Health systems challenges, mitigation strategies and adaptations to maintain essential health services during the COVID-19 pandemic: learnings from the six geopolitical regions in Nigeria

BACKGROUND

The COVID-19 pandemic control strategies disrupted the smooth delivery of essential health services (EHS) globally. Limited evidence exists on the health systems lens approach to analyzing the challenges encountered in maintaining EHS during the COVID-19 pandemic. This study aimed to identify the health system challenges encountered and document the mitigation strategies and adaptations made across geopolitical zones (GPZs) in Nigeria.

METHODS

The national qualitative survey of key actors across the six GPZs in Nigeria involved ten states and the Federal Capital Territory (FCT) which were selected based on resilience, COVID-19 burden and security considerations. A pre-tested key informant guide was used to collect data on service utilization, changes in service utilization, reasons for changes in primary health centres' (PHCs) service volumes, challenges experienced by health facilities in maintaining EHS, mitigation strategies implemented and adaptations to service delivery. Emerging sub-themes were categorized under the appropriate pillars of the health system.

RESULTS

A total of 22 respondents were interviewed. The challenges experienced in maintaining EHS cut across the pillars of the health systems including: Human resources shortage, shortages in the supply of personal protective equipments, fear of contracting COVID-19 among health workers misconception, ignorance, socio-cultural issues, lockdown/transportation and lack of equipment/waiting area (. The mitigation strategies included improved political will to fund health service projects, leading to improved accessibility, affordability, and supply of consumables. The health workforce was motivated by employing, redeploying, training, and incentivizing. Service delivery was reorganized by rescheduling appointments and prioritizing some EHS such as maternal and childcare. Sustainable systems adaptations included IPC and telehealth infrastructure, training and capacity building, virtual meetings and community groups set up for sensitization and engagement.

CONCLUSION

The mitigation strategies and adaptations implemented were important contributors to EHS recovery especially in the high resilience LGAs and have implications for future epidemic preparedness plans.

Experiences of female clients in the assisted reproductive technology process in Nigeria

Background

Though assisted reproductive technology (ART) has been a source of hope for many infertile couples, it is known to be associated with physical, social, psychological, and ethical challenges in different settings.

Objective

The study objective was to explore the experiences of female clients who accessed services in ART clinics in Nigeria.

Methods

An exploratory qualitative design, using snowballing technique was employed. It involved in-depth interviews of eight women who had gone through the assisted conception process, using an interview guide. Data collection was from November 2019 to January 2020. Results: The age range of the participants was 30 - 52 years with a mean of 41.88 years. Majority of the clients presented at advanced age to their ART providers because of lack of funds and ignorance. Other challenges were suboptimal risk disclosure, high cost of services, feelings of shame and stigmatization during and after the process.

Conclusion

Cost of ART remain unaffordable to most Nigerians hence the need for government subsidization and in-corporation of ART services into the National Health Insurance Scheme. Additionally, lack of adequate information disclosure, shared decision-making and gendered suffering are areas of great concern among the study participants. A national regulatory guideline will ensure uniform international standard of care.

Capacity-Building for Stroke Genomic Research Data Collection: The African Neurobiobank Ethical, Legal, and Social Implications Project Experience

Background: The fields of stroke genomics, biobanking, and precision medicine are rapidly expanding in sub-Saharan Africa. However, the ethical, legal, and social implications (ELSI) of emerging neurobiobanking and genomic data resources are unclear in an emerging African scientific landscape with unique cultural, linguistic, and belief systems. Objective: This article documents capacity-building experiences of researchers during the development, pretesting, and validation of data collection instruments of the African Neurobiobank for Precision Stroke Medicine-(ELSI) Project. Methods: The African Neurobiobank for Precision Stroke Medicine-ELSI project is a transnational, multicenter project implemented across seven sites in Ghana and Nigeria. Guided by the Community-Based Participatory Research framework, we conducted three workshops with key stakeholders to review the study protocol, ensure uniformity in implementation; pretest, harmonize, and integrate context-specific feedback to ensure validity and adaptability of data collection instruments. Workshop impact was assessed using an open-ended questionnaire, which included questions on experience with participation in any of the workshops, building capacity in Genetic and Genomic Research (GGR), level of preparedness toward GGR, the genomic mini-dictionary developed by the team, and its impact in enhancing understanding in GGR. Data were analyzed qualitatively using a thematic framework approach. Results: Findings revealed the usefulness of the workshop in improving participants' knowledge and capacity toward GGR implementation. It further identified local, context-specific concerns regarding quality data collection, the need to develop culturally acceptable, genomic/biobanking data collection tools, and a mini-dictionary. Participants-reported perceptions were that the mini-dictionary enhanced understanding, participation, and data collection in GGR. Overall, participants reported increased preparedness and interest in participating in GGR. Conclusion: Capacity-building is a necessary step toward ELSI-related genomic research implementation in African countries where scholarship of ELSI of genomics research is emerging. Our findings may be useful to the design and implementation of ELSI-GGR projects in other African countries.

Heterosexual Oral and Anal Sex: Perceptions, Terminologies, and Attitudes of Younger and Older Adults in Ibadan, Nigeria

Although heterosexual oral and anal sexual behaviors have been reported in sub-Saharan Africa, little is known about how they are understood and perceived, particularly, in West Africa. We undertook a qualitative exploration of local terminologies and sexual scripts associated with heterosexual oral and anal sex in preparation for a quantitative survey. We held focus group discussions (18) and interviews (44) with younger and middle-aged men and women from the general population and female sex workers (FSWs) in selected communities in Ibadan. Most participants had heard of oral and anal sex. Younger adults aged 18-25 years, particularly male participants and FSWs, appeared more informed than older adults in the general population. Sexually explicit movies were the most cited source of information. Oral and anal sexual behaviors were considered sensitive, with different local names, meanings, and interpretations. Participants advised against the use of slang terms in research. We identified six different scripts employed by participants in discussing oral and anal sex practices: protecting sexual relationship, financial reward, an alternative to vaginal sex, pleasure, male dominance and control, and risk, stigma, and disgust.

Individual and ecological analyses of antenatal care: Prospects for delivery assistance and use of modern family planning in Nigeria

Despite the availability of healthcare centres for the provision of antenatal care (ANC) services in Nigeria, the services are still underutilized by pregnant women. ANC services not only reduce maternal mortality and birth defects, but also have a strong link to many causes of maternal deaths. This study explored the individual and ecological relationships between antenatal care, skilled birth assistance during delivery, and family planning use across states in Nigeria. This study was a secondary analysis of data from the 2018 National Nutrition and Health Survey (NNHS) carried out among 24,985 women aged 15-49 years in the 36 states and the Federal Capital Territory (FCT) in Nigeria. Analysis was carried out at the level of individual women and at the ecological level. Only 68.3% visited a health professional (doctors, nurses, midwives, community health extension workers, and community health officers) for ANC in the most recent pregnancy before the survey. At delivery, 44.9% were assisted by delivery attendants with about half (50.1%) assisted by non-professional (traditional birth attendants, relatives and friends) during delivery. There was a significant variation in use of modern family planning (FP) across types of ANC provider. There was a strong positive correlation between ANC utilisation and skilled birth attendance (SBA) (r=0.706, p <0.001), and between SBA and FP (r=0.730, p <0.001). These results have implications for the design of appropriate interventions for strengthening the role of healthcare providers to enhance ANC patronage, utilization of safe delivery services and sustained use of reproductive health services.

Missed opportunities for HIV counselling and testing service delivery among pregnant women in Nigeria: Evidence from the 2018 National nutrition and health survey

According to UNAIDS, the 90-90-90 strategy calls for 90% of HIV-infected individuals to be diagnosed by 2020, 90% of whom will be on anti-retroviral therapy (ART) and 90% of whom will achieve sustained virologic suppression. HIV counselling and testing (HCT) is an important entry point for effective prevention of mother-to-child transmission of HIV. However, evidence abounds that HCT is often missed by pregnant women during antenatal care in Nigeria. We used secondary data from the 2018 Nigerian National Nutrition and Health Survey (NNHS) to determine the pattern of missed opportunities within the HCT algorithm and the factors associated with the missed opportunities. Of the 8,329 eligible women, 2,327 (27.9%) missed HCT because of lack of antenatal care; 1,493 (24.9%) missed HIV pre-test counselling; 180 (4.0%) missed HIV testing after participating in pre-test counselling, while 793 (18.2%) missed collection of HIV result and post-test counselling. Generally, most of the women that missed HCT were from the North West (43.3%) and had their antenatal care with traditional birth attendants. The odds of missing ANC were higher in women in the Northern and Southern regions. Concerning pre-test HIV counselling, the odds of missing it were higher among women in the Northwest and Southeast while the odds of missing post-test counselling of HIV test were higher among women in the Northeast and Southeast relative to other regions. Using TBA as a care provider was associated with higher odds of women missing pre-test and post-test counselling of HIV during ANC compared to those that used doctors or midwives or CHEWs. Missed opportunities are common in different stages of HIV counselling and testing pathway in Nigeria, particularly in the Northern regions. Future studies would need to identify the specific reasons for these missed opportunities, enabling the targeting of more specific policy reform and interventions.

Prevalence and predictive factors for early initiation of breastfeeding in Nigeria: Evidence from the Nigerian demographic and health survey (2003-2018)

Early initiation of breastfeeding (EIBF) is an essential first step in exclusive breastfeeding that is expected to commence within an hour after childbirth. This study examined the prevalence and the factors associated with EIBF among nursing mothers in Nigeria based on an analysis of the 2003, 2008, 2013, and 2018 Nigerian Demographic Health Survey (NDHS) data. The prevalence of early breastfeeding initiation by women's demographic, socio-economic and reproductive characteristics were computed for each of the survey rounds. The differences in the prevalence estimates for early breastfeeding initiation between the last two survey periods were calculated. A crude and adjusted model to examine association between explanatory variables and early breastfeeding initiation were fitted using Poisson regression model. The mean age of respondents was 29 years (SD=7.3). The prevalence of EIBF increased from 31.5% in 2003 (95% CI 28.4-34.5) to 43.8% in 2018 (95% CI 42.6-45.0), with a decline to 35.3% in 2013 (95% CI 34.0-36.7). The identified risk factors associated with EIBF were being 35-39 years, having at least a primary education, lower wealth quintiles, multiparity, and delivery in a public hospital. EIBF was lower among women that had skilled occupation, access to media, decided to delay pregnancy, history of previous caesarean section, small size baby at birth, and women who received antenatal care. The results indicate that the proportion of women with EIBF in Nigeria is low. Addressing the barriers identified in this paper will help promote EIBF practices in the country.

Uptake of modern and traditional contraceptive methods in Nigeria: Lessons from a nationwide initiative on programming for results (2015-2018)

In general, family planning uptake promotes healthy living among couples and their children, in addition to aiding national development. This study was a secondary analysis of data collected from two nationally representative data - 2015 and 2018 National Nutrition and Health Surveys (NNHS) - aimed at measuring the uptake of modern and traditional contraceptive methods among women of reproductive age in Nigeria. The data were analysed by presenting differentials in prevalence of modern and traditional contraceptives between 2015 and 2018. The results showed that during the periods modern contraceptive uptake in Nigeria ranged between 10% and 17%. By contrast, the prevalence of the traditional methods was 8.3% and 10.0%. Within four years (2015-2018), the average national modern contraceptive uptake among women increased by 7%, while the traditional contraceptive uptake reduced by 2%. The uptake of both modern and traditional contraceptive methods varied by ages group of women, geo-political regions, and State of residence. We conclude that the uptake of modern contraception is below expectation in all regions in Nigeria. The uptake is worse in the northern regions as compared to the southern regions. Government needs to invest more to increase access to and utilization of modern contraceptive methods.

Prevalence and patterns of anthropometric failure among under-five children in Nigeria: Evidence from the National nutrition and health survey, 2018

Globally, malnutrition among under-five children remains a public health concern. There is increasing concern at research and policy levels about anthropometric failure and the double burden of child malnutrition across different groups of children. The objective of this study was to describe the magnitude and distribution of various forms of anthropometric failure (AF) among children under age five in Nigeria. We used the 2018 National Nutrition and Health Survey data collected among 19,471 under-five children in Nigeria. The most prevalent AF was stunting only (17.7%) followed by stunting and underweight (13.9%). Wasting, stunting and underweight was found among 3.5% of the sample. Wasting, stunting and underweight was most common in age 6-11 months (7.0%) and 12-23 months (6.9%). Overall, about 1 out of 5 under-five children has multiple anthropometric failure. The peak age group for multiple AFs was between six months and 35 months. Multiple AF was less likely among females compared to males (RR=0.74, CI: 0.69, 0.80). The risk of multiple AF was higher in both North East (RR=2.15, CI: 1.78, 2.59) and North West (RR=2.98, CI: 2.51, 3.55) relative to the North Central. In contrast, the risk was lesser in the South East (RR=0.75, CI: 0.59, 0.95) and other southern regions. The study showed that multiple anthropometric failure is a common problem among children in Nigeria. Programmes that will support prevention and early identification of different types of malnutrition among under-five children across States in Nigeria are recommended.

Non-Malaria Causes of Fever among under-5 Children with Negative Results for Malaria Rapid Diagnostic Test in South-Western Nigeria

BACKGROUND

Although the global malaria burden is decreasing, there are still concerns about overdiagnosis of malaria and the danger of misdiagnosis of non-malaria causes of fever. Clinicians continue to face the challenge of differentiating between these causes despite the introduction of malaria rapid diagnostic tests (mRDTs).

AIM

To determine the prevalence and causes of non-malaria-caused fever in children in South-Western Nigeria.

METHODS

Secondary analysis of data obtained to evaluate the effect of restricting antimalarial treatment to positive mRDT children in rural and urban areas of southwest Nigeria. Clinical examinations, laboratory tests for malaria parasites (including thick blood film and mRDT) and bacterial identification were performed on children aged 3-59 months (n = 511). The non-malaria group comprised febrile children who had both negative mRDT and microscopy results, while the malaria group included those who were positive for either mRDT or microscopy. We compared the causes of fever among children with non-malaria fever and those with malaria.

RESULTS

The prevalence of non-malaria fever and bacteria-malaria co-infection was 37.2% and 2.0%, respectively. Non-malarial pathogens identified were viral (54.7%) and bacterial (32.1%) infections. The bacterial infections included bacteriaemia (2.7%), urinary tract infections (21.6%), skin infections (11.6%) and otitis media (2.6%). The leading bacterial isolates were Staphylococcus aureus, Pseudomonas aeruginosa and Streptococcus pneumoniae.

CONCLUSION

The high prevalence and wide range of non-malarial infections reinforces the need for point-of-care tests to identify bacterial and viral infections to optimize the treatment of febrile illnesses in malaria-endemic areas.

Health service utilisation during the COVID-19 pandemic in sub-Saharan Africa in 2020: a multicountry empirical assessment with a focus on maternal, newborn and child health services

INTRODUCTION

There are concerns about the impact of the COVID-19 pandemic on the continuation of essential health services in sub-Saharan Africa. Through the Countdown to 2030 for Women's, Children's and Adolescents' Health country collaborations, analysts from country and global public health institutions and ministries of health assessed the trends in selected services for maternal, newborn and child health, general service utilisation.

METHODS

Monthly routine health facility data by district for the period 2017-2020 were compiled by 12 country teams and adjusted after extensive quality assessments. Mixed effects linear regressions were used to estimate the size of any change in service utilisation for each month from March to December 2020 and for the whole COVID-19 period in 2020.

RESULTS

The completeness of reporting of health facilities was high in 2020 (median of 12 countries, 96% national and 91% of districts ≥90%), higher than in the preceding years and extreme outliers were few. The country median reduction in utilisation of nine health services for the whole period March-December 2020 was 3.9% (range: -8.2 to 2.4). The greatest reductions were observed for inpatient admissions (median=-17.0%) and outpatient admissions (median=-7.1%), while antenatal, delivery care and immunisation services generally had smaller reductions (median from -2% to -6%). Eastern African countries had greater reductions than those in West Africa, and rural districts were slightly more affected than urban districts. The greatest drop in services was observed for March-June 2020 for general services, when the response was strongest as measured by a stringency index.

CONCLUSION

The district health facility reports provide a solid basis for trend assessment after extensive data quality assessment and adjustment. Even the modest negative impact on service utilisation observed in most countries will require major efforts, supported by the international partners, to maintain progress towards the SDG health targets by 2030.

Perception of Key Ethical Issues in Assisted Reproductive Technology (ART) by Providers and Clients in Nigeria

PURPOSE

In the past decade, developments in the field of Assisted Reproductive Technology (ART) have intensified the hopes and the desires of infertile people to overcome infertility, resulting in an increasing demand for such services worldwide. However, as developments in ART have evolved rapidly, so have ethical, social, and political controversies surrounding many aspects arisen. It is known that societal ethics is dependent on the values and culture of a given group. We sought to explore how practitioners and clients in Nigeria perceive some Key ethical issues surrounding ART.

MATERIALS AND METHODS

This was an explorative descriptive study involving in-depth interview of three ART providers and eight female ART clients, all domiciled in Southeastern Nigeria. Sampling was by purposive and snowballing techniques for providers and clients, respectively. Ethical approval was obtained from University of Ibadan/University College Hospital and University of Nigeria Teaching Hospital Research Ethics Committees. Responses were grouped into themes for ease of discussion.

RESULTS

Providers and clients were in support of sex selection for family balancing, and multiple embryo transfers. They also perceive that the health of the woman should be the factor considered and not biological age for service provision. However, views differed on marital status as an access factor. Participants were in support of legally binding regulations to guide practice.

CONCLUSION

A culturally sensitive national regulation is recommended to guide practice in this vital area of reproduction.

Risk communication during COVID-19: a comparative analysis of four countries

Background

Risk communication (RC) is fundamental to ensuring public engagement in public health emergencies. Existing studies describe the mechanisms that integrate RC into emergency responses, but knowledge about which governing structures and policies are needed to ensure effective RC in public health emergencies is lacking. We compare RC across four epidemiological, socio-political, and geo-economic settings and identify key structural factors that can lead to effective RC in public health emergencies.

Methods

A multisite international study was implemented using qualitative research methods in Germany, Guinea, Nigeria, and Singapore. We mapped and assessed RC governing structures, drawing on a document review and semi-structured key informant interviews with 155 stakeholders involved in the design and implementation of RC strategies at national and sub-national levels.

Results

A comparative analysis of the content, process, actors, and context of the distinct RC structures in the four countries as well as related strengths and weaknesses are presented. Early integration of RC into preparedness and response plans alongside the use of previous experiences and structures are key to effective implementation of RC during public health emergencies. A lack of coordination increases the risk of parallel structures, missed opportunities, duplication of resources, and public confusion due to a cacophony of messages. Building on previous experiences of outbreaks and on existing structures and relationships can help governments to more quickly mobilise effective RC strategies during pandemics.

Conclusions

RC is key to effective pandemic responses and can help to reduce infection and transmission. Yet, considerable potential exists for countries to improve RC in public health emergencies. Learning from mistakes and successes during COVID-19 can help improve RC strategies and governing structures and prepare for future pandemics.

Key messages

Strengthening RC preparedness and response enables governments to more effectively implement the International Health Regulations. COVID-19 provides ample learning opportunities to improve communication in public health emergencies.

Community acceptance, satisfaction, and support for case management of malaria of various degrees in selected rural communities in Ibadan, Oyo-State

Objectives

This study aimed to assess communities' perception and adoption of the evidenced-based malaria diagnosis and case management intervention targeted at under-five children. The effectiveness of trained Volunteer Community Health Workers (VCHWs) to diagnose malaria among under-five children using rapid diagnostic testing kit, provide treatment using Artemisinin Combination Therapy and rectal Artesunate were assessed.

Design

A qualitative evaluation study was conducted in October 2015.

Setting

Communities in the 6 rural wards in Ona-Ara Local Government Area, Oyo State Nigeria.

Participants

Caregivers of under-five children, community-based frontline health workers, and community leaders selected using purposively sampling.

Methods

Nine Focus Group Discussions and 15 Key Informant Interviews were conducted using a pre-tested guide. Data were subjected to thematic analysis.

Results

It was disclosed that VCHWs promoted people's access to prompt and appropriate malaria treatment. The communities accepted the VCHWs; the reasons given for this included the following: effectiveness of VCHWs in case management of malaria; good inter-personal relationship with caregivers; and the positive health outcomes associated with services provided by them. In addition, community members expressed satisfaction with the VCHWs and provided them with all the support needed to function throughout the malaria case management intervention. The VCHWs considered the support as a great source of encouragement.

Conclusions

The use of VCHWs to treat malaria was adjudged to be effective and considered acceptable to the communities. The adoption of the intervention and its integration into the primary health system by the government is advocated for in medically underserved rural communities.

Funding

This work was supported by UNICEF/UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland (project ID: A80550 [Nigeria] through funds made available by the European Commission (FP7) for research to improve community access to health interventions in Africa.

Comparative evaluation of three histidine-rich Protein-2 based rapid diagnostic tests, microscopy and PCR for guiding malaria treatment in Ibadan, Southwest Nigeria

Background

Malaria rapid diagnostic tests (mRDTs) are the preferred option for programmatic deployment.

Aims

There are numerous mRDTs on the Nigerian market and there is a need to guide practitioners on the relative performance of the commonly used brands of mRDT in Nigeria.

Subjects and Methods

The performance of three commonly used Histidine-Rich-Protein-2-based mRDTs (SD-Bioline™, Carestart™ and Paracheck-Pf™) against microscopy of Giemsa stained blood and polymerase chain reaction (PCR) was evaluated among 190 febrile under-5 children in Ibadan, Nigeria. We calculated the sensitivity, specificity, predictive values, accuracy, and agreements.

Results

There were 53.2% males. The prevalence of malaria parasite by microscopy was 46.8% and 57.9% by PCR. Malaria parasite detection by SD-Bioline™ was 60.5%, Carestart™: 60.0% and Paracheck-Pf™ 60.0%. Using microscopy as the gold standard, the sensitivities of SD-Bioline™, Carestart™ and Paracheck-Pf™ mRDT were 97.8%, 96.7% and 97.8% respectively while the specificities were 73.0%, 72.0% and 74.0% respectively. Using PCR as the gold standard, the sensitivity for both SD-Bioline™ and Paracheck-Pf™ was 85.5% and for CareStart was 84.6% while the specificity of SD-Bioline™, Carestart™, and Paracheck-Pf™ was 73.8%, 72.4%, and 75.0% respectively. The test accuracy was 81.0% for both SD-Bioline™ and Paracheck-Pf™ and 80.0% for Caresatrt™. The kappa coefficient of agreement between PCR and each of SD-Bioline™, Carestart, ParaCheck™ and microscopy was 0.597, 0.578, 0.609 and 0.739 respectively.

Conclusion

The performance of the three mRDTs is a proof that any of the three is suitable for use in the diagnosis of malaria in the southwest of Nigeria.

The fidelity of implementation of recommended care for children with malaria by community health workers in Nigeria

BACKGROUND

In the context of task shifting, a promoted approach to healthcare delivery in resource-poor settings, trained community health workers (CHWs) have been shown to be effective in delivering quality care of malaria for febrile under-5 children. While their effectiveness has been documented, the fidelity of implementation (FOI) has not been adequately studied. By understanding and measuring whether an intervention has been performed with fidelity, researchers and practitioners gain a better understanding of how and why an intervention works, and the extent to which outcomes can be improved. The objective of this study was to assess the FOI of a recommended protocol for malaria care by CHWs in a resource-poor setting in Nigeria.

METHODS

Thirty-five female CHWs who participated in a 3-day training on home management of malaria among under-5 children were studied. They managed 1,646 children over the implementation period and then underwent evaluation via a one-time hospital-based observation by the trainers. During the evaluation, a pre-tested standard checklist was used to compute performance scores for CHWs; doctors and nurses were selected to serve as the gold standard for comparison. Performance scores (PS) recorded during the evaluation were used to assess adherence and compliance with the recommended treatment protocol.

RESULTS

Of the 4 skill domains assessed, adherence was greatest for compliance with malaria treatment recommendations (94%) and lowest for post-treatment initiation counseling of home-based caregivers (69%). The average overall adherence of 83% was comparable to adherence by gold standard comparators. Mean PS was not found to be significantly associated with CHW demographics. Scores for clinical evaluation among those whose occupation was not healthcare-related were significantly lowered by 0.52 [95% CI (1.05-0.01), p = 0.05]. Compliance with the treatment protocol increased by 23% for every unit increase in total PS (p = 0.07) and doubled for every unit increase in scores for post-treatment initiation counseling of caregivers (p = 0.002).

CONCLUSIONS

Studying intervention fidelity stands to identify the shortcomings of implementation and specific areas to target for improvement in future adoption or implementation. This study concludes that future trainings should emphasize clinical evaluation and post-treatment counseling of caregivers by CHWs to ensure the best outcome for children.

Assessment of the Holistic Model of Neurosurgical Patient Care at the University College Hospital (UCH), Ibadan

BACKGROUND

Holistic ward round (HWR) is a polyadic, multiphasic, holistic model of neurosurgical patient care. It is a multidisciplinary ward round where all healthcare providers involved in patients care, the patients, the relations, as well as clergymen (depending on the patients' faith and need) collectively work to review patient's condition and make decisions in the patient's best interest.

OBJECTIVES

The study assessed the effectiveness of the holistic model of care and identified the challenges facing this model of healthcare delivery.

METHODS

The study was qualitative in design and In-depth Interviews (IDIs) were conducted with eighteen (18) participants who were purposively selected. They include neurosurgeons, nurses, medical social workers and physiotherapists. The data were thematically content analysed with the help of ATLAS.ti (v.7) software.

RESULTS

The study found that patients and relations have immensely benefitted from the model of care through psychosocial support. The major challenges facing HWR were logistic, timing and common problems found in the Nigerian healthcare system.

CONCLUSION

It was concluded that for HWR to effectively help spinal cord injured patients further, the healthcare providers, patients and their families require support in different forms from outside the hospital.

Survey datasets on patterns of utilization of mental healthcare services among people living with mental illness

The data was obtained from a field survey aimed at measuring the patterns of utilization of mental healthcare services among people living with mental illness. The data was collected using a standardized and structured questionnaire from People Living with Mental Illness (PLMI) receiving treatment and the care-givers of People Living with Mental Illness. Three psychiatric hospitals in Ogun state, Nigeria were the population from which the samples were taken. Chi-square test of independence and correspondence analysis were used to present the data in analyzed form.

Compliance With Referral Advice After Treatment With Prereferral Rectal Artesunate: A Study in 3 Sub-Saharan African Countries

Background. Children aged <5 years were enrolled in a large study in 3 countries of sub-Saharan Africa because they had danger signs preventing them from being able to take oral medications. We examined compliance and factors associated with compliance with referral advice for those who were treated with rectal artesunate.

Methods. Patient demographic data, speed of accessing treatment after danger signs were recognized, clinical symptoms, malaria microscopy, treatment-seeking behavior, and compliance with referral advice were obtained from case record forms of 179 children treated with prereferral rectal artesunate in a multicountry study. We held focus group discussions and key informant interviews with parents, community health workers (CHWs), and facility staff to understand the factors that deterred or facilitated compliance with referral advice.

Results. There was a very high level of compliance (90%) among patients treated with prereferral rectal artesunate. Age, symptoms at baseline (prostration, impaired consciousness, convulsions, coma), and malaria status were not related to referral compliance in the analysis.

Conclusions. Teaching CHWs to diagnose and treat young children with prereferral rectal artesunate is feasible in remote communities of Africa, and high compliance with referral advice can be achieved.

Feasibility of Malaria Diagnosis and Management in Burkina Faso, Nigeria, and Uganda: A Community-Based Observational Study

Background. Malaria-endemic countries are encouraged to increase, expedite, and standardize care based on parasite diagnosis and treat confirmed malaria using oral artemisinin-based combination therapy (ACT) or rectal artesunate plus referral when patients are unable to take oral medication.

Methods. In 172 villages in 3 African countries, trained community health workers (CHWs) assessed and diagnosed children aged between 6 months and 6 years using rapid histidine-rich protein 2 (HRP2)–based diagnostic tests (RDTs). Patients coming for care who could take oral medication were treated with ACTs, and those who could not were treated with rectal artesunate and referred to hospital. The full combined intervention package lasted 12 months. Changes in access and speed of care and clinical course were determined through 1746 random household interviews before and 3199 during the intervention.

Results. A total of 15 932 children were assessed: 6394 in Burkina Faso, 2148 in Nigeria, and 7390 in Uganda. Most children assessed (97.3% [15 495/15 932]) were febrile and most febrile cases (82.1% [12 725/15 495]) tested were RDT positive. Almost half of afebrile episodes (47.6% [204/429]) were RDT positive. Children eligible for rectal artesunate contributed 1.1% of episodes. The odds of using CHWs as the first point of care doubled (odds ratio [OR], 2.15; 95% confidence interval [CI], 1.9–2.4; P < .0001). RDT use changed from 3.2% to 72.9% (OR, 80.8; 95% CI, 51.2–127.3; P < .0001). The mean duration of uncomplicated episodes reduced from 3.69 ± 2.06 days to 3.47 ± 1.61 days, Degrees of freedom (df) = 2960, Student's t (t) = 3.2 (P = .0014), and mean duration of severe episodes reduced from 4.24 ± 2.26 days to 3.7 ± 1.57 days, df = 749, t = 3.8, P = .0001. There was a reduction in children with danger signs from 24.7% before to 18.1% during the intervention (OR, 0.68; 95% CI, .59–.78; P < .0001).

Conclusions. Provision of diagnosis and treatment via trained CHWs increases access to diagnosis and treatment, shortens clinical episode duration, and reduces the number of severe cases. This approach, recommended by the World Health Organization, improves malaria case management.

Clinical Trials Registration. ISRCTN13858170.

Training Community Health Workers to Manage Uncomplicated and Severe Malaria: Experience From 3 Rural Malaria-Endemic Areas in Sub-Saharan Africa

Background. Use of community health workers (CHWs) to increase access to diagnosis and treatment of malaria is recommended by the World Health Organization. The present article reports on training and performance of CHWs in applying these recommendations.

Methods. Two hundred seventy-nine CHWs were trained for 3–5 days in Burkina Faso, Nigeria, and Uganda, and 19 were certified to diagnose and treat only uncomplicated malaria and 235 to diagnose and treat both uncomplicated and severe malaria. Almost 1 year after training, 220 CHWs were assessed using standard checklists using facility staff responses as the reference standard.

Results. Training models were slightly different in the 3 countries, but the same topics were covered. The main challenges noticed were the low level of education in rural areas and the involvement of health staff in the supervision process. Overall performance was 98% (with 99% in taking history, 95% in measuring temperature, 85% for measuring respiratory rates, 98% for diagnosis, 98% for classification, and 99% for prescribing treatment). Young, single, new CHWs performed better than their older, married, more experienced counterparts.

Conclusions. Training CHWs for community-based diagnosis and treatment of uncomplicated and severe malaria is possible with basic and refresher training and close supervision of CHWs’ performance.

Clinical Trials Registration. ISRCTRS13858170.

Malaria Rapid Diagnostic Tests and Malaria Microscopy for Guiding Malaria Treatment of Uncomplicated Fevers in Nigeria and Prereferral Cases in 3 African Countries

Background. The World Health Organization recommends that malaria treatment be based on demonstration of the infecting Plasmodium parasite specie. Malaria rapid diagnostic tests (RDTs) are recommended at community points of care because they are accurate and rapid. We report on parasitological results in a malaria study in selected rural communities in 3 African countries.

Methods. In Nigeria, community health workers (CHWs) performed RDTs (SD-Bioline) and thick blood smears on all children suspected to have malaria. Malaria RDT-positive children able to swallow received artemisinin-based combination therapy (Coartem). In all countries, children unable to take oral drugs received prereferral rectal artesunate irrespective of RDT result and were referred to the nearest health facility. Thick blood smears and RDTs were usually taken at hospital admission. In Nigeria and Burkina Faso, RDT cassettes and blood smears were re-read by an experienced investigator at study end.

Results. Trained CHWs enrolled 2148 children in Nigeria. Complete parasitological data of 1860 (86.6%) enrollees were analyzed. The mean age of enrollees was 30.4 ± 15.7 months. The prevalence of malaria parasitemia in the study population was 77.8% (1447/1860), 77.6% (1439/1855), and 54.1% (862/1593) by RDT performed by CHWs vs an expert clinical research assistant vs microscopy (gold standard), respectively. Geometric mean parasite density was 6946/µL (range, 40–436 450/µL). There were 49 cases of RDT false-negative results with a parasite density range of 40–54 059/µL. False-negative RDT results with high parasitemia could be due to non-falciparum infection or result from a prozone effect. Sensitivity and specificity of SD-Bioline RDT results as read by CHWs were 94.3% and 41.6%, respectively, while the negative and positive predictive values were 86.1% and 65.6%, respectively. The level of agreement in RDT reading by the CHWs and experienced research staff was 86.04% and κ statistic of 0.60. The malaria parasite positivity rate by RDT and microscopy among children with danger signs in the 3 countries was 67.9% and 41.8%, respectively.

Conclusions. RDTs are useful in guiding malaria management and were successfully used for diagnosis by trained CHWs. However, false-negative RDT results were identified and can undermine confidence in results and control efforts.

Motivation of Community Health Workers in Diagnosing, Treating, and Referring Sick Young Children in a Multicountry Study

Background. Community health workers (CHWs) are an important element of care provision for a wide range of conditions, but their turnover rate is high. Many studies have been conducted on health workers’ motivation, focusing on formal sector staff but not CHWs. Although CHWs are easy to recruit, motivating and retaining them for service delivery is difficult. This article investigates factors influencing CHW motivation and retention in health service delivery.

Methods. Quantitative and qualitative data were collected to identify the key factors favoring motivation and retention of CHWs as well as those deterring them. We interviewed 47, 25, and 134 CHWs in Burkina Faso, Nigeria, and Uganda, respectively, using a structured questionnaire. Focus group discussions (FGDs) were also conducted with CHWs, community participants, and facility health workers.

Results. Except for Burkina Faso, most CHWs were female. Average age was between 38 and 41 years, and most came from agricultural communities. The majority (52%–80%) judged they had a high to very high level of satisfaction, but most CHWs (approximately 75%) in Burkina Faso and Uganda indicated that they would be prepared to leave the job, citing income as a major reason. Community recognition and opportunities for training and supervision were major incentives in all countries, but the volume of unremunerated work, at a time when both malaria-positive cases and farming needs were at their peak, was challenging.

Conclusions. Most CHWs understood the volunteer nature of their position but desired community recognition and modest financial remuneration.

Clinical Trials Registration. ISRCTN13858170.

Assessing Acceptability of a Diagnostic and Malaria Treatment Package Delivered by Community Health Workers in Malaria-Endemic Settings of Burkina Faso, Nigeria, and Uganda

Background. The efficacy of artemisinin-based combination therapy (ACT) and rectal artesunate for severe malaria in children is proven. However, acceptability of a package of interventions that included use of malaria rapid diagnostic tests (RDTs), ACTs, and rectal artesunate when provided by community health workers (CHWs) is uncertain. This study assessed acceptability of use of CHWs for case management of malaria using RDTs, ACTs, and rectal artesunate.

Methods. The study was carried out in Burkina Faso, Nigeria, and Uganda in 2015 toward the end of an intervention using CHWs to provide diagnosis and treatment. Focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with parents of sick children, community leaders, and health workers to understand whether they accepted the package for case management of malaria using CHWs. Transcripts from FGDs and KII recordings were analyzed using content analysis. The findings were described, interpreted, and reported in the form of narratives.

Results. Treatment of malaria using the CHWs was acceptable to caregivers and communities. The CHWs were perceived to be accessible, diligent, and effective. There were no physical, social, or cultural barriers to accessing the CHWs’ services. Respondents were extremely positive about the intervention and were concerned that CHWs had limited financial and nonfinancial incentives that would reduce their motivation and willingness to continue.

Conclusions. Treatment of malaria using CHWs was fully accepted. CHWs should be compensated, trained, and well supervised.

Clinical Trials Registration. ISRCTN13858170.

Compliance With Malaria Rapid Diagnostic Testing by Community Health Workers in 3 Malaria-Endemic Countries of Sub-Saharan Africa: An Observational Study

Background. The World Health Organization recommends that all malaria management be based on parasitological identification. We monitored performance of trained community health workers (CHWs) in adhering to this recommendation to restrict artemisinin-based combination therapies (ACTs) to positive rapid diagnostic test (RDT)–confirmed cases in children in 3 malaria-endemic sub-Saharan African countries.

Methods. In 33 villages in Burkina Faso, 45 villages in Nigeria, and 84 villages in Uganda, 265 CHWs were trained over a minimum of 3 days to diagnose malaria using RDTs (prepare, read, record results, and inform the patient about results) and treat RDT-confirmed uncomplicated malaria cases with ACTs. In Nigeria, CHWs were also taught to obtain a thick blood smear. Spent RDT kits and prepared blood slides were collected and interpreted independently in Burkina Faso and Nigeria to confirm CHWs' diagnoses. Interviews were held with 12 of 17 CHWs who prescribed ACTs for patients with RDT-negative test results, and with 16 of 29 caregivers to determine factors related to noncompliance.

Results. Of 12 656 patients treated with ACTs in the participating countries (5365 in Burkina Faso, 1648 in Nigeria, and 5643 in Uganda), 29 patients (8 from Burkina Faso, 17 from Nigeria, 4 from Uganda) were RDT negative. The small number of RDT-negative ACT-treated cases limits statistical analysis. Only a few CHWs were involved, and they were more likely to be traders rather than farmers (odds ratio [OR], 6.15; 95% confidence interval [CI], 2.09–18.07; P = .0004). RDT-negative children who were treated with ACTs had a significantly higher probability of residing in a village other than that of the CHW (OR, 3.85; 95% CI, 1.59–9.30; P = .0018). Parental pressure was identified in interviews with parents.

Conclusions. Noncompliance with results of RDT tests is relatively rare when CHWs are trained and well supervised.

Clinical Trials Registration. ISRCTN13858170.

Factors Affecting Women's Autonomous Decision Making In Research Participation Amongst Yoruba Women Of Western Nigeria

Research is a global enterprise requiring participation of both genders for generalizable knowledge; advancement of science and evidence based medical treatment. Participation of women in research is necessary to reduce the current bias that most empirical evidence is obtained from studies with men to inform health care and related policy interventions. Various factors are assumed to limit autonomy amongst the Yoruba women of western Nigeria. This paper seeks to explore the experience and understanding of autonomy by the Yoruba women in relation to research participation. Focus is on factors that affect women's autonomous decision making in research participation. An exploratory qualitative approach comprising four focus group discussions, 42 in-depth interviews and 14 key informant interviews was used. The study permits a significant amount of triangulation, as opinions of husbands and religious leaders are also explored. Interviews and discussions were audiotaped and transcribed verbatim. Content analysis was employed for data analysis. Findings show that concepts of autonomy varied amongst the Yoruba women. Patriarchy, religion and culture are conceived to have negative impact on the autonomy of women in respect to research participation. Among the important findings are: 1) male dominance is strongly emphasized by religious leaders who should teach equality, 2) while men feel that by making decisions for women, they are protecting them, the women on the other hand see this protection as a way of limiting their autonomy. We recommend further studies to develop culturally appropriate and workable recruitment methods to increase women's participation in research.

Perception and attitude towards Ebola Virus Disease among traditional healers in Ibadan, Nigeria

BACKGROUND

Nigeria experienced her first outbreak of Ebola Virus Disease (EVD) in the second-half of 2014. Since its first occurrence in Zaire and Sudan in 1976, most studies on EVD were clinically based and were carried out using biomedical approaches. No empirical social science/behavioural-oriented study exists on the deadly EVD in Nigeria.

OBJECTIVE

This study examined the traditional healers' perception and attitude towards Ebola virus disease in Ibadan metropolis.

STUDY DESIGN

Purposive sampling method was used to select a total of 23 traditional healers who specialized in different areas of traditional medicine (such as herbs selling, faith healing, divination, and general practice). In-depth interview (IDI) method was employed in the study.

RESULTS

The study found some misconceptions about the disease while the dominant attitude among the healers was that of avoidance and caution on safety.

CONCLUSION

The healers' interpretations of the disease rested on the culture and individual experiences. There is thus a need to take the local cultural perceptions of the Ebola Virus Disease into consideration when controlling the disease in the future.

Awareness of antimalarial policy and use of artemisinin-based combination therapy for malaria treatment in communities of two selected local government areas of Ogun State, Nigeria

With limited data on the awareness of changes in the use of antimalaria drugs and availability and use of artemisinin-based combination therapy (ACT) in the context of the Roll Back Malaria (RBM) program, we conducted this descriptive cross-sectional study of 262 registered women attending antenatal clinics and 233 mothers of under-five children. We used a questionnaire to assess the awareness, availability and use of ACT in Ijebu North and Yewa North Local Government Areas (LGAs) of Ogun State. Malaria is holo-endemic in these areas, and the RBM program has been implemented for years prior to the 2010 RBM deadline. Data were also collected through focus group discussions, along with secondary data from hospital records. Hospital stock records showed inadequate and inconsistent supplies of ACT drugs in hospitals surveyed. Only 23.0% of respondents knew about ACT drugs. About 48% preferred analgesics over ACT drugs (0.6%) for malaria treatment. Lack of awareness was the major reason for non-use of ACT drugs (86.1%). Communities in Yewa North had more supplies of ACT drugs and knew more about ACT than those in Ijebu North. Adequate information on ACT needs to be made available and accessible under a public-private partnership if 2010 RBM targets (now past) and the 2015 Millennium Development Goal (ongoing) for malaria are to be realized in the study communities and Ogun State in general.

Factors influencing motivation and retention of primary healthcare workers in the rural areas of Oyo State, Nigeria

BACKGROUND

Limited data exist on retention of primary healthcare (PHC) staff in rural areas, crippling the already fragile healthcare systems in Nigeria. This study investigated why PHC staff would or would not want to work in rural areas and how they could be retained.

METHODS

Four hundred and twelve (412) health workers and caregivers, and 21 key informants were interviewed in Ona-Ara LGA. Logistic regression statistics was used to analyse quantitative data and narrative for qualitative data.

RESULTS

There was no significant factor influencing health workers' unwillingness to work in rural areas and, relationship between their demographic characteristics and perceived reasons to do so. Combined factors influencing PHC workers' willingness to work in rural areas influenced use of PHC.

CONCLUSION

Financial and non-financial incentives are responsible for workers' motivation to work in rural areas. The mal-distribution of health facilities and health workers between urban and rural areas must be addressed.

Assessing resources for implementing a community directed intervention (CDI) strategy in delivering multiple health interventions in urban poor communities in Southwestern Nigeria: a qualitative study

Background

Many simple, affordable and effective disease control measures have had limited impact due to poor access especially by the poorer populations (urban and rural) and inadequate community participation. A proven strategy to address the problem of access to health interventions is the Community Directed Interventions (CDI) approach, which has been used successfully in rural areas. This study was carried out to assess resources for the use of a CDI strategy in delivering health interventions in poorly-served urban communities in Ibadan, Nigeria.

Methods

A formative study was carried out in eight urban poor communities in the Ibadan metropolis in the Oyo State. Qualitative methods comprising 12 focus group discussions (FGDs) with community members and 73 key informant interviews (KIIs) with community leaders, programme managers, community-based organisations (CBOs), non-government organisations (NGOs) and other stakeholders at federal, state and local government levels were used to collect data to determine prevalent diseases and healthcare delivery services, as well as to explore the potential resources for a CDI strategy. All interviews were audio recorded. Content analysis was used to analyse the data.

Results

Malaria, upper respiratory tract infection, diarrhoea and measles were found to be prevalent in children, while hypertension and diabetes topped the list of diseases among adults. Healthcare was financed mainly by out-of-pocket expenses. Cost and location were identified as hindrances to utilisation of health facilities; informal cooperatives (esusu) were available to support those who could not pay for care. Immunisation, nutrition, reproductive health, tuberculosis (TB) and leprosy, environmental health, malaria and HIV/AIDs control programmes were the ongoing interventions. Delivery strategies included house-to-house, home-based treatment, health education and campaigns. Community participation in the planning, implementation and monitoring of development projects was reported as common practice. The resources available for these activities and which constitute potential resources for the CDI process include community volunteers, CBOs and NGOs. Others are landlords; professional, women and youth associations; social clubs, religious organisations and the available health facilities.

Conclusion

This study’s findings support the feasibility of using the CDI process in delivering health interventions in urban poor communities and show that potential resources for the strategy abound in the communities.

Patients' knowledge and perceived reactions to medical errors in a tertiary health facility in Nigeria

BACKGROUND

Human errors in healthcare delivery pose serious threats to patients undergoing treatment. While clinical concern is growing in response, there is need to report social and behavioural context of the problem in Nigeria.

OBJECTIVE

To examine patients' knowledge and perceived reactions to medical errors.

METHODS

A cross-sectional survey was conducted using a semi-structured questionnaire was used to collect data from 269 in-patients and 10 In-Depth Interviews were conducted among health caregivers in the University of Calabar Teaching Hospital, Nigeria.

RESULTS

Majority (64.5%) of respondents reported annoyance and disappointment with medical errors. Severity of error (88.5%) and the perception of negligence mediated intention to litigate. Voluntary disclosure significantly reduced patients' intention to litigate caregivers (chi(2)=3.584; df=1; P=0.053). Frustration/anger was not more likely to influence patient to litigate than feelings of resignation/forgiveness (chi(2)=2.156; df=1; P>.05). Financial difficulties arising from error had an important influence on litigation. Health caregivers admitted possibility of errors; and insisted that although notifying patients/relatives about errors is appropriate, disclosure was dependent on the seriousness, health implications and the causes.

CONCLUSION

Voluntary disclosure and teamwork is very important in dealing with medical error. The role of medical social workers could be important in the discourse and disclosure of medical error.

Cultural and ethical challenges of assisted reproductive technologies in the management of infertility among the Yoruba of southwestern Nigeria

This paper discusses the cultural and ethical issues arising from the use of Assisted Reproductive Health Technologies. Twenty-five In-depth interviews were conducted with 5 couples of reproductive age who have never conceived or brought pregnancy to term after one year of unprotected intercourse, 4 adult males, 4 adult females, a gyneacologist, a nurse, a herbalist and 2 religious leaders in Ibadan, Nigeria. Content analysis was used for data analysis. Legitimacy of children born through ART, religious obligation, patriarchy, polygamy and value of children are cultural issues surrounding ARTs while decision making about it, discrimination against children born through ART, psychological problems and loss of self esteem, side effects of the technologies and the cost of accessing them are the ethical challenges. The findings have methodological implications for conducting infertility research in non-western societies.

Culture and genetic screening in Africa

Africa is a continent in transition amidst a revival of cultural practices. Over previous years the continent was robbed of the benefits of medical advances by unfounded cultural practices surrounding its cultural heritage. In a fast moving field like genetic screening, discussions of social and policy aspects frequently need to take place at an early stage to avoid the dilemma encountered by Western medicine. This paper, examines the potential challenges to genetic screening in Africa. It discusses how cultural practices may affect genetic screening. It views genomics science as a culture which is trying to diffuse into another one. It argues that understanding the existing culture will help the diffusion process. The paper emphasizes the importance of genetic screening for Africa, by assessing the current level of burden of diseases in the continent and shows its role in reducing disease prevalence. The paper identifies and discusses the cultural challenges that are likely to confront genetic screening on the continent, such as the worldview, rituals and taboos, polygyny, culture of son preference and so on. It also discusses cultural practices that may promote the science such as inheritance practices, spouse selection practices and naming patterns. Factors driving the cultural challenges are identified and discussed, such as socialization process, patriarchy, gender, belief system and so on. Finally, the paper discusses the way forward and highlights the ethical considerations of doing genetic screening on the continent. However, the paper also recognizes that African culture is not monolithic and therefore makes a case for exceptions.

Ethics of social and behavioural research in cancer

Unlike biomedical research, social and behavioural research has not been thought to require rigorous or mandatory ethical review on the assumption that it can do no harm. As a result, little or no attention is paid to its involvement in health researches. This paper discusses the ethical challenges of social and behavioural research in cancer to identify potential areas for research. Inferences were made from documentary analysis of characteristics of cancer patients. A total of 76 papers were reviewed covering the period from1960 to 2007. The data shows that conducting social and behavioural research on cancer patients in Africa is associated with ethical challenges. These include; respect for person and autonomy, risk minimization, exploitation, inducement and compensation, benefit sharing, gaining access to participant, third party issue, informed consent, coercion, discrimination, conflict of interest and scientific misconduct. The paper concludes that cultural challenges of cancer research, management and administration of informed consent, access to research participant, compensation of research participant and benefit sharing are major potential areas of research.

Understanding informed consent for participation in international health research

To participate in health research, there is a need for well-administered informed consent. Understanding of informed consent, especially in international health research, is influenced by the participants' understanding of information and the meaning attached to the information communicated to them regarding the purpose and procedure of the research. Incorrect information and the power differential between researcher and participants may lead to participants becoming victims of harmful research procedures. Meningitis epidemics in Kano in early 1996 led to a response from drug companies, especially Pfizer, as well as humanitarian workers from Médecins Sans Frontiers, which resulted in an unethical trial. Pfizer's drug trial during the epidemics has left a lasting controversy, which has yet to be resolved. This paper examines the key issues surrounding the controversy, discusses the context of informed decision-making, the ethical issues and implications of the incident, and concludes with some recommendations. Relevant texts, journals, Internet materials, newspaper articles and documentary materials on the conduct of the Pfizer's Trovan trial have been consulted. Four types of action (act intuitively, act rationally, act ignorantly, and act contextually - based on information provided) are identified as possible options for decision making. Participants most likely acted in ignorance due to poor understanding of the information contained in the verbal informed consent administered, thereby raising ethical issues. It is concluded that health research ethics committees have an important role to play nationally and locally in overseeing research, and in avoiding future occurrences.

Culture and HIV/AIDS in Africa: promoting reproductive health in light of spouse-sharing practice among the Okun people, Nigeria

The Okun tribe, numbering about a million persons, accepts sexual relations between men and wives of their male kin. We identified and used features of spouse sharing that affect reproductive health to develop an interactive, community-based intervention. The intervention promoted discussion of spouse sharing as a risk factor in HIV/AIDS transmission, knowledge of AIDS/sexually transmitted diseases (STDs), perception of risk and alternative behaviors to avoid contracting HIV/AIDS. The intervention effects were evaluated using data collected in baseline and follow-up surveys in May 1999 and June 2000 among 1018 sexually active respondents in two sets of Okun communities - one with and the other without intervention. The intervention significantly increased knowledge of HIV/AIDS, perception of risk of contracting the disease and the intention to discontinue spouse sharing in the intervention communities. Those who perceived themselves at risk of contracting HIV/AIDS were more likely to express intention to discontinue spouse sharing (odds ratio 2.87) than those who did not. It was recommended that future community-based interventions to address traditional practices that could transmit HIV/AIDS should address the aspects of the practice that could transmit the disease and actively involve the people to make impact.

A pilot study to evaluate malaria control strategies in Ogun state, Nigeria

With limited evidence of decreases in malaria-related mortality and morbidity, and nearly half the time to the 2010 deadline of Roll Back Malaria (RBM) targets now past, we conducted this study to assess the awareness, accessibility and use of malaria control strategies among at-risk groups within the context of RBM in Nigeria. It was a descriptive, cross-sectional pilot study of 34 registered women attending antenatal clinics and 34 mothers of children less than five years old, using a questionnaire in a malaria holo-endemic community of Ogun State, Nigeria. Results showed that 14.7% and 16.2% of all respondents interviewed were aware of the home management of malaria (HMM) program (17.6% of mothers of children under five years vs. 11.8% of pregnant women) and the change in policy on malaria treatment (23.5% of mothers of children under five years vs. 8.8% of pregnant women) respectively. Younger respondents knew more about HMM than older ones (p <.05). Most (63.2%) of the 68 respondents (64.7% of mothers of children under five years vs. 61.8% of pregnant women) interviewed knew about insecticide treated nets (ITNs); however, only 22.1% were using the treated material. Reasons given by those not using ITNs included: they did not know about ITN prior to the interview (43.3%(, they had no money (41.5%) and they did not know where to get it (7.6%). Only 5.8% of mothers of children less than five years old, and none of the pregnant women, had taken the new combination drug. Eight (23.5%) of the 34 pregnant women interviewed knew about intermittent preventive treatment of malaria for pregnant women (IPT), while two (25.0%) of these eight women had received a preventive treatment dose. The results of this pilot study showed that efforts need be intensified to make adequate information and materials relating to the different malaria control strategies more available and accessible at the community level to achieve and sustain the RBM goals, both in Ogun State and in Nigeria in general. However, a larger study is needed to provide more generalized findings.

Gender and health analysis of sexual behaviour in south-western Nigeria

This paper reports the main results of a series of interviews conducted among the Yoruba of south-western Nigeria. Fifty men and fifty women differing in socio-demographic backgrounds were studied. The study revealed that during their first sexual experience, Yoruba girls are at risk of contacting sexually transmitted diseases and of having unplanned pregnancies because of the traditional control measures and lack of adequate sex education even among those from non-traditional backgrounds. Choice of marriage partner is influenced by the kin, which encourages early marriage and multiple sexual relationships through polygyny. Yoruba men do not like contraceptives and the women suffer more of the consequences of sexual relationships than men. Sexual decision-making in Yoruba culture is characterised by certain specific problems of structural and cultural origins such as separate lifestyle of men and women, seeing the discussion of sexuality as a taboo, male dominance, and the perceived side effects of contraceptives. There is need for expanded sexual and reproductive health education strategies targeted at both males and females in this community especially among the adolescent group.