Title : Beyond coverage: Urban-rural disparities in caregiver knowledge, participation, and operational quality during azithromycin mass drug administration in kebbi state, Nigeria

Background: Azithromycin mass drug administration is an evidence-based child-survival intervention deployed in high under-five mortality settings. While programme performance is typically assessed through aggregate coverage indicators, equity in participation, caregiver understanding, and operational delivery quality remain underexplored. This study evaluates disparities in caregiver participation, knowledge of treatment instructions, communication pathways, and operational delivery quality between rural and urban populations.

Methods: A cross-sectional analytical study was conducted using data from the Kebbi State End Process Assessment, conducted in August 2025, complemented by in-process monitoring data from Rounds 1 and 2, covering 5,484 household visits (4,081 rural; 1,403 urban)  . Local Government Areas were classified as urban (Birnin Kebbi, Argungu, Jega, Zuru, Yauri) or rural (all remaining LGAs) using a hybrid urbanicity classification framework. Primary outcomes included child participation in AZM MDA, caregiver campaign awareness, correct knowledge of adverse event response, and primary communication sources. Operational indicators included screening practices and caregiver satisfaction. Pearson chi-square tests were used to compare proportions across settlement strata.

Results: Participation was significantly higher in rural areas compared to urban areas (86.6% vs 80.1%, p<0.001). Awareness of the campaign was also higher among rural caregivers (90.1% vs 79.7%, p<0.001). However, correct knowledge of the appropriate response to vomiting within five minutes of dosing was significantly higher in urban areas (46.2% vs 30.6%, p<0.001). Knowledge of the appropriate response to severe adverse events (breathing difficulty/unconsciousness) was comparable across strata (81.0% vs 81.1%, p=0.932). Communication pathways differed markedly: rural communities relied predominantly on interpersonal mobilisation networks, health facility staff, local leaders, town announcers, and religious leaders, while urban caregivers were more dependent on distributor-based information. Operational screening indicators were modestly but significantly stronger in rural settings, including health status inquiry (90.9% vs 88.2%, p=0.009), antibiotic use screening (90.0% vs 87.1%, p=0.008), and eligibility assessment (91.1% vs 88.6%, p=0.015). Caregiver satisfaction was high and comparable across strata (>96%).

Conclusion: High aggregate coverage masked important behavioural and knowledge inequities across settlement types. Rural communities demonstrated stronger participation and operational fidelity but weaker comprehension of dosing safety instructions, while urban communities exhibited better knowledge retention but lower campaign engagement. Uniform mobilisation strategies risk concealing context-specific vulnerabilities. Settlement-tailored communication and supervisory strategies are essential to optimise safety, equity, and effectiveness in large-scale child-survival MDA programmes.

Keywords: azithromycin; mass drug administration; child survival; urban–rural equity; caregiver knowledge; Kebbi State; Nigeria; SARMAAN

Emmanuel Eneojo Akagu is a project manager and monitoring & evaluation specialist. He serves as a Project Manager for the SARMAAN II project under Malaria Consortium, where he leads the implementation of mass drug administration interventions aimed at reducing childhood mortality.

Emmanuel is currently pursuing a PhD in Urban and Regional Planning at the Federal University of Technology, Minna. He also holds an MBA in Healthcare Management from Jain University, India, a Master’s degree in Urban and Regional Planning from the Federal University of Technology, Minna, and a Bachelor’s degree in Environmental Management Technology from Abubakar Tafawa Balewa University, Bauchi.