Benign breast disease and breast cancer risk in African women: a case-control study.

PURPOSE: To examine the association between benign breast disease (BBD) and breast cancer (BC) in a heterogeneous population of African women. METHODS: BC cases and controls were enrolled in three sub-Saharan African countries, Nigeria, Cameroon, and Uganda, between 1998 and 2018. Multivariable logistic regression was used to test the association between BBD and BC. Risk factors dually associated with BBD and BC were selected. Using a parametric mediation analysis model, we assessed if selected BC risk factors were mediated by BBD. RESULTS: Of 6,274 participants, 55.6% (3,478) were breast cancer cases. 360 (5.7%) self-reported BBD. Fibroadenoma (46.8%) was the most commonly reported BBD. Women with a self-reported history of BBD had greater odds of developing BC than those without (adjusted odds ratio [aOR] 1.47, 95% CI 1.13-1.91). Biopsy-confirmed BBD was associated with BC (aOR 2.25, 95% CI 1.26-4.02). BBD did not significantly mediate the effects of any of the selected BC risk factors. CONCLUSIONS: In this study, BBD was associated with BC and did not significantly mediate the effects of selected BC risk factors.

Contextual factors influencing the roles of patent medicine vendors in the provision of injectable contraception services in Nigeria.

BACKGROUND: Patent medicine vendors (PMVs) play vital roles in the delivery of family planning services in Nigeria and other developing countries. There is a growing recognition of the need to integrate them into the formal health care system as a strategy to increase the contraceptive prevalence rate and achieve universal health coverage. Though promising, the success of this proposition is largely dependent on a critical analysis of the factors which influence their operations. This study was designed to identify the contextual factors influencing the provision of injectable contraceptive services by PMVs and the broader effects of their activities on the health system to inform similar interventions in Nigeria. METHODS: This was a qualitative study guided by the UK Medical Research Council's Framework for Complex Interventions. Twenty-seven in-depth interviews were conducted among officials of the association of PMVs, health workers, government regulatory officers and programme implementers who participated in a phased 3-year (2015-2018) intervention designed to enhance the capacity of PMVs to deliver injectable contraceptive services. The data were transcribed and analyzed thematically using NVIVO software. RESULTS: The contextual factors which had implications on the roles of PMVs were socio-cultural and religious, the failing Nigerian health system coupled with government regulatory policies. Other factors were interprofessional tensions and rivalry between the PMVs and some categories of health care workers and increasing donors' interest in exploring the potentials of PMVs for expanded healthcare service provision. According to the respondents, the PMVs bridged the Nigerian health system service delivery gaps serving as the first point of contact for injectable contraceptive services and this increased contraceptive uptake in the study sites. A negative effect of their operation is the tendency to exceed their service provision limits, which has spurred a planned tiered PMV accreditation system. CONCLUSIONS: This study has highlighted the contextual factors which define the roles and scope of practice of PMVs involved in injectable contraceptive service provision. Strategies and interventions aimed at expanding the healthcare delivery roles of PMVs must be encompassing to address the broader contextual factors which underpin their capacities and functions.

Cervical Cancer and Human Papillomavirus Vaccine Knowledge, Utilisation, Prevention Educational Interventions and Policy Response in Nigeria: A Scoping Review.

PURPOSE: This review evaluated the knowledge, utilisation, prevention education, and policy response across the six geopolitical regions of Nigeria to inform national efforts for the prevention and control of cervical cancer. METHODS: A keyword-based systematic search was conducted in PubMed/MEDLINE (NCBI), Google Scholar, and AJOL electronic databases, including a manual scan of papers, journals and websites to identify relevant peer-reviewed studies. Articles were screened and assessed for eligibility. RESULTS: Many (158) articles were downloaded and after duplicates were removed, 110 articles were included in the final analysis. These were made up of qualitative, quantitative (cross-sectional), intervention and policy studies. Studies have generally reported poor knowledge and awareness of cervical cancer screening but those carried out in urban areas demonstrated a slightly higher level of awareness of Human Papilloma Virus (HPV) vaccine, HPV vaccination uptake and utilization of cervical cancer preventive services than the rural studies. The studies did not show strong government support or policies in relation to cervical cancer control. CONCLUSION: Knowledge and uptake of cervical cancer preventive services across diverse groups in Nigeria remain poor. These could be linked to socio-cultural factors, the lack of an organised cervical cancer screening programme and low financial resource pool for cervical cancer prevention. Therefore, it is necessary to increase government, donor prioritisation and political support in order to ensure increased investment and commitment to cervical cancer elimination in Nigeria.

Indepth Interviews' on Acceptability and Concerns for Human Papilloma Virus Vaccine Uptake among Mothers of Adolescent Girls in Community Settings in Ibadan, Nigeria.

Human papillomavirus (HPV) vaccine offers protection of between 80 and 100% for anogenital warts and 60-80% in reducing the incidence of pre-malignant lesions from cervical cancer. However, uptake remains low in Nigeria among adolescent girls. This study was a qualitative study that assessed mothers' acceptability and concerns regarding uptake of HPV vaccine by their adolescent daughters. In-depth interviews were conducted with 20 mothers of adolescents girls aged 9-15 years. A snowballing sampling technique was adopted to select the mothers within the community. Consent was obtained for the use of audiotapes, which were transcribed verbatim with thematic analysis of data. Mothers were between the ages of 30-49 years and most of them were traders. Almost all of the women have heard about cervical cancer, but their knowledge about cervical cancer and HPV vaccine was low. Despite their low knowledge, most of the mothers accepted that the vaccine is good and was willing for their adolescent daughters to take the HPV vaccine for the prevention of HPV. However, cost of the vaccine, side effects, and potential exposure of their daughters to promiscuity after taking the vaccine for protection were the major concerns expressed by the mothers as regards to HPV vaccine uptake by their daughters. Findings highlight the need for health promotion and education programs about cervical cancer, HPV, and HPV vaccine to increase awareness and knowledge among mothers of adolescent girls. Also, HPV vaccination should be included as part of routine immunization for female adolescents.

Qualitative views of Nigerian school principals and teachers on the barriers and opportunities for promoting students' physical activity behaviours within the school settings.

BACKGROUND: Insufficient physical activity (PA) is a growing public health challenge among Nigerian adolescents. Significant information gap exists on the school-related factors which influence the participation of adolescents in school-based physical activity programmes in Nigeria. This study was conducted to document the qualitative views of school principals and teachers on the barriers and opportunities for promoting the physical activity behaviours of adolescents within the school settings in light of the socio-ecological model. METHODS: This was a qualitative study conducted in 12 public and private schools in two local government areas of Oyo state, Nigeria. Two key sources and data collection methods (i.e key informant interviews and focus group discussions) were used. Six key informant interviews were held with school principals and six focus group discussions with classroom teachers using pre-tested guides. Data was analysed using thematic analysis. RESULTS: Fourteen sub-themes were identified as barriers to PA and linked to different levels of the socio-ecological model. Three themes were categorised as parental factors, three themes as socio-cultural and religious factors while the school-related factors had eight sub-themes. Specifically, the school-related barriers were the declining number of trained physical health education teachers, limited opportunities for continuing education and low prioritisation of physical health education. Other school-related factors such as increasing demand for classroom academic time, negative attitudinal dispositions of other teachers and inadequate funding for schools which hampered the provision of facilities and equipment were identified as factors that limit the effective implementation of policies and programmes for physical activity in schools. Opportunities to promote PA within the school settings during assemblies, breaktime, after-school and inter-house sports competition exist. However, these opportunities are hampered by competing academic time, security threats, fear of causalities to students due to poor supervision after school, poor funding and brawling associated with competitive school-based sporting events. CONCLUSIONS: Factors that contribute to insufficient physical activity among in-school adolescents in the school settings are multi-factorial. Implementation of holistic, multi-component interventions which address the social-cultural and school-level factors and enhance students' opportunities for physical activity in schools are recommended.

Tuberculosis treatment outcomes and associated factors in two states in Nigeria.

OBJECTIVE: To determine the treatment success rate among TB patients and associated factors in Anambra and Oyo, the two states with the largest burden of tuberculosis in Nigeria. METHODS: A health facility record review for 2016 was conducted in the two states (Anambra and Oyo). A checklist was used to extract relevant information from the records kept in each of the selected DOTS facilities to determine TB treatment success rates. Treatment success rate was defined as the proportion of new smear-positive TB cases registered under DOTS in a given year that successfully completed treatment, whether with bacteriologic evidence of success ('cured') or without ('treatment completed'). Treatment success rate was classified into good (≥85%) and poor (<85%) success rates using the 85% national target for TB treatment outcome. Data were analysed using descriptive statistics and chi-square at P < 0.05. RESULTS: There were 1281 TB treatment enrollees in 2016 in Anambra and 3809 in Oyo (total = 4835). An overall treatment success rate of 75.8% was achieved (Anambra-57.5%; Oyo-82.0%). The percentage cure rates were 61.5% for Anambra and 85.2% for Oyo. Overall, only 28.6% of the facilities in both states (Anambra-0.0%; Oyo-60.0%) had a good treatment success rate. More facilities in Anambra (100.0%) than Oyo (40.0%) had a poor treatment success rate (p < 0.001), as did more private/FBO (100.0%) than public health facilities (60.0%) (p = 0.009). All tertiary facilities had a poor treatment success rate followed by 87.5% of secondary health facilities and 56.5% of primary healthcare facilities (P = 0.035). CONCLUSION: Treatment success and cure rates in Anambra state were below the 85.0% of the recommended target set by the WHO. Geographical location, and level/tier and type of facility were factors associated with this. Interventions are recommended to address these problems.

OBJECTIF: Déterminer le taux de succès du traitement chez les patients TB et les facteurs associés à Anambra et Oyo, les deux Etats avec la plus grande charge de TB au Nigéria. MÉTHODES: Un examen des dossiers des établissements de santé pour 2016 a été réalisé dans les deux Etats (Anambra et Oyo). Une liste de contrôle a été utilisée pour extraire les informations pertinentes des registres conservés dans chacun des établissements DOTS sélectionnés afin de déterminer les taux de succès du traitement antituberculeux. Le taux de succès du traitement a été défini comme la proportion de nouveaux cas de TB à frottis positif enregistrés dans le cadre du DOTS au cours d'une année donnée qui ont terminé le traitement avec succès, que ce soit avec des preuves bactériologiques de succès («guéri¼) ou sans («traitement terminé¼) . Le taux de succès du traitement a été classé en bons (≥ 85%) et mauvais (<85%) taux de réussite en utilisant l'objectif national de 85% pour l'issue du traitement de la TB. Les données ont été analysées à l'aide de statistiques descriptives et du Chi carré à p <0,05. RÉSULTATS: Il y avait 1.281 personnes inscrites au traitement antituberculeux en 2016 à Anambra et 3.809 à Oyo (total = 4835). Un taux de succès global du traitement de 75,8% a été atteint (Anambra, 57,5%; Oyo, 82,0%). Les taux de guérison en pourcentage étaient de 61,5% pour Anambra et de 85,2% pour Oyo. Dans l'ensemble, seuls 28,6% des établissements des deux Etats (Anambra, 0,0%; Oyo, 60,0%) avaient un bon taux de réussite du traitement. Plus d'établissements à Anambra (100,0%) qu'à Oyo (40,0%) avaient un faible taux de réussite du traitement (p <0,001), tout comme plus d'établissements de santé privés/FBO (100,0%) que publics (60,0%) (p = 0,009). Tous les établissements tertiaires avaient un faible taux de réussite du traitement, suivis de 87,5% des établissements de santé secondaires et 56,5% des établissements de soins de santé primaires (p = 0,035). CONCLUSION: Le succès du traitement et les taux de guérison dans l'Etat d'Anambra étaient inférieurs aux 85,0% de l'objectif recommandé fixé par l'OMS. L'emplacement géographique, le niveau et le type d'établissement étaient des facteurs associés à cela. Des interventions sont recommandées pour résoudre ces problèmes.

General and tuberculosis-specific service readiness in two states in Nigeria.

BACKGROUND: Tuberculosis is the world's deadliest infectious disease and a leading cause of death in Nigeria. The availability of a functional healthcare system is critical for effective TB service delivery and attainment of national and global targets. This study was designed to assess readiness for TB service delivery in Oyo and Anambra states of Nigeria. METHODS: This was a facility-based study with a mixed-methods convergent parallel design. A multi-stage sampling technique was used to select 42 primary, secondary, and tertiary healthcare facilities in two TB high burden states. Data were collected using key informant interviews, a semi-structured instrument adapted from the WHO Service Availability and Readiness Assessment tool and facility observation using a checklist. Quantitative data were analysed using descriptive and inferential statistics while qualitative data were transcribed and analysed thematically. Data from both sources were integrated to generate conclusions. RESULTS: The domain score for basic amenities in both states was 48.8%; 47.0% in Anambra and 50.8% in Oyo state with 95% confidence interval [- 15.29, 7.56]. In Oyo, only half of the facilities (50%) had access to constant power supply compared to 72.7% in Anambra state. The overall general service readiness index for both states was 69.2% with Oyo state having a higher value (73.3%) compared to Anambra with 65.4% (p = 0.56). The domain score for availability of staff and TB guidelines was 57.1% for both states with 95% confidence interval [- 13.8, 14.4]. Indicators of this domain with very low values were staff training for the management of HIV and TB co-infection and training on MDR -TB. Almost half (47.6%) of the facilities experienced a stock out of TB drugs in the 3 months preceding the study. The overall tuberculosis-specific service readiness index for both states was 75%; this was higher in Oyo (76.5%) than Anambra state (73.6%) (p = 0.14). Qualitative data revealed areas of deficiencies for TB service delivery such as inadequate infrastructure, poor staffing, and gaps with continuing education on TB management. CONCLUSIONS: The weak health system remains a challenge and there must be concerted actions and funding by the government and donors to improve the TB healthcare systems.

Implementing oncology clinical trials in Nigeria: a model for capacity building.

BACKGROUND: There is both higher mortality and morbidity from cancer in low and medium income countries (LMICs) compared with high income countries (HICs). Clinical trial activities and development of more effective and less toxic therapies have led to significant improvements in morbidity and mortality from cancer in HICs. Unfortunately, clinical trials remain low in LMICs due to poor infrastructure and paucity of experienced personnel to execute clinical trials. There is an urgent need to build local capacity for evidence-based treatment for cancer patients in LMICs. METHODS: We conducted a survey at facilities in four Teaching Hospitals in South West Nigeria using a checklist of information on various aspects of clinical trial activities. The gaps identified were addressed using resources sourced in partnership with investigators at HIC institutions. RESULTS: Deficits in infrastructure were in areas of patient care such as availability of oncology pharmacists, standard laboratories and diagnostic facilities, clinical equipment maintenance and regular calibrations, trained personnel for clinical trial activities, investigational products handling and disposals and lack of standard operating procedures for clinical activities. There were two GCP trained personnel, two study coordinators and one research pharmacist across the four sites. Interventions were instituted to address the observed deficits in all four sites which are now well positioned to undertake clinical trials in oncology. Training on all aspects of clinical trial was also provided. CONCLUSIONS: Partnerships with institutions in HICs can successfully identify, address, and improve deficits in infrastructure for clinical trial in LMICs. The HICs should lead in providing funds, mentorship, and training for LMIC institutions to improve and expand clinical trials in LMIC countries.

Multisectoral approach and WHO 'Bestbuys' in Nigeria's nutrition and physical activity policies.

Unhealthy diet and physical inactivity are modifiable risk factors for non-communicable diseases. Policies formulated in line with international guidelines are required for the implementation of population-level interventions to reduce the risks. This study describes the utilization of multisectoral approach (MSA) for the formulation of nutrition and physical activity policies and the extent to which they align with the WHO 'Best Buy Interventions'. The research utilized a descriptive case study design and the theoretical model guiding the study was the Walt and Gilson framework for policy analysis. Data were obtained through the interview of 44 key informants using pre-tested guides and document review of 17 policies and articles obtained from government institutions or through the search of electronic databases. Data were integrated and analysed using thematic analysis. Between 2000 and 2016, Nigeria had formulated 10 nutrition-related policies and 5 guidelines with actions to promote physical activity. Only three nutrition and two physical activity policies adopted a high level of MSA. In line with the WHO best buy interventions, educational interventions for the general population are proposed to reduce sugar and salt intake and replace transfat with polyunsaturated fats but there are no legal regulatory acts to support these actions. Policy documents with actions to reduce physical inactivity do not include the WHO best buys. The country should adopt a wider range of actors to formulate and review policies, integrate all the WHO best buy interventions and develop effective legislation to regulate the salt and sugar content of processed foods.

Experience of Stress and Coping Mechanism Among Police Officers in South Western Nigeria.

Prior research on stress among police officers in Nigeria is limited. Most researchers have focused on the predictors of workplace stress among the police officer, and fewer still have examined their coping mechanisms. This study assessed the stress experienced and coping mechanism among police officers in Ibadan Metropolis, Oyo State, Nigeria. The study was a descriptive cross-sectional study, which utilized a pretested self-administered questionnaire. The study population included 342 selected respondents using a multistage sampling technique from police stations in Ibadan North Local Government, Oyo State, Nigeria. The data were analyzed using descriptive statistics, χ2 test, and Fisher's exact test at p = .05. Results revealed that majority (92.5%) of the respondents had poor knowledge of stress with a mean knowledge of 5.4 ± 1.7. Majority (80.1%) of the respondents reported experience of stress such as feeling depressed sometimes at work, while 60.5% said that they usually have headache and body ache. In addition, 36.9% had good coping mechanism and more than half (58.8%) had a fair coping mechanism with a mean coping score of 5.0 ± 3.0. This study showed that knowledge of stressors was poor and respondents perceived that they experienced stress and its symptoms. Strategies such as training using teaching, discussion, and explanation to educate the police officers about stress and its coping mechanism and policy interventions to facilitate the construction of standard stress management centers would be appropriate strategies to reduce stress, increase the knowledge of police officers on stressors, and enhance their coping mechanism.

Analysis of alcohol policy in Nigeria: multi-sectoral action and the integration of the WHO "best-buy" interventions.

BACKGROUND: Harmful alcohol use is a modifiable risk factor contributing to the increasing burden of non-communicable diseases and deaths and the implementation of policies focused on primary prevention is pivotal to address this challenge. Policies with actions targeting the harmful use of alcohol have been developed in Nigeria. This study is an in-depth analysis of alcohol-related policies in Nigeria and the utilization of WHO Best Buy interventions (BBIs) and multi-sectoral action (MSA) in the formulation of these policies. METHODS: A descriptive case study design and the Walt and Gilson framework of policy analysis was utilized for the research. Components of the study included a scoping review consisting of electronic search of Google and three online databases (Google Scholar, Science Direct and PubMed) to identify articles and policy documents with no language and date restrictions. Government institution provided documents which were not online. Thirteen policy documents, reports or articles relevant to the policy formulation process were identified. Other components of the study included interviews with 44 key informants (Bureaucrats and Policy Makers) using a pretested guide. The qualitative data were coded and analyzed using thematic analysis. RESULTS: Findings revealed that policy actions to address harmful alcohol use are proposed in the 2007 Federal Road Safety Act, the Non-communicable Diseases Prevention and Control Policy and the Strategic Plan of Action. Only one of the best buy interventions, (restricted access to alcohol) is proposed in these policies. Multi-sectoral action for the formulation of alcohol-related policy was low and several relevant sectors with critical roles in policy implementation were not involved in the formulation process. Overall, alcohol currently has no holistic, health-sector led policy document to regulate the marketing, promotion of alcohol and accessibility. A major barrier is the low government budgetary allocation to support the process. CONCLUSIONS: Nigeria has few alcohol-related policies with weak multi-sectoral action. Funding constraint remains a major threat to the implementation and enforcement of proposed policy actions.

Access to Information on Family Planning and Use of Modern Contraceptives Among Married Igbo Women in Southeast, Nigeria.

This study was conducted among married Igbo women in Nigeria who have the lowest median birth interval coupled with a culture of sex preference and low use of modern contraceptives. We examined the relationship between access to information on family planning and sex preference on the use of modern contraceptive (MC). The 2013 Nigeria Demographic and Health Survey data were used. The data of 1,661 women of reproductive age were analyzed in this study. Access to information on family planning was low, and almost half (48.6%) of the women had a score of zero. Controlling for possible confounding variables, the data show that women who have good (odds ratio [ OR]= 3.92; CI [2.28, 6.75], p < .001) and poor ( OR = 2.56; CI [1.85, 3.56], p < .001) access to information on family planning were more likely to use MC than those with no access to information on family planning. Sex preference showed no relationship with the use of MC. Families where husbands want more children than their wives inhibit ( OR = 0.62, CI [0.42, 0.90], p < .05) the use of MC compared with those families where husbands and wives fertility desire is the same. Public health programs by government and donors should intensify interventions to increase access to family planning information to promote the use of MC among married Igbo women.

Analysis of tobacco control policies in Nigeria: historical development and application of multi-sectoral action.

BACKGROUND: Tobacco use is a major risk factor for non-communicable diseases and policy formulation on tobacco is expected to engrain international guidelines. This paper describes the historical development of tobacco control policies in Nigeria, the use of multi-sectoral action in their formulation and extent to which they align with the World Health Organisation "best buy" interventions. METHODS: We adopted a descriptive case study methodology guided by the Walt and Gilson Policy Analysis Framework. Data collection comprised of document review (N = 18) identified through search of government websites and electronic databases with no date restriction and key informant interviews (N = 44) with stakeholders in public and private sectors. Data was integrated and analyzed using content analysis. Ethical approval was granted by the University of Ibadan and University College Hospital Ethics Review Committee. RESULTS: Although the agenda for development of a national tobacco control policy dates back to the 1950s, a comprehensive Framework Convention for Tobacco Control (FCTC) compliant policy was only developed in 2015, 10 years after Nigeria signed the FCTC. Lack of funding and conflict of interest (of protecting citizens from harmful effect of tobacco viz. a viz. the economic gains from the industry) are the major barriers that slowed the policy process. Current tobacco -related policies developed by the Federal Ministry of Health were formulated through strong multi-sectoral engagement and covering all the four WHO "best buy" interventions. Other policies had limited multi-sectoral engagement and "best buy" strategies. The tobacco industry was involved in the development of the Standards for Tobacco Control of 2014 contrary to the long-standing WHO guideline against engagement of the industry in policy formulation. CONCLUSIONS: Nigeria has a comprehensive national policy for tobacco control which was formulated a decade after ratification of the FCTC due to constraints of funding and conflict of interest. Not all the tobacco control policies in Nigeria engrain the principles of multisectorality and best buy strategies in their formulation. There is an urgent need to address these neglected areas that may hamper tobacco control efforts in Nigeria.

Multi-sectoral action in non-communicable disease prevention policy development in five African countries.

BACKGROUND: The rise of non-communicable diseases (NCDs) in Africa requires a multi-sectoral action (MSA) in their prevention and control. This study aimed to generate evidence on the extent of MSA application in NCD prevention policy development in five sub-Saharan African countries (Kenya, South Africa, Cameroon, Nigeria and Malawi) focusing on policies around the major NCD risk factors. METHODS: The broader study applied a multiple case study design to capture rich descriptions of policy contents, processes and actors as well as contextual factors related to the policies around the major NCD risk factors at single- and multi-country levels. Data were collected through document reviews and key informant interviews with decision-makers and implementers in various sectors. Further consultations were conducted with NCD experts on MSA application in NCD prevention policies in the region. For this paper, we report on how MSA was applied in the policy process. RESULTS: The findings revealed some degree of application of MSA in NCD prevention policy development in these countries. However, the level of sector engagement varies across different NCD policies, from passive participation to active engagement, and by country. There was higher engagement of sectors in developing tobacco policies across the countries, followed by alcohol policies. Multi-sectoral action for tobacco and to some extent, alcohol, was enabled through established structures at national levels including inter-ministerial and parliamentary committees. More often coordination was enabled through expert or technical working groups driven by the health sectors. The main barriers to multi-sectoral action included lack of awareness by various sectors about their potential contribution, weak political will, coordination complexity and inadequate resources. CONCLUSION: MSA is possible in NCD prevention policy development in African countries. However, the findings illustrate various challenges in bringing sectors together to develop policies to address the increasing NCD burden in the region. Stronger coordination mechanisms with clear guidelines for sector engagement are required for effective MSA in NCD prevention. Such a mechanisms should include approaches for capacity building and resource generation to enable multi-sectoral action in NCD policy formulation, implementation and monitoring of outcomes.

Non-communicable disease prevention policy process in five African countries.

BACKGROUND: The increasing burden of non-communicable diseases (NCDs) in sub-Saharan Africa is causing further burden to the health care systems that are least equipped to deal with the challenge. Countries are developing policies to address major NCD risk factors including tobacco use, unhealthy diets, harmful alcohol consumption and physical inactivity. This paper describes NCD prevention policy development process in five African countries (Kenya, South Africa, Cameroon, Nigeria, Malawi), including the extent to which WHO "best buy" interventions for NCD prevention have been implemented. METHODS: The study applied a multiple case study design, with each country as a separate case study. Data were collected through document reviews and key informant interviews with national-level decision-makers in various sectors. Data were coded and analyzed thematically, guided by Walt and Gilson policy analysis framework that examines the context, content, processes and actors in policy development. RESULTS: Country-level policy process has been relatively slow and uneven. Policy process for tobacco has moved faster, especially in South Africa but was delayed in others. Alcohol policy process has been slow in Nigeria and Malawi. Existing tobacco and alcohol policies address the WHO "best buy" interventions to some extent. Food-security and nutrition policies exist in almost all the countries, but the "best buy" interventions for unhealthy diet have not received adequate attention in all countries except South Africa. Physical activity policies are not well developed in any study countries. All have recently developed NCD strategic plans consistent with WHO global NCD Action Plan but these policies have not been adequately implemented due to inadequate political commitment, inadequate resources and technical capacity as well as industry influence. CONCLUSION: NCD prevention policy process in many African countries has been influenced both by global and local factors. Countries have the will to develop NCD prevention policies but they face implementation gaps and need enhanced country-level commitment to support policy NCD prevention policy development for all risk factors and establish mechanisms to attain better policy outcomes while considering other local contextual factors that may influence policy implementation such as political support, resource allocation and availability of local data for monitoring impacts.

Influence of the WHO framework convention on tobacco control on tobacco legislation and policies in sub-Saharan Africa.

BACKGROUND: The World Health Organization's Framework Convention on Tobacco Control, enforced in 2005, was a watershed international treaty that stipulated requirements for signatories to govern the production, sale, distribution, advertisement, and taxation of tobacco to reduce its impact on health. This paper describes the timelines, context, key actors, and strategies in the development and implementation of the treaty and describes how six sub-Saharan countries responded to its call for action on tobacco control. METHODS: A multi-country policy review using case study design was conducted in Cameroon, Kenya, Nigeria, Malawi, South Africa, and Togo. All documents related to the WHO Framework Convention on Tobacco Control and individual country implementation of tobacco policies were reviewed, and key informant interviews related to the countries' development and implementation of tobacco policies were conducted. RESULTS: Multiple stakeholders, including academics and activists, led a concerted effort for more than 10 years to push the WHO treaty forward despite counter-marketing from the tobacco industry. Once the treaty was enacted, Cameroon, Kenya, Nigeria, Malawi, South Africa, and Togo responded in unique ways to implement tobacco policies, with differences associated with the country's socio-economic context, priorities of country leaders, industry presence, and choice of strategies. All the study countries except Malawi have acceded to and ratified the WHO tobacco treaty and implemented tobacco control policy. CONCLUSIONS: The WHO Framework Convention on Tobacco Control provided an unprecedented opportunity for global action against the public health effects of tobacco including non-communicable diseases. Reviewing how six sub-Saharan countries responded to the treaty to mobilize resources and implement tobacco control policies has provided insight for how to utilise international regulations and commitments to accelerate policy impact on the prevention of non-communicable diseases.

Correction to: Non-communicable disease prevention policy process in five African countries.

After publication of the article [1], it was noticed that the title has erroneously included 'authors' in the end.

Effects of a multi-level intervention on the pattern of physical activity among in-school adolescents in Oyo state Nigeria: a cluster randomised trial.

BACKGROUND: Physical inactivity contributes to the global burden of non-communicable diseases. The pattern of physical activity in adulthood are often established during adolescence and sedentary behaviours in the early years could influence the development of diseases later in life. Studies on physical activity in Nigeria have focused largely on individual behaviours and the effects of school-based interventions have not been well investigated. The aim of the proposed study is to identify factors influencing; and evaluate the effects of a multi-level intervention on the physical activity behaviours of in-school adolescents in Oyo state, Nigeria. METHODS: The study will adopt a cluster randomised controlled trial design and schools will serve as the unit of randomisation. The sample size is 1000 in-school adolescents aged 10-19 years. The study will be guided by the socio-ecological model and theory of reasoned action and baseline data will be obtained through a mixed methods approach comprising a cross sectional survey to document the self-reported physical activity levels coupled with objectively measured physical activity levels using pedometers for a subset of the sample. Other measurements including weight, height, waist and hip circumferences, fitness level using the 20-m shuttle run test (20-mSRT) and blood pressure will be obtained. The schools' built environment and policy support for physical activity will be assessed using structured questionnaires coupled with key informant interviews and focus group discussions with the school authorities. Baseline findings will guide the design and implementation of a 12-week multi-level intervention. The primary outcome measures are self-reported and 7-day objectively measured physical activity. Other secondary outcome measures are body-mass-index for age, waist-to-hip ratio, cardioresiratory fitness and blood pressure. The association between behavioural factors and physical activity levels will be assessed. Follow-up measurements will be taken immediately after the intervention and 3-months post intervention. DISCUSSION: Physical activity behaviours of adolescents in Nigeria are influenced by multiple factors. There is an urgent need for effective school-based interventions with a potential to improve the physical activity behaviours of adolescents in Nigeria and other low and middle income countries. TRIAL REGISTRATION: Pan African Clinical Trial Registry. TRIAL REGISTRATION NUMBER: PACTR201706002224335 , registered 26 June 2017.

Correction to: Effects of a multi-level intervention on the pattern of physical activity among in-school adolescents in Oyo state Nigeria: a cluster randomised trial.

CORRECTION: After publication of the article [1], it has been brought to our attention that there is an error in figure 1. The number of excluded secondary schools should read "50" and not "72". The rest of the data in the figure is accurate.

Maternal Education and Diarrhea among Children aged 0-24 Months in Nigeria.

Childhood diarrhea remains a problem in countries like Nigeria where access to potable water, good hygiene and sanitation are lacking. Maternal education is an important determinant of health status of under-five children. Very few studies have investigated the relationship between maternal education and diarrhea in children in Nigeria. Therefore, this study was implemented to fill the gap. The study design was cross-sectional and 2013 National Survey was used. Children aged 0-24 months were investigated and the dependent variable was diarrhea status of the index child in the last two weeks prior the survey. The main independent variable was maternal education. Data were analyzed using Chi-square and Logistic regression models (α=0.05). Diarrhea prevalence was 13.7% and higher (15.5%) among children of women who have no formal education, and mothers living in the North East region of Nigeria experienced the highest prevalence (26.4%). Children whose mothers had no formal education were 2.69(CI= 1.800-4.015, p <0.001) more likely to have diarrhea as compared to those who had higher education. Maternal education is an important predictor of diarrhea among children aged 0-24 months in Nigeria. Policies to reduce diarrhea among children in Nigeria should target children of the illiterate, less educated mothers and those living in the North-West.