Barriers and enablers of post-COVID-19 acute care follow-up in Nigeria from service providers' perspective: a nominal group technique.

BACKGROUND: Despite modest efforts to study and document the complications that arise after acute treatment of patients with coronavirus disease, its ramifications and regional variations are yet to be clearly understood. Progress in sub-Saharan Africa, notably Nigeria, has been impeded by patient disengagement from care and insufficient or non-existent follow-up arrangements. The aim of this study was to describe the barriers and enablers for follow-up services after discharge from COVID-19 care pathway in Nigeria. METHODS: Seventeen experts involved directly in the care of patients with COVID-19 participated in brainstorming using the nominal group technique during a national workshop to review the new guidelines for COVID-19 case management in Nigeria. Participants discussed the barriers and facilitators of post-acute care follow-up of patients discharged from COVID-19 pathway and ranked their recommendations to arrive at three major factors per question. RESULTS: Participants were mostly middle aged and predominantly clinicians. The top three barriers were patients' perception of their symptom severity, lack of organizational clarity/structure/policies on follow-up care after discharge, and financial constraints. Similarly, participants identified providers' initiated education on the reasons for follow-up at discharge, written organizational policies/structure and clarity and free follow-up services as the top three facilitators. CONCLUSION: This study has enumerated barriers to follow-up care after discharge patients with coronavirus disease and highlighted providers, institutional and governmental responses that will facilitator follow-up care after discharge of patients with COVID-19. The implication is that, there is need for clear institutional guidelines for tracking and documenting post-COVID condition. In the future, it would be necessary to assess the achievements and shortcomings of post-COVID condition tracking in Nigeria through the use of implementation science outcomes.

In-hospital psychoeducation for family caregivers of Nigerian children with cancer (The RESCUE Study).

OBJECTIVES: High levels of caregiver burden (CB) are experienced by informal caregivers of pediatric patients with cancer. There is increasing evidence highlighting the extent of CB across sub-Saharan African countries, although there remains lack of interventions that target improvements in their experience. This study aimed to determine the impact of a structured psychoeducation program on caregivers' outcomes relating to preparedness to provide care, burden of caregiving, and quality of life (QoL). METHODS: This quasi-experimental (pre-and-posttest) design, involved family caregivers of children on admission for cancer treatment in 4 Nigerian tertiary hospitals. Eligible participants received 2 structured, psychoeducational training sessions delivered by a multidisciplinary oncology team, focusing on the management of patients' condition, spiritual care, self-care, and support. RESULTS: Subjects were mainly female (79.5%) and mostly mothers to children undergoing cancer treatment (74.7%). Commonest cancer type was acute lymphoblastic leukemia (23.9%) with evidence of metastatic disease found in 9.6% of children. Significant improvements were observed between pre- and posttest for unmet needs (z = -9.3; p < 0.001), preparedness for caregiving in palliative care (PCPC) (z = -7.0; p < 0.001), and overall QoL (z = -7.3; p < 0.001). A significant reduction in CB was also reported (z = -8.7; p < 0.001). SIGNIFICANCE OF RESULTS: This psychoeducational intervention (PEI) resulted in significant improvements in unmet needs, CB and significant improvements in PCPC. However, a reduction in QoL of the family caregivers was also observed. Findings from this study should encourage the use of well-crafted PEIs, delivered within hospital settings to promote improvements in outcomes for informal caregivers of hospitalized children suffering from cancer, in an African context. Further intervention development is required to better understand intervention components influencing changes in outcomes, while exploring feasibility testing and adaptation to similar settings in Nigeria and within Africa.

Use of coercion in mental healthcare services in Nigeria: Service providers' perspective.

BACKGROUND: There is increasing advocacy to reduce coercive practices in mental healthcare. Little research has been done on the topic in developing countries. AIMS: To explore what mental health professionals in Nigeria think about coercion, why it is used, and what contextual factors influence its use in mental healthcare services. METHODS: Semi-structured interviews were carried out with 16 doctors and 14 nurses from two psychiatric hospitals in two regions of Nigeria. The audio-recorded interviews were analyzed thematically with the aid of MAXQDA software. RESULTS: Three broad categories relating to the perception of, reasons for, and barriers/facilitators to the use of coercion were derived. Coercion was viewed as being for the best interests of patients, a means to an end, and effective for achieving desired outcomes. Safety was both a reason to use a coercive measure and a deterrent to using specific coercive measures thought to be unsafe. The socio-cultural context, obsolete mental health legislation, staff shortages, and attitudes were factors influencing the use of coercion in mental healthcare. CONCLUSION: Coercion was perceived to be ultimately beneficial in mental health practice. There is need for a new mental health legislation and more resources for mental health care in Nigeria to address the problem of coercion.

Neurological soft signs in first episode psychosis among psychiatric hospital patients and its relationship with dimensions of psychopathology: A comparative study.

Background: Neurological soft signs (NSS), as subtle, nonlocalising neurological abnormalities, are considered as the potential markers of psychosis. However, comparative studies of antipsychotic-naïve patients with first-episode psychosis (FEP) and first degree relatives (FDRs) are uncommon. We compared the prevalence and pattern of NSS in FEPs, their healthy FDRs and a healthy non-relatives' control group (HC), highlighted the relationship between NSS and psychopathology and proposed cut-off scores for prevalence studies. Materials and Methods: Two hundred and two participants per group were recruited. The FEPs were consecutive attendees; FDRs were accompanying caregivers; while the HC were from hospital staff. The Brief Psychiatric Rating Scale and the Neurological Evaluation Scale were used to assess psychopathology dimensions and NSS, respectively. Results: Using an item score of two ('substantial impairment'), the prevalence of at least one NSS was: 91.5% (95% confidence interval [CI]: 86.7%-94.9%), 16.8% (95% CI: 11.8%-22.7%) and 6.5% (95% CI: 3.5%-10.9%), respectively, for FEP, FDRs and HC. FEPs were impaired in a broad range of signs. The noteworthy relationships were as follows: (i) a significant correlation between the negative symptoms' dimension versus number of NSS (r = 0.4), and NSS total score (r = 0.3), (ii) the anxiety/depression dimension correlated negatively with number of NSS (r = -0.3) and (iii) NSS cut across psychosis categories. We propose a cut-off score of ≥ 4 for the number of signs signifying probable impairment. Conclusion: The findings indicate that, subject to further studies, NSS could be regarded as a broader phenotype of neurologic dysfunction associated with psychosis proness.

A qualitative integrative analysis of service users' and service providers' perspectives on ways to reduce coercion in mental health care.

PURPOSE: The movement to develop and implement non-coercive alternatives in the provision of mental health care is gaining momentum globally. To strengthen the basis of potential interventions that will be contextually relevant, and to complement the body of literature which is largely from high-income settings, the current study sought to explore the suggestions of service users and providers in Nigeria on how to reduce the use of coercive measures in mental health settings. METHODS: Semi-structured interviews with 30 mental health professionals and four focus group discussions among 30 service users from two psychiatric hospitals in Nigeria were conducted. The data were analyzed thematically with the aid of MAXQDA. RESULTS: The suggestions proposed by service users and mental health professionals were within the broad themes of communication, policies and legislation, and increased resources. Service users felt that improved communication, home consultations, non-legal advocates and clear rules and legislation would reduce the use of coercion, while service providers suggested increased public mental health literacy, better interpersonal relationships with patients, increased resources for mental health care, more research on the topic and regulation of coercive measures. CONCLUSION: Many of the suggestions from this study reinforce strategies already in place to decrease coercion in other settings. However, additional recommendations that are relevant to the study setting, such as enhancing public mental health literacy, mental health legislation reform and increasing access to mental health services, deserve further consideration.

Experiences and perceptions of coercive practices in mental health care among service users in Nigeria: a qualitative study.

BACKGROUND: People with mental health problems are more vulnerable to a broad range of coercive practices and human rights abuses. There is a global campaign to eliminate, or at the very least decrease, the use of coercion in mental health care. The use of coercion in psychiatric hospitals in developing countries is poorly documented. The primary aim of this study was to explore service users' perceptions and experiences of coercion in psychiatric hospitals in Nigeria. METHODS: Four focus group discussions were carried out among 30 service users on admission in two major psychiatric hospitals in Nigeria. The audio recordings were transcribed verbatim and then analyzed thematically with the aid of MAXQDA software. RESULTS: The Focus group participants included 19 males and 11 females with a mean age of 34.67 ± 9.54. Schizophrenia was the most common diagnosis (40%, n = 12) and had a secondary school education (60%, n = 18). The focus group participants perceived coercion to be a necessary evil in severe cases but anti-therapeutic to their own recovery, an extension of stigma and a vicious cycle of abuse. The experience of involuntary admission revolved mainly around deception, maltreatment, and disdain. Participants in both study sites narrated experiences of being flogged for refusing medication. Mechanical restraint with chains was a common experience for reasons including refusing medications, to prevent absconding and in other cases, punitively. The use of chains was viewed by participants as dehumanizing and excruciatingly painful. CONCLUSION: The experiences of coercion by participants in this study confirm that human rights violations occur in large psychiatric hospitals and underscore the need for mental health services reform. The use of coercion in this context reflects agelong underinvestment in the mental health care system in the country and obsolete mental health legislation that does not protect the rights of people with mental health problems. The study findings highlight an urgent need to address issues of human rights violations in psychiatric hospitals in the country.

Nigeria's mental health and substance abuse bill 2019: Analysis of its compliance with the United Nations convention on the rights of persons with disabilities.

Countries are struggling with reconciling their national mental health legislation with the CRPD approach, which stresses equality as the focal point of legislation, policies, and practices that affect people with disabilities. Several failed attempts have been made over the last two decades to update Nigeria's obsolete mental health legislation. The most recent attempt is the Mental Health and Substance abuse Bill 2019, which aims to protect the rights of people with mental health needs. It addresses many areas neglected by previous bills, such as non-discrimination of people with mental and substance use problems in the exercise of their civil, political, economic, social, full employment, religious, educational, and cultural rights. It categorically prohibits the use of seclusion in the treatment of people with mental health problems, makes provision for service users to be members of the Mental health review tribunal and allows for the protection of privacy and confidentiality of information about people with mental health problems. While keeping to most of WHO's recommendations for mental health legislation, the bill diverges from the CRPD's recommendations by allowing forced admission and treatment based on mental capacity, substitute decision-making by legal representatives or closest relatives, and non-prohibition of coercive practices. The bill does not make provisions for advance directives and is silent on informed consent to participate in research. Despite the bill's deficiencies, it would be a significant step forward for the country, whose current mental health legislation is the Lunacy Act of 1958. Although the CRPD has left it unclear how countries, especially low resource countries, should go about creating a workable legal framework, it is clear that all countries are expected to join the current global effort to eliminate, or at least reduce to the barest minimum, the use of coercion in mental health care. We expect that future revisions of this bill will examine its limitations in light of Nigeria's socio-cultural context.

Aftermath of COVID-19: Forestalling Irreparable Medical Brain Drain in Sub-Saharan Africa.

With the escalation of the novel coronavirus disease (COVID-19) across the globe, shortages in the already scarce medical workforce are imminent. Historically, more developed economies have looked abroad to augment their health systems. This paper aims to offer plausible solutions on how to avert future medical brain drain from sub-Saharan Africa (SSA) in the aftermath of COVID-19. We opine that emigration of medical workers from low-resource settings to more industrialized regions should be viewed by the destination countries as both a moral and an ethical issue. Countries in SSA must generally provide good leadership, diversify their economies, and ensure adequate security. Specifically, there are needs to improve health care workers' remuneration, provide more opportunities for specialization, and reduce waiting time for employment. It is our opinion that such multisectoral and multi-modal approaches will effectively halt and even reverse the on-going brain drain in the region, converting it to brain gain.

Association of family history of schizophrenia and history of obstetric complications at birth: relationship with age at onset and psychopathology dimensions in a Nigerian cohort.

BACKGROUND: The nature of the association between obstetric complications (OCs) at birth and the genetic aetiology of schizophrenia remains unclear, as some authors suggest that it is an independent risk factor while others support either interactionism or an epiphenomenon perspective. OBJECTIVE: To examine the association of family history of schizophrenia (FHS) with history of OCs, with a view to assessing whether this relationship moderates clinical phenotypes such as symptom dimensions and age at onset of illness. METHODS: This study examined OCs among schizophrenia probands using the Obstetric Complications Scale. An inquiry into family history was performed using the Family history method. Psychopathological symptom dimensions were assessed using standard scales. Data were analyzed to examine the interaction of FHS and history of OCs with age at onset and symptom dimensions, using ANCOVA. RESULTS: FHS was significantly associated with the disorganized symptoms dimension (p=0.03). History of OCs was significantly associated with earlier age at onset (p=0.007). However, in ANCOVA, the effect of the interaction between FHS and history of OCs was not significant for age at onset and symptom dimensions (P = 0.059). CONCLUSION: FHS was significantly associated with disorganization syndrome, and OCs was significantly associated with age at onset.

Correlates of fasting blood glucose among children living with hiv in a Nigerian tertiary hospital: a cross-sectional study.

BACKGROUND: There is growing concern as regards the emergence of metabolic disorders among children living with the Human Immunodeficiency Virus (HIV) worldwide. However, there is paucity of data on the correlates of metabolic indices among HIV-positive children in Africa. METHODS: This study examined 84 HIV-positive children on HAART recruited from the paediatric infectious diseases clinic of the University of Nigeria Teaching Hospital for blood glucose levels using finger-prick testing with an Accu-check glucose meter and test strips. Clinical information was obtained via clinical history and medical records. Data was analyzed to examine the relationship between FBG and the classes of HAART, duration of illness and treatment using analysis of variance (ANOVA). RESULTS: FBG was significantly associated with the classes of HAART (x2=12.4, p = 0.017). In addition, there was a significant association between FBG and duration of illness [F(2, 81) = 6.0; P = 0.004], as well as FBG and duration on HAART [F(2, 81) = 7.9; P = 0.001]. However, duration on HAART and type of HAART were the significant predictors of FBG in this study accounting for 10.5% and 4.1% of the variance, respectively. CONCLUSIONS: There is a greater risk of dysglycemia in paediatric patients with a longer cumulative exposure to HAART. Routine blood glucose checks among children on HAART, especially those who have received HAART for a longer duration of time may therefore be useful in their management.

Impact of neoadjuvant chemotherapy in improving operative intervention in the management of cervical cancer in low resource setting: a preliminary report.

There is paucity of data on interventions to improve cancer outcome in the low-resource setting. This study aims to determine the effect of Neoadjuvant Chemotherapy (NACT) in improving operative outcomes of cervical cancer. This was a longitudinal intervention study of patients diagnosed with FIGO stage IIB - IIIA cervical cancer that had NACT. Patients were re-evaluated after treatment with 4 cycles of chemotherapy for operability. McNemar test was used to determine changes in operability of the tumour. There was a significant difference in the number of patients that converted from inoperable to operable tumor post-chemotherapy. This study shows some promise for NACT for FIGO stage IIB - IIIA cancer of the cervix, especially in low-resource settings, where radiotherapy is scarce.

Academic performance and intelligence quotient of primary school children in Enugu.

INTRODUCTION: intellectual capacity measured as intelligence quotient (IQ) is one of the determinants of school performance of children. It influences academic achievement, future personal health, social well-being and therefore, is of public health significance. The objective of the study was to determine the intelligence quotient (IQ) and academic performance of primary school children in Enugu-East LGA. METHODS: children who met the inclusion criteria were recruited from both public and private primary schools in the Local Government Area (LGA) using a proportionate multistage sampling technique. Academic performance was classified into high, average and low academic using past records of class assessment. Intelligence quotient was assessed using the Raven´s Standard Progressive Matrices (RSPM) and was grouped into optimal and suboptimal. A semi-structured questionnaire was used to obtain data such as-age, gender, socio-economic indices and family size of the study participants. Analysis was done with Statistical Package for Social Sciences (IBM-SPSS). RESULTS: a total of 1,122 pupils aged 6 to 12 years were recruited. Optimal IQ and high academic performance were found in 54.0% and 58.8% of the study participants. Being from upper social class, in private school, and family size less than 4 were the significant determinants of high IQ and good academic performance (p<0.001). CONCLUSION: low socio-economic status, large family size and public school attendance impact negatively on IQ and academic performance. Hence, measures to curb large family sizes (i.e.>4 children) and improve the socio-economic status of families are needed environmental measures to improve intelligence and academic performance.

The need for psychosocial support amid COVID-19 crises in Nigeria.

With the closure of all public places, the stay-at-home order and the worsening economic indices occasioned by the fall in the price of crude oil with no foreseeable end, learned helplessness, negative emotions, and other psychosocial problems are bound to thrive. Interventions to improve social capital, coping resources, resilience, and good community and family cohesion are needed to promote psychosocial well-being during and after the COVID-19 pandemic in Nigeria. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Naturalistic clinical and psychosocial outcome of incident cases of schizophrenia in Enugu Federal Psychiatric Hospital: A preliminary report at 4-month follow-up.

INTRODUCTION: Longitudinal outcome studies based on incident and predominantly neuroleptic-naïve cases of schizophrenia are uncommon in the modern literature. AIMS: To determine the proportion of persons with schizophrenia with different levels of clinical and functional outcome at monthly intervals of naturalistic treatment follow-up for 4 months: response, remission and recovery; and to examine the predictors of outcome. SUBJECTS AND METHODS: Consecutive incident cases that fulfilled stringent criteria for schizophrenia were recruited into the study. After a baseline assessment, 160 incident cases of schizophrenia were followed up 4-weekly for indicators of symptomatic and functional outcome for 16 weeks. Standard rating scales were used to assess clinical and functional outcome. Sociodemographic and clinical variables were evaluated as predictors of outcome using multiple regression analysis. RESULTS: The attrition rate at week 16 was 29.4%; hence, 113 subjects (out of 160) were available for assessment at the end of follow-up. Of the 113, 66.4%, by Brief Psychiatric Rating Scale (BPRS), met criteria for response (i.e., >50% reduction), while 20.3% could be judged to be clinically non-responsive to treatment (i.e., <20% decrease). Also, 60.2%, by BPRS, met the criteria for remission, while 44.5% met the criteria for recovery. The most important predictor, at week 16, of clinical and psychosocial outcome was social support (48.7%-51.8% of variance). CONCLUSION: Although as a preliminary report, the present findings are hypothesis-generating, the implication of the results is that, as a group, over a 4-month period of modern hospital treatment, schizophrenia patients who were incident cases progressively experienced significant reduction in psychopathology. The findings, therefore, support earlier international cross-cultural reports of relatively good clinical outcome from developing countries, thereby encouraging the idea of treatment optimism in schizophrenia in Africa.

Socio-demographic characteristics as correlates of psychological distress.

Purpose The purpose of this paper is to assess the level of psychological distress of offenders newly brought into prison custody in a Nigerian prison and investigate the relationship with socio-demographic and penal characteristics. Design/methodology/approach A cross-sectional study involving 236 new prison entrants who were assessed for psychological distress using the 12-item General Health Questionnaire (GHQ-12) and the Hospital Anxiety and Depression Scale (HADS). Findings A total of 267 prison inmates were newly brought to prison custody over a three-month period. Out of this, 236 (88.4 per cent) of them participated in the study. Majority of the inmates were males 225 (95.3 per cent), awaiting-trial inmates 208 (88.1 per cent), single 144 (61 per cent), Christian 224 (94.9 per cent), first time offenders 218 (92.4 per cent) and charged with violent offences 136 (57.6 per cent). Majority of the inmates scored above cut-off points on the GHQ-12 and the HADS. In total, 157 (66.5 per cent) on HADS anxiety subscale, 201 (85.2 per cent) on HADS depression subscale and 199 (84.3 per cent) on GHQ-12. Significant relationship was observed between GHQ-12 "caseness", prison category and type of offence. Prison situation and type of offence were significantly associated with HADS depression subscale, whereas age was associated with HADS anxiety subscale. Research limitations/implications Some limitations were encountered in the course of the study. First, the study relied on self-report questionnaires for collection of data. Second, information given by the respondents could neither be corroborated by family members, who were not present during the interview, nor by the officers and men of the Nigeria Prisons Service, who knew little or nothing about the respondents. Participants in this study had spent maximum of three days in prison during the interview, thus certain levels of distress within three days after incarceration may not entail "caseness" in the sense of the presence of a psychiatric disorder. Therefore assessment over a longer period is needed. Practical implications Screening prison inmates on reception into prison custody provides a vista of opportunity to identify mental health problems and socio-demographic and forensic correlates of psychological distress among new entrants into prison custody. This will facilitate early identification and management of prison inmates with health needs. Health screening on reception will also help in identifying the various penal or forensic characteristics of prison inmates, which will be put into consideration during selection of appropriate rehabilitation and reformation activities that best fit a particular prison inmate. Early screening of prison inmates upon reception in the prison will also help in identifying prison inmates who have high risk of suicide and self-harm, thus preventing cases of death that may arise as a result of these mental health problems. Findings from this study will also enrich the body of knowledge on mental health problems of prison inmates entering the prison; this will also help the criminal justice system in decision making, especially with emphasis on psychological evaluation of prison inmates before dispensing judgment. On the part of the prison authority, the prison inmates identified to have psychological distress and some forensic characteristics can be properly classified, and kept in cells that will not aggravate their distress. Finally, this is the first study of prison inmates on reception into Enugu Maximum Security Prison, Enugu State Nigeria. The implication of this is that findings from this research will form a baseline on which further research on prison inmates upon reception in the prison can be conducted. Originality/value This study demonstrated that prison inmates are faced with high level of psychological distress during their early days in prison, and that some socio-demographic and forensic variables had significant association with psychological distress as itemised in Tables III and IV . Therefore, screening new inmates on prison reception will help in early identification and treatment of vulnerable groups. This will also help in proper classification and allocation into appropriate cells of prison inmates by the prison authority.

Familial aggregation of mood disorders among relatives of schizophrenia probands admitted in a hospital in South-Eastern Nigeria: A family comparative study.

INTRODUCTION: The debate on the current nosological status of schizophrenia and mood disorders as distinct entities is very active among scholars. There is a paucity of genetic epidemiological data to contribute an African perspective to this debate. AIM: This study aimed to assess the morbid risk of mood disorders in the relatives of schizophrenia probands, in comparison with the families of a sample of healthy controls. SUBJECTS AND METHODS: This study elicited the information on the morbid risk of mood disorders among 5259 relatives of schizophrenia probands (n = 138) and 6734 relatives of healthy controls (n = 138) through direct interview of patients, available relatives of patients and the comparison group. The family history approach using the Family Interview for Genetic Studies was utilised to obtain information on the morbid risk of all relatives that could be recalled. The diagnosis of available relatives was confirmed using the Diagnostic Interview for Genetic Studies. Morbid risk estimates were calculated using the Weinberg shorter method for age correction. RESULTS: Morbid risk for mood disorders in the first-, second- and third-degree relatives of schizophrenia probands were 1.39% (95% confidence interval [CI] = 1.23-1.55), 0.86% (95% CI = 0.80-0.92) and 0.55% (95% CI = 0.53-0.57), respectively, compared with 0.45% (95% CI = 0.39-0.51), 0.11% (95% CI = 0.07-0.51) and 0.08% (95% CI = 0.06-0.09), respectively, for the healthy comparison group. CONCLUSION: This result supports the impression that familial risk for mood disorders is significantly higher among relatives of schizophrenia patients, compared with healthy controls and that there could be familial relationship between the predisposition to schizophrenia and mood disorders.