African Rigorous Innovative Stroke Epidemiological Surveillance: Protocol for a Community-Based Mobile-Health Study.

Despite projections of stroke being a leading cause of mortality in Africa, reliable estimates of stroke burden on the continent using rigorous methods are not available. We aimed to implement a mobile-Health community-based interactive Stroke Information and Surveillance System to sustainably measure stroke burden and improve stroke health literacy and outcomes in urban and rural sites in Nigeria. African Rigorous Innovative Stroke Epidemiological Surveillance (ARISES) is an observational cohort study, which will be conducted in urban (Ibadan North LGA Ward 3) and rural (Ibarapa Central LGA) sites with a combined base population of over 80,000 people. The study will use a consultative approach to establish an mHealth-based Stroke Information and Surveillance System comprising a Stroke Alert System and a Stroke Finding System. These systems will enable the community to report stroke events and the research team/health workers find stroke cases using phone calls, short message service, and Voice Over Internet Protocols (VoIP). We will update community household data and geo-locate all households. Over the 5 years of the study, the system will collect information on stroke events and educate the community about this disease. Reported stroke cases will be clinically adjudicated at home and in prespecified health facilities. Baseline and endline community surveys will be conducted to assess stroke occurrence and other important study variables. The proportion of strokes alerted and found will be determined over the study period. Focus group discussions and key informant interviews will be conducted to understand community stroke literacy and perspectives. The study will also assess any impact of these efforts on time from stroke onset to referral, community uptake of orthodox health services for stroke patients. ARISES is anticipated to establish proof of concept about using mHealth for stroke surveillance in Africa. The potential impact of the SISS on improving patient outcomes will also be determined.

Predictors and prognoses of new onset post-stroke anxiety at one year in black Africans.

BACKGROUND: There is relatively limited information on the risk factors and outcome of new onset Poststroke Anxiety (PSA) in Low- and Middle-Income Countries. We estimated incidence, cumulative incidence, risk factors and outcome of new onset anxiety in the first year of stroke among African stroke survivors. METHODS: We analyzed the dataset of a completed clinical trial comprising patients enrolled to test an intervention designed to improve one-year blood pressure control among recent (≤ one month) stroke survivors in Nigeria. Anxiety was measured using the Hospital Anxiety and Depression Scale. Outcomes were assessed using the modified Rankin Scale (mRS), Community screening instrument for dementia (CSID) and Health Related Quality of Life in Stroke Patients (HRQOLISP-26). RESULTS: Among 322 stroke survivors who were free of anxiety at baseline, we found a one-year cumulative incidence of 34% (95% CI = 28.6-39.3). Rates were 36.2% (95% CI =29.6-42.7) for men and 29.2% (95% CI =19.9-38.3) for women. In multivariate Cox regression analyses, haemorrhagic stroke type was associated with higher risk of new onset PSA (Hazard Ratio=1.52, 95% CI =1.01-2.29). New onset PSA was independently associated with cognitive [(mean difference (MD) in CSID scores=1.1, 95% C.I=0.2, 1.9)] and motor decline (MD in mRS scores= -0.2, 95% C.I= -0.4, -0.02), as well as poorer quality of life overtime (MD in total HRQOLISP-26 scores=3.6, 95% C.I=1.0, 6.2). CONCLUSION: One in 3 stroke survivors in Nigeria had PSA at one year. Clinicians in SSA should pay special attention to survivors of haemorrhagic stroke as they are at higher risk of incident anxiety and therefore its consequences.

Inequalities in access to healthcare services among people living with HIV/AIDS in Nigeria.

The study investigated the magnitude of social inequities in access to subsidised healthcare services among people living with HIV and AIDS (PLWHA) in Nigeria. Structured interviews were conducted with 1 056 PLWHA selected from 60 community based support groups in 12 local government areas across 3 Nigerian states and the federal capital territory, using a multi-stage cluster sampling method. Data were collected on socio-economic characteristics of the respondents; awareness about location of health facilities; current health status; distance to facilities; and utilisation and expenditure on healthcare. The socio-economic characteristics of the respondents were used to compare their level of access to healthcare services from antiretroviral therapy (ART) sites and government hospitals. Awareness about location of health facilities was generally high (≥79%) among the respondents but higher among males, urban dwellers and those in highest wealth class (p < 0.05). About 60% of rural PLWHA and 55.2% of those in the lowest wealth class reported illness compared with 49.4% of urban residents and 47.4% of those in the highest wealth class. However, PLWHA in urban areas utilised government hospitals more than those in rural areas while rural PLWHA and those in the lowest wealth class travelled longer distances to ART sites (p < 0.05). PLWHA in lowest wealth class and females faced catastrophic health expenditure of 67.6% and 55.5% of their monthly income respectively. Social inequities were observed in the subsidised HIV-treatment programme in Nigeria. Expansion of ART sites in rural areas and decentralisation of HIV care at government hospitals will reduce travel distance and transport costs and ensure universal access to healthcare services among PLWHA.

Geo-Demographic and Socioeconomic Determinants of Diagnosed Hypertension among Urban Dwellers in Ibadan, Nigeria: A Community-based Study.

Background: The relationship between diagnosed high blood pressure (HBP) and proximity to health facilities and noise sources is poorly understood. We investigated the relationship between proximity to noise sources, sociodemographic and economic factors, and diagnosed HBP in Ibadan, Nigeria. Methods: We investigated 13,531 adults from the African Rigorous Innovative Stroke Epidemiological Surveillance (ARISES) study in Ibadan. Using a Geographic Information System (GIS), the locations of healthcare facilities, pharmaceutical shops, bus stops, churches, and mosques were buffered at 100m intervals, and coordinates of persons diagnosed with HBP were overlaid on the buffered features. The number of persons with diagnosed HBP living at every 100m interval was estimated. Gender, occupation, marital status, educational status, type of housing, age, and income were used as predictor variables. Analysis was conducted using Spearman rank correlation and binary logistic regression at p<0.05. Results: There was a significant inverse relationship between the number of persons diagnosed with HBP and distance from pharmaceutical shops (r=-0.818), churches (r=-0.818), mosques (r=-0.893) and major roads (r=-0.667). The odds of diagnosed HBP were higher among the unemployed (AOR=1.58, 95% CI: 1.11-2.24), currently married (AOR=1.45, CI: 1.11-1.89), and previously married (1.75, CI: 1.29-2.38). The odds of diagnosed HBP increased with educational level and age group. Conclusion: Proximity to noise sources, being unemployed and educational level were associated with diagnosed HBP. Reduction in noise generation, transmission, and exposure could reduce the burden of hypertension in urban settings.

Horizontal Inequity in the Utilization of Maternal and Reproductive Health Services: Evidence From the 2018 Nigeria Demographic and Health Survey.

Background: Maternal mortality and poor reproductive health outcomes remain major public health challenges in low-resource countries. The Sustainable Development Goals have proposed new targets to reduce global maternal mortality ratio to 70 per 100,000 live births and ensure universal access to sexual and reproductive healthcare services by 2030. Inequity in the utilization of maternal and reproductive health services leads to poor reproductive health outcomes and maternal mortality. Despite reduction in global maternal mortality over the decades, the level of maternal mortality remains unacceptably high in Nigeria with limited attention given by governments to addressing health inequities. This study aimed to examine horizontal inequity in the utilization of maternal and reproductive health services in Nigeria. Methods: Secondary data from the 2018 Nigeria Demographic and Health Survey were utilized to examine horizontal inequity in the utilization of maternal and reproductive health services such as postnatal care, delivery by cesarean section, modern contraceptive use, and met need for family planning. Equity was measured using equity gaps, equity ratios, concentration curves, and concentration indices. All analyses were performed using ADePT 6.0 and STATA version 14.2 software. Results: The overall coverage level of postnatal care, delivery by cesarean section, modern contraceptive use, and met need for family planning was 20.81, 2.97, 10.23, and 84.22%, respectively. There is inequity in the utilization of postnatal care, delivery by cesarean section, and modern contraceptive favoring the rich, educated, and urban populations. Met need for family planning was found to be almost perfectly equitable. Conclusion: There is inequity in the utilization of maternal and reproductive health services in Nigeria. Inequity in the utilization of maternal and reproductive health services is driven by socioeconomic status, education, and location. Therefore, governments and policymakers should give due attention to addressing inequities in the utilization of maternal and reproductive health services by economically empowering women, improving their level of education, and designing rural health interventions. Addressing inequities in the utilization of maternal and reproductive health services would also be important toward achieving the Sustainable Development Goal targets 3.1 and 3.7.

Determinants of Mental Healthcare-Seeking Behavior of Postpartum Women in Ibadan, Nigeria.

The mental healthcare-seeking behavior of postpartum mothers has received little attention in Nigeria. Previous studies in the country have focused on determinants of physical health-seeking behavior, choice of maternal healthcare provider, prevalence, and determinants of maternal mental illness, yet, determinants of maternal mental health-seeking behavior among Nigerian women has been understudied. This study, therefore, examined the determinants of mental health-seeking behavior among postpartum women in Ibadan, Nigeria. Maternal mental illness, which was proxied using postpartum depression, was computed using the Edinburgh Postpartum Depression Scale. Data for the study were obtained through a survey method using a 9-page questionnaire. A 3-stage sampling technique was employed. The first stage was a stratified sampling to disaggregate the health facilities offering postnatal and immunization services on the basis of ownership of public and private healthcare providers. In the second stage, seven healthcare facilities comprising three (3) private and four (4) public healthcare were purposively selected based on the number of attendees. The final stage was a random selection of 390 postpartum mothers attending postnatal and immunization clinics across seven healthcare facilities. The prevalence of depression among the mothers was 20.8%. While only 39.5% of the depressed women sought care, 22.3% of the non-sufferers also sought mental healthcare. This revealed that both sufferers and non-sufferers sought mental healthcare. Also, a higher incidence of postpartum depression among the sufferers increased the likelihood of seeking mental healthcare. Age, family history of postpartum depression, and having the desired gender of child were determinants of mental health-seeking behavior. Among the sufferers of postpartum depression who failed to seek care, a low perceived need for mental healthcare, the perception that the depressive symptoms will go on their own, as well as fear of being stigmatized as a "weak mother", were reasons for not seeking mental healthcare. Thus, to promote mental healthcare, the non-cost factors, like availability and accessibility to a mental healthcare facility should be addressed. To achieve this, mental healthcare sensitization programs should be integrated into maternal healthcare at all levels, and mothers attending antenatal clinics should be routinely screened for early symptoms of depression in the postpartum period.

The effects of market concentration on health care price and quality in hospital markets in Ibadan, Nigeria.

Evidence about the Nigerian health indicators show that the quality of health care in Nigeria is low and inflation of health care prices also persists. Theoretically, by observing the market concentration, inferences can be drawn as to how hospitals conduct themselves, which allows the evaluation of the market performance. Therefore, the effects of market concentration on the health care price and quality were examined. Market concentration was measured by Herfindahl Hirschman Index (HHI) and four hospital concentration ratios (CR4). The values of HHI were disaggregated into the less and more concentrated markets. Quality of health care was measured by the staff-nurse-patient ratio. Ordinary Least Square (OLS) was used to estimate the effects of market concentration on price and quality of health care. The price of health care was found to be 13.4% lower in the less concentrated markets than in the more concentrated market. Income significantly and positively influenced health care prices by 17.8%. Also, a low HHI lead to 33.4% increase in Staff-nurse Patient Ratio (SPR) indicating that the quality of health care was higher in less concentrated markets as hospitals increased the treatment intensity via staff-nurse patient ratio. A less concentrated market is linked with higher health care quality and lower health care prices. Therefore, a strategy that will reduce market concentration so as to enhance consumer welfare in terms of price and quality is recommended.

Randomized Trial of an Intervention to Improve Blood Pressure Control in Stroke Survivors.

BACKGROUND: We conducted the first-of-its kind randomized stroke trial in Africa to test whether a THRIVES (Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke) intervention improved blood pressure (BP) control among patients with stroke. METHODS AND RESULTS: Intervention comprised a patient global risk factor control report card, personalized phone text-messaging, and educational video. Four hundred patients recruited from 4 distinct medical facilities in Nigeria, aged ≥18 years with stroke-onset within one-year, were randomized to THRIVES intervention and control group. The control group also received text messages, and both groups received modest financial incentives. The primary outcome was mean change in systolic BP (SBP) at 12 months. There were 36.5% females, 72.3% with ischemic stroke; mean age was 57.2±11.7 years; 93.5% had hypertension and mean SBP was 138.33 (23.64) mm Hg. At 12 months, there was no significant difference in SBP reduction from baseline in the THRIVES versus control group (2.32 versus 2.01 mm Hg, P=0.82). In an exploratory analysis of subjects with baseline BP >140/90 mm Hg (n=168), THRIVES showed a significant mean SBP (diastolic BP) decrease of 11.7 (7.0) mm Hg while control group showed a significant mean SBP (diastolic BP) decrease of 11.2 (7.9) mm Hg at 12 months. CONCLUSIONS: THRIVES intervention did not significantly reduce SBP compared with controls. However, there was similar significant decrease in mean BP in both treatment arms in the subgroup with baseline hypertension. As text-messaging and a modest financial incentive were the common elements between both treatment arms, further research is required to establish whether these measures alone can improve BP control among stroke survivors. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01900756.

The epidemiology of stroke in Africa: A systematic review of existing methods and new approaches.

Accurate epidemiological surveillance of the burden of stroke is direly needed to facilitate the development and evaluation of effective interventions in Africa. The authors therefore conducted a systematic review of the methodology of stroke epidemiological studies conducted in Africa from 1970 to 2017 using gold standard criteria obtained from landmark epidemiological publications. Of 1330 articles extracted, only 50 articles were eligible for review grouped under incidence, prevalence, case-fatality, health-related quality of life, and disability-adjusted life-years studies. Because of various challenges, no study fulfilled the criteria for an excellent stroke incidence study. The relatively few stroke epidemiology studies in Africa have significant methodological flaws. Innovative approaches leveraging available information and communication technology infrastructure are recommended to facilitate rigorous epidemiological studies for accurate stroke surveillance in Africa.

Cost and cost-effectiveness analysis of a bundled intervention to enhance outcomes after stroke in Nigeria: Rationale and design.

The economic and social costs of stroke to the society can be enormous. These costs can cause serious economic damage to both the individual and the nation. It is thus important to conduct a cost effectiveness analysis to indicate whether an intervention provides high value where its health benefits justify its costs. This study will provide evidence based on the costs of stroke with a view of improving intervention and treatments of stoke survivors in Nigeria. This study utilizes two types of economic evaluation methods - cost-effectiveness analysis and cost-benefit analysis - to determine the economic impact of Tailored Hospital-based Risk Reduction to Impede Vascular Events after Stroke (THRIVES) intervention. The study is conducted in four Nigerian hospitals where 400 patients are recruited to participate in the study. The cost-effectiveness of THRIVES post-discharge intervention is compared with the control Intervention scenario, which is the usual and customary care delivered at each health facility in terms of cost per quality adjusted life years (QALYs). It is expected that successful implementation of the project would serve as a model of cost-effective quality stroke care for implementation.

Tailored Hospital-based Risk Reduction to Impede Vascular Events After Stroke (THRIVES) study: qualitative phase protocol.

BACKGROUND: There is an urgent need to develop effective strategies to improve stroke outcomes in Sub-Saharan Africa (SSA), where use of evidence-based therapies among patients receiving conventional care is poor. Designs of behavioral interventions to improve stroke care in SSA need to be sensitive to both individual and community factors (including local perceptions and public policies) contributing to the likelihood of compliance with recommended therapeutic goals. This article presents a community-based participatory research protocol that will evaluate systems and processes affecting the continuum of stroke-preventive care in an SSA country. METHODS: Phase 1 of the Tailored Hospital-based Risk Reduction to Impede Vascular Events study will be implemented from 2013 to 2014 at 4 different types of hospital settings in Nigeria. Six adult stroke survivor focus group discussions and six caregiver focus group discussions, each lasting about 120 minutes will be conducted. Each group will comprise 6 to 8 participants. We will also conduct 22 semi-structured key informant interviews (informed by the Theoretical Domains Framework) with several types of providers and hospital administrators. Purposive and maximum variation sampling will be used to identify and recruit participants from participating hospitals. Transcript data will be analyzed by reviewers in an iterative process to identify recurrent and unifying themes using a constructivist variant of the grounded theory methodology, and will involve participatory co-analysis with key stakeholders to enhance authenticity and veracity of findings. DISCUSSION: On the basis of the results of Tailored Hospital-based Risk Reduction to Impede Vascular Events phase 1, we intend to develop a culturally sensitive, system-appropriate, multipronged intervention whose efficacy to boost adherence to evidence-based stroke-preventive care will be tested in a future randomized trial (phase 2).

Randomized controlled trial of a multipronged intervention to improve blood pressure control among stroke survivors in Nigeria.

RATIONALE: Stroke is the second-leading cause of death in low- and middle-income countries, but use of evidence-based therapies for stroke prevention in such countries, especially those in Africa, is extremely poor. This study is designed to enhance the implementation and sustainability of secondary stroke-preventive services following hospital discharge. AIM/HYPOTHESIS: The primary study aim is to test whether a Chronic Care Model-based initiative entitled the Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke (THRIVES) significantly improves blood pressure control after stroke. DESIGN: This prospective triple-blind randomized controlled trial will include a cohort of 400 patients with a recent stroke discharged from four medical care facilities in Nigeria. The culturally sensitive, system-appropriate intervention comprises patient report cards, phone text messaging, an educational video, and coordination of posthospitalization care. STUDY OUTCOMES: The primary outcome is improvement of blood pressure control. Secondary endpoints include control of other stroke risk factors, medication adherence, functional status, and quality of life. We will also perform a cost analysis of THRIVES from the viewpoint of government policy-makers. DISCUSSION: We anticipate that a successful intervention will serve as a scalable model of effective postdischarge chronic blood pressure management for stroke in sub-Saharan Africa and possibly for other symptomatic cardiovascular disease entities in the region.

Demand for child healthcare in Nigeria.

Nigeria with an estimated $350 per capital annually still ranks near the bottom 158 out of 177 countries in the UN Human Capital Development Index in terms of per capita income, with more than half of the population living in poverty. Over the past decade U5MR is estimated to be 201 deaths/1000 lives births,the high rates of child mortality especially the 0-5 years shows the total breakdown of social and economic well-being of the country .This paper examined child health care demand in Nigeria using the Nested Multinomial Logit Model estimation technique.The study used parents' education as a proxy for child education,while the decision to make a choice of the health facilities was also assumed to be that of the House-Hold head. The study found out that female child has a higher probability of seeking health care facility ahead of their male counterpart. Also, the household head educational level was found to be a determinant of health care seeking behavior of the child. Empirical evidence also revealed that that the probability of seeking healthcare increases with household size and that demand for child health care in Nigeria is non linear in nature.Based on this, the paper recommends the need to show greater commitment to child health care and that government should reduce the problems militating against effective performance of the health sector such as, inefficiency, wasteful use of resources, low quality of service and poor enabling environment.