Homecare of confirmed COVID-19 cases in Nigeria: Current situation, challenges in implementation, and strategies for improvement

Olayinka Stephen Ilesanmi^1,2, Aanuoluwapo Adeyimika Afolabi^1,&

 

¹Department of Community Medicine, College of Medicine, University of Ibadan, Oyo State, Nigeria, ²Department of Community Medicine, University College Hospital, Ibadan, Oyo State, Nigeria

 

 

^&Corresponding author
Aanuoluwapo A. Afolabi, Department of Community Medicine, University of Ibadan, Oyo State, Nigeria

 

 

 

 

The emergence of novel Coronavirus disease (COVID-19), a member of the Severe Acute Respiratory Syndrome family, has introduced remarkable changes into the health sector locally and globally [1,2,3]. Confirmed COVID-19 positives are being managed at designated isolation centers by infectious disease experts. Facility-based management of COVID-19-positive persons have overwhelmed both health facilities and the entire health system [2]. This has resulted to an exhaustion of available bed units, denial of admittance of newly diagnosed persons, and extra work loads for healthcare workers [4,5]. The sole inadequacy of facility-based management of COVID-19 cases reveal the need for the exploration of home-based care (HBC) in the containment and control strategies for COVID-19 [6,7]. HBC has quickly become the mainstay of COVID-19 management in some states in Nigeria.

 

The World Health Organization (WHO) has defined HBC as any form of help rendered directly to an ill individual at home by family and community members while at the same time receiving substantial evidence-based professional advice and support from trained health workers [8,9,10]. HBC serves as an alternative strategy for the management of patients from the comfort of their homes [8]. In the COVID-19 context, HBC affords the opportunity for provision of evidence-based care for asymptomatic and mildly symptomatic COVID-19 cases who have no underlying health conditions. Compared to the conventional facility-based care, HBC avails the opportunity for meeting the spiritual, physical, and emotional needs of COVID-19 positives [10]. Also, HBC overcomes the challenge of overcrowding, a risk factor for COVID-19 transmission which is obtained in hospital settings [11]. Building on these advantages, HBC is completely adapted to the COVID-19 situation and should be optimized for the assurance of delivery of the continuum of healthcare amidst the COVID-19 pandemic.

 

Caring for an infected person in the home, rather than in a medical or other specialized facility, increases the risk of transmitting the virus to others in the home. However, the isolation of people who are infected with SARS-CoV-2 that causes COVID-19 can make an important contribution to breaking the chain of transmission of the virus. The decision regarding the isolation and provision of care to a COVID-19 patient in home settings depends on the following three factors, namely: clinical evaluation of the COVID-19 patient for severity or underlying illness(es), an evaluation of the home setting, as well as the ability to monitor the clinical progression of a COVID-19 patient [12].

 

The WHO has developed guidelines for HBC of COVID-19 positives and their contacts [12]. HBC is well suited for Nigeria, a resource-limited country. The Nigeria Center for Disease Control (NCDC) has similarly developed guidelines on HBC management of COVID-19 positives with practicability for the Nigerian context [13]. Many States have commenced HBC management of COVID-19 positives. Presently, there are no publicly available literature on HBC for COVID-19 management in Nigeria. Evidence is however currently required from such literatures in charting the Nigerian experience regarding HBC of COVID-19 positives. The high proportion of asymptomatic and mild COVID-19 cases could promote the adoption of HBC especially where isolation is possible. Studies on HBC are required for the assessment of HBC performance, identification of the challenges, and the projection of adaptive strategies for HBC in the Nigerian context. This study therefore aimed to assess the current situation of HBC in Nigeria, implementation challenges, and strategies for its improvement.

 

 

We conducted the situation analysis on the 27th November, 2020; nine months after Nigeria reported her index case of COVID-19. The study utilized a desk review and a qualitative data collection technique (key informant interview).

 

Study Area and Population

 

Six members of the rapid response team were included from across the six geopolitical zones in Nigeria. We purposively included states with the highest number of confirmed COVID-19 cases from each zone. Thus, Lagos State was selected to represent the South-west zone, Enugu State for the South-east, Delta State for the South-south, Gombe State for the North-east, Katsina State for the North-west, and the Federal Capital Territory (FCT) for the North-central zone. The selection was done in a bid to assess the implementation of HBC across the states in the geopolitical zones in Nigeria.

 

Study Population

 

The study population were the COVID-19 positives undergoing HBC. To obtain the details on HBC of the positives, interviews were conducted among epidemiologists who had been deployed into the COVID-19 outbreak rapid response team in some states in Nigeria where COVID-19 cases had been confirmed. As of the time when this study was conducted, there were 15 members of the rapid response team deployed to 14 States and the FCT.

 

Data collection

 

The investigators, who had been involved in the training of community health volunteers to promote COVID-19 awareness and voluntary testing, conducted the interviews independently with each participant. One of the authors served as the main interviewer, while the other documented notes and handled the midget. The interview guide consisted of the following 12 questions: “Have some COVID-19 positives survived on home-based care? If yes, what proportion are they? Has the state formally commenced home-based care? Who qualifies for home-based care? What steps are being followed before home-based care is commenced? Is the NCDC guidelines followed in home-based care of COVID-19 positives? Are the following available for COVID-19 home-based care in your state: dedicated personnel, personnel category for home-based care, data tool, State guidelines for COVID-19 home-based care, home visitors, thermometers, applications for monitoring, and applications for data capturing? Other questions included sources of support to the state, trainings (if yes, type of training, and who the participants are), other human, financial, or material resources available in the state, preference for home-based care among COVID-19 positives in the state, performance gaps in home-based care for COVID-19, anticipated challenges, and suggestions for the improvement of home-based care of COVID-19”. Probing phrases such as “Could you explain further?” and “Could you provide more information?” were used to gain more depth into the discussion.

 

Due to the COVID-19 situation, the engagement of study participants in the COVID-19 response at the time the study was conducted, and the need to document respondents´ facial expressions during the interview, the interviews were conducted virtually through zoom. Each interview session lasted for 20-30 minutes. The interviews were audiotaped after permission was obtained from study respondents. Transcription of the interviews was done verbatim.

 

Data analysis

 

The desk review and key informant interview informed on three different types of need including: (1) the comparative need based on a country-wide comparison using available COVID-19 case data; (2) the normative need based on a document review comparing the HBC practices in each geopolitical zone with the NCDC guideline for the management of COVID-19 positives; and (3) strategies for action based on a content analysis of HBC situation from the participants Table 1. A key informant interview guide was developed from the National COVID-19 HBC guideline. Through the exploration of the situation analysis via desk review and key informant interview, methods triangulation was done to reduce potential bias which could be associated with the use of only a single method. The deductive approach, in which data analysis is done based on preconceived themes expected from the study objective, was applied. Both authors independently drafted a list of recurrent observations from the data. Thereafter, we collaboratively refined observations that captured the experience of each state.

 

Ethical approval

 

Ethical approval to conduct this study was obtained from the National Institute of Medical Research Institutional Review Board (Reference number: IRB/20/048). The study was conducted in tandem with the World Medical Association Declaration of Helsinki. Verbal informed consent was sought from each of the participants. Confidentiality of information was assured to each participant prior to the commencement of the interview, and this was ensured by maintaining anonymity of participants. The participants were informed of the right to withdraw from the interview prior to its completion without any consequence. No known harm was inflicted on the participants because of their participation in this study.

 

 

The average age of the respondents was 45.90±4.52 years, 4 (66.7%) were males, and the average period of engagement in the COVID-19 outbreak response effort was 7.20±1.68 months. Table 2 shows the information on COVID-19 data reported across selected Nigerian States, while Table 3 summarizes the HBC situation, alongside the challenges and strategies for improving HBC delivery in each of the included states.

 

Theme One: Situation Analysis of home-based care

 

Lagos State has formally commenced HBC of COVID-19 positives. Presently, <25% of COVID-19 positives in Lagos State have been managed in their homes. The qualification criterion for HBC include asymptomatic or mildly symptomatic COVID-19 positives who have no underlying illness. The NCDC guidelines are being followed in the home management of COVID-19 positives. In addition, dedicated personnel, including doctors and nurses are actively involved in COVID-19 Homecare management. Home visitors who are staff of the Primary Health care Board have been trained and assigned on home visits to intended settings where COVID-19 positives are to be managed.

 

“Evaluation of where the person will stay is done. We ascertain that the home meets up with the standard for home-based care.” (L)

 

These trainings have been conducted for Environmental Health Officers, Community Health Extension Workers, doctors, and nurses. In addition, guidelines have been developed by Lagos State for managing COVID-19 positives. Also, tools and applications for data capturing and monitoring are available. Other available resources for HBC in Lagos State include financial resources for contacting positives, as well as material resources such as gloves, face masks, hand sanitizers and other personal protective equipment. In addition, external support from the United Nations International Children´s Fund are available.

 

“We have human, financial, and material resources available. However, we need more thermometers for the home visitors in Lagos State.” (L)

 

Enugu State has commenced HBC, although the terms are unclear. The qualification criterion for HBC in Enugu State include asymptomatic or mildly symptomatic COVID-19 positives with no underlying health condition. Although the NCDC guidelines are known and Enugu State has developed a guideline for home-based care of COVID-19 positives, HBC in Enugu State is unstructured and has not formally commenced. In addition, there is no monitoring for HBC in Enugu State.

 

“Enugu State has developed a local version of the NCDC home-based care guideline, but we do not have a solid and formal structure yet. So, home-based care is yet to officially commence in Enugu State” (E)

 

Presently, less than 25% of COVID-19 positives are managed at home, and some COVID-19 positives have survived without hospital care.

 

HBC in Delta State is fully sponsored and coordinated by the State, with no external support received. In addition to the NCDC guidelines, Delta state has developed guidelines for HBC management of COVID-19 cases in the State. Of the nearly 1,802 confirmed COVID-19 cases in Delta State as of 30th November 2020, >50% of cases have been managed at home, and is indicative of the preference for HBC among COVID-19 positives in the State. Many COVID-19 positives have survived without hospital care. All asymptomatic and mildly symptomatic COVID-19 cases qualify for HBC. In addition to the NCDC guidelines for COVID-19, Delta State has developed guidelines for HBC management of COVID-19 cases. Prior to the commencement of COVID-19 HBC, pre-assessment exercise was conducted by Disease Surveillance and Notification Officer and Executive Secretary case managers. Home visits are also conducted by the Disease Surveillance and Notification Officer and Executive Secretary case managers regarding HBC in Delta State.

 

“We currently have no external support for COVID-19 home-based care in Delta State.” (D)

 

“We make unannounced visits to homes where COVID-19 positives are being managed to ensure they are abiding by the guidelines.” (D)

 

In addition to the dedicated available human resources, tools for data collection and thermometers are available. Material and financial resources are also available for HBC in Delta State. To guide the HBC operations, Delta State has developed an algorithm in this regard.

 

“Delta State currently has developed an algorithm to guide home-based care operations in Delta State. This feat has not been achieved in any other state in Nigeria…” (D)

 

In Gombe State, HBC of COVID-19 cases have formally commenced for over one month, and some COVID-19 positives have survived without hospital care. In addition to the NCDC guidelines for COVID-19 home management, Gombe State has developed guidelines for HBC. All asymptomatic or mildly symptomatic COVID-19 positives qualify for HBC. Less than 25% of COVID-19 positives have been managed on HBC. Home supervision for settings in which COVID-19 positives are to be managed as well as the supervision for the entire HBC process is conducted by members of the Incident Management System.

 

“All Incident Management System members take part in home-based care of COVID-19 positives.” (G)

 

“We do house supervision before allowing COVID-19 positives to be managed in their homes. Sometimes, we also visit them without informing them of our intentions.” (G)

 

Findings from Katsina State located in the North-west geopolitical zone revealed that some COVID-19 positives have survived solely through HBC. Of the 857 COVID-19 confirmed cases in Katsina State as of 30th November 2020, >50% have been managed via HBC. All asymptomatic COVID-19 cases qualify for HBC.

 

“Being an asymptomatic COVID-19 case is a major requirement for COVID-19 home-based care in Katsina State.” (K)

 

In the FCT, >50% of COVID-19 positives have been managed at home, and some COVID-19 positives have survived without hospital care. The NCDC guidelines for COVID-19 HBC is known in the FCT. In addition, the FCT has developed her COVID-19 HBC guidelines. Asymptomatic or mildly symptomatic cases of COVID-19 qualify for HBC.

 

“I am very proud to inform you that the Federal Capital Territory has developed her own guidelines for home-based care of COVID-19 cases. Our local guidelines were developed from the ones developed by the Nigeria Centre for Disease Prevention and Control” (F)

 

Theme Two: Challenges in the implementation of home-based care

 

Gaps such as insufficient incentives for trainees have been identified. Anticipated challenges for HBC of COVID-19 positives in Lagos State include pre-care house visits and increased frequency of visits.

 

“Pre-care home visits may be difficult to conduct due to the distance of the homes in which patients are to be managed. Increased frequency of visits may be challenging to conduct. We have other responsibilities for which we must deliver.” (L)

 

There is no external support for the management of COVID-19 positives in Enugu State. Performance gaps such as inadequate personnel and poor surveillance have been identified and increasing rate of community transmission of COVID-19 is an anticipated challenge for HBC in Enugu State.

 

“We are short of surveillance officers in Enugu State. As a result, community transmission of home-based care is an anticipated challenge of home-based care of COVID-19 positives in Enugu State.” (E)

 

No performance gaps have been identified in HBC. However, applications for monitoring and data capturing are not presently available in Delta State,

 

“Although our algorithms have been developed, applications to capture the data of contacts and COVID-19 cases themselves are lacking.” (D)

 

“There are no performance gaps in home-based care in Delta State. We are performing optimally.” (D)

 

Non-adherence to recommended home stay has however been identified as a performance gap for HBC in Gombe State.

 

“People who are supposed to be on home isolation still move around. This is a notable challenge to home-based care of COVID-19 cases in Gombe State.” (G)

 

Identified gaps in HBC in Katsina State included lack of documented policy, no monitoring, and lack of workforce for HBC of COVID-19 positives.

 

“There are no assigned personnel for Homecare in Katsina State.” (K)

 

“The lack of home-based care policy in Katsina State, and monitoring of COVID-19 positive cases are the challenges facing the implementation of ome-based care in Katsina State.” (K)

 

“In Katsina State, HBC has not been formally commenced, and the NCDC guidelines are not being used.” (K)

 

The FCT is yet to formally commence HBC of COVID-19 cases. Therefore, no steps are being currently followed regarding management of COVID-19 positives who are isolated at home. HBC resources are also inadequate in the FCT.

 

“In the Federal Capital Territory, monitoring of COVID-19 positives who are on home-based care is yet to commence formally” (F)

 

“A lot of people doing home treatment do not meet the conditions. We need to ensure adherence of all COVID-19 positives to the Federal Capital Territory home-based care guidelines.” (F)

 

“Human, financial, and material resources are inadequate in the Federal Capital Territory.” (F)

 

Theme Three: Strategies for improving the quality and delivery of home-based care

 

Suggestions such as increased incentives have been identified as important ways to improve the workability of HBC in Lagos State.

 

“HBC personnel should be provided with more incentives such as call and transportation allowances.” (L)

 

Regarding suggestions to improve the practicability of HBC in Enugu State, more contact tracers and increased adherence to the outlined criterion for HBC are required.

 

“COVID-19 community infections are increasing in Enugu. Therefore, we need more contact tracers for prompt identification of contacts of COVID-19 cases.” (E)

 

“Improved adherence to home treatment is required among COVID-19-positive persons who opt for HBC. More funding is required for the outbreak response in Enugu State.” (E)

 

An important strategy towards improving the effectiveness of HBC in Delta State is improved monitoring of contacts, and active case search.

 

“We need more people to monitor contacts. Active case search should also be enhanced in Delta State.” (D)

 

A useful strategy to improve HBC in Gombe State is the engagement of enforcement officers to help enforce adherence to HBC recommendations.

 

“When police officers and local enforcement officers are engaged and recruited into the home-based care monitoring team, I am certain that adherence to home-based care in Gombe will improve significantly.” (G)

 

The development and implementation of the HBC policy is a strategy to make HBC work better in Katsina State.

 

“The development of the home-based care policy is of utmost importance to address the challenges in home-based care in Katsina State.” (K)

 

To improve the quality and delivery of HBC in the FCT, a scale-up in the provision of resources is required.

 

“More contact tracers and surveillance officers are needed to improve the quality of home-based care in the Federal Capital Territory.” (F)

 

“Since the Federal Capital Territory ranks next to Lagos on the COVID-19 statistics, a large pool of funds, as well as material resources are needed to improve the outbreak response efforts.” (F)

 

 

We found that HBC practice for COVID-19 is suboptimal in some states. This has led to poor monitoring of COVID-19 positives and has in turn resulted to insufficient data with which to track the successes and inadequacies of HBC in concerned settings. The lack of tools for data collection has been reported to have hindered the workability of HBC in the COVID-19 context [13]. In addition, the lack of applications for data capturing could have further compromised HBC in Nigeria. Furthermore, the gross inadequacy of material resources such as personal protective equipment, as well as the lack of financial support in many settings from external organizations could have limited the workability of HBC.

 

This study found that the lack of personnel for HBC is a major challenge faced by the management of COVID-19 positives in Nigeria. The dearth of human resources has hindered active case search of COVID-19 positives and prevented the assessment of settings in which COVID-19 positives are to be managed. In addition, lack of HBC personnel could have similarly encouraged non-adherence to COVID-19 safety measures while COVID-19 positives are being managed at home. Non-adherence to safety measures have also been reported of HIV studies [14]. A lack of documented policy for HBC is also an hinderance to HBC across some states in Nigeria. Due to the lack of policies to suit the peculiarities of each State, home isolation of confirmed COVID-19 cases is poorly done. This is evident in the unrestricted relationship either among family members or community members observed in many settings where COVID-19 positives are isolated.

 

We identified certain strategies for improved workability of HBC for COVID-19 positives in Nigeria. Firstly, the development and documentation of policies for Homecare of COVID-19 positives is highly required. This could either be presented as policies or guidelines. When these guidelines are present, knowledge would be available regarding the dos and don´ts of HBC. Such adequate knowledge would be important to recognize the falls and successes in HBC, and to channel strategies through which it could be improved.

 

Secondly, the involvement of more human resources would provide immense benefits to HBC for COVID-19 positives. This has been reported to improve the results obtained from primary healthcare interventions [15]. The availability of HBC personnel would enhance reporting of persons who have been placed on Homecare, and the outcome of each patient. Such efficient reporting system would be needful to promote the reality of COVID-19 especially in settings where its existence is being denied [16]. Increased human resources for COVID-19 HBC would also be important to facilitate record keeping for patients being managed at home. Trainings also would be required for HBC personnel. Also, contact tracing and active case search activities would therefore be properly implemented when human resources are available in adequate measures. These measures would be needful in charting a primary care approach for the Homecare of COVID-19 positives [17].

 

In addition, improved availability of tools for data collection would be highly required to improve HBC for COVID-19 positives. These tools could be presented as algorithms or in paper-based forms. Web-based tools for data collection could also be utilized [18]. When these tools are adequately developed and appropriately utilized, data collection would be efficiently performed, data capturing would be well coordinated, and monitoring would be enhanced across Nigeria. The availability of data collection tools would be cost-intensive, and for this reason external support is needed to intensify HBC in the COVID-19 context. Increased incentives are also needed to be regularly provided to personnel who are involved in HBC for COVID-19 positives. The enhancement of innovations on improved healthcare deliver via HBC should be encouraged culling from lessons learnt from the Ebolavirus disease outbreak [19].

 

Findings from this study revealed that HBC is indeed being accepted as an alternative to hospital-based management of COVID-19 positives. This is an expected finding because HBC affords cases the opportunity for recuperation in a friendly environment unlike the “imprisonment” notion associated with isolation at treatment centers. Similar experiences were reported regarding HBC in the home-based end of life care [20]. Although costs are borne by the government while COVID-19 positives are isolated at designated treatment centers, HBC occasions no separation between positives and family members. Difficulty in adherence to HBC recommendations have been reported in many settings, increased infection rates have been only observed in fewer settings. In lieu of this occurrence, it is required that complete adherence to the restrictive measures outlined during HBC should be properly communicated by healthcare workers to COVID-19 positives and their caregivers. Also, when COVID-19 positives are informed of their transfer to isolation centers once defaulting from the measures are observed, adherence to HBC guidelines could be enhanced. Also, the engagement of stakeholders such as community and religious leaders as well as heads of opinion groups could improve compliance to recommended guidelines for COVID-19 management [21].

 

Strengths and Limitations

 

The findings in this study could have been limited using a representative state for each of the geopolitical zones in the sampling strategy. Despite this limitation, this study provides credible evidence on HBC in the COVID-19 context, while informing on challenges experienced, and improvement strategies.

 

 

The HBC for the management of COVID-19 positives presents a promising strategy for the efficient management of COVID-19 cases in their homes without the associated overwhelming of the health system. Unfortunately, HBC within the framework of primary health care has not been fully harnessed because of the ease with which the COVID-19 pandemic has been handled. Gaps such as lack of guidelines, inadequate personnel, as well as poor data collection and reporting tools have hindered the effectiveness of HBC in the Nigerian context. We therefore recommend the prompt development and documentation of policies for homecare of COVID-19 positives in each State. Also, increased availability of HBC personnel, as well as the organized trainings for HBC should be enhanced. In addition, improved commitment to the availability of tools for data collection should be addressed. All needed support should be well provided and well channeled towards improving HBC of COVID-19 positives in Nigeria.

 

 

The authors declare no competing interests.

 

 

OSI conceptualized the study. Both OSI and AAA participated in data collection. AAA wrote the initial draft of the manuscript. Both OSI and AAA revised the manuscript for critical intellectual content. Both authors approved the final version of the manuscript.

 

 

The authors are grateful to all members of the COVID-19 response team who participated in this study.

 

 

Table 1: Methods adopted in the COVID-19 home based care situation analysis

Table 2: COVID-19 data information reported across selected Nigerian states

Table 3: Summary of the home-based care situation, challenges, and improvement strategies in selected settings in Nigeria

Figure 1: Summary of themes identified from the key informant interviews with members of the COVID-19 outbreak response team in Nigeria, 2020

 

 

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