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.

Health workforce incentives and dis-incentives during the COVID-19 pandemic: experiences from Democratic Republic of Congo, Nigeria, Senegal, and Uganda.

BACKGROUND: The COVID-19 pandemic presented a myriad of challenges for the health workforce around the world due to its escalating demand on service delivery. A motivated health workforce is critical to effectual emergency response and in some settings, incentivizing health workers motivates them and ensures continuity in the provision of health services. We describe health workforce experiences with incentives and dis-incentives during the COVID-19 response in the Democratic Republic of Congo (DRC), Senegal, Nigeria, and Uganda. METHODS: This is a multi-country qualitative research study involving four African countries namely: DRC, Nigeria, Senegal, and Uganda which assessed the workplace incentives instituted in response to the COVID-19 pandemic. Key informant interviews (n = 60) were conducted with staff at ministries of health, policy makers and health workers. Interviews were virtual using the telephone or Zoom. They were audio recorded, transcribed verbatim, and analyzed thematically. Themes were identified and quotes were used to support findings. RESULTS: Health worker incentives included (i) financial rewards in the form of allowances and salary increments. These motivated health workers, sustaining the health system and the health workers' efforts during the COVID-19 response across the four countries. (ii) Non-financial incentives related to COVID-19 management such as provision of medicines/supplies, on the job trainings, medical care for health workers, social welfare including meals, transportation and housing, recognition, health insurance, psychosocial support, and supervision. Improvised determination and distribution of both financial and non-financial incentives were common across the countries. Dis-incentives included the lack of personal protective equipment, lack of transportation to health facilities during lockdown, long working hours, harassment by security forces and perceived unfairness in access to and inadequacy of financial incentives. CONCLUSION: Although important for worker motivation, financial and non-financial incentives generated some dis-incentives because of the perceived unfairness in their provision. Financial and non-financial incentives deployed during health emergencies should preferably be pre-determined, equitably and transparently provided because when arbitrarily applied, these same financial and non-financial incentives can potentially become dis-incentives. Moreover, financial incentives are useful only as far as they are administered together with non-financial incentives such as supportive and well-resourced work environments. The potential negative impacts of interventions such as service delivery re-organization and lockdown within already weakened systems need to be anticipated and due precautions exercised to reduce dis-incentives during emergencies.

Demographic and epidemiological transitions and burden of adolescent healthcare in sub-Saharan Africa: A review.

This review's main objective is to discuss how demographic and epidemiological transitions relate to the burden of adolescent healthcare in sub-Saharan Africa (SSA). The review explicitly discussed the burden of adolescent healthcare, the current African policies on adolescent healthcare, and gaps in the African policies compared with Europe and North America. We also examined how adolescent healthcare policies evolve and documented the recommended essential part of the policy for enhancing its sustainability. The burden of adolescent health is high in SSA with diseases and reproductive health-related problems prevailing among adolescents. However, variations exist in the burden of adolescent healthcare across countries in the region. While some SSA countries are currently undergoing demographic and epidemiological transition processes concerning adolescent health care, the majority are either at an early stage of the transition or yet to commence the process. Policy-makers should consider effective ways to improve adolescents' health in SSA through preventive mechanisms and a multi-dimensional approach.

A Comparative Assessment of Intimate Partner Violence Perpetration among Male Military Personnel and Civil Servants in Ibadan, Nigeria.

The mode of training and work of the military personnel is different from that of civil servants and may affect their relationships with their intimate partners. This study assessed and compared the prevalence and correlates of self-reported Intimate Partner Violence (IPV) perpetration against female partners by male military personnel and civil servants in Ibadan, south-western Nigeria. A cross sectional survey of 1240 respondents, comprising 631 military personnel and 609 civilians, was conducted using a multistage sampling technique. A self-administered questionnaire was used to collect data on the respondents' characteristics and the different types of IPV perpetrated by them. Chi square test was used to compare the proportions of the different types of IPV perpetration and logistic regression analysis was used to determine the predictors of IPV perpetration in the two study groups. Military personnel reported significantly more IPV such as physical abuse, psychological abuse and controlling behaviors than the civil servants. Childhood exposure to inter-parental IPV and history of physical fight with another woman significantly increased the odds of perpetration of each type and any form of IPV in the two populations after controlling for other variables. Military personnel were significantly more likely to perpetrate any form of IPV than the civil servants. IPV was prevalent in both groups but was more among the military personnel. There is a need for multidisciplinary interventions such as psycho-education and conflict management skills to address violence against female intimate partners especially among the military population in Nigeria.

Money, Power, and Relationships: Economic Vulnerability in Girls' Lives and Risk for Partner Violence Among Girls in Ibadan, Nigeria.

This study explored the experience of economic vulnerability and its effect on girls' future aspirations, relationships, and financial reliance on male partners, as well as risk for intimate partner violence (IPV) and related health consequences. Thirteen Focus Group Discussions (FGDs) were conducted among 122 female adolescents aged 15-19 years. Participants reported that lack of economic resources limits girls' ability to be economically independent by reducing opportunities to receive education or enter into a trade. Economic vulnerability decreases girls' ability to become economically independent, increasing financial reliance on male partners, and in turn, increasing risk for IPV, sexually transmitted infections, and unintended pregnancy.

Cost-Effectiveness and Validity Assessment of Cyscope Microscope, Quantitative Buffy Coat Microscope, and Rapid Diagnostic Kit for Malaria Diagnosis among Clinic Attendees in Ibadan, Nigeria.

Background. Unavailability of accurate, rapid, reliable, and cost-effective malaria diagnostic instruments constitutes major a challenge to malaria elimination. We validated alternative malaria diagnostic instruments and assessed their comparative cost-effectiveness. Method. Using a cross-sectional study design, 502 patients with malaria symptoms at selected health facilities in Ibadan between January and April 2014 were recruited consecutively. We examined malaria parasites using Cyscope®, QBC, and CareStart™ and results were compared to light microscopy (LM). Validity was determined by assessing sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Costs per hour of use for instruments and turnaround time were determined. Result. Sensitivity of the instruments was 76.0% (CareStart), 95.0% (Cyscope), and 98.1% (QBC). Specificity was 96.0% (CareStart), 87.3% (Cyscope), and 85.5% (QBC). PPV were 65.2%, 67.5%, and 84.7%, while NPV were 93.6%, 98.6%, and 99.4% for CareStart, Cyscope, and QBC with Kappa values of 0.75 (CI = 0.68-0.82) for CareStart, 0.72 (CI = 0.65-0.78) for Cyscope, and 0.71 (CI = 0.64-0.77) for QBC. Average cost per hour of use was the lowest ($2.04) with the Cyscope. Turnaround time was the fastest with Cyscope (5 minutes). Conclusion. Cyscope fluorescent microscope had the shortest turnaround time and is the most cost-effective of all the malaria diagnostic instruments evaluated.

Women's status within the household as a determinant of maternal health care use in Nigeria.

BACKGROUND: Although gender inequality is often cited as a barrier to improving maternal health in sub-saharan Africa, there is lack of empirical data on how women's socio-cultural characteristics may influence use of health services in Nigeria. OBJECTIVE: To describe how women's position in the household affects receipt of maternity care services. METHODS: Secondary data analysis of 10,052 and 4,590 currently married women aged 15 to 49 years from the 2008 Nigerian DHS who receive skilled antenatal and delivery care at least till pregnancy was done. RESULTS: Receipt of skilled delivery care was by 37.9% while, natal care was by 98.4%. Education, residence and wealth index all significantly influenced receipt of maternal health care. Women who were involved in decision making on their own health (aOR=1.97; 95%CI=1.88-2.06) and were employed throughout the year (aOR=1.11; 95%CI=1.01-1.23) were more likely to receive skilled antenatal care, while those who justified physical intimate partner violence were less likely to receive both skilled antenatal care (aOR=0.92; 95%CI=0.85-0.98) and delivery services (aOR 0.54; 95% CI 0.33-0.87). CONCLUSION: Interventions aimed at improving maternal care should promote women empowerment (decision making, self worth, educational and economic) and should involve partners.

Are very poor women more vulnerable to violence against women? Comparison of experiences of female beggars with homemakers in an urban slum settlement in Ibadan, Nigeria.

This study compared the prevalence and nature of violence against women (VAW) experienced by 104 female beggars with those of 219 homemakers in Sabo, an urban migrant slum settlement in Ibadan, Nigeria. The lifetime experience of VAW was 66.3% (95%CI: 62.5-70.1) among the beggars and 54.8% (95%CI: 52.2-57.6) among the homemakers (p=.05), while six months preceding the survey was: 56.7% (95%CI: 55.2-58.2) and 21.9% (95%CI: 20.8.2-23.0) respectively p=.0001). Psychological violence was experienced by 34.7% and 20.8% (p=.05); physical violence by 31.9% and 16.7% (p=.02) and sexual by 20.3% and 0.8% (p=.0001) of the beggars and homemakers respectively. Beggars with higher knowledge levels (aOR 0.23; 95%CI 0.07-0.80) and with more egalitarian attitudes (aOR 0.38; 95%CI 0.12-0.91) were less likely to experience violence. Suggestions to end VAW included female education (27.8%) and economic empowerment (59.2%). There is need to protect beggars by increasing access to health information, schooling, vocational training and income generating activities.

Intimate partner violence in southwestern Nigeria: are there rural-urban differences?

The researchers in this study assessed the prevalence of different types and experience of intimate partner violence among 600 women aged 15 to 49 years in selected rural and urban communities in southwestern Nigeria between October and December, 2007. Lifetime prevalence of intimate partner violence was 64% in the rural and 70% in the urban areas. Controlling behavior was the most frequently reported type of intimate partner violence experienced by both groups of women, and sexual violence was reported least. More urban women reported sexual violence and controlling behaviors than rural women (16.4% versus 11.6% and 57.7% versus 42.0%, respectively). More rural women had experienced physical violence (28% versus 14%). More urban women experienced controlling behaviors, while more rural women experienced physical violence. In both locations, history of partners' involvement in physical fights was significantly associated with reporting sexual violence (rural: odds ratio [OR] = 3.9; 95% confidence interval [CI] 1.2-12.3; urban: OR = 8.4; 95% CI 1.4-51.8). History of alcohol consumption by partners was significantly associated with reporting physical violence (rural: OR = 2.3; 95% CI 1.2-4.4; urban: OR = 3.2; 95% CI 1.4-7.2). However, among rural respondents, younger partners were more likely to perpetuate controlling behavior (OR = 5.1; 95% CI 1.7-15.6) and being in a relationship for ≥10 years was related to psychological and physical violence. Among urban respondents, history of partners' involvement in physical fights was associated with controlling behavior (OR = 8.2; 95% CI 1.1-65.4) and physical violence (OR = 4.5; 95% CI 1.2-17.3). These results suggest that intimate partner violence is a frequent experience in women in both communities, although the types of intimate partner violence experienced differed, and multidisciplinary strategies are required to reduce intimate partner violence.

The autopsy: knowledge, attitude, and perceptions of doctors and relatives of the deceased.

CONTEXT: Despite the crucial role that autopsy plays in the development of the science and practice of medicine, autopsy rates have been declining throughout the world in recent decades. OBJECTIVE: To identify factors influencing the acceptance of autopsies in Nigeria. DESIGN: Cross-sectional survey of the knowledge, attitude, and perceptions of doctors and relatives of deceased patients on factors influencing acceptance of autopsy at the University College Hospital, Ibadan, Nigeria. RESULTS: Only 38% of relatives had satisfactory knowledge about autopsy and about 50% of doctors knew that physicians' desire for autopsy should not override patients' consent. Doctors identified difficulty in obtaining consent from relatives of deceased patients, administrative problems in requesting autopsy, and delay in obtaining autopsy report as major reasons responsible for the decline in autopsy requests, whereas relatives of the deceased cited fear of mutilation, concerns about delaying the funeral, and objection by the patient before death as reasons for refusal to grant permission for an autopsy. Sociodemographic factors such as age, occupation, religion, ethnicity, and level of education significantly influenced willingness to give consent for autopsy. CONCLUSIONS: There is need for concerted effort on the part of clinicians, pathologists, the public, and the government to resuscitate and sustain the practice of autopsy in Nigeria.

Economic violence to women and girls: is it receiving the necessary attention?

Most studies on gender-based violence (GBV) have focused on its physical, sexual, and psychological manifestations. This paper seeks to draw attention to the types of economic violence experienced by women, and describes its consequences on health and development. Economic violence experienced included limited access to funds and credit; controlling access to health care, employment, education, including agricultural resources; excluding from financial decision making; and discriminatory traditional laws on inheritance, property rights, and use of communal land. At work women experienced receiving unequal remuneration for work done equal in value to the men's, were overworked and underpaid, and used for unpaid work outside the contractual agreement. Some experienced fraud and theft from some men, illegal confiscation of goods for sale, and unlawful closing down of worksites. At home, some were barred from working by partners; while other men totally abandoned family maintenance to the women. Unfortunately, economic violence results in deepening poverty and compromises educational attainment and developmental opportunities for women. It leads to physical violence, promotes sexual exploitation and the risk of contracting HIV infection, maternal morbidity and mortality, and trafficking of women and girls. Economic abuse may continue even after the woman has left the abusive relationship. There is need for further large-scale studies on economic violence to women. Multi-strategy interventions that promote equity between women and men, provide economic opportunities for women, inform them of their rights, reach out to men and change societal beliefs and attitudes that permit exploitative behavior are urgently required.

Knowledge, attitudes and perceptions of the teacher's role in sexuality education in public schools in Nigeria.

UNLABELLED: The purpose of this study was to describe the knowledge, attitude, and perception of teachers of their role in the sexuality education of secondary school students with a viewto suggesting strategies for improvement. METHODS: The study was a descriptive cross-sectional survey. Information was collected from 305 secondary school teachers selected by multi-stage random sampling method from Osun state, Nigeria using a pre-tested semi-structured questionnaire. RESULTS: Median age of respondents was 36 +/- 8.18 years. Male/female ratio was 1:1.2. Knowledge about key reproductive issues was poor and inadequate. Knowledge of more than one contraceptive method was low (39.0%), Condom was the most frequently mentioned (59.3%). The teachers exhibited poor perception of their role in sexuality education of their students. 52.8% placed the sole responsibility for sexuality education on parents and only 20.7% found that it should start before age 10 years. Mean menarcheal age was 13.1 +/- 1.7 y. A statistically significant association was found between respondents' gender and knowledge of menarcheal age (p = .03); and between class taught and knowledge of menarcheal age (p = .003). 86.90% had positive attitude towards inclusion of sexuality education in the school curriculum; however, 43.6% felt that contraceptive methods should not be part of the course content. CONCLUSION: An urgent need exists for education and re-orientation of teachers through seminars and workshops, in-service training education program to equip them properly for the task. Policy makers need to formulate a definite, explicit, and workable sexuality education policy.

Intimate partner abuse: wife beating among civil servants in Ibadan, Nigeria.

Wife beating is one of the most common forms of violence against women by husbands or other intimate male partners. Although violence against women is pervasive, there are only few studies documenting the magnitude of the problem especially among the working class. The civil service comprises of persons from all socio-economic levels and different backgrounds. They act in advisory capacity and assist those responsible for making state policy Thus, 431 civil servants of the Oyo State government service were interviewed using a 44-item self-administered questionnaire. Results revealed that prevalence of wife beating was 31.3%. Ninety one (42.5%) men had been perpetrators, while 44 (23.5%) women had been victims. Consuming alcohol and growing up in an environment where parents fight publicly were significantly associated (p < 0.05) with men beating their wives; while being young, unmarried and a parental background of fighting was significantly associated with women being beaten (p < 0.05). Female respondents justified reasons for various types of domestic violence, including beating, more than the males (p < 0.05). Younger respondents had significantly worse attitudes (p < 0.05), while married and educated respondents had better attitude (p < 0.05). "Not wanting the children to suffer" (60.7%) and "hoping that partner will change" (28.8%) were reasons given for remaining in abusive relationships. There is an urgent need for education of the women on their rights, sensitisation of the men on gender-based violence and punishment for perpetrators. Supportive care and counselling services should also be provided for victims of violence.

Interventions for violence prevention among young female hawkers in motor parks in south-western Nigeria: a review of effectiveness.

An intervention study was carried out among hawkers, drivers, instructors, police and judicial officers to reduce the incidence of violence against young female hawkers in three states of south-western Nigeria. Knowledge and experience of violence among the hawkers before and after the interventions were then compared. Findings show that they had greater knowledge of the different types of violence (p < 0.05), were more aware of their vulnerability to violence (99.4% after compared to 82.7% before intervention) and sought help or redress (76.3% after compared to 45.8% before intervention) following violent acts. Sexual violence was the commonest type experienced (30.4% and 15.7% at base line and end line respectively). The rate of violence also decreased. We conclude that multidisciplinary interventions that empower women economically and educationally and involve all stakeholders are effective in preventing violence against women.