by the village head. Others 20 mentioned the CDD (16.6%), health workers (2.4%) as their main sources of information about the availability of the drugs in the communities.

These finding is however mediated by the locality of the respondents. See Figure 1 for details.

Fig. 1: Distribution of Respondents on Dosage Determination and Source of lnformation by LGA

100 trAninri EOjiRiver

60 ss0 40

0 Age Weight Height Do not Town CDD Health Village Do not know crier worker head know Dosage Source of Information

Figure I shows that whereas 67.9 per cent of the respondents from Aninri indicated that dosage was determined by age whereas in Oji River 55.0 per cent of the respondents indicated same. None of the respondents from Aninri indicated that dosage was determined by weight while more than a quarter of those from Oji River indicated that dosage depends on the weight of the person treated. On the hand, 26.0 per cent of those from Aninri against 13.3 per cent of those from Oji River indicated that dosage depends on height. The difference in the knowledge about the mode of determinilrg dosage in both LGAs differed significantly on a Pearson's chi square test for difference (t'=44.830, p<0.0001). Further test using thL Pearson's Coefficient of contingency (c=0.4) reveals

Figure 1 also shows that72.9 per cent of the respondents from Aninri LGA depend on the announcement made by the town crier while as many as 82.5 per cent of the respondents in Oji River rely on the same medium, that is through the village announcement. On the other hand, a greater proportion (22.6%) of the respondents from Aninri LGA than the respondents from Oji River LGA (10.0%) rely on CDDs. This difference was significant on a Pearson's chi square test for difference d:9.902, p:0.042). Further test using the Pearson's Coefficient of coniingency (c=0.194) reveals an association between the source of information and the locality of the respondents. 2l

An important finding from this section however, is that the respondents are very familiar with the CDTI strategy, where community take major decisions and direct the process of drug distribution in the community. The next part of this study is to ascertain the opinion of the community member on the possibility of using the CDTI strategy as a vehicle for delivering other health prograrnmes in the communities.

3.4 Health System Issues

Almost all the respondents (91.7%) think that the CDTI process has recorded success in providing health services, with special reference to onchocerciasis control and 94.4 per cent of this category of respondents think it would be a good idea if the system could be adopted for the control of other health problems in the study communities and listed on Table 4 below.

Table 4: Distribution of Respondents by Opinion on Using Community Member for Health Care Provisioning

Opinion Frequency Percentage Has CDTI been Successful? Yes 233 91.7 No 2l 8.3 Can CDTI System be Adopted for Control of other Health Problems in the Community? Yes 23s 94.4 No l4 5.6 Most Important Health Problems to be Delivered with CDTI Strategy HIV/AIDS 32 13.7 Maternal health 2 0.9 Child Health 10 4.3 Schistosomiasis 33 t4.2 Onchocerciasis 79 33.9 ARI 76 32.6 Others (malaria, body pain, stomach ) 1 0.1

Without prompting, the respondents list HIV/AIDS control, schistosomiasis and Acute Respiratory Infections, apart from onchocerciasis, as health problems that should be better delivered with a system like the CDTI, where community members are involved. Other health problems mentioned include maternal and child health as well as such other health problems as malaria control, body and stomach pain among others. The respondents were asked to rank these health problems after listing to get one that should be urgently integrated into the CDTI process. 22

The ranking of the unprompted list of health problems to be integrated into the CDTI process gave AR[, after onchocerciasis control as the topmost health problem to be considered for delivery through the CDTI process, with almost one-third (32.6%) of the respondents mentioning it. HIV/AIDS was the third most important health problem the respondents considered necessary for inclusion in the CDTI process.

This finding was cross-tabulated with some background variables of the respondents. The results are contained in Figure 2 below.

Fig. 2: Distribution of Respondents on Perceived Most lmportant Health Problem for lnclusion in CDTI Process by LGA Sex and Agegroup

100 tr HM/AIDS I l/hternal l-lealth g Ctrild Flealth g Schistosoniasis l Onchocerciasis tr ARI I Other 90

s50 40

10 I 0 Aninri Oji River Male Female <24 24-U 35-4/- 45-il 55-64 65+

LGA sE( Age Group

Figure 2 shows that in all the cases after the control of onchocerciasis, ARI ranked topmost in the respondents' rating of health problems to be delivered through the CDTI process. This cuts across different age groups, LGA and sex of the respondents, albeit with varying degrees. However, the health problems that came next to this depended on the LGA, sex or age group of the respondents. For instance in Aninri, HIV/AIDS came second with 13.5 per cent while schistosomiasis control came second in Oji River with 16.8 per cent and this differed significantll d:l3.273, p:0.04). Further test using the Pearson's Coefficient of contingency (c=0.232) reveals a moderate association between LGA and preference for the next most important health problem to be included in the CDTI process.

With respect to the age groups, Figure 2 revealed that except for those aged 35-44 years old, HIV/AIDS is the second most important health problem, after ARI, preferred for inclusion in the CDTI process. The difference in the distribution here is not statistically significant d46.732, p:0.185). 23

With respect to sex distribution of the respondents on the preferred health problem for inclusion in the CDTI process, one finds no statistically significant differenc e (t:4.111, p>0.6). More of the male (16.70/o) than female (10.3%) respondents preferred the inclusion of HIV/AIDS in the CDTI process.

This finding is corroborated with the qualitative data on the kind of health programmes members of the communities would want community members involved in. In all the 24 FGD sessions conducted during this survey, members ranked HIV/AIDS among the health problem they would want to see cofirmunity members involved in and delivered like the CDTI process. According to adult males in Enugu Agu,

We htow about HIV/AIDS very well. As we said earlier on, it is good to go from house-to-house as is done for onchocerciasis. They can also do house-to-house teaching about HIV/AIDS. That is why we are planning to start giving the CDDs something to encourage them because they have the best chance to disseminate information as they move house to house (Adult males, Umumba, Enugu State).

Many people have died including husbands and wives as well as pregnant women. AIDS should be controlled using the same method (Village head, Amudo, Enugu State)

Yes any body who dies now is suspected of dying of HIV/AIDS (Village head, Amudo, Enugu State).

Yes, il has cleared many people in this village. It is a problem in the community, so many have died due to AIDS. It is a very serious problem and many people have died (Village head, Amaorji, Enugu State)

An investigation of the issues of HIV/AIDS revealed that it is a major problem of concern for the people. More than two-thirds (76.2%) of the respondents indicated the existence of person infected with HIV or affected by AIDS. More than eight in ever ten persons interviewed and asked about the adoption of the CDTI strategy for delivery of HIV/AIDS control services were positively disposed to it. See Table 5.

Table 5: Distribution of Respondents on Issues about HIV/AIDS

About HMAIDS Frequency Percentage Ever Heard of HIV/AIDS? Yes 244 96.4 No 9 3.6 Any Infected/affected persons? Yes 189 76.2 No 59 23.8 Mode of Transmission Blood transfusion 96 37.2 About HIV/AIDS Frequenqy Percentage Sharing sharp objects (unsterilized) t29 49.2 Sexual Intercourse 234 91.1 Mother-to-child transmission 4 1.6 Do not know 2 0.8 Prevention Sterilization of sharp objects before use 50 19.8 Safe sex (use condoms) 72 28.6 Blood screening t9 7.5 Abstinence 153 60.7 Faithfulness 42 16.7 Creating Awareness 43 t7.L Do no know 6 2.4 What is done to control HMAIDS in the community? Awareness creation 246 99.2 Condom promotion 247 100.0 Referral of Infected persons 247 100.0 Counseling 247 100.0 Who is Responsible for HIV Control in the Community? Health workers 2t5 87.8 Community members 15 6.1 Non-governmental Organizations 15 6.1 Has HIV Control been Successful in the community? Yes 90 4t.s No 127 58.5 Adapting CDTI for HIV/AIDS control Yes 224 88.2 No 30 I 1.8 Reason for Adapting CDTI for HIV Control It is easy 122 48.4 Involve community members 55 2t.8 Intimacy 6 2.4 Sustainability 9 3.6 Coverage t4 5.6 Opposition to adapting CDTI for HIV Control No privacy (intrusion) 10 4.9 No Volunteers 204 100.0 No Skills 4 2.0 No free drugs l0 4.9 Aspects of HIV/AIDS amenable to CDTI approach Distribution of condoms and drugs 7 2.9 Health education 202 83.s Counseling and Referrals for testing 242 100.0 Home based Care 4 r.7 Prevention Messages that will be most Beneficial Definition of HIV/AIDS 25 9.7 25

About HMAIDS Frequency Percentage Symptoms 220 84.6 How it is contracted 33 t2.7 How it is not contracted 82 31.5 Major prevention-rnaj ors 39 15.0 Perceived Willingness of CDD to take on HIV/AIDS prevention activities Yes 209 83.6 No 4l 16.4

Efforts to control the spread of HIV/AIDS have been mainly in the area of awareness creation (99.2%), referral of infected persons for testing (100.0%) and counseling (100.0%). The health workers in the communities drive these efforts, according to 87.8 per cent of the respondents. Fifteen respondents (6.1%) indicated the it is managed by community members while another 6.1 per cent indicated that it is managed by the Non-governmental organization operating in the communities.

According to the village head in Ihueze,

Some days, boys and girls are educated on HIV/AIDS by community Chairman, women leader, lectures held in lhueze town hall twice a month (Village head, Ihueze, Enugu State)

However, these efforts have not been very successful and 5 1.8 per cent of the respondents attested to this. Further more, 88.2 per cent of the respondents support the integration of the HIV/AIDS control programme into the CDTI process, where the community members would take major decisions and implement the control prograrnme. For almost half (48.4%) the respondents, the CDTI process is 'easy'. Other reasoning for opting for the inclusion of HIV/AIDS control activities in the CDTI process include the involvement of community members, and the sustainability of the programme. Over eighty (83.6%) of the respondents indicated that the CDDs will be willing to take on the tasks of HIV/AIDS control in addition to their routine functions in the control of onchocerciasis.

In the qualitative study, members of the communities studied as well as their leaders called for the inclusion of the HIV/AIDS control prograrnmes in the CDTI process. They argued that the CDTI has been very successful and should be adopted for HIV/AIDS control. According to village head for Amaorji,

CDTI is the best way to reach the grassroots because community leaders mobilize themfor this purpose.

CDTI has been very successful because the CDDs have been trained properly by health fficers from the health centers to deliver drugs from house to house (Village head, Ihueze). 26

CDTI has been very successful since house to house distribution ensures every body receives the drug instead of going to the health center (Village head, Amudo).

The health center is good too. But you find that doctors are never there...(Adult male, Enugu Agu).

It is good in a way because the community members know all the nool

It is good to use them because while they are going house to house to distribute drugs for onchocerciasis they can also deliver HIV/AIDS services, such as counseling and referrals to community members with HIV/AIDS problems (Adult female, Amudo).

~~3.5 Attitudes of CDDs to Inclusion of HIV/AIDS Control in CDTI~~

A total of fifteen community directed distributors (CDDs) were also interviewed in this study. Eighty per cent of the CDDs were males and 93.3 per cent of the CDDs were selected in a true CDTI process that is by the community members. See Table 6 below.

~~Table 6: Distribution of CDDs by Selected Characteristics~~

Selected characteristics Frequencv Percentages Sex of CDD Male t2 80.0 Female J 20.0 Mode of Selection as CDD At village meeting t4 93.3 Another CDD I 6.7 Mode of Distribution House to house l0 66.7 Central place 1 6.7 Both 4 16.6 Ever been Supervised by Health worker Yes l3 86.7 No 2 t3.3 Role as a CDD Treat the people l3 86.7 Record treatment 5 33.3 Health educate the people 11 73.3 Mobilization 1 6.7 Collection 2 23.3 Support from community 27

~~Selected characteristics Frequency Percentages Transportation J 20.0 Financial incentives 2 13.3 Other incentives 2 13.3 Nothing 8 53.4 Problems with CDTI Distance 7 50.0 Poor Support 2 14.3~~

~~Refusals 1 7.1 Others 4 28.6 Community Response Good I4 93.3 Bad 1 6.7~~

The CDDs were very clear on their roles in the CDTI process. According to the CDDs their roles in the CDTI process include treatment of members of the communities (86.7o/r), health education of the people in the communities (73.3%). However, rather small proportions of the CDDs consider record keeping (33.3%), mobilization (6.7%) and collection of drugs (23.3%) as their responsibility. This may be informed by the CDDs'understanding of the role of the entire community as distinct from their specific roles as CDDs. Within the CDTI guideline, the responsibility for community mobilization does not lie with the CDDs alone. Instead, community mobilization is the responsibility of the entire community especially its leadership. The same goes with the collection of Mectizan@. Any body in the community could be detailed to collect the drug from an agreed point.

The CDDs, however, noted some challenges they face in the execution of the CDTI. The challenges include distance for 50.0 per cent of the respondents. Others complained of poor support from community members and refusals. All the same, a majority (93.3%) of the respondents indicated that CDTI is well received in the communities.

The CDDs also indicated willingness to take on the additional task of HIV/AIDS control prograrnme. Almost all the CDDs (93.3%) attested to this. See Table 7 for details on the attitude of CDDs to the inclusion of HIV/AIDS in CDTI process

~~Table 7: Distribution of CDDs on Attitudes to Additional Health Tasks~~

Attitudes to Additional Health Tasks Freq uency Percentages Priority Health Problems for CDTI Process HIV/AIDS Ja 20.0 ARI 2 13.3 Child Health 1 6.7 Others (malaria, body pain, etc) 9 60.0 Extent of HIV/AIDS Problem Minor J 27.3 Maior 8 72.7 Willingness to Take on HIV/AIDS & CDTI 28

Attitudes to Additional Health Tasks Frequency Percentages Yes T4 93.3 No I 6.7 Aspects of HIV/AIDS Prevention to Combine with CDTI Awareness Creation 9 60.1 Condom Distribution 2 13.3 ARV Drug 2 13.3 Care for Persons Living with HIV/AIDS 2 13.3 What needs to be done for combined HIV/AIDS and CDTI Programme Train 5 33.3

~~Mobilize the people 1 6.7 Create awareness 3 20.0 Others (provision of materials) 5 33.3 Who should be Involved? Community leader 7 46.7 Health worker 5 33.3 Youths 4 26.7 Elders J 20.0~~

Twenty per cent of the CDDs prioritized HIV/AIDS as a health problem to be included in the CDTI process. However, more than two-thirds (72.7%) of the respondents recognized HIV/AIDS as a major problem in the communities. Almost two thirds (60.1%) of the respondents indicated that the aspects of the HIV/AIDS prevention that should be included in the CDTI process, is the creation of awareness on HIV/AIDS. The CDDs however, indicated the need for more training (33.3%) and the provision of control materials such as drugs and condoms. 29

~~4.0 CONCLUSIONS~~

HIV/AIDS is a major concern for the people in the study communities. This was acknowledged in both the quantitative and qualitative arms of the study. Many noted that devastating effect of the HIV/AIDS pandemic on the communities. In some of the communities, it was indicated that the impact of the pandemic cuts across age and social class. It was stressed that both male and females die of the disease. Pregnant women and schoolgirls are also known to have died from the disease. In some communities, however, it was alleged that people get infected in the city and come to the village to die.

2. Not much is done about this problem in the communities. However, in some efforts are made to create awareness and educate the youths about the dangers of the diseases. These efforts have involved NYSC members, the Local Government Chairman and other public-spirited persons. The health facilities have not been of much use in the communities with respect to the delivery of preventive health care in particular. The members of the communities opined that much as the health center staff are good, one hardly find a doctor in the health centers. Thus the people often resort to whatever is available in the communities for their health needs. Consequently, for more than half of the respondents in the quantitative study the efforts at controlling HIV/AIDS in the communities have not been successful.

3. Members of the communities studied expressed desire to have HIV/AIDS services delivered in the communities as is done for the control of onchocerciasis. For many of them, CDTI has been very successful. They demonstrated good knowledge of the workings of the CDTI process, in which the community members make the major decisions for its implementation. They were also aware of their responsibilities, which include ensuring that the community members accept the drug, as well as support the distributors. In many communities, the CDDs were supported financially. In some, CDDs were mandated to collect fixed amount from families treated. In all the communities studied, there were community members who collect Mectizan@ from agreed points.

4. The people wished this process to be extended to the control of HIV/AIDS because the CDDs understand the people and know the nooks and crannies of the communities. They were also very optimistic of the CDDs' willingness to take on the HIV/AIDS tasks as part of their CDTI responsibilities. The CDTI process, according to the respondents in both the quantitative and qualitative studies, has been very effective as many people were treated. Thus they suggested that the CDDs could deliver HIV/AIDS services as they distribute Mectizan, house to house, which is the predominant mode of Mectizan@ distribution in the communities.

5. The CDDs also indicated their willingness to take on the delivery of HIV/AIDS services as part of their responsibilities in the CDTI process in the communities. They however demanded that the communities should be sensitized and mobilized about the new 30 developments. Like the community leaders, they also requested for deliberate training on the delivery of the HIV/AIDS services. 3l

~~5.0 RECOMENDATION~~

~~1. The HIV/AIDS control programme should be incorporated into the already established CDTI process in the communities~~

~~2. Community members should be sensitized and mobilized to accept the delivery of HIV/AIDS services through the CDTI process as well as support the CDDs~~

3. CDDs should be trained on their new roles in the delivery of HIV/AIDS services. b0 (\t E E c.) ti d d d B a a a dE 0 U) (r) >. X -uB d (B d (o b6! c0 d a o .;E d (B (g ar) (n tr(! CB (B d E.= E € b0 o! b{ b0 b[ b{ o! o{ o0 o{ cd (n E3, o o d "(6 €o o o o o o o o o o o o o o o o o o o o o o (D C) (.) C) o0 d d d € € E 00 bc (! (! (d c!3 (6 (d (! 4) .!p $ (.)o (.) o Cd 'o'5 o E] tr tr € G)Y (B-^ d-" d-. o o o o o o o o o o o o o di o o o dtr C) (.) (.) o o E3 'a o o o o o() o o O o o o o o o o C) C) o C) o o 0) C) o c) c) o o) c) C) L (!o ^AL li F o SE Ei H} 0. o o o o o o o o o O o ri () 0a .EB 'Er o o o o o o o o o o o o o o o o o C) CE EE F (! (B (! (n d d d (n d (t (! d 6) (oQ,tro tro tro () L cdo do a (t (B (B (t (€ (! (! (t (! d d c0 d o C) &8 EP =d)IfT L =o)If{ ! O a o t-.,t a o o a li a a a o a n H o IJ o tri trr I!

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~~HOUSEHOLD QUESTIONNAIRE (ENUGU STATE)~~

A: Introduction: Good morning/afternoon. My name is . I am here on behalf of the Ministry of Health and Global Health Awareness Research Foundation, a Nigerian Non-governmental Organization based in Enugu. We are carrying out a study on the health problems of people in this State. I would like to ask you some questions. We are going to use the information to advice Government and World Health Organization on how best to address some of the health problems of people in this and other States in Nigeria. Should you agree to discuss with me, the information will be kept confidential. Thanks you for your assistance.

~~Consent Yes t No t )(Stop interview)~~

~~Respondent's Identity No.~~

~~Household ldentity No.~~

~~B: Instructions for questionnaire administration~~

Interview one household member aged 15-49 years and above Mark (X) all answers given, in boxes provided. Do not read out answers to respondents, except where directed to do so. Write in answers, in spaces provided, if the provided options or checklists do not cover response.

~~C: Identification: (To be completed by Interviewer, with or without respondent)~~

~~Community name LGA State~~

~~Clinic/Flealth Facility Present l: Yes tl 2: No tl~~

~~If yes, Name of Clinic/Health Facility:~~

~~Interviewer's Name: Date of Interview~~

~~Time Interview Started: Time Interview Ended: 35~~

~~D: Respondent's Background Information:~~

~~I Sex 1) Male tl 2) Female tl 2. Age _(Enter Direct) 99) Don't Know t I 00) No Response [ ] (estimate age with local events, where the respondent is unsure)~~

~~J Marital Status 1) Single t 2) Married- polygamous I 3) Divorced/Separated t 4) Widowed t 5) Married monogamousI~~

~~5 Religion I ) Christianity (speciff denomination tl 2) Muslim t l 3) Traditionalist (ATR) t l 4) Other (Please, Specify~~

6. What is the income-earning activity that takes most of your time in a week? 1 ) Farming/Hunting/Fishing/Wine Tapping t 2) Trader t 3) Housewife/Unemployed t 4) Professional (Teacher, Nurse, etc) t 5) Artisan (Tailor, Hairdresser, Furnishing, etc) t 6) Other (Please, specify)

~~7. Kindly estimate your average weekly income from the income-earning activity mentioned above (in Q~~

8. What level of education did you attain? 1) Primary Uncompleted t l 2) Pimary Completed t l 3) Secondary Uncompleted t l 4) Secondary Completed t l 5) Diploma./University Degree t l 6) None t l Other (Please, specify) 36

~~9. What are the priority health problems in your community (list starting with the most important)? 1. 2. J. 4. 5. Do not know CDTI Shategy~~

~~10. Have you heard about the drug Mectizan/ivermectin?~~

~~L Yes 2. No~~

~~1 1. When did you start taking the drug in your communitylfamily 1. One years ago 2. 2-3 years ago 3. 4-5 years ago 4. More than 5 years ago 5. Donotknow~~

~~12. How often is its distribution carried out in ayear 1. Once a year 2. Twice ayear 3. Every month 4. Every week 5. Donotknow~~

~~13. When was the last distribution (State)~~

~~14. In your view are there advantages of taking the drug, what are the advantages 1. 2. 3. 4. 5. Do not know~~

~~I 5. How many people would you say accept it in this community 1. Few 2. Vz upto half of the community members 3. Everybody 4. Do not know 37~~

~~16. What are the reasons for the acceptance among those who accept it?~~

~~1 2 3 4~~

~~I7. What would you say are the reasons for refusals among those who refuse it? l. 2. 3. 4.~~

~~18. Who are responsible for the distribution of the drug in your community? I. CDDS 2. Health workers 3. Village committee 4. Village members 5. Donotknow~~

~~I 9. Who selects/appoints the distributors? 1. Village head 2. Health worker 3. Village committee 4. Village members 5. Donotknow~~

~~20. How do they distribute the drug? l. House to house 2. Centrally 3. Combined (house to house & central place) method 4. Do not know~~

~~2 L Does the community compensate the CDDs in any way? 1. Yes - Move to Q 21 2. No - Skip to Q22 3. Do not know - Skip to Q 23~~

~~22 If Yes in what way? 1. 2. J. 4.~~

~~23. IfNo why? 38~~

~~24 Were you treated during the last distribution? Yes - Move to Q 24 No - Skip to Q 26~~

~~25 How many tablets did you receive during last distribution? l. I tablet ! 2. 2 tablets EI 3. 3 tablets E 4. 4 tablets tr 5. Do not know E~~

~~26. How was the number of tablets determined by the CDD? 1. By age ! 2. Weight n 3. Use of measurement stick E 4. DonotKnowE~~

~~27 How do you know when drug is available in this village? 1. Through village announcement E 2. CDDs tr 3. Health worker tr 4. Village head tr 5. Donotknow E~~

~~Health System Issues~~

~~28. Do you think this distribution method (CDTI system) has been successful in your community 1. Yes tr Please give reasons 2. No E Please give reasons~~

~~29. Do you think this system could be adopted for control of other health problems in your community?~~

~~L Yes E 2. Notr~~

~~30 Could you list the health problems that this system could apply to? (Rank them, I : most important) 1. 2. J. 4. 39~~

~~HMAIDS (If HMAIDS was not mentioned, specifically ask about HMAIDS)~~

~~31. Have you heard about HIV/AIDS? 1. Yes E 2. Notr~~

~~32. How is it transmitted (list)~~

~~33. Name some of the ways for prevention of the spread of HIV/AIDS in your community? 1. 2. 3. 4. 5. Don't know~~

~~34 Are there people infected/affected by HIV/AIDS in your community? 1. Yes tr 2. Notr~~

~~35 How is HIV/AIDS controlled in your community?~~

~~l. What is presently being done to solve this health problem E~~

~~2. Who is responsible for this? tr~~

~~36. Has it been successful Yes No~~

~~l. If no why?~~

~~2. If yes why?~~

~~INTEGRATION~~

~~37 Do you think CDTI strategy could be adopted for control of HIV/AIDS in your community? l. Yes EI - Move to Q 36 2. No tr -SkiptoQ3T~~

~~38 If yes why? 1. 2. 3. 40~~

~~39 IfNo why? L 2. 3. 4.~~

~~40. If yes to Q 35, What aspect of HIV/AIDS will you advise that the CDTI should be used? 1. 2. 3. 4.~~

41. What prevention message will be most beneficial (tick as many as mentioned) 1. Definition of HIV/AIDS tr 2. Symptoms tr 3. How it is contracted tr 4. How it is not contracted tr 5. Major prevention measures tr

~~42. Do you think the CDDs will be willing to add this on to their mectizan distribution? l. Yes tr Give reasons 2. No tr Give reasons~~

~~43. What strategies do you suggest should be used in carrying this combined activities by CDDS? 1. 2. 3. 4. 5.~~

~~44 Do you have any questions~~

~~45 Thank you for your patience 4t~~

~~INDEPTH INTERVIEW: VILLAGE HEADS/CBO ENUGU STATE~~

~~Name of village_ village code_ LGA-~~

~~Name of village Head Date~~

~~CDTI Strategy~~

1. Please tell us about the Onchocerciasis treatment prograrnme in your village: (Please note that issues on when the treatment started and how long treatment has gone on in the community should be addressed.)

~~2. How was the time (month/season) for distributes decided?~~

~~3. What mode of distribution was decided?~~

~~4. How was mode of distribution decided?~~

~~5. How many persons in the village (CDD) gave out the drug~~

~~6. How were the CDD's selected?~~

~~7. Does your village compensate the CDDs in any way? (Probe for ways of compensating CDDs)~~

~~8. If CDDs are not compensated, probe for reasons.~~

~~9. How well have the CDDs done the work?~~

~~10. How would you describe the level of acceptance of Mectizan in your community? (Probe for reasons for the answer).~~

~~I L What are the advantages of taking the drug? 1. 2. J. 4. 5. 42~~

~~12. ln what ways is your community involved in mectizan distribution?~~

~~13. How successful would you describe the distribution strategy (probe for reasons for the answer)~~

~~Health System Issues~~

~~14. Do you think this distribution method could be adopted for the control of other health problems in your community?~~

~~15 If yes list some of the priority health problems starting from the most important.~~

~~1 2 3 4~~

~~HIV/AIDS~~

~~16. In your opinion, would you consider HIV/AIDS as a problem in your community? l. Yes tr 2. No tr~~

~~17. How serious is it as a problem in this community?~~

~~18. What efforts are being made presently to control it in this community?~~

~~1 2 3 4~~

~~19. Who is presently responsible for these activities in your village?~~

~~20. How successful are the efforts?~~

~~INTEGRATION~~

~~21. Do you think CDTI strategy could be adopted for community education on HIV / AIDS to community members in your community? Yes / No 43~~

~~(a) If Yes, why do you think CDTI strategy is appropriate for this 1. 2. J. 4.~~

~~(b) If No, Why~~

~~22. Do you think HIV/AIDS programme will be an overload on CDDs? Yes E No tr If Yes, why~~

~~23. If No what aspects of HIV/ AIDS education would you advice that CDDs should be included in?~~

~~24. Do you think the CDDs will be willing to add this on to their mectizan dishibution?~~

~~25. What strategies do you suggest should be used in carrying out this combined activities by other community members? 1. 2. J. 4.~~

~~26. Thankyou 44~~

~~INTERVIEW GUIDE FOR CDDS (ENUGU STATE)~~

~~Name of village: Village code: LGA: Name of CDD: Sex: male \ female Date:~~

~~CDTI Strategy~~

~~1. How were you selected to do the work? 1. At village meeting 2. village elders 3. village chief/ leader 4. health worker 5. Village committee 6. Others (specify)~~

~~2. How many CDDs are there in your village? (Probe for sex composition)~~

~~a) How many are males~~

~~b) How many are females (Probe for the supervisors)~~

~~3. Have you ever been supervised? Yes tr No tr If yes, who supervised you? 1. Health staff 2. Village Health committee member 3. NGO partner 4. Village head /Chief 5. Others (speciff)~~

~~4. How was the time for distribution decided? 1. At the village meeting 2. Village elders 3. Village Chief / leader 4. Health worker 5. Village committee 6. Others~~

~~5. What mode of distribution was decided? 1. House to house 2. Central place 3. l&2combined 4. Others (speciff)~~

~~6. Did you receive education on the importance of taking ivermectin tablets annual ly before distribution? Yes / No 45~~

~~7. Did you provide the community with education on ivermectin treatment? Yes / No~~

~~8. If Yes, when did you usually provide the education to the community? l. During the l't meeting 2. Before distribution 3. During distribution 4. After distribution 5. Others (Specify)~~

~~9. What did you tell the community? l. Taking the drug annually for several years. 2. Benefits of treatment. 3. Community responsibility 4. Side effects~~

~~10. Did you receive any training on mectizan treatment? Yes / No~~

~~11. If Yes, who carried out the training And when~~

~~12. What are your roles as a CDD?~~

~~13. Who collects the drug for your community? 1. 2.~~

~~14. Where is the collection point?~~

~~15. Where do you normally keep the tablet?~~

~~16. How do you determine number of tablets to give individuals? 1. Take height measurement 2. Use weight 3. Visual observation 4. Age 5. Other (Speciff)~~

~~17. What kind of support do you receive from the community if any? 1. Transportation for drug collection 2. Incentives (specify) 46~~

~~3. Others (specifu)~~

~~I 8. Do you have problem doing the work of CDD? (If yes probe for problems and how they are resolved).~~

19. Could you tell us about the programme generally; as it relates to - Community response - Constraints - Satisfaction - How to sustain the programme in the community - Rate the success of the programme

~~Health System~~

~~20. What other health progralnme do you think the CDTI strategy could be adapted for?~~

~~21. List / mention the priority / specific health prograrnme that could be involved 1. 2. J. 4.~~

~~HIV/AIDS 22.\Nhat is the extent of HIV/AIDS problem in this community?~~

~~23. Are you willing to carry out both mectizan distribution and HIV/AIDS prevention activities? (Probe for reasons for the response)~~

~~24.What aspects of the HIV/ AIDS prevention activities can you comfortably combine with your CDD activities? 1. 2. 3. 4.~~

~~25. What do you think should be done to make this combined activity feasible?~~

~~26. Who should also be involved in carrying out this activity? I 2 3 4~~

~~27. Thankyou 47~~

~~IN-DEPTH INTERVIEW GUIDE FOR HEALTH PERSONNEL AT THE COMMUNITY LEVEL (ENUGU STATE)~~

~~1. Are you aware of CDTI programme in this community - Yes fl No tr~~

CDTI 2. When was CDTI introduced in the community? Also probe into: o Number of people selected and trained to be CDDs o Number of such people who are still functioning o What community was told about its role or contribution regarding ivermectin distribution o Benefits or useful experience so far o Problem being faced with ivermectin distribution

~~3. How were the CDDs selected as cofirmunity distributors? What were the criteria?~~

~~4. How many CDDs do you supervise? If any?~~

~~Health System 5. Apart from distribution of ivermectin are there other health interventions you think CDDs can participate in this community? Yes tr No tr~~

~~If yes, E Please mention them~~

~~If HIV/AIDS is not mentioned. (Probe for HIV/AIDS)~~

~~6. What roles will the CDDs play in this programmes?~~

~~7. What will be the effect of involvement of CDDs in these new health activities?~~

~~8. How do you think information on HIV/AIDS prevention in the community could be improved? I 2 Ja 4 5 Don't know~~

9. How is HIV/AIDS problem presently being controlled in your community? a. What is presently being done to solve HIV/AIDS problem b. Who is responsible for this activity? c. Has it been successful d. If no why? e. If yes why? 48

~~HIV/AIDS~~

~~10. Do you think CDTI strategy could also be adapted for Community Education on HIV/AIDS?~~

~~I 1. Do you this will be an overload on the CDDs already involved in Mectizan Distribution? Probe for reasons.~~

~~12. If no, what aspects of the HIV/AIDS Education/Prevention activities will you advise that CDDs should be involved in?~~

~~13. What strategies do you suggest should be used in carrying out these combined activities by the CDDS?~~

~~Performance:~~

~~14. How would you rate the performance of the CDDS in the past? (Probe for reason) l5 Are the CDDS compensated in any way? (Probe). (i) Type of compensation~~

~~(ii) Why are they not compensated 49~~

~~FOCUS GROUP DISCUSSION (FGD) FOR COMMUNITY MEMBERS (ENUGU STATE)~~

~~A. Introduction/Establishment of Rapport:~~

a Good day. I am...... And my colleagues are We thank you for agreeing to come and participate in this discussion. a We are from ...... and we are here to learn from you about the involvement of community members in the delivery of health programmes and CDTI. a We have invited you because of your wealth of experience in this community and the confidence we have in you. a Please in this discussion there are no right or wrong answers. Everyone's opinions are important and should be freely expressed. o What we will learn from you today will be useful in future to plan how health programmes activities can go on and without problems. a We crave your indulgence to allow us use a tape recorder to record the proceedings of these discussions. This is to ensure we do not forget all the useful opinions you would share with us. We however assure you that what ever you disclosed to us will not be disclosed to any one else or used against you in any way. We therefore appeal to you to participate fully and honestly in these discussions. a Once again thank you for coming.

~~B: General~~

1. What are the health care facilities in this community? Probe into: o For Availability of health care facilities and how they function in the community o How well are these health care facilities satisffing the need of this community o Existence of VHWs and types of activities they perform (Probe) o Services provided by this health care facilities o If no health care facility in the community, Probe into the distance of the community to the nearest health facility.

CDTI 2. When was CDTI introduced in the community? Probe into: o Number of people selected and trained to be CDDs o Number of CDDs and how they are still functioning o Probe for what community was told about its role or contribution regarding ivermectin distribution o Benefits or useful experience so far o Problem being faced with ivermectin distribution

~~3. How were the CDDs selected as community distributors? What were the criteria? 50~~

~~4. How are the CDDs performing? Do they have any problems? If yes, what are the problems?~~

~~Health System 5. What would be your assessment in using community members to distribute drugs? Probe for benefits and disadvantages~~

~~6. How would you view using community members to participate in delivery other heath programmes in this community?~~

~~7. What kind of health programmes do you think the community members can be involved in? Please rank them.~~

8. What is your opinion about the advantages and disadvantages of involving CDDs in other health prograrnmes such as distributing drugs to pregnant mothers? Probe into: e Whether it will work and should be encouraged. o Whether it will not work and should be discouraged o Whether it will affect CDDs role in ivermectin distribution

9. What is your opinion about the advantages and disadvantages of involving CDDs in other health programmes such as providing information on HIV/AIDS control? Probe into: o Whether it will work and should be encouraged. o Whether it will not work and should be discouraged o Whether it will affect CDDs role in ivermectin distribution

~~Performance~~

~~CDTI~~

10. What do you think about the performance of CDDs in this community? (PROBE) o Are people satisfied or not? Please explain o Has the performance of the CDD improved or dropped since s/he became CDD o Have there been any problems? Please explain what problems and how they were addressed? o Have any CDDs been changed? If yes, please explain circumstances.

11. What types of (cash, kind, moral) were given to CDDs, by the community, to help them do their jobs better? What types of support will be given for other health activities? Probe for any? Please explain; who gave assistance?

~~12. What other kinds of help or assistance were provided? What kind; who provided? 51~~

~~FOCUS GROUP GUIDE (ENUGU STATE)~~

~~Target group: Adolescents - Males and female Adult males and females~~

~~CDTI Strategy~~

~~1. Please tell us what you know about Onchocerciasis treatment programme in your community (emphasize on the following issues)~~

~~Role of the community when prograrnme started in community How many rimes drug have been distributed in the community~~

2. Please described how the community took decision on the time and mode of distributions (probe for) Person involved in decisions Time of distribution Why time was choosen Method of distribution Why method was choosen

3. Please described how the community took decisions on the persons responsible for distributing drugs to community Person involved in decision-making Who will be responsible How the persons were selected Method of drug collection

~~4. What were you told about the need for community treatment with Ivermectin (probe for annual treatment for several years, benefits since of information and community responsibility?~~

5. How is the drug brought into the community and distributed to community members (probe for) Part of collection Person responsible for bringing the drug Person responsible for distribution Mode of distribution

~~6. How was dosage determined by the CDDS (probe for measuring device)~~

~~7. How prepared is the community to take control of the distribution programme and what they need to sustain the exercise for several years? 52~~

~~8 What support has the community gives to the CDDS (probe for ) Ivermectin Community mobilization Ensuring compliance Provision of means of transport~~

~~Health System~~

~~9. Could you please tell how successful the CDTI progralnme in your community is? (probe for some important measures)~~

~~10. Do you think CDTI could be adopted for control of other health programme in your State? (probe for priority health programme and what aspects) and its feasibility~~

~~I L What strategies do they think will be most suited for integration t2 What is your view on workload for CDD with regard to the adapted? (probe for advantages and disadvantages)~~

~~13 What will be the role of the community in the adapted on prograrnme (probe for suggestions on how the community could be enhanced to make the programme successful~~

~~14, Do you know of any Disease called HIV/AIDS YesA.{o~~

~~What is the local name?~~

~~15 How is it transmitted/Prevented L L 2. 2. 3. 3. 4. 4. 5. DK. 5. DR.~~

~~16. Do you know any body in the community who is presently infected or who have died due to HIV/AIDS.~~

~~YesA.{o 53~~

~~II SCHEDULE OF KAP SURVEY IN NENWE EMULEMOKE COMMUNITY~~

~~Villages Emudo Uhueze Agbada Amaoji~~

~~FGD (4) Male Adult Female Male Adult Female Adult~~

~~Adult Female Male Female Adolescent Male Adolescent Adolescent~~

~~Adolescent~~

~~Questionnaire~~

~~CDD~~

~~HW As applicable~~

~~CBO Leaders Female Male Female Male 54~~

~~III SCHEDULE OF KAP SURVEY IN ACHI COMMUNITY~~

~~Villages Ahani Amaetiti Akwu Adu Enugu~~

~~Agu~~

~~FGDs Male Adult Female Male Adult Female Male Adult~~

~~Adult Female Adult Female Female Adolescent Male Adolescent Male Adolescent~~

~~Adolescent Adolescent~~

Questionnaire ** ** ** ** **

~~CDD 2 2 2 2 2~~

~~HW 1 1 1 1 cBo Female Female Male Female Female~~

~~VH 1 1 1 1 I~~