Setting research priorities to reduce malaria burden in a post graduate training programme: lessons learnt from the Nigeria field epidemiology and laboratory training programme scientific workshop

Although several research groups within institutions in Nigeria have been involved in extensive malaria research, the link between the research community and policy formulation has not been optimal. The workshop aimed to assist post graduate students to identify knowledge gaps and to develop relevant Malaria-related research proposals in line with identified research priorities. A training needs assessment questionnaire was completed by 22 students two week prior to the workshop. Also, a one page concept letter was received from 40 residents. Thirty students were selected based the following six criteria: - answerability and ethics; efficacy and impact; deliverability, affordability; scalability, sustainability; health systems, partnership and community involvement; and equity in achieved disease burden reduction. The workshop was over a three day period. The participants at the workshop were 30 Nigeria Field Epidemiology and Laboratory Training Programme (NFELTP) residents from cohorts 4 and 5. Ten technical papers were presented by the experts from the academia, National Malaria Elimination (NMEP) Programme, NFELTP Faculty and Implementing partners including CDC/PMI. Draft proposals were developed and presented by the residents. The “strongest need” for training was on malaria prevention, followed by malaria diagnosis. Forty seven new research questions were generated, while the 19 developed by the NMEP were shared. Evaluation revealed that all (100%) students either “agreed” that the workshop objectives were met. Full proposals were developed by some of the residents. A debriefing meeting was held with the NMEP coordinator to discuss funding of the projects. Future collaborative partnership has developed as the residents have supported NMEP to develop a research protocol for a national evaluation. Research prioritization workshops are required in most training programmes to ensure that students embark on studies that address the research needs of their country and foster collaborative linkages.


Introduction
Malaria is highly endemic in Nigeria and it remains one of the leading causes of childhood and maternal morbidity and mortality in the country [1]. High temperature, humidity, and rainfall are some of the factors that enhance mosquito breeding and malaria transmission [2]. Malaria accounts for 60% of outpatient visits, and for 30% of hospitalisations among children under five years of age [3,4]. Childhood deaths resulting from malaria have been estimated at over 300,000 deaths per year in Nigeria [5]. At this rate, malaria accounts for more deaths per year than HIV/AIDS, and is the major contributor to deaths in children under-five years and in pregnant women [3]. The National Malaria Indicator Survey of 2010 showed that slide positivity rate was 42% in children under-five [5].
Pregnant women living in places where malaria is highly prevalent are four times more likely than other adults to get malaria and twice as likely to die of the disease [6]. Malaria related deaths account for up to 11% of maternal mortality, 25% of infant mortality, and 20% of under-five mortality resulting in 300,000 childhood deaths annually [3,5]. The Federal Government of Nigeria is deeply committed to making progress towards the achievement of the Millennium Development Goals and it recognizes that, without firm efforts to control malaria, achievement of the targets related to child mortality, maternal mortality, and reducing the burden of communicable disease will not be possible [1]. Malaria therefore internationally [3]. Also NMEP has prioritized a list of research priorities of which some researchers are unaware [1]. The Field Epidemiology and Laboratory Training Programme (FELTP) is a two year master's training in applied epidemiology. FELTP serves to build local capacity to improve and strengthen countries' public health systems and infrastructure. The Nigeria FELTP commenced in 2008, and since then has been working to build capacity in the public health workforce [7]. Presently, the programme is in its sixth cohort of student intake (www.nigeria-feltp.net). With support from The program has helped to improve public health systems within the country by developing a cadre of well-trained and competent public health professionals [7].
The residents are expected to conduct research projects and write a dissertation as part of the requirements for award of the Master degree. They are also encouraged to participate in scientific conferences, write field reports and publish as part of their training.
Hence, malaria-related research studies have been conducted by the graduates and trainees of the programme. A review of previous malaria projects of the residents admitted in the first two years of the programme showed that three students (11.5%) out of the 26 residents in the first two cohorts had done original research on malaria. These studies assessed case management practices and evaluated laboratory diagnostic tools and services. Other studies conducted by the residents on the programme have included evaluation of malaria surveillance systems at the different tiers of the health system and secondary data analyses of malaria databases [8]. However, there is a need to involve more residents in research on Malaria and expand the scope of these studies to include contemporary international, national and local issues. Also, there is the need to ensure that the studies conducted are addressing the research needs and agenda of the country. PMI is one of the funders of the program, therefore the residents work need to reflect PMI focus. Lastly, there is a crucial need for a comprehensive inventory of research areas that address the problems identified in malaria control in the country. This road map should address the research needs identified by the various stakeholders involved in Malaria control and elimination in Nigeria. Furthermore, the inventory will assist future NFELTP residents to identify topics for their research work.

Methods
The implementation of the workshop was done in three stages, namely pre workshop, the workshop and post work shop activities.

Pre-Workshop
The pre workshop stage also had three main activities:preparatory activities, training needs assessment and the submission of concept notes.
Preparatory work: Preparatory to the workshop, the "NFELTP organization of a workshop checklist" was used as a guide [9]. The were scored as follows -"strong need" -2 marks, "need" -1 mark.
Persons who were undecided or who indicated less or no need scored no marks, while those who stated that they were not sufficiently informed were excluded from the scoring ( Table 1).
Twenty two residents responded to the needs assessment hence non response rate was 25.6%. On the general areas in which research are strongly needed, most residents indicated "malaria prevention", followed by "malaria treatment" and then "malaria diagnosis " (Figure 1). As regards the specific themes requiring most urgent research on malaria prevention most of the residents indicated "vector control", that is, "uptake of insecticidal treated nets (ITN) and long lasting insecticidal nets (LLIN), followed by "maternal knowledge, attitude and practice and childhood malaria infection". On "malaria treatment" the strongest need (50%) was indicated on "use of rapid diagnostic test (RDTs) and adherence to treatment guidelines in the public and private sector". While on malaria diagnosis it was "quality control/assessment measures of microscopy and RDT and its effect on malaria diagnosis" ( Table   2 (a), Table 2 (b)).

Development of concepts:
Based on the specific questions on the thematic areas, the students submitted one page concept notes to address any of the needs identified. Concepts consisted of an introduction, research question, methodology and expected outcomes. Forty concepts notes were received from which 30 were selected. Selection was based on the following six criteria:answerability and ethics (5 questions); efficacy and impact (3); deliverability, affordability, scalability, sustainability (6); health systems, partnership and community involvement (4); and equity in achieved disease burden reduction (4). Each of these criteria was scored 0, 1 or 2 points based on response to a series of questions that addressed these issues. Scores were summarized for each concept; the maximum score obtainable was 44, while the minimum was 0. Scores were then converted into percentage ( Table   2 (a), Table 2 (b)). The scoring was done by two experts who were NFELTP faculty. Analysis of the concept letters showed that 7(23.3%) were from students in cohort 4 and 23 (76.7%) cohort 5 residents. Sixteen students were from the medical (53.3-%), two (6.7-%) from the veterinary and 12 (40.0%) from the laboratory tracks ( Table 3). Most of the concepts (9/30) addressed "Prevention of Malaria" although there was overlap in themes of the concept letters. None was on "Monitoring and Evaluation" (0/30).

The Workshop
The workshop was held between the 23rd and 25th of September, 2013. The participants were selected NFELTP residents from cohort Opening: Welcome remarks were given by the representative of the national coordinator of the NMEP. The gathering was reassured that there was political will and support for malaria elimination in Nigeria. The participants were also reminded the importance of operational research in guiding policy and program performance, and informed that the outcome of the deliberations would be useful in the forthcoming strategic plan review. The director of the programme, asked the experts to identify the knowledge gaps and enhance the skills of the residents through applied research, while the resident advisor encouraged the residents to be ready to work hard to get the best from the workshop. Table 3 Evaluation: The evaluation form was filled by 10 participants. All (100%) either "strongly agreed or agreed" that the workshop objectives were met and overall the workshop was satisfactory. The subject matter was found to be useful to their dissertation or training. All also either strongly agreed or agreed that adequate time was allotted for explanations/group work and the presentations/materials provided was satisfactory. The group work was stated by 50% as what they liked most about the workshop followed by the presentation of the facilitators (40%). What was liked least about the workshop was that some facilitators were not fully available for the group work (10%), some said it was the lectures given (10%), while many (80%) had no response. If the workshop was repeated, what should be changed were as follows:-10% said it should be extended to five days, 10% said allocate more time for group work while, 20% wanted all the resource materials to be made available before the workshop commences.

Post workshop Next Steps/Follow-Up
At the end of the workshop it was agreed that a revised draft

Discussion
The fact that malaria still constitutes a public health challenge that is high on the research agenda of the country was evident at the workshop. Malaria accounts for more cases and deaths in Nigeria than any other country in the world, affecting 97% of its population.
Persons most vulnerable to malaria and its complications are children under five years and pregnant women [10]. Thus Malaria is a topical issue for researchers including post graduate students to work on [11]. This was obvious at the programme, as prior to the workshop some students had already conducted field investigations on the disease. These studies included primary surveys and secondary data analysis [8]. Also many submitted concept notes suggesting interest in malaria research. Majority of the residents who sent concepts were the students in their first year of training.
These are students who were trying to identify research topics for their dissertation and took the opportunities provided at the workshop to do so. Most of the students in the second year had already commenced their research work on different public health problems and were in various stages of implementation (hence our relatively high non response rate). However, those who had ongoing malaria research projects seized the opportunity to fine-tune their proposals with expert guidance. The timing of the workshop was also beneficial to first year residents who were in the nurturing process of developing research ideas for their university thesis. The highest proportion of concept notes was on "prevention of malaria", followed by "malaria treatment". This is may be the thrust of the FELTP training is on disease prevention and control. The theme of the concept notes also reflected the students training tracts, most were in the medical track. There was some overlap in some of the FMOH themes namely -"prevention"," treatment", "diagnosis" and "case management", therefore for the group work exercises, the methodology and target population of the proposed study were taken into consideration. The students did not submit concepts on "procurement and supply chain management". Also the students did not indicated interest for training on this aspect during the needs assessment. This may because they did not knowledge on this aspect of malaria control or the skills to conduct studies in this area. The workshop facilitators stimulated interest of the students in research on this aspect and currently, a student is now conducting a research study on Procurement and Supply Chain Management. Also students did not submit concepts on "Monitoring and Evaluation", of which surveillance is a crucial aspect, probably because many were experienced in evaluating disease surveillance systems. But this might also be because, developing a research protocol on Monitoring and Evaluation is tasking, requires innovation and technical expertise [13]. Deliverability, affordability, scalability, and sustainability of the study proposed was the criterion that was awarded the highest scores in the assessment of the submitted concept notes. This is because it is recognized that although these were small scale studies which were to be implemented as student's projects, they should have potential to be scaled up to national or sub national levels in the future. "Answerability and ethics" scored . These similarities were particularly remarkable in the areas of "malaria in pregnancy" and "case management of malaria". These students were assisted to develop proposals by resource persons from the NMEP. There are also request for funding by the NMEP for these studies.
The workshop had limitations. Firstly, most of the students intended to conduct the research as part of their dissertation. This implies that they have limited time, (ideally one year from initiation of the concept till defense of the dissertation) and limited funds to implement the study [15]. Hence all the concept notes received were cross sectional surveys. The limitation of this is that it may take considerable amount of time to translate the findings to interventions that can be rolled out on a large scale and impact public health practice in the country. Another limitation of the workshop is that some important knowledge gaps and research ideas may not have been identified by our technical experts.
Similarly some ideas might have been included due to personal interest or excessive media interest [15].      Availability and access to IPT for pregnant women 0(0) 1.3

Tables and figures
Promotion of malaria preventive practices with the use of the present health promotion mediums (media, print) 0(0) 1.1 Potentials of larviciding as part of the scale up of integrated vector management 2(9.1) 1.2 Household size/composition effect on adherence to use of ITN 0(0) 1.2 Evaluation of combination of prevention approaches -ITNs/IRS & Laviciding 2(9.1) 1.1 The cost effectiveness of LLINs compared to IRS 2(9.1) 0.7 Training for midwives to improve IPT uptake 0(0) 0.8

Malaria diagnosis
Quality control measures on laboratory diagnostic testing (microscopy and rapid testing) 0(0) 1.

Socio-behavioral
Effect on health seeking behaviors and prompt diagnosis and treatment 1(4.5) 1.1 Community involvement in recognizing malaria incidences and improving health-seeking behaviors 0(0) 1.0 Link between socioeconomic status of caregivers and malarial outcomes on mothers and child 1(4.5) 1.1

Monitoring & evaluation
Causes of poor and inaccurate data reporting in Nigeria 0(0) 1.4 SMS applications and DHIS to improve the data quality and feedback 0(0) 1.1 Surveillance systems and its effectiveness in tracking insecticide and drug resistances 0(0) 1.4 Record-keeping measures in health facilities and its adequacy 0(0) 1.2 Evaluating the use and upkeep of the LLINs 1(4.5) 1.0