Understanding the factors enabling and blocking sustained implementation of cholera interventions in a fragile region of Nigeria: a multi-phase group model building study protocol

Introduction: Adamawa and Bauchi are cholera endemic states in the north-east region of Nigeria, each with local government areas classified as cholera hotspots. Ineffective implementation of multi-sectoral cholera interventions in both states could make obtaining the global target for cholera control in Nigeria out of reach. A major contributing factor to this challenge is fragility of the region due to persistent Boko Haram insurgency activities, often characterised by the destruction of health infrastruture and displacement of communities to areas with suboptimal living conditions. Given the complexity of disease control in such a fragile setting, this study aims to systematically examine the barriers and/or facilitators influencing the implementation of existing cholera interventions in these states. Methods: The study will use a systems dynamic approach. First, we will conduct a health facility survey to determine the current health system capacity to support multi-sectoral cholera interventions, and conduct key informant interviews with purposely selected state and national cholera stakeholders to identify the context-specific facilitators and barriers to the implementation of cholera interventions in these states. We will then conduct nine group model building workshops (four in both the Adamawa and Bauchi states and one in Abuja) among cholera stakeholders similar to those recruited for the interviews. Conclusion: By engaging diverse and relevant cholera stakeholders, including community members, this study has the potential to provide a rich understanding of context-specific factors influencing the implementation of multi-sectoral cholera interventions in a fragile region of Nigeria, with a view to achieve sustainable progress towards cholera control in the country. Moreover, this study could have an impact on the control of other water-borne diarrheagenic diseases in the country.