Leveraging Responsive Feedback to Redesign a Demand Generation Strategy: Experience From the IntegratE Project in Lagos State, Nigeria.

Use of modern contraceptives in Nigeria is low (12%) despite very high knowledge of modern methods (92%). Knowledge of modern methods of contraception in Lagos and Kaduna is high at nearly 100% and 94%, respectively, yet contraceptive use in Lagos and Kaduna remains low at 29% and 14%, respectively. Demand generation was a key strategy in increasing contraceptive uptake through the involvement of providers in the private sector (community pharmacists and patent and proprietary medicine vendors) in family planning service delivery.We describe how an interpersonal communication strategy was modified using a responsive feedback approach and detail the insights gained in implementing an individual compared with a group interpersonal communication strategy during the implementation of the IntegratE Project in Lagos State, Nigeria. We conducted monthly pause-and-reflect sessions for interpersonal communication agents to pause and reflect on lessons learned and address challenges. Using the responsive feedback approach helped to improve contraceptive uptake by adopting a group strategy. Also, the monthly pause-and-reflect sessions have helped interpersonal communication agents see program implementation as a collective responsibility.

Changes in clients' perceptions of family planning quality of care in Kaduna and Lagos States, Nigeria: A mixed methods study.

Community Pharmacists (CPs) and Patent and Proprietary Medicine Vendors (PPMVs) are crucial to improving access to family planning (FP) services in Nigeria. Although the private sector is preferred for convenience, availability of commodity, privacy, and timeliness, less well known is the quality of care received by clients who obtain FP services from CPs and PPMVs. This paper seeks to explore the use of validated quality of care measures for programming in Kaduna and Lagos States and to assess how these measures worked in capturing changes in quality of care using client exit interviews implemented at two time points. Using validated measures of quality of care, 598 and 236 exit interviews in rounds 1 and 2 were conducted with FP clients aged 18-49 years old. The quality of care domains were assessed using 22 questions. A weighted additive quality score was created, and scores were grouped into three: low, medium, and high quality. Changes in quality of care received were examined using χ 2 test. A subset of 53 clients were selected for in-depth interviews. Deductive and inductive approaches were used for coding, and data analysis was thematic. In Lagos, we observed increases in 16 out of 22 items while in Kaduna increases were only observed in 8 items. For instance, increases were observed in the proportion of women who experienced visual privacy between rounds 1 and 2 in Lagos (74%-89%) and Kaduna (66%-82%). The quality of care received by clients changed over time. Women who reported high quality care in Lagos increased from 42% to 63%, whereas women who reported high quality care in Kaduna decreased from 35% to 21%. In both states, in-depth interviews revealed that women felt they were treated respectfully, that their sessions with providers were visually private, that they could ask questions, and that they were asked about their preferred method. This study demonstrates that clients received high quality of care services from providers (CPs and PPMVs) especially in Lagos, and such services can be improved over time. Continuous support may be required to maintain and prevent reduction in quality of FP counseling and services, particularly in Kaduna.

Nigerian stakeholders' perceptions of a pilot tier accreditation system for Patent and Proprietary Medicine Vendors to expand access to family planning services.

BACKGROUND: Community Pharmacists (CPs) and Patent and Proprietary Medicine Vendors (PPMVs) are often the first point of care for many Nigerians, and when sufficiently trained, they contribute to the expansion of family planning services. Nigeria's task shifting policy and existing regulatory and licensing bodies provide the enabling environment for PPMVs to be stratified and trained. This study explored the perceptions of stakeholders toward the pilot three-tier accreditation system instituted by the Pharmacists Council of Nigeria with support from the IntegratE project. METHODS: Two rounds of qualitative phone interviews were conducted among stakeholders in Kaduna and Lagos states in 2020 and 2021. In addition, there were two rounds of phone interviews with CPs and PPMVs (program recipients) from Lagos and Kaduna states. All participants were purposively selected, based on their involvement in the IntegratE project activities. Interviews were recorded, transcribed, and coded using Atlas.ti software. Thematic analysis was conducted. RESULTS: Fifteen stakeholders and 28 program recipients and 12 stakeholders and 30 program recipients were interviewed during the first and second rounds of data collection respectively. The data are presented around three main themes: 1) the pilot three-tier accreditation system; 2) enabling environment; and 3) implementation challenges. The accreditation system that allows for the stratification and training of PPMVs to provide family planning services was perceived in a positive light by majority of participants. The integrated supportive supervision team that included representation from the licensing and regulatory body was seen as a strength. However, it was noted that the licensing process needs to be more effective. Implementation challenges that need to be addressed prior to scale up include bottlenecks in licensing procedures and the deep-rooted mistrust between CPs and PPMVs. CONCLUSION: Scale up of the three-tier accreditation system has the potential to expand access to family planning services in Nigeria. In other resource-poor settings where human resources for health are in short supply and where drug shops are ubiquitous, identifying drug shop owners, training them to offer a range of family planning services, and providing the enabling environment for them to function may help to improve access to family planning services.

The role of job aids in supporting task sharing family planning services to community pharmacists and patent proprietary medicine vendors in Kaduna and Lagos, Nigeria.

BACKGROUND: CPs and PPMVs are an important source of modern contraceptives in Nigeria, yet many lack the requisite knowledge and skills to capably provide these services. This skills gap might be addressed through targeted family planning (FP) training. This study measures family planning knowledge retention of CPs and PPMVs after receiving training in FP counseling and services in Kaduna and Lagos States, in Nigeria. METHODS: In a quasi-experimental longitudinal design without a comparison group, 559 CPs and PPMVs who were enrolled in the IntegratE project between January and December 2019, completed a self-administered questionnaire to assess their knowledge related to the provision of FP counseling, and injectable and implant contraceptive services at three points in time: 1) before the training; 2) immediately after the training; and 3) 9-months after the training in Kaduna and Lagos states, Nigeria. Adjusted multivariate logistic regression analysis was used to assess the effect of provider characteristics and receipt of job aids on FP knowledge retention 9 months after the training. 95% confidence intervals and p-values were used to assess statistical significance. RESULTS: Majority of study participants were females (60.3%) and between 30 and 49 years old (63.4%). The study revealed the importance of jobs aids as influence on knowledge retention. CPs and PPMVs who reported having the Balanced Counseling Strategy plus (BCS+) counseling cards, were more likely to retain knowledge (AOR: 2.92; 95% CI: 1.01-8.40, p-value = 0.05) at 9 months follow-up. Similarly, in terms of knowledge of injectable contraceptives, CPs and Tier 2 PPMVs who reported receiving the Medical Eligibility Criteria (MEC) Wheel were 2.1 times more likely to retain knowledge of injectable contraceptives 9-months later on (95% CI: 1.14-3.99, p-value = 0.02). CONCLUSION: Community Pharmacists and Proprietary Medicine Vendors had good retention of family planning knowledge, especially when combined with job aids. Training and providing them with job aids on FP will therefore support task shifting and task sharing on family planning services provision in Nigeria.

Strengthening and monitoring health system's capacity to improve availability, utilization and quality of emergency obstetric care in northern Nigeria.

BACKGROUND: Quality improvement in emergency obstetric care (EmOC) is a critical and cost-effective suite of interventions for the reduction of maternal and newborn mortality and morbidity. This study was undertaken to evaluate the impact of quality improvement interventions following a baseline assessment in Bauchi state, Nigeria. METHODS: This was a prospective before and after study between June 2012, and April 2015 in Bauchi State, Nigeria. The surveys included 21 hospitals designated by Ministry of Health (MoH) as comprehensive EmOC centers and 38 primary healthcare centers (PHCs) designated as basic EmOC centers. Data on EmOC services was collected using structured established EmOC tools developed by the Averting Maternal Death and Disability (AMDD), and analyzed using univariate and bivariate statistical analyses. RESULTS: Facilities providing seven or nine signal EmOC functions increased from 6 (10.2%) in 2012 to 21 (35.6%) in 2015. Basic EmOC facilities increased from 1 (2.6%) to 7 (18.4%) and comprehensive EmOC facilities rose from 3 (14.3%) to 13 (61.9%). Facility birth increased from 3.6% to 8.0%. Cesarean birth rates increased from 3.8% in 2012 to 5.6% in 2015. Met need for EmOC more than doubled from 3.3% in 2012 to 9.9% in 2015. Direct obstetric case fatality rates increased from 3.1% in 2012 to 4.0% in 2015. Major direct obstetric complications as a percent of total maternal deaths was 70.9%, down from 80.1% in 2012. CONCLUSION: The rise in the percent of facility-based births and in met need for EmOC suggest that interventions recommended and implemented after the baseline study resulted in increased availability, access and utilization of EmOC. Higher patient load, late arrival and better record keeping may explain the associated increase in case fatality rates.

Striving to Meet Healthy People 2020 Objectives: Trend Analysis of Maternal Smoking.

OBJECTIVES: We examined trends in prevalence rates of smoking and smoking cessation during pregnancy among women in the United States to assess achievement of Healthy People 2020 prevention targets. METHODS: We assessed the smoking habits of 30 667 mothers whose children were born between 1985 and 2014 and who were sampled by the National Health and Nutrition Examination Survey, 1999-2014. Sampled participants were children aged 0-15 at the time of interview; however, an adult proxy-usually the biological mother-responded on the child's behalf and reported information about maternal tobacco use during pregnancy. We calculated prevalence rates, adjusted odds ratios (aORs), and predicted annual increase or decrease of smoking and quitting smoking during pregnancy, adjusting for mother's age at delivery and income level and child's race/ethnicity and sex. RESULTS: The average annual prevalence of smoking at any time during pregnancy decreased from 25.7% (95% confidence interval [CI], 15.3%-36.0%) in 1985 to 10.1% (95% CI, 7.1%-13.0%) in 2014 ( P < .001), and quitting smoking at any time during the index pregnancy increased from 36.6% (95% CI, 20.3%-52.9%) in 1985 to 54.9% (95% CI, 44.4%-65.4%) in 2008 ( P = .002). The adjusted annual risk of smoking during pregnancy decreased significantly by 3% (aOR = 0.97; 95% CI, 0.95-0.98; P < .001). The prevalence rate of smoking in the year 2020 extrapolated from the current trend would be 6.1%. CONCLUSIONS: Smoking during pregnancy in the United States is declining. However, renewed public health measures are needed to achieve the Healthy People 2020 objectives of preventing smoking among pregnant women in the United States.

Trends in newborn umbilical cord care practices in Sokoto and Bauchi States of Nigeria: the where, who, how, what and the ubiquitous role of traditional birth attendants: a lot quality assurance sampling survey.

BACKGROUND: Neonatal infections caused by unsafe umbilical cord practices account for the majority of neonatal deaths in Nigeria. We examined the trends in umbilical cord care practices between 2012 and 2015 that coincided with the introduction of chlorhexidine digluconate 7.1% gel in Bauchi and Sokoto States. METHODS: We obtained data from three rounds of lot quality assurance samples (LQAS) surveys conducted in 2012, 2013 and 2015. Households were randomly sampled in each round that totaled 1140 and 1311 households in Bauchi and Sokoto States respectively. Mothers responded to questions on cord care practices in the last delivery. Coverage estimates of practice indicators were obtained for each survey period. Local Government Area (LGA) estimates for each indicator were obtained with α ≤ 5%, and ß ≤20% statistical errors and aggregated to State-level estimates with finite sample correction relative to the LGA population. RESULTS: Over 75 and 80% of deliveries in Bauchi and Sokoto States respectively took place at home. The proportion of deliveries in public facilities reported by mothers ranged from 19% in 2012 to 22.4% in 2015 in Bauchi State and from 12.9 to 13.2% in 2015 in Sokoto State. Approximately 50% of deliveries in Bauchi and more than 80% in Sokoto States were assisted by traditional birth attendants (TBAs) or relatives and friends, with little change in the survey periods. In Bauchi and in Sokoto States, over 75% and over 80% of newborn cords were cut with razor blades underscoring the pervasive role of the TBAs in the immediate postpartum period. Use of chlorhexidine digluconate 7.1% gel for cord dressing significantly increased to the highest level in 2015 in both States. Health workers who attended deliveries in health facilities switched from methylated spirit to chlorhexidine. There were no observable changes in cord care practices among the TBAs. CONCLUSION: Unsafe umbilical cord care practices remained prevalent in Bauchi and Sokoto States of Nigeria, although a recent introduction of chlorhexidine digluconate 7.1% gel positively changed the cord care practices toward safer practices among public health providers. TBAs, friends and relatives played the strongest immediate postpartum roles and mostly retained the unsafe cord care practices such as use of ash, cow dung and hot compress. We recommend that existing TBAs are retrained and refocused to forge stronger links between communities and the primary health centers to increase mothers' access to skilled birth attendants.

Availability, utilization, and quality of emergency obstetric care services in Bauchi State, Nigeria.

OBJECTIVE: To report the availability, utilization, and quality of emergency obstetric care (EmOC) services in Bauchi State, Nigeria. METHODS: Between June and July 2012, a cross-sectional survey of health facilities was conducted. Data on the performance of EmOC services between June 2011 and May 2012 were obtained from records of 20 general hospitals and 39 primary healthcare centers providing delivery services. Additionally, structured interviews with facility managers were conducted. RESULTS: Only 6 (10.2%) of the 59 facilities met the UN requirements for EmOC centers. None of the three senatorial zones in Bauchi State had the minimum acceptable number of five EmOC facilities per 500 000 population. Overall, 10 517 (4.4%) of the estimated 239 930 annual births took place in EmOC facilities. Cesarean delivery accounted for 3.6% (n=380) of the 10 517 births occurring in EmOC facilities and 0.2% of the 239 930 expected live births. Only 1416 (3.9%) of the expected 35 990 obstetric complications were managed in EmOC facilities. Overall, 45 (3.2%) of 1416 women with major direct obstetric complications treated at EmOC facilities died. Among 379 maternal deaths, 317 (83.6%) were attributable to major direct obstetric complications. CONCLUSION: Availability, utilization, and quality of EmOC services in Bauchi State, Nigeria, are suboptimal. The health system's capacity to manage emergency obstetric complications needs to be strengthened.

Attenuation of cyclophosphamide-induced neurotoxicity in rat by yellow dye extract from root of Brimstone tree (Morinda lucida).

Cyclophosphamide is an anticancer and immunosuppressant drug that induces reactive oxygen species (ROS) production, so causing malondialdehyde (MDA) production, which is toxic to cells. This study therefore sought to assess the antioxidant and the protective effect of dietary inclusion (0.5 and 1.0%) of yellow dye from root of Brimstone tree (used to enhance the sensory quality of foods and in folk medicine) on cyclophosphamide-induced oxidative stress in brain. Wistar strain albino rats were placed on diet containing 0.5 and 1.0% yellow dye preparation from root of Brimstone tree for 14 days. Intraperitoneal administration of cyclophosphamide (75 mg/kg of body weight) 24 h before the termination of the experiment caused a significant (P<0.05) increase in the brain malondialdehyde (MDA) content (147.2%) and serum activities of aspartate aminotransferase (AST) (21.7 UI/l), alanine amino-transferase (ALT) (29.6 UI/l), alkaline phosphatase (43.8 UI/l) and total bilirubin (1.7 mg/dl). However, there was a significant decrease (P<0.05) in the MDA of content of the brain and serum enzyme activities, in those rats fed diet containing the yellow dye in a dose dependent manner. The inhibition of oxidative stress in brain and serum enzymes and metabolites by the dye could be attributed to its high total phenol content and antioxidant activity as typified by its reducing power, free-radical scavenging ability, Fe(II) chelating ability and inhibition of lipid peroxidation. Therefore, dietary inclusion of the yellow dye from root of Brimstone tree could prevent cyclophosphamide-induced oxidative stress in brain and the associated toxicity to the liver.

Inhibition of cyclophosphamide-induced oxidative stress in rat brain by polar and non-polar extracts of Annatto (Bixa orellana) seeds.

Annatto (Bixa orellana) seeds are widely distributed throughout the Tropics and have been used to provide both colour and flavour to food. This study sought to assess the ability of dietary inclusion of polar (water) and non-polar (chloroform) extracts of Annatto (B. orellana) seeds on cyclophosphamide-induced oxidative stress in rat brain. The total phenol content and antioxidant activities of polar (water) and non-polar (chloroform) extracts of Annatto seeds were determined in vitro and in vivo. The results of the study showed that intraperitoneal administration of cyclophosphamide (75 mg/kg of body weight) caused a significant increase (P<0.05) in the malondialdehyde (MDA) content of the brain; however, dietary inclusion of Annatto seed extracts (0.1% and 0.2%) caused dose-dependent significant decrease (P<0.05) in the MDA content of the brain. Likewise, the extracts also caused dose-dependent inhibition of the elevated serum glutamate oxaloacetate transaminase (SGOT), glutamate pyruvate transaminase (SGPT), alkaline phosphatase and total bilirubin. However, the non-polar extract had significantly higher inhibitory effects on the elevated MDA production in brain and serum liver function markers. This higher protective effect of the non-polar extract could be attributed to its higher antioxidant properties as typified by its significantly higher (P<0.05) reducing power, free-radical scavenging and Fe (II) chelating ability. Therefore, dietary inclusion of Annato seed extracts as food colourant could prevent oxidative stress occasioned by cyclophosphamide administration, but the non-polar extract is a better protectant.

Inhibition of cyclophosphamide-induced oxidative stress in brain by dietary inclusion of red dye extracts from sorghum (Sorghum bicolor) stem.

The stem of sorghum is used as color additives in cooking meals and taken as beverages when steeped or boiled in water as folklore for the management of anemia and some other diseases. This study sought to assess the antioxidant and neuroprotective potentials of red dye extract from sorghum stem on cyclophosphamide-induced oxidative stress in rat brain. Wistar strain albino rats were fed diet supplemented with the red dye (0.5% and 1.0% inclusion) for 14 days. There was no significant difference (P > .05) in average feed intake and weight gain of rats fed the basal diet and the red dye-supplemented diet. However, intraperitoneal administration of cyclophosphamide (75 mg/kg of body weight) 24 hours prior the termination of the experiment caused a significant (P < .05) increase in the brain malondialdehyde (MDA) content and serum activities of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase in those rats fed diet without the dye supplement, whereas there was a significant decrease (P < .05) in brain MDA content and serum enzyme activities in rats fed diet with the dye in a concentration-dependent manner. The protective effect of the red dye against cyclophosphamide-induced oxidative stress could be attributed to the high phenolic content (56.2%) and antioxidant activities of the red dye as typified by 2,2-diphenyl-1-picrylhydrazyl free radical scavenging ability, reducing properties, and Fe(2+) chelating ability. Therefore, dietary inclusion of the red dye from sorghum stem could be harnessed in the management of neurodegenerative diseases associated with oxidative stress.