Comparative effectiveness of implementation strategies for Accelerating Cervical Cancer Elimination through the integration of Screen-and-treat Services (ACCESS study): protocol for a cluster randomized hybrid type III trial in Nigeria.

BACKGROUND: Despite the increased risk of cervical cancer (CC) among women living with HIV (WLHIV), CC screening and treatment (CCST) rates remain low in Africa. The integration of CCST services into established HIV programs in Africa can improve CC prevention and control. However, the paucity of evidence on effective implementation strategies (IS) has limited the success of integration in many countries. In this study, we seek to identify effective IS to enhance the integration of CCST services into existing HIV programs in Nigeria. METHODS: Our proposed study has formative and experimental activities across the four phases of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Through an implementation mapping conducted with stakeholders in the exploration phase, we identified a core package of IS (Core) and an enhanced package of IS (Core+) mostly selected from the Expert Recommendations for Implementing Change. In the preparation phase, we refined and tailored the Core and Core+ IS with the implementation resource teams for local appropriateness. In the implementation phase, we will conduct a cluster-randomized hybrid type III trial to assess the comparative effectiveness of Core versus Core+. HIV comprehensive treatment sites (k = 12) will be matched by region and randomized to Core or Core+ in the ratio of 1:1 stratified by region. In the sustainment phase, we will assess the sustainment of CCST at each site. The study outcomes will be assessed using RE-AIM: reach (screening rate), adoption (uptake of IS by study sites), IS fidelity (degree to which the IS occurred according to protocol), clinical intervention fidelity (delivery of CC screening, onsite treatment, and referral according to protocol), clinical effectiveness (posttreatment screen negative), and sustainment (continued integrated CCST service delivery). Additionally, we will descriptively explore potential mechanisms, including organizational readiness, implementation climate, CCST self-efficacy, and implementation intentions. DISCUSSION: The assessment of IS to increase CCST rates is consistent with the global plan of eliminating CC as a public health threat by 2030. Our study will identify a set of evidence-based IS for low-income settings to integrate evidence-based CCST interventions into routine HIV care in order to improve the health and life expectancy of WLHIV. TRIAL REGISTRATION: Prospectively registered on November 7, 2023, at ClinicalTrials.gov no. NCT06128304. https://classic. CLINICALTRIALS: gov/ct2/show/study/NCT06128304.

The outcome of complementary and alternative medicine use among pregnant women in South-East Nigeria: a multi-centre prospective study.

There is a global increasing trend of complementary and alternative medicine (CAM) use among pregnant women. This study aimed at determining the maternal and perinatal outcome of CAM use among the pregnant women in South-East Nigeria. This was a prospective study in which self-administered semi-structured questionnaires were used to collate information from the consenting pregnant women who use CAM and those who did not use CAM from the gestational age of 36 weeks at four hospitals in South-East Nigeria. Both groups were matched for age, parity and address. Every participant was followed up until delivery. Data were analysed using SPSS version 23 (SPSS Inc., Chicago, IL). This study's ethical clearance number was NHREC/05/01/2008B-FWA00002458-1RB00002323 and it was obtained at UNTH and on February 15 2019. CAM use in pregnancy was associated with low haemoglobin concentration, maternal complications, high caesarean section rate, low birth weight, low APGAR score, large placental weight and high hospital admission of babies when compared with non-CAM users (p value= <.05). In conclusion, CAM use in pregnancy was associated with poor maternal and perinatal health indices, hence the need to implement policies aimed at reversing them.Impact StatementWhat is already known on this subject? There is an increasing trend of CAM use among pregnant women in the world. Pregnancy is associated with certain conditions that predispose women to CAM use. The clinical indications for CAM use by the pregnant women are nausea and vomiting, labour pain, induction of labour, pedal oedema and waist pain.What the results of this study add? CAM use in pregnancy was associated with low haemoglobin concentration, maternal complications, high caesarean section rate, low birth weight, low APGAR score, large placental weight and high hospital admission of the babies when compared with non-CAM users.What the implications are of these findings for clinical practice and/or further research? CAM use in pregnancy was associated with poor maternal and perinatal health indices, hence the need to implement policies aimed at reversing them.

The impact of community health educators on uptake of cervical and breast cancer prevention services in Nigeria.

OBJECTIVE: To determine the impact of trained community health educators on the uptake of cervical and breast cancer screening, and HPV vaccination in rural communities in southeast Nigeria. METHODS: A prospective population-based intervention study, with a before-and-after design, involved four randomly selected communities in southeast Nigeria from February 2014 to February 2016. Before the intervention, baseline data were collected on the uptake of cervical and breast cancer prevention services. The intervention was house-to-house education on cervical cancer and breast cancer prevention. Postintervention outcome measures included the uptake of cervical and breast cancer screening, and HPV vaccination within 6 months of intervention. RESULTS: In total, 1327 women were enrolled. Before the intervention, 42 (3.2%) women had undergone cervical cancer screening; afterwards, 897 (67.6%) women had received screening (P<0.001). Clinical breast examination was performed for 59 (4.4%) women before and 897 (67.6%) after the intervention (P<0.001). Only 2 (0.9%) of 214 children eligible for HPV vaccination had received the vaccine before versus 71 (33.2%) after the intervention (P<0.001). CONCLUSION: The use of community health educators for house-to-house cervical and breast cancer prevention education was associated with significant increases in the uptake of cervical cancer screening, clinical breast examination, and HPV vaccination.

Effect of early amniotomy on the outcome of spontaneous labour: a randomized controlled trial of pregnant women in Enugu, South-east Nigeria.

BACKGROUND: Early amniotomy is common in obstetric practice but, its effectiveness has not been proven. OBJECTIVES: To determine the effects of early amniotomy on the duration of labour, and other maternal / neonatal outcomes of uncomplicated pregnancies in Enugu, South-east Nigeria. METHODS: A randomized controlled study of 214 consenting term pregnant women at the University of Nigeria Teaching Hospital Enugu, Nigeria. Intervention group received amniotomy early in active labour while the control group had their membranes conserved. RESULTS: Mean duration of labour for the amniotomy group (279.4 ± 53.7 minutes) was significantly lower than that of control group (354.4 ± 67.5 minutes), (t = -8.988, p <0.001). Three (3.8%) women in amniotomy group needed oxytocin augmentation as against 21 (19.6%) women in the control group RR = 0.14, (CI 95%: 0.04 - 0.46), NNT = 16. The two groups did not vary with respect to cesarean section rate, newborn Apgar scores, and need for new born special care unit admission. CONCLUSION: Early amniotomy when compared to fetal membrane conservation reduced the duration of labour and need for oxytocin augmentation among term singleton pregnant women in Enugu, Nigeria. Its routine use in well selected cases may reduce prolonged labour and its complications.

Cervical Cancer Screening among HIV-Positive Women in Nigeria: An Assessment of Use and Willingness to Pay in the Absence of Donor Support.

INTRODUCTION: The sustainability of donor-supported cervical cancer screening for HIV-positive women in underresourced setting is a concern. The authors aimed to determine the willingness of HIV-positive women for out-of-pocket payment for the cancer screening, if necessary. METHODS: Questionnaires were administered to 400 HIV-positive women at the Adult HIV clinic, University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria. RESULTS: In all 11 (2.8%) respondents were aware of Pap smear, but only 1 (9.1%) of them had used it. After cervical cancer screening counseling, 378 (94.5%) respondents were willing to pay for Pap smear, irrespective of the cost. This willingness showed no trend across marital or educational groups. Younger age of respondents was not associated with willingness to pay for Pap smear (odds ratio = 1.24; confidence interval 95%: 0.52, 2.94). CONCLUSION: Willingness to pay for Pap smear by HIV-positive women in Enugu, Nigeria, is high. This has implication for the program sustainability.

Malaria and anaemia in pregnancy: a cross-sectional study of pregnant women in rural communities of Southeastern Nigeria.

BACKGROUND: Several strategies are used in the care of pregnant women accessing antenatal care in primary health centres in Nigeria, with the aim of reducing the burden of malaria and anaemia. The objective of the study was to appraise the prevalence of malaria parasitaemia and anaemia in pregnant women attending antenatal clinics in rural communities of Southeastern Nigeria where malaria preventive strategies are in place. METHODS: We undertook a cross-sectional study of 300 pregnant women receiving antenatal care in randomly selected primary health centres in the Nkanu West local government area (LGA), Enugu state, Nigeria from August to September 2010. RESULTS: The prevalence of malaria parasitaemia was 92.0% (276/300) (mild in 86.7% [260/300] and moderate in 15.3% [16/300]). The prevalence of anaemia was 49.3% (148/300) (mild in 29.3% [88/300] and moderate in 20% [60/300]). There were no severe cases of malaria parasitaemia or anaemia. The educational status and occupation of participants were significantly associated with the occurrence of peripheral parasitaemia and anaemia respectively (p<0.05). CONCLUSION: The prevalence of malaria and anaemia is very high in the Nkanu West LGA of Enugu State, Nigeria. Efforts to reduce the prevalence of malaria parasitaemia and anaemia in pregnancy should be intensified in rural settings of Enugu state and Nigeria as a whole.

Women's perception of accuracy of ultrasound dating in late pregnancy: a challenge to prevention of prolonged pregnancy in a resource-poor Nigerian setting.

BACKGROUND: Expected date of delivery (EDD) is estimated from the last menstrual period (LMP) or ultrasound scan. Conflicts between these estimates especially on the part of the physician and his/her patient could pose a challenge to prevention of prolonged pregnancy. The objective of this study was to determine the perception and acceptability of menstrual dating (EDD derived from LMP) with regard to timing of labor induction for postdatism by pregnant women who have a late pregnancy (≥23 weeks' gestation) ultrasound scan. METHODS: This cross-sectional study included 443 consecutive pregnant women receiving antenatal care at two tertiary health institutions in Enugu, Nigeria, from January 1, 2013 to March 31, 2013. RESULTS: The mean age of the women was 27.9±2.41 (range 17-45) years. Most ultrasound scans (90.8%, 357/389) were carried out in late pregnancy, and 41.9% (167/389) were self-referred. The majority of the respondents (51.7%, 229/443) did not accept induction of labor for postdatism at a certain menstrual dating-derived gestational age of 40 weeks plus 10 days if the late pregnancy ultrasound scan dating was less. Predictors of this poor attitude to timing of induction of labor for postdatism included low educational level, low social class, and poor knowledge of the limitations of ultrasound scan dating in late pregnancy (P<0.05). CONCLUSION: The worrisome confidence in ultrasound scan dating is a challenge to the prevention of prolonged pregnancy and its complications in our environment. Antenatal health education should discourage self-referral for ultrasound scan dating and emphasize its limitations in late pregnancy as well as the perinatal effects of prolonged pregnancy.

Trends of tuberculosis prevalence and treatment outcome in an under-resourced setting: The case of Enugu state, South East Nigeria.

BACKGROUND: The burden of tuberculosis (TB) in Nigeria is high. Unfortunately, the data from the TB programme of the States' ministries of health are usually unpublished, which possibly contribute to the prevailing ignorance and poor attitude of Nigerians to the disease. This study determined the trends of TB burden and treatment outcome in Enugu state, Nigeria; and relate the State's disease burden to that of the Nation. MATERIALS AND METHODS: A descriptive study of secondary data from the TB control programme, Ministry of Health, Enugu state, the National annual report of 2008, and World Health Organisation (WHO) TB database for the 10-year period of 2000-2009. RESULTS: The number of female TB cases was higher than males within the 0-14 age group only. The annual number of all TB cases showed a rising trend from 914 cases in the year 2000 to 1684 in 2009; but the proportion of new sputum smear (ss+) pulmonary tuberculosis (PTB) cases declined (Trend X(2) = 7.37, P = 0.007). The average number of extra-pulmonary TB cases increased fourfold from 2000-2004 to 2005-2009 (36 versus 150 cases). The median treatment success rate was 82% (range: 78-85). For the period 2004-2008, 2.0% of all new ss + PBT cases reported in Nigeria, originated from Enugu state. The proportion of new ss + PTB reported in Enugu state was significantly higher than national value (59.6% versus 52.6%) [P < 0.001, OR = 1.33 (95% CI: 1.26, 1.40)]. CONCLUSION: The burden of TB in Enugu state of Nigeria had increased over the period reviewed. However, the State's contribution to the disease burden in Nigeria was low.

Leiomyomatosis peritonealis disseminata in a Nigerian woman.

Leiomyomatosis peritonealis disseminata (LPD) is a rare condition. A 48-year-old multiparous woman was referred because of an incidental ultrasound finding suggestive of LPD. She had a 6-year past history of use of combined oral contraceptive pills. LPD was also suspected at laparotomy and confirmed by histology. She had total abdominal hysterectomy, bilateral salpingo ophorectomy and infracolic omentectomy. Patient was being followed-up. LSD is a rare gynecological condition which can pose a diagnostic challenge. Removal of estrogen sources as was done for the patient is the mainstay of treatment. Patient follow-up is very important because of the risk of malignant transformation.

Tuberculosis: a review of current concepts and control programme in Nigeria.

BACKGROUND: The burden of tuberculosis in Nigeria is the highest in Africa. Therefore, improved knowledge of health workers on the current issues concerning the disease, including the National guideline, is important for effective disease control. METHODS: An in-depth search of relevant literature on the subject area. This includes texts and operational documents of the Nigerian national tuberculosis programme, as well as online searches using Pubmed, Africanjournal online (Ajol), and Google scholar. RESULTS: About one third of the world population is infected with tuberculous bacilli with up to 10% lifetime risk of developing the disease. Pulmonary tuberculosis (PTB) especially the reactivated latent infection is the major source of the infection in communities. In an effort to increase case detection, a single acid fast bacillus in at least one of two sputum smears is currently adequate to diagnose PTB. Furthermore, there is a global effort to eliminate the disease by the year 2050 and these efforts are coordinated in Nigeria by the National tuberculosis controlprogramme. CONCLUSION: Tuberculosis is an impediment to human development in developing countries, especially in this era of HIV pandemic. Continuing education of health professional on tuberculosis and its accessible treatment, will improve patients' education, proper management and appropriate referral.

Labor support: an overlooked maternal health need in Enugu, south-eastern Nigeria.

OBJECTIVES: The current call for continuous support by women for women during labor takes for granted that women prefer to be supported by other women rather than their husbands. This study aimed at identifying the experiences and preferences of parturients as regards support in labor. METHODS: Questionnaires were administered to 395 parturients at the University of Nigeria Teaching Hospital, Enugu, south-eastern Nigeria from January to August 2006. Data analysis was both descriptive and inferential at 95% confidence level. RESULTS: None of the respondents' husband, relations or friends was allowed into the labor room. Ninety-five (24.1%) parturients did not wish to be supported in labor by their husbands. Sixty-five (68.4%) of this group preferred to be supported in labor by medical/midwifery staff only, while the remaining 30 (31.6%) would have preferred a relation. Three hundred (75.9%) parturients, if permitted, would have preferred labor support by their husbands. The preference for labor support by husband was significantly associated with maternal educational status (p=0.003), parity groups (p=0.022), and age category (p=0.037). CONCLUSIONS: Labor support by a non-medical employee of health institutions is not practiced in Enugu, south-eastern Nigeria. Most women would prefer to be supported by their husbands during labor. There is a strong desire by mothers for a policy change as regards labor support by family and friends.

Adenomyosis and uterine rupture during labour in a primigravida: an unusual obstetric emergency in Nigeria.

The primigravid uterus is believed to be immune to rupture during labour. This may not be true for those who have had prior adenomyomectomy, hence this report. The patient was a 28-year-old nullipara who became pregnant 11 months after an adenomyomectomy. Twelve hours after vaginal delivery at term, she developed haemoperitoneum of unclear cause. Emergency laparotomy and subsequent histology showed a fundal complete uterine rupture through the adenomyomectomy site, which was repaired. It is concluded that adenomyomectomy predisposes a pregnant uterus to rupture during labour. Therefore, such women should be offered elective caesarean delivery at term.

Improved awareness of Pap smear may not affect its use in Nigeria: a case study of female medical practitioners in Enugu, southeastern Nigeria.

Improved awareness of Pap test by Nigerian women may not necessarily increase its use. This hypothesis was tested using female medical practitioners in Enugu state, Nigeria. They were expected to be advocates of disease screening and therefore should lead by example. All respondents were aware of the Pap smear but only 18% had used it. The mean frequency of Pap smear was 1.8+/-1.2 (range 1-5). Repeat Pap tests were observed only among respondents that had screened as routine. The majority (32%) of those who never screened for cervical cancer had no reason. There may be more to the use of Pap smear among women in Nigeria than its awareness.

An unmet cancer screening need of HIV-positive women in southeastern Nigeria.

CONTEXT: HIV infection and cervical cancer are common in Nigeria. HIV-positive women have a higher risk for cervical neoplasm; therefore, counseling and regular cervical cancer screening are recommended. After post-HIV testing counseling, HIV-positive women should be aware of the Papanicolaou (Pap) smear. OBJECTIVE: To determine the coverage of cervical cancer screening information for HIV-positive women by the post-HIV testing counseling. METHODS: Questionnaires were administered to 150 HIV-positive women and 150 HIV-negative controls after post-HIV testing counseling at the voluntary counseling and testing clinic of University of Nigeria Teaching Hospital, Enugu, Nigeria. Proportions of responses were compared by using a chi-square test at a 95% confidence level. RESULTS: Thirty-three (22.0%) HIV-positive women and 57 (38%) HIV-negative women were aware of cervical cancer. The awareness of the Pap smear among HIV-positive women (4.0%) was lower than that of HIV-negative women (21.3%) (P < .001). However, this finding became insignificant after adjustment for educational status groups (P > .05). No respondent agreed to being informed of Pap smears during post-HIV testing counseling. After counseling on cervical cancer, 96.0% of the HIV-positive group and 98.7% of the HIV-negative group expressed willingness to undergo routine Pap screening. CONCLUSIONS: Cervical cancer screening information is not part of post-HIV testing counseling for women in Enugu, southeastern Nigeria.

Acute uterine inversion in a rural African woman: a rare consequence of child birth.

A case study of Ms. TE a 38-year-old Para7(+0) with seven living children is presented. Ms. TE had no antenatal care and was rushed to hospital with features of acute incomplete uterine inversion, 90 min after a spontaneous vaginal birth at home. The birth was supported by the second wife of her husband who had no experience in birth attendance. Her third stage of labour was not managed actively. Successful repositioning of the uterus was achieved under anaesthesia in the hospital. Uninformed mismanagement of third stage of labour was probably the reason for the condition of Ms. TE. Though acute uterine inversion is rare, accessible primary health care services are necessary for safe motherhood and for supporting women to birth safely.

Uterine procidentia in an African adolescent: an uncommon gynecological challenge.

BACKGROUND: Uterovaginal prolapse in adolescents is rare, hence this report. CASE: Miss O.N. was a 17-year-old Para 1(+0) A1. She had a regular menstrual cycle. She presented with complaints of mass protruding from her vagina of twenty months duration. The problem started four months after a normal delivery at a maternity home. Her mother had a similar problem after her last delivery. A diagnosis of uterine procidentia was made. The patient and her care giver consented to use of ring pessary only. SUMMARY AND CONCLUSION: Uterovaginal prolapse can occur in a black adolescent with normal menstrual cycle and in the absence of obvious musculoskeletal or neurogenic defect. The etiology could be multifactoral. Ring pessary is an effective non-surgical treatment option in the young.

The prevalence of anemia among pregnant women at booking in Enugu, South Eastern Nigeria.

BACKGROUND: More than half of the pregnant women in the world have hemoglobin levels indicative of anemia. Knowledge of the current situation of the condition in our environment is necessary. This knowledge will motivate antenatal caregivers toward early detection and prompt management of anemia in pregnancy. AIMS: Our aim was to determine the prevalence of anemia among pregnant women at registration for antenatal care at a major tertiary healthcare center in Enugu, southeastern Nigeria. METHODS: This was a retrospective study of 530 normal pregnant women registered with the antenatal unit of the University of Nigeria Teaching Hospital (UNTH), Enugu, between January 1, 2005 and October 30, 2005. Data on the age, parity, gestational age at booking, interval between last confinement and last menstrual period in the index pregnancy, hemoglobin concentration at booking, and HIV status were obtained and analyzed. RESULTS: The mean gestational age at booking was 21.7 +/- 7.1 weeks (range, 6-37). Two hundred fourteen (40.4%) of the women were anemic (hemoglobin [Hb] < 11.0 g/dL). The majority (90.7%) of these anemic patients were mildly anemic, whereas 9.3% were moderately anemic. There was no case of severe anemia (Hb < 7.0 g/dL). The prevalence of anemia at booking was significantly higher in those who registered for antenatal care in the third trimester than in those who registered in the second trimester, and in HIV-positive pregnant women than in HIV-negative ones (P = .00). The patients' age, parity, and the interval between the last confinement and the index pregnancy had no significant relationship with the hemoglobin concentration of pregnant women at booking (P > .05). CONCLUSION: The prevalence of anemia in pregnancy at booking is still high in Enugu. Preconception care, including iron and folic acid supplementation, is advocated to reduce this problem. Early antenatal booking and improved antenatal care are also necessary for early diagnosis and treatment of the condition. All would ensure safe motherhood.