Lessons from Participatory Community Mapping to Inform Neglected Tropical Disease Programmes in Nigeria

"By promoting bottom-up approaches for the inclusion of community voices in programme design, the reality of how communities engage with their structures was identified."

Participatory research methods promote collaborations between researchers and communities to collectively overcome implementation challenges for sustainable social change. This study developed and piloted contextualised participatory methods to identify community structures that could improve the equity of medicine administration for neglected tropical diseases (NTDs) in Nigeria. By engaging with a variety of community stakeholders, some of whom are frequently marginalised within mass administration of medicines (MAM) delivery, the paper highlights how visual participatory mapping processes can enhance and ensure equity in NTDs programme delivery.

As explained here, inequities in MAM delivery are largely due to a reduction in community engagement that can support programmes to understand how to deliver medicines at a time, place, and space that suits them. For example, in Nigeria, women, girls, migrants, the elderly, youth, urban populations, and some ethnic and religious groups are left out of MAM, which potentially increases health inequities. The study was conducted in Ogun (northwestern) and Kaduna (southwestern) states. From 2017-2020, the therapeutic coverage of NTDs in Ogun ranged from 41-66.1%; in Kaduna, the coverage range was 65-95%.

Between January 2018 and October 2019, as part of the COUNTDOWN project (Calling Time on Neglected Tropical Diseases), state-level implementers were trained and facilitated transect walks (TWs) and social mappings (SMs), analysed data, and implemented the study. TWs were tools for understanding the areas where different groups are located and interact and how they are or could be used to deliver health programmes within the community; SM sessions, during which community members drew maps, provided in-depth visual descriptions of how they are currently engaged or could be engaged in the delivery of MAM. Community participants were community leaders and members from different social groups. Power dynamics were managed by disaggregating participants by cadre, gender and age. The research team guided participants to ensure that everyone was free to contribute to discussions and decisions.

The participatory nature of the methods meant that analysis was an ongoing process; it focused on maps, matrices, audio-recorded discussions between the researcher and the participants, sketches and notes, or photographs taken by the researcher during TWs. It was learned that the study participants in both states generally had fair to good knowledge of NTDs, as they could identify existing and potential structures along the MAM pathway (sensitisation, mobilisation, communication, and medicine distribution) that were relevant for programme implementation. They had also received many years of MAM campaigns, and some had one or more NTDs or had family and friends who had been affected by an NTD.

In short, the study found that using visual participatory methods with a diverse set of stakeholders facilitated the identification of new structures within the community that could be used to improve the equity of medicine distribution and access. Available materials such as sticks, stones, and leaves were appropriately used by respondents in the rural areas, which increased meaningful engagement, irrespective of literacy level. Structures identified included Qur'anic schools, football grounds, mechanics shops, shrines, village heads' houses, and worship centres. Challenges in using these structures for medicine distribution included resistance from school authorities and restrictions to women's access due to traditions and norms, particularly within palaces and mosques.

During the participatory research process itself, there were challenges across all contexts (specifically in urban communities), such as sociocultural issues around access. For example, the Fulani in the migrant context gathered at the king's palace and had to be mobilised and granted permission from him prior to the exercise. They mentioned that they were usually mobilised for such activities but were often forgotten at implementation.

On the other hand, there were some strengths to the approach, including the intentional use of disaggregation. The TWs in the study included community leaders, and SM sessions consisted of other community members, so that perspectives were not influenced by power and position. Disaggregating the SMs provided room for gendered and varied community stratification group views, as evidenced in the findings. For example, women could identify gidan mata (home of women, where commercial sex workers reside) as potential structures due to the women's ability to freely discuss MAMs without the presence of men. (In Nigeria, individuals tend to speak more freely when in similar gender and age groups, due to sociocultural norms.)

In conclusion, this article highlights the importance of meaningful community engagement methods and engaging gatekeepers in visual participatory methods. It emphasises the importance of including divergent views of various population groups in order to ensure that all communities are reached by NTDs programmes.