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Introduction: Efforts to improve oxygen access have focused mainly on the supply side, but it is important to understand demand barriers, such as oxygen refusal among caregivers. We therefore aimed to understand caregiver, community and healthcare provider (HCP) perspectives and experiences of medical oxygen treatments and how these shape oxygen acceptance among caregivers of sick children in Lagos and Jigawa states, which are two contrasting settings in Nigeria., Methods: Between April 2022 and January 2023, we conducted an exploratory qualitative study using reflexive thematic analysis, involving semistructured interviews with caregivers (Jigawa=18 and Lagos=7), HCPs (Jigawa=7 and Lagos=6) and community group discussions (Jigawa=4 and Lagos=5). We used an inductive-deductive approach to identify codes and themes through an iterative process using the theoretical framework of acceptability and the normalisation process theory as the analytic lens., Results: Medical oxygen prescription was associated with tension, characterised by fear of death, hopelessness about a child's survival and financial distress. These were driven by community narratives around oxygen, past negative experiences and contextual differences between both settings. Caregiver acceptance of medical oxygen was a sense-making process from apprehension and scepticism about their child's survival chances to positioning prescribed oxygen as an 'appropriate' or 'needed' intervention. Achieving this transition occurred through various means, such as trust in HCPs, a perceived sense of urgency for care, previous positive experience of oxygen use and a symbolic perception of oxygen as a technology. Misconceptions and pervasive negative narratives were acknowledged in Jigawa, while in Lagos, the cost was a major reason for oxygen refusal., Conclusion: Non-acceptance of medical oxygen treatment for sick children is modifiable in the Nigerian context, with the root causes of refusal being contextually specific. Therefore, a one-size-fits-all policy is unlikely to work. Financial constraints and community attitudes should be addressed in addition to improving client-provider interactions., Competing Interests: Competing interests: SA, TA, CC and PV are employed by Save the Children UK who are part of the partnership funding the research. TFO, MM are employees of GSK, a multinational for-profit pharmaceutical company that produces pharmaceutical products for childhood pneumonia, including a SARS-CoV-2 vaccine, and no direct financial interests in oxygen or pulse oximeter products. AAB, HRG and AGF are principal officers of Oxygen for Life Initiative, a not-for-profit organization in Nigeria with focus on medical oxygen system in health facilities., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: In this study, we used the information generated by community members during an intervention design process to understand the features needed for a successful community participatory intervention to improve child health., Design: We conducted a concurrent mixed-methods study (November 2019-March 2020) to inform the design and evaluation of a community-facility linkage participatory intervention., Setting: Kiyawa Local Government Area (Jigawa State, Nigeria)-population of 230 000 (n=425 villages)., Participants: Qualitative data included 12 community conversations with caregivers of children under-5 (men, older and younger women; n=9 per group), 3 focus group discussions (n=10) with ward development committee members and interviews with facility heads (n=3). Quantitative data comprised household surveys (n=3464) with compound heads (n=1803) and women (n=1661)., Results: We analysed qualitative data with thematic network analysis and the surveys with linear regression-results were triangulated in the interpretation phase. Participants identified the following areas of focus: community health education; facility infrastructure, equipment and staff improvements; raising funds to make these changes. Community involvement, cooperation and empowerment were recognised as a strategy to improve child health, and the presence of intermediate bodies (development committees) was deemed important to improve communication and solve problems between community and facility members. The survey showed functional community relations' dynamics, with high levels of internal cohesion (78%), efficacy in solving problems together (79%) and fairness of the local leaders (82%)., Conclusions: Combining the results from this study and critical theories on successful participation identified community-informed features for a contextually tailored community-facility link intervention. The need to promote a more inclusive approach to future child health interventions was highlighted. In addition to health education campaigns, the relationship between community and healthcare providers needs strengthening, and development committees were identified as an essential feature for successfully linking communities and facilities for child health., Trial Registration Number: ISRCTN39213655., Competing Interests: Competing interests: HG, EDM and CK are advisors to Lifebox Foundation on pulse oximetry. AAAB, AGF and HG are board members for Oxygen for Life Initiative, a private non-profit that has provided services to the INSPIRING Project. PV is employed by Save the Children UK which is part of the partnership funding the research., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The COVID-19 pandemic has highlighted global oxygen system deficiencies and revealed gaps in how we understand and measure 'oxygen access'. We present a case study on oxygen access from 58 health facilities in Lagos state, Nigeria. We found large differences in oxygen access between facilities (primary vs secondary, government vs private) and describe three key domains to consider when measuring oxygen access: availability, cost, use. Of 58 facilities surveyed, 8 (14%) of facilities had a functional pulse oximeter. Oximeters (N=27) were typically located in outpatient clinics (12/27, 44%), paediatric ward (6/27, 22%) or operating theatre (4/27, 15%). 34/58 (59%) facilities had a functional source of oxygen available on the day of inspection, of which 31 (91%) facilities had it available in a single ward area, typically the operating theatre or maternity ward. Oxygen services were free to patients at primary health centres, when available, but expensive in hospitals and private facilities, with the median cost for 2 days oxygen 13 000 (US$36) and 27 500 (US$77) Naira, respectively. We obtained limited data on the cost of oxygen services to facilities. Pulse oximetry use was low in secondary care facilities (32%, 21/65 patients had SpO 2 documented) and negligible in private facilities (2%, 3/177) and primary health centres (<1%, 2/608). We were unable to determine the proportion of hypoxaemic patients who received oxygen therapy with available data. However, triangulation of existing data suggested that no facilities were equipped to meet minimum oxygen demands. We highlight the importance of a multifaceted approach to measuring oxygen access that assesses access at the point-of-care and ideally at the patient-level. We propose standard metrics to report oxygen access and describe how these can be integrated into routine health information systems and existing health facility assessment tools., Competing Interests: Competing interests: HRG, EM and CK are advisors to the Lifebox Foundation on pulse oximetry. AAB, AGF and HRG are board members for Oxygen for Life Initiative (OLI), a private non-profit that has provided services to the INSPIRING project. SA, TA, CC and PV are employed by Save the Children UK who are part of the partnership funding the research. TFO and MM are employees of and stockholders in GSK, a multinational for-profit pharmaceutical company that produces pharmaceutical products for childhood pneumonia, including a SARS-CoV-2 vaccine, and no direct financial interests in oxygen or pulse oximeter products., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)