Symptoms, concerns, and experiences of women living with and beyond breast cancer in Africa: A mixed-methods systematic review.

OBJECTIVE: A mixed-methods systematic review to determine reported symptoms, concerns, and experiences of women living with and beyond breast cancer in Africa. METHODS: Literature searches were conducted in Medline, Embase, PsycINFO, Global Health, Web of Science, CINAHL, and the Cochrane Library. Quantitative and qualitative studies that comprised study populations of women with breast cancer from countries in Africa, detailing symptoms, concerns, and experiences of living with and beyond breast cancer were included. Inductive framework analysis was applied to organise existing literature with the Adversity, Restoration, and Compatibility framework and quality was assessed using the Mixed Methods Appraisal Tool. RESULTS: In total, 48 studies were included, comprising quantitative (n = 24), qualitative (n = 23) and mixed method (n = 1) studies. Women reported multiple complex and burdensome symptoms at all stages of the breast cancer disease trajectory. Multiple pervasive factors influencing participants' experiences included a lack of cancer knowledge, being removed from decision-making, religion, and the presence and use of traditional medicines. Literature relating to benefit finding, understanding identity for the future, and broader perspectives of well-being was absent. CONCLUSIONS: This review contributes insights and mapping of symptoms, concerns, and experiences of women with breast cancer in Africa. There is a great necessity to increase an understanding of the needs and experiences of women with breast cancer in Africa following cancer treatment, stages of remission, and longer-term monitoring and follow-up. This is required to ensure access to prompt and timely clinical and individualized supportive care for women with breast cancer in Africa.

Demand and supply analysis for maternal and child health services at the primary healthcare level in Nigeria.

BACKGROUND: The low demand for maternal and child health services is a significant factor in Nigeria's high maternal death rate. This paper explores demand and supply-side determinants at the primary healthcare level, highlighting factors affecting provision and utilization. METHODS: This qualitative study was undertaken in Anambra state, southeast Nigeria. Anambra state was purposively chosen because a maternal and child health programme had just been implemented in the state. The three-delay model was used to analyze supply and demand factors that affect MCH services and improve access to care for pregnant women/mothers and newborns/infants. RESULT: The findings show that there were problems with both the demand and supply aspects of the programme and both were interlinked. For service users, their delays were connected to the constraints on the supply side. On the demand side, the delays include poor conditions of the facilities, the roads to the facilities are inaccessible, and equipment were lacking in the facilities. These delayed the utilisation of facilities. On the supply side, the delays include the absence of security (fence, security guard), poor citing of the facilities, inadequate accommodation, no emergency transport for referrals, and lack of trained staff to man equipment. These delayed the provision of services. CONCLUSION: Our findings show that there were problems with both the demand and supply aspects of the programme, and both were interlinked. For service users, their delays were connected to the constraints on the supply side.

Physical activity service provision in hospice care: A national mixed-methods study.

BACKGROUND: Physical activity (PA) interventions help people with advanced incurable diseases to manage symptoms and improve their quality of life. However, little is known about the extent to which PA is currently delivered in hospice care in England. OBJECTIVES: To determine the extent of and intervention features of PA service provision in hospice care in England alongside barriers and facilitators to their delivery. METHODS: An embedded mixed-methods design using (1) a nationwide online survey of 70 adult hospices in England and (2) focus groups and individual interviews with health professionals from 18 hospices. Analysis of the data involved applying descriptive statistics to the numeric items and thematic analysis to the open-ended questions. Quantitative and qualitative data were collected and analyzed separately. RESULTS: The majority of responding hospices (n = 47/70, 67%) promoted PA in routine care. Sessions were most often delivered by a physiotherapist (n = 40/47, 85%) using a personalized approach (n = 41/47, 87%) and included resistance/thera bands, Tai Chi/Chi Qong, circuit exercises, and yoga. The following qualitative findings were revealed: (1) variation among hospices in their capacity to deliver PA, (2) a desire to embed a hospice culture of PA, and (3) a need for an organizational commitment to PA service provision. SIGNIFICANCE OF RESULTS: While many hospices in England deliver PA, there is considerable variation in its delivery across sites. Funding and policy action may be needed to support hospices to initiate or scale up services and address inequity in access to high-quality interventions.

Repercussions of overturning Roe v. Wade for women across systems and beyond borders.

June 24th, 2022, a day that will be etched in today and future generations' textbooks as a historic day, the United States of America revoked the constitutional right to seek safe abortion care. Overturning Roe v Wade allowed the divided individual states to independently decide the legal parameters regarding abortion care. A decision that disproportionately effects the reproductive lives of women residing on the land of America. Given the systemic impacts of racism, neoliberalism and white supremacy, it is the Black, racialized and poor women who suffer terrible repercussions. In this commentary the authors begin by discussing the historical biopolitical perspective, colonial systems and longstanding impacts on racialized women's bodies in America. The discussion transitions to the implications of geopolitics at play nationally and cascading impacts globally, focusing on humanitarian and emergency settings. Using a medical humanities perspective, authors highlight the collision between politics and reproductive health policy and its implications on social determinants of health, such as women's education, employment, housing, racial and gender equity and wellbeing. Long standing advocates, community leaders and healers, leading scientists, birth attendants, doctors, nurses, allied health professionals/providers and humanitarian workers - and many others - are reminded and live the weight of the continuous battle of population control, stemming from the oppressive history of control and exploitation.

The role, impact, and support of informal caregivers in the delivery of palliative care for patients with advanced cancer: A multi-country qualitative study.

BACKGROUND: Cancer is increasing in its prevalence in sub-Saharan Africa. Informal caregivers are key to supporting engagement and interaction with palliative care services, but limited literature on their role impedes development of supportive interventions. AIM: We aimed to understand the role, impact, and support of informal caregivers of patients with advanced cancer when interacting with palliative care services in Nigeria, Uganda, and Zimbabwe. DESIGN: Secondary analysis of qualitative interview transcripts. The dataset was assessed for fit and relevance and framework approach was used. SETTING/PARTICIPANTS: Interview transcripts of informal caregivers included participants aged over 18 years of age recruited from palliative care services across participating countries. RESULTS: A total of 48 transcripts were analyzed. Mean age was 37 (range 19-75) with equal numbers of men and women. Five themes emerged from the data: (1) caregivers are coordinators of emotional, practical, and health service matters; (2) caregiving comes at a personal social and financial cost; (3) practical and emotional support received and required; (4) experience of interacting and liaising with palliative care services; and (5) barriers and recommendations relating to the involvement of palliative care. CONCLUSIONS: The role of informal caregivers is multi-faceted, with participants reporting taking care of the majority of medical, physical, financial, and emotional needs of the care recipient, often in the face of sacrifices relating to employment, finances, and their own health and social life. Efforts to develop comprehensive cancer control plans in sub-Saharan Africa must take account of the increasing evidence of informal caregiver needs.

Socio-cultural and economic barriers, and facilitators influencing men's involvement in antenatal care including HIV testing: a qualitative study from urban Blantyre, Malawi.

BACKGROUND: Male partner involvement in antenatal care (ANC) is associated with positive maternal and neonatal outcomes. However, only a handful of men attend ANC with their partners. This study aimed to understand the underlying barriers and facilitators influencing men's ANC attendance including HIV testing in Blantyre, Malawi. METHODS: Data were collected during a formative qualitative study of a cluster-randomised trial. Six focus group discussions (FGDs) with 42 men and women and 20 in-depth interviews (IDIs) were conducted at three primary health centres in urban Blantyre, Malawi. FGD participants were purposively sampled with IDI participants subsequently sampled after FGD participation. Thematic analysis was used to analyse the data. RESULTS: The economic requirement to provide for their families exerted pressure on men and often negatively affected their decision to attend ANC together with their pregnant partners despite obvious benefits. Peer pressure and the fear to be seen by peers queueing for services at ANC, an environment traditionally viewed as a space for women and children made men feel treated as trespassers and with some level of hostility rendering them feeling emasculated when they attend ANC. Health system problems associated with overall organization of the ANC services, which favours women created resistance among men to be involved. An association between ANC and HIV testing services discouraged men from attending ANC because of their fear of testing HIV-positive in the presence of their partners. The availability of a male friendly clinic offering a private, quick, supportive/sensitive and flexible service was considered to be an important incentive that would facilitate men's ANC attendance. Men described compensation to cover transport and opportunity cost for attending the clinic as a motivator to attending ANC services and accepting an HIV test. CONCLUSION: Peer and economic influences were the most influential barriers of men attending ANC and testing for HIV with their pregnant partners. Addressing these socio-economic barriers and having a male friendly clinic are promising interventions to promote male ANC attendance in this setting.

Stakeholder perspectives and requirements to guide the development of digital technology for palliative cancer services: a multi-country, cross-sectional, qualitative study in Nigeria, Uganda and Zimbabwe.

INTRODUCTION: Coverage of palliative care in low and middle-income countries is very limited, and global projections suggest large increases in need. Novel approaches are needed to achieve the palliative care goals of Universal Health Coverage. This study aimed to identify stakeholders' data and information needs and the role of digital technologies to improve access to and delivery of palliative care for people with advanced cancer in Nigeria, Uganda and Zimbabwe. METHODS: We conducted a multi-country cross-sectional qualitative study in sub-Saharan Africa. In-depth qualitative stakeholder interviews were conducted with N = 195 participants across Nigeria, Uganda and Zimbabwe (advanced cancer patients n = 62, informal caregivers n = 48, health care professionals n = 59, policymakers n = 26). Verbatim transcripts were subjected to deductive and inductive framework analysis to identify stakeholders needs and their preferences for digital technology in supporting the capture, transfer and use of patient-level data to improve delivery of palliative care. RESULTS: Our coding framework identified four main themes: i) acceptability of digital technology; ii) current context of technology use; iii) current vision for digital technology to support health and palliative care, and; iv) digital technologies for the generation, reporting and receipt of data. Digital heath is an acceptable approach, stakeholders support the use of secure data systems, and patients welcome improved communication with providers. There are varying preferences for how and when digital technologies should be utilised as part of palliative cancer care provision, including for increasing timely patient access to trained palliative care providers and the triaging of contact from patients. CONCLUSION: We identified design and practical challenges to optimise potential for success in developing digital health approaches to improve access to and enhance the delivery of palliative cancer care in Nigeria, Uganda and Zimbabwe. Synthesis of findings identified 15 requirements to guide the development of digital health approaches that can support the attainment of global health palliative care policy goals.

Data and information needs of policymakers for palliative cancer care: a multi-country qualitative study.

BACKGROUND: Despite regional efforts to address concerns regarding the burden of advanced cancer in Africa, urgent attention is still required. Widespread issues include late symptom presentation, inaccessibility of palliative care services, limited resources, poor data quality, disparity in data availability, and lack of stakeholder engagement. One way of helping to address these issues is by understanding and meeting the data and information needs of policymakers in palliative cancer care. AIMS: To explore the views of policymakers regarding data availability, data gaps and preferred data formats to support policy and decision making for palliative cancer care in Nigeria, Uganda and Zimbabwe. METHODS: A secondary analysis of interview data collected as part of a cross-sectional qualitative study that aimed to explore the data and information needs of patients, policymakers and caregivers in Nigeria, Uganda and Zimbabwe. Framework analysis, guided by the MEASURE evaluation framework, was used to qualitatively analyse the data. RESULTS: Twenty-six policymakers were recruited. The policymakers data and information concerns are aligned to the MEASURE evaluation framework of data and information use and include; assessing and improving data use (e.g. low prioritisation of cancer); identifying and engaging the data user (e.g. data processes); improving data quality (e.g. manual data collection processes); improving data availability (e.g. the accessibility of data); identifying information needs (e.g. what is 'need to know'?); capacity building in core competencies (e.g. skills gaps); strengthening organisational data demand and use (e.g. policy frameworks); monitoring, evaluating and communicating of data demand and use (e.g. trustworthiness of data). CONCLUSIONS: We present evidence of data sources, challenges to their access and use, guidance on data needs for policymakers, and opportunities for better engagement between data producers, brokers and users. This framework of evidence should inform the development of strategies to improve data access and use for policy and decision making to improve palliative cancer services in participating countries with relevance to the wider region.

"If you are on duty, you may be afraid to come out to attend to a person": fear of crime and security challenges in maternal acute care in Nigeria from a realist perspective.

BACKGROUND: Maternal and Child Health is a global priority. Access and utilization of facility-based health services remain a challenge in low and middle-income countries. Evidence on barriers to providing and accessing services omits information on the role of security within facilities. This paper explores the role of security in the provision and use of maternal health services in primary healthcare facilities in Nigeria. METHODS: Study was carried out in Anambra state, Nigeria. Qualitative data were initially collected from 35 in-depth interviews and 24 focus groups with purposively identified key informants. Information gathered was used to build a programme theory that was tested with another round of interviews (17) and focus group (4) discussions. Data analysis and reporting were based on the Context-Mechanism-Outcome heuristic of Realist Evaluation methodology. RESULTS: The presence of a male security guard in the facility was the most important security factor that facilitated provision and uptake of services. Others include perimeter fencing, lighting and staff accommodation. Lack of these components constrained provision and use of services, by impacting on behaviour of staff and patients. Security concerns of facility staff who did not feel safe to let in people into unguarded facilities, mirrored those of pregnant women who did not utilize health facilities because of fear of not being let in and attended to by facility staff. CONCLUSION: Health facility security should be key consideration in programme planning, to avert staff and women's fear of crime which currently constrains provision and use of maternal healthcare at health facilities.

What makes advocacy work? Stakeholders' voices and insights from prioritisation of maternal and child health programme in Nigeria.

BACKGROUND: The Nigerian government introduced and implemented a health programme to improve maternal and child health (MCH) called Subsidy Reinvestment and Empowerment programme for MCH (SURE-P/MCH). It ran from 2012 and ended abruptly in 2015 and was followed by increased advocacy for sustaining the MCH (antenatal, delivery, postnatal and immunization) services as a policy priority. Advocacy is important in allowing social voice, facilitating prioritization, and bringing different forces/actors together. Therefore, the study set out to understand how advocacy works - through understanding what effective advocacy implementation processes comprise and what mechanisms are triggered by which contexts to produce the intended outcomes. METHODS: The study used a Realist Evaluation design through a mixed quantitative and qualitative methods case study approach. The programme theory (PT) was developed from three substantive social theories (power politics, media influence communication theory, and the three-streams theory of agenda-setting), data and programme design documentation, and subsequently tested. We report information from 22 key informant interviews including national and State policy and law makers, policy implementers, CSOs, Development partners, NGOs, health professional groups, and media practitioners and review of relevant documents on advocacy events post-SURE-P. RESULTS: Key advocacy organizations and individuals including health professional groups, the media, civil society organizations, powerful individuals, and policymakers were involved in advocacy activities. The nature of their engagement included organizing workshops, symposiums, town hall meetings, individual meetings, press conferences, demonstrations, and engagements with media. Effective advocacy mechanism involved alliance brokering to increase influence, the media supporting and engaging in advocacy, and the use of champions, influencers, and spouses (Leadership and Elite Gendered Power Dynamics). The key contextual influences which determined the effectiveness of advocacy measures for MCH included the political cycle, availability of evidence on the issue, networking with powerful and interested champions, and alliance building in advocacy. All these enhanced the entrenchment of MCH on the political and financial agenda at the State and Federal levels. CONCLUSIONS: Our result suggest that advocacy can be a useful tool to bring together different forces by allowing expression of voices and ensuring accountability of different actors including policymakers. In the context of poor health outcomes, interest from policymakers and politicians in MCH, combined with advocacy from key policy actors armed with evidence, can improve prioritization and sustained implementation of MCH services.

Using a mHealth tutorial application to change knowledge and attitude of frontline health workers to Ebola virus disease in Nigeria: a before-and-after study.

BACKGROUND: The Ebola epidemic exposed the weak state of health systems in West Africa and their devastating effect on frontline health workers and the health of populations. Fortunately, recent reviews of mobile technology demonstrate that mHealth innovations can help alleviate some health system constraints such as balancing multiple priorities, lack of appropriate tools to provide services and collect data, and limited access to training in health fields such as mother and child health, HIV/AIDS and sexual and reproductive health. However, there is little empirical evidence of mHealth improving health system functions during the Ebola epidemic in West Africa. METHODS: We conducted quantitative cross-sectional surveys in 14 health facilities in Ondo State, Nigeria, to assess the effect of using a tablet computer tutorial application for changing the knowledge and attitude of health workers regarding Ebola virus disease. RESULTS: Of 203 participants who completed pre- and post-intervention surveys, 185 people (or 91%) were female, 94 participants (or 46.3%) were community health officers, 26 people (13 %) were nurses/midwives, 8 people (or 4%) were laboratory scientists and 75 people (37%) belonged to a group called others. Regarding knowledge of Ebola: 178 participants (or 87.7%) had foreknowledge of Ebola before the study. Further analysis showed an 11% improvement in average knowledge levels between pre- and post-intervention scores with statistically significant differences (P < 0.05) recorded for questions concerning the transmission of the Ebola virus among humans, common symptoms of Ebola fever and whether Ebola fever was preventable. Additionally, there was reinforcement of positive attitudes of avoiding the following: contact with Ebola patients, eating bush meat and risky burial practices as indicated by increases between pre- and post-intervention scores from 83 to 92%, 57 to 64% and 67 to 79%, respectively. Moreover, more participants (from 95 to 97%) reported a willingness to practice frequent hand washing and disinfecting surfaces and equipment following the intervention, and more health workers were willing (from 94 to 97%) to use personal protective equipment to prevent the transmission of Ebola. CONCLUSIONS: The modest improvements in knowledge and reported attitudinal change toward Ebola virus disease suggests mHealth tutorial applications could hold promise for training health workers and building resilient health systems to respond to epidemics in West Africa.

Development of oral health policy in Nigeria: an analysis of the role of context, actors and policy process.

BACKGROUND: In Nigeria, there is a high burden of oral health diseases, poor coordination of health services and human resources for delivery of oral health services. Previous attempts to develop an Oral Health Policy (OHP) to decrease the oral disease burden failed. However, a policy was eventually developed in November 2012. This paper explores the role of contextual factors, actors and the policy process in the development of the OHP and possible reasons why the current approved OHP succeeded. METHODS: The study was undertaken across Nigeria; information gathered through document reviews and in-depth interviews with five groups of purposively selected respondents. Analysis of the policy development process was guided by the policy triangle framework, examining context, policy process and actors involved in the policy development. RESULTS: The foremost enabling factor was the yearning among policy actors for a policy, having had four failed attempts. Other factors were the presence of a democratically elected government, a framework for health sector reform instituted by the Federal Ministry of Health (FMOH). The approved OHP went through all stages required for policy development unlike the previous attempts. Three groups of actors played crucial roles in the process, namely academics/researchers, development partners and policy makers. They either had decision making powers or influenced policy through funding or technical ability to generate credible research evidence, all sharing a common interest in developing the OHP. Although evidence was used to inform the development of the policy, the complex interactions between the context and actors facilitated its approval. CONCLUSIONS: The OHP development succeeded through a complex inter-relationship of context, process and actors, clearly illustrating that none of these factors could have, in isolation, catalyzed the policy development. Availability of evidence is necessary but not sufficient for developing policies in this area. Wider socio-political contexts in which actors develop policy can facilitate and/or constrain actors' roles and interests as well as policy process. These must be taken into consideration at stages of policy development in order to produce policies that will strengthen the health system, especially in low and middle-income countries, where policy processes and influences can be often less than transparent.

A qualitative study on stigma experienced by young adults living with sickle cell disease in Accra, Ghana.

BACKGROUND: Sickle cell disease (SCD) describes a group of multisystem, genetic and stigmatising blood conditions that are prevalent in sub-Saharan Africa. Health-related stigma is a negative experience or adverse social judgement about a group based on an enduring feature conferred by a particular health problem. Literature shows that stigmatisation is experienced by people with SCD with negative implications on their lives. This study investigated self-reported views and lived experiences of young adults in Accra, Ghana, regarding SCD-related stigma and its impact on their lives. METHODS: Data were collected from 19 males and females with SCD using semi-structured individual interviews and focus group discussions. Transcripts were analysed using Braun and Clark's framework for thematic analysis. RESULTS: Five themes were identified: exclusion; status loss; SCD misconceptions; internalised stigma; and stigma and health outcomes. Overall, interpersonal and institutional levels of stigma were evident throughout the data with a lack of public education, limited specialist care and religion acting as determinants of SCD-related stigma. CONCLUSIONS: Stigma has detrimental consequences for young adults with SCD. Multilevel stigmatisation of SCD at interpersonal and institutional levels should be addressed through multipronged approaches including increased public education, investment in specialist healthcare and collaboration with socioreligious institutions. Further research is needed to investigate the experiences of young adults in rural Ghana.

Places Nigerians visited during COVID-19 government stay-home policy: evidence from secondary analysis of data collected during the lockdown.

Introduction: Compliance with the Government's lockdown policy is required to curtail community transmission of Covid-19 infection. The objective of this research was to identify places Nigerians visited during the lockdown to help prepare for a response towards future infectious diseases of public health importance similar to Covid-19. Methods: This was a secondary analysis of unconventional data collected using Google Forms and online social media platforms during the COVID-19 lockdown between April and June 2020 in Nigeria. Two datasets from: i) partnership for evidencebased response to COVID-19 (PERC) wave-1 and ii) College of Medicine, University of Lagos perception of and compliance with physical distancing survey (PCSH) were used. Data on places that people visited during the lockdown were extracted and compared with the sociodemographic characteristics of the respondents. Descriptive statistics were calculated for all independent variables and focused on frequencies and percentages. Chi-squared test was used to determine the significance between sociodemographic variables and places visited during the lockdown. Statistical significance was determined by P<0.05. All statistical analyses were carried out using SPSS version 22. Results: There were 1304 and 879 participants in the PERC wave-1 and PCSH datasets, respectively. The mean age of PERC wave-1 and PCSH survey respondents was 31.8 [standard deviation (SD)=8.5] and 33.1 (SD=8.3) years, respectively.In the PCSH survey, 55.9% and 44.1% of respondents lived in locations with partial and complete covid-19 lockdowns, respectively. Irrespective of the type of lockdown, the most common place visited during the lockdown was the market (shopping); reported by 73% of respondents in states with partial lockdown and by 68% of respondents in states with the complete lockdown. Visits to families and friends happened more in states with complete (16.1%) than in states with partial (8.4%) lockdowns. Conclusions: Markets (shopping) were the main places visited during the lockdown compared to visiting friends/family, places of worship, gyms, and workplaces. It is important in the future for the Government to plan how citizens can safely access markets and get other household items during lockdowns for better adherence to stay-at-home directives for future infectious disease epidemics.

Remote Symptom Monitoring to Enhance the Delivery of Palliative Cancer Care in Low-Resource Settings: Emerging Approaches from Africa.

This paper brings together researchers, clinicians, technology developers and digital innovators to outline current applications of remote symptom monitoring being developed for palliative cancer care delivery in Africa. We outline three remote symptom monitoring approaches from three countries, highlighting their models of delivery and intended outcomes, and draw on their experiences of implementation to guide further developments and evaluations of this approach for palliative cancer care in the region. Through highlighting these experiences and priority areas for future research, we hope to steer efforts to develop and optimise remote symptom monitoring for palliative cancer care in Africa.

Impact of sustained health policy and population-level interventions on reducing the prevalence of obesity in the Caribbean region: A qualitative study from The Bahamas.

Background: The 2020 Global Nutrition Report highlights that despite improvements in select nutrition indicators, progress is too slow to meet the 2025 Global Nutrition Targets. While the Latin America and the Caribbean (LAC) region has achieved the greatest global reduction in undernutrition (stunting, underweight, and wasting) in the past decade, it also has the highest prevalence of people with overweight worldwide. Since the early 2000s, the region has mounted increasingly comprehensive and multi-sectoral policy interventions to address nutritional health outcomes. The Bahamas is one such LAC country that has used consistent policy responses to address evolving nutritional challenges in its population. After addressing the initial problems of undernutrition in the 1970s and 80s, however, overconsumption of unhealthy foods has led to a rising prevalence of obesity which The Bahamas has grappled with since the early 2000s. Objective: This study develops a timeline of obesity-related health policy responses and explores the macrosocial factors and conditions which facilitated or constrained public health policy responses to obesity in The Bahamas over a 20-year period. Methods: This multi-method case study was conducted between 2019 and 2021. A document review of health policies was combined with secondary analysis of a range of other documents and semi-structured interviews with key actors (policymakers, health workers, scholars, and members of the public). Data sources for secondary data analysis included policy documents, national survey data on obesity, national and regional newspaper websites, and the Digital Library of the Caribbean database. An adapted framework approach was used for the analysis of semi-structured interviews. Results: Between 2000 and 2019, a series of national policies and community-level interventions were enacted to address the prevalence of obesity. Building on previous interventions, obtaining multi-sectoral collaboration, and community buy-in for policy action contributed to reducing obesity prevalence from 49.2 to 43.7% between 2012 and 2019. There are, however, constraining factors, such as political and multi-sectoral challenges and gaps in legislative mandates and financing. Conclusion: Sustained multilevel interventions are effective in addressing the prevalence of obesity. To maintain progress, there is a need to implement gender-specific responses while ensuring accessibility, availability, and affordability of nutritious food for all.

Sustainability of the Effects and Impacts of Using Digital Technology to Extend Maternal Health Services to Rural and Hard-to-Reach Populations: Experience From Southwest Nigeria.

BACKGROUND: Nigeria has one of the worst health and development profiles globally. A weak health system, poor infrastructure, and varied socio-cultural factors are cited as inhibitors to optimal health system performance and improved maternal and child health status. eHealth has become a major solution to closing these gaps in health care delivery in low- and middle-income countries (LMICs). This research reports the use of satellite communication (SatCom) technology and the existing 3G mobile network for providing video training (VTR) for health workers and improving the digitization of healthcare data. OBJECTIVE: To evaluate whether the expected project outcomes that were achieved at the end-line evaluation of 2019 were sustained 12 months after the project ended. METHODS: From March 2017 to March 2019, digital innovations including VTR and data digitization interventions were delivered in 62 healthcare facilities in Ondo State, southwest Nigeria, most of which lacked access to a 3G mobile network. Data collection for the evaluation combined documents' review with quantitative data extracted from health facility registers, and 24 of the most significant change stories to assess the longevity of the outcomes and impacts of digital innovation in the four domains of healthcare: use of eHealth technology for data management, utilization of health facilities by patients, the standard of care, and staff attitude. Stories of the most significant changes were audio-recorded, transcribed for analysis, and categorized by the above domains to identify the most significant changes 12 months after the project closedown. RESULTS: Findings showed that four project outcomes which were achieved at end-line evaluation were sustained 12 months after project closedown namely: staff motivation and satisfaction; increased staff confidence to perform healthcare roles; improved standard of healthcare delivery; and increased adoption of eHealth innovations beyond the health sector. Conversely, an outcome that was reversed following the discontinuation of SatCom from health facilities is the availability of accurate and reliable data for decision-making. CONCLUSION: Digital technology can have lasting impacts on health workers, patients, and the health system, through improving data management for decision-making, the standard of maternity service delivery, boosting attendance at health facilities, and utilization of services. Locally driven investment is essential for ensuring the long-term survival of eHealth projects to achieve sustainable development goals (SDGs) in LMICs.

Village health worker motivation for better performance in a maternal and child health programme in Nigeria: A realist evaluation.

BACKGROUND: Community health workers play an important role in linking communities with formal health service providers, thereby improving access to and utilization of health care. A novel cadre of community health workers known as village health workers (VHWs) were recruited to create demand for maternal health services in the Nigerian Subsidy Reinvestment Programme (SURE-P/MCH). In this study, we investigated the role of contextual factors and underlying mechanisms motivating VHWs. METHODS: We used realist evaluation to understand the impact of a multi-intervention maternal and child health programme on VHW motivation using Anambra State as a case study. Initial working theories and logic maps were developed through literature review and stakeholder engagement; programme theories were developed and tested using focus group discussions and in-depth interviews with various stakeholder groups. Interview transcripts were analysed through an integrated approach of Context, Mechanism and Outcomes (CMO) categorisation and connecting, and matching of patterns of CMO configurations. Motivation theories were used to explain factors that influence VHW motivation. Explanatory configurations are reported in line with RAMESES reporting standards. RESULTS: The performance of VHWs in the SURE-P maternal and child health programme was linked to four main mechanisms of motivation: feelings of confidence, sense of identity or feeling of acceptance, feeling of happiness and hopefulness/expectation of valued outcome. These mechanisms were triggered by interactions of programme-specific contexts and resources such as training and supervision of VHWs by skilled health workers, provision of first aid kits and uniforms, and payments of a monthly stipend. The monthly payment was considered to be the most important motivational factor by VHWs. VHWs used a combination of innovative approaches to create demand for maternity services among pregnant women, and their performance was influenced by health system factors such as organisational capacity and culture, and societal factors such as relationship with the community and community support. CONCLUSION: This paper highlights important contextual factors and mechanisms for VHW motivation that can be applied to other interventions that seek to strengthen community engagement and demand creation in primary health care. Future research on how to sustain VHW motivation is also required.

Role of trust in sustaining provision and uptake of maternal and child healthcare: Evidence from a national programme in Nigeria.

Despite increasing attention to implementation research in global health, evidence from low- and middle-income countries (LMICs) using realist evaluations, in understanding how complex health programmes work remains limited. This paper contributes to bridging this knowledge gap by reporting how, why and in what circumstances, the implementation and subsequent termination of a maternal and child health programme affected the trust of service users and healthcare providers in Nigeria. Key documents were reviewed, and initial programme theories of how context triggers mechanisms to produce intended and unintended outcomes were developed. These were tested, consolidated and refined through iterative cycles of data collection and analysis. Testing and validation of the trust theory utilized eight in-depth interviews with health workers, four focus group discussions with service users and a household survey of 713 pregnant women and analysed retroductively. The conceptual framework adopted Hurley's perspective on 'decision to trust' and Straten et al.'s framework on public trust and social capital theory. Incentives offered by the programme triggered confidence and satisfaction among service users, contributing to their trust in healthcare providers, increased service uptake, motivated healthcare providers to have a positive attitude to work, and facilitated their trust in the health system. Termination of the programme led to most service users' dissatisfaction, and distrust reflected in the reduction in utilization of MCH services, increased staff workloads leading to their decreased performance although residual trust remained. Understanding the role of trust in a programme's short and long-term outcomes can help policymakers and other key actors in the planning and implementation of sustainable and effective health programmes. We call for more theory-driven approaches such as realist evaluation to advance understanding of the implementation of health programmes in LMICs.