Decisional Conflict amongst Women Undergoing Caesarean Section in Health Facilities in Ibadan, Nigeria.

BACKGROUND: Despite the global trend of increasing caesarean section rates, aversion to this procedure is common among Nigerian women. This gives rise to conflict during counselling and consent taking for the procedure. OBJECTIVE: This study was done to assess decisional conflict in women undergoing caesarean section. METHODS: This was a prospective cross-sectional study among four hundred and seven booked women undergoing elective caesarean section at secondary and tertiary health facilities in Ibadan, Nigeria. A multi-stage sampling method was used in the selection of participants and informed consent was obtained. The survey instrument was an interviewer-administered questionnaire during the counselling session before the surgery. The decisional conflict scale (DCS), low literacy version was used to quantify decisional conflict. Data was entered into SPSS version 21. The statistical level of significance was set at less than 5%. RESULTS: Most (73.5%) participants booked late for antenatal care and had a tertiary level of education (67.6%). A majority, 316 (77.6%) were not accompanied to antenatal visits. The husband (58.7%) was the sole decision maker with respect to health issues. Eighty-six participants (21.1%) experienced significant decisional conflict. The mean decisional conflict score in those who experienced decisional conflict was 41.1 ± 14.6. Recruitment site (p<0.001), educational level (p=<0.001), and family fecundity (p=0.009) were predictive of having decisional conflict. CONCLUSION: One in five women undergoing caesarean section experience significant decisional conflict, so we recommend the application of the decisional conflict scale to improve counselling of patients having difficulties in giving informed consent.

CONTEXTE: Malgré la tendance mondiale à l'augmentation des taux de césarienne, l'aversion pour cette procédure est courante chez les femmes nigérianes. Cela donne lieu à des conflits lors du conseil et de l'obtention du consentement à l'intervention. OBJECTIF: Cette étude a été réalisée pour évaluer les conflits décisionnels chez les femmes qui subissent une césarienne. MÉTHODES: Il s'agit d'une étude transversale prospective portant sur quatre cent sept femmes inscrites pour une césarienne élective dans des établissements de santé secondaires et tertiaires d'Ibadan, au Nigeria. Une méthode d'échantillonnage à plusieurs niveaux a été utilisée pour sélectionner les participantes et le consentement éclairé a été obtenu. L'instrument d'enquête était un questionnaire administré par un enquêteur lors de la séance de conseil avant l'intervention chirurgicale. L'échelle de conflit décisionnel (DCS), version faible niveau d'alphabétisation, a été utilisée pour quantifier le conflit décisionnel. Les données ont été saisies dans SPSS version 21. Le niveau de signification statistique a été fixé à moins de 5 %. RÉSULTATS: La plupart (73,5 %) des participantes ont pris des rendez-vous tardifs pour des soins prénatals et avaient un niveau d'éducation tertiaire (67,6 %). La majorité, 316 (77,6%), n'étaient pas accompagnées lors des visites prénatales. Le mari (58,7%) était le seul à prendre des décisions en matière de santé. Quatre-vingt-six participantes (21,1 %) ont connu un conflit décisionnel important. Le score moyen de conflit décisionnel chez celles qui en ont fait l'expérience était de 41,1 ± 14,6. Le lieu de recrutement (p= 0,000), le niveau d'éducation (p=0,000) et la fécondité de la famille (p=0,009) étaient des facteurs prédictifs de conflit décisionnel. CONCLUSION: Une femme sur cinq subissant une césarienne est confrontée à un conflit décisionnel important. Nous recommandons donc l'application de l'échelle de conflit décisionnel pour améliorer le conseil aux patientes ayant des difficultés à donner leur consentement éclairé. Mots-clés: Conflit décisionnel, césarienne, établissement de santé, consentement éclairé, confessionnel.

KNOWLEDGE OF EMERGENCY CONTRACEPTION AND PREDICTORS OF ITS USE AMONG FEMALE UNDERGRADUATES IN TWO NIGERIAN UNIVERSITIES.

Background: Unintended pregnancies contribute to the high burden of unsafe abortion, maternal deaths and morbidities among undergraduates. Objective: To assess the determinants of good knowledge and evaluate the trends in the practice of Emergency Contraception (EC) among female undergraduates. Methods: This was a cross sectional study involving four hundred and twenty female undergraduates from two universities in Ibadan, Nigeria. Participants were recruited from their hostels and classrooms. Data collection was done using self-administered questionnaires and good knowledge was defined as three correct answers to five questions testing knowledge. The questionnaires also addressed their practices of EC. The data was stored on the computer, cleaned and analyzed using the Statistical Package for the Social Sciences (SPSS) version 22. Statistical significance was set at p <0.05. Results: Two hundred and fourteen (51.0%) participants were aware of EC and the common sources were friends (43.4%), media (42.9%) and pharmacies (42.0%). One hundred and sixty-four participants (39.1%) had good knowledge of EC. Participants in the age group 20-24 years, second year of study, those who were aware of EC and had ever used EC were associated with good knowledge. Less than half (48%) of the sexually active participants used EC in the past six months and Levonogestrel (51%) was the commonest EC used. Menstrual irregularity and abdominal pain were the major side effects of EC. Conclusion: The practice of EC is poor and with poor knowledge demonstrated among female undergraduates. There is therefore the need to improve information and access to EC in the university community.

Descriptive epidemiology of coronavirus disease 2019 in Nigeria, 27 February-6 June 2020.

The objective of this study was to describe the epidemiology of COVID-19 in Nigeria with a view of generating evidence to enhance planning and response strategies. A national surveillance dataset between 27 February and 6 June 2020 was retrospectively analysed, with confirmatory testing for COVID-19 done by real-time polymerase chain reaction (RT-PCR). The primary outcomes were cumulative incidence (CI) and case fatality (CF). A total of 40 926 persons (67% of total 60 839) had complete records of RT-PCR test across 35 states and the Federal Capital Territory, 12 289 (30.0%) of whom were confirmed COVID-19 cases. Of those confirmed cases, 3467 (28.2%) had complete records of clinical outcome (alive or dead), 342 (9.9%) of which died. The overall CI and CF were 5.6 per 100 000 population and 2.8%, respectively. The highest proportion of COVID-19 cases and deaths were recorded in persons aged 31-40 years (25.5%) and 61-70 years (26.6%), respectively; and males accounted for a higher proportion of confirmed cases (65.8%) and deaths (79.0%). Sixty-six per cent of confirmed COVID-19 cases were asymptomatic at diagnosis. In conclusion, this paper has provided an insight into the early epidemiology of COVID-19 in Nigeria, which could be useful for contextualising public health planning.

FACTORS ASSOCIATED WITH SEXUAL DYSFUNCTION AMONG FEMALE PATIENTS IN A NIGERIAN AMBULATORY PRIMARY CARE SETTING.

BACKGROUND: Sexual dysfunction is a common but under-reported problem of public health importance among female adults in Nigeria. Empirical evidence on sexual dysfunction among female Nigerians is scarce. OBJECTIVE: To determine the prevalence and risk factors associated with sexual dysfunction among female patients presenting at the General Outpatient Clinic (GOPC), University College Hospital (UCH), Ibadan, Nigeria. METHODOS: This was a cross-sectional study of 480 married female patients who presented consecutively at the GOPC, UCH, Ibadan, Nigeria. The 28-item Sexual Function Questionnaire (SFQ-28) was used to determine sexual dysfunction. Information on their sociodemographic characteristics, obstetric and gynecological history were obtained. Bivariate and multivariate analyses were carried out and alpha was set at 0.05. RESULTS: Point prevalence of sexual dysfunction was 80.0%. The most common sexual dysfunction was problems with sexual desire (99.4%), while the least common was problems with arousal cognition (5.8%). There was a significant association between the prevalence of sexual dysfunction and age, years of relationship, number of children alive, parity, level of education, age at coitarche and family dysfunction. Age (OR=0.893; 95% CI=0.821-0.972, p=0.008), parity (OR=3.093; 95% CI=1.174- 8.151, p=0.022), having family dysfunction (OR=2.096; 95% CI= 1.129-3.891, p=0.019) and having ≥10 years of formal education (OR=4.808; 95% CI= 2.604-8.928, p<0.0001) were found to be the predictors of sexual dysfunction. CONCLUSION: Sexual dysfunction among female married adults in our setting was high. We propose that modifiable factors such as socio-demographic and gynaecological variables should be evaluated during the consultation of female patients at first contact.

Breast self-examination practices in Nigerian women attending a tertiary outpatient clinic.

BACKGROUND: The morbidity and mortality caused by breast cancer can be decreased by early detection with breast self-examination (BSE). The objective of this study was to determine the prevalence and the factors determining the practice of BSE. MATERIALS AND METHODS: The study was conducted on 140 women aged above 18 years who presented consecutively in a General Outpatient's clinic in a tertiary hospital in Nigeria. This was the baseline study from an intervention study which looked at the effect of demonstration of BSE on improving Clinical Breast Examination (CBE) among two groups of respondents. Structured questionnaires were validated and administered by an interviewer and the data were analyzed using Statistical Package for Social Sciences (SPSS) version 12. RESULTS: The overall self-reported prevalence of BSE practice was 62.1% among the respondents. Older women (16, 76.2%), married women (63, 65.6%) and women with tertiary education (51, 68.9%) had the highest prevalence of BSE practice. Prevalence rate was highest for civil servant (25, 78.1%), P = 0.04. The practice of BSE was higher among women with a previous history of breast disease (15, 68.2%) and in respondents with a family history of breast disease (7, 63.6%), Only 11 (12.6%) performed BSE as per guidelines, which was once in a month. CONCLUSION: The prevalence of BSE was found to be high, especially in those with tertiary education and in those with a past personal or family history of breast disease. In resource-constrained countries, BSE is a screening tool that can be employed to help reduce the breast cancer burden because routine mammography screening is not yet feasible. Women need to be informed about the when and how to perform BSE.

Primary ovarian pregnancy mimicking abdominal pregnancy.

The objectives of this study were to emphasise that ectopic pregnancy (EP) can occasionally occur in rare sites such as the ovary, and to show that it may be difficult making the diagnosis clinically and radiologically. It also highlighted the benefit of early surgical intervention in reducing mortality and morbidity from this condition. The case was a 31-year-old nulliparous woman who presented with amenorrhoea of 20 weeks and a 2-month history of lower abdominal pain. Radiological studies suggested abdominal pregnancy coexisting with uterine fibroids for which she had an exploratory laparotomy, which revealed a primary right ovarian pregnancy necessitating the performance of right ovariectomy. Locating the sites of EP may still pose a diagnostic challenge. Despite the benefits and reliability of ultrasound scanning, there will still be situations where the definitive diagnosis can only be confirmed at surgery.

Cervical ectopic pregnancy managed with methotrexate and tranexamic acid: A case report.

BACKGROUND: Cervical pregnancy is a rare life-threatening form of ectopic pregnancy and when it occurs, it is challenging to decide the management options. Surgical intervention has been documented to be complicated by intractable haemorrhage and most often necessitating hysterectomy. We hereby report a case of cervical pregnancy managed conservatively with medical agents prior to surgical intervention. CASE PRESENTATION AND MANAGEMENT: A 29 year old primiparous woman with gestational diabetes mellitus who presented at 10 weeks gestation with 5 days history of brownish vaginal discharge and 2 days history of painless vaginal bleeding. On pelvic examination the cervix was disproportionately larger than the uterus with a closed internal os. Transvaginal and abdominal ultrasound scanning confirmed a live cervical pregnancy. She had intramuscular methotrexate and tranexamic acid followed by suction evacuation combined with balloon tamponade. Examination at 6 weeks post procedure revealed a normal cervix. CONCLUSION: Cervical pregnancy still occurs in this environment despite its rarity. Surgical intervention usually results in hysterectomy and adopting medical management as a first line treatment option offers the benefit of uterine preservation.

Livolin ameliorates elevations in alanine transaminase in HIV infected patients commencing highly active antiretroviral therapy.

BACKGROUND: HAART associated hepatoxicity is an important cause of poor adherence to therapy in HIV infected persons. An initial manifestation is elevation in the level ofAlanine Transaminase (ALT) in blood. We sought to evaluate the protective effects of Livolin, a phosphatidylcholine containing preparation, against elevations in this enzyme in persons just commencing HAART. METHODOLOGY: All consenting patients deemed eligible for HAART and who were sero-negative for Hepatitis B and C were recruited into the study. Subjects were divided into a test group which received a thrice daily dose of Livolin capsules for 3 months in addition to HAART and a control group that received only HAART. Blood samples were collected at baseline and after 3 months and analysed for ALT, Aspartate aminotransferase, alkaline phosphatase and creatinine. The specific HAART combination, age and gender were also noted. RESULTS: Seventy nine (79) persons comprised of 43 test and 36 control subjects completed the study. Sixty six percent (79%) of all subjects were on Nevirapine containing combinations. In total, 8.9% and 11.7% of our patients had elevations at baseline and after 3 months respectively. These were mostly grade I, with grade II toxicity being observed in 3.3% of patients after 3 months of HAART. There was no instance of severe toxicity. For individuals with an elevation in ALT values at baseline, the mean drop at 3 months was significantly more in the test group compared with the control group (34.67 iu/L vs. 14.90 iu/L, p=0.005). Among subjects with on Nevirapine, the mean increment in ALT in the control group was 7.73 iu/L compared with 1.73 iu/L for the test group. CONCLUSION: The findings in this study mirror findings in both animal experiments and human studies of a potential benefit of phosphatidylcholine preparations, like Livolin, in protecting against drug induced hepatotoxicity.

Acceptability of counselling and testing for HIV infection in women in labour at the University College Hospital, Ibadan, Nigeria.

BACKGROUND: Many patients are referred to labour ward as emergencies, and therefore do not benefit from the antenatal HIV counselling and testing and treatment offered to registered patients. OBJECTIVE: To assess the acceptability and suitability of offering HIV counselling and testing to women of unknown HIV status presenting in labour. METHODS: A cross-sectional study comprising counselling and obtaining consent for HIV testing among 104 unregistered patients who presented in labour over a 3-month period. Rapid and enzyme-linked immunosorbent assay screening was performed for 90 consenting respondents. Reactive results were confirmed by Western blot. Appropriate therapy was instituted. RESULTS: Acceptance rate for HIV testing was 86.5%, prevalence of HIV was 6.7%. Women of lower educational status were more likely to accept testing in labour (OR: 0.3; 95% CI: 0.1-0.7; p=0.01); age, parity, occupation and knowledge of HIV had no influence. Most women (66.3%) had satisfactory knowledge of HIV. No one admitted to feeling coerced to test in fear of being denied care. Most refusals for screening were to avoid needle pricks (28.6%). Compared to ELISA screening test, specificity of the rapid test was 100%, sensitivity 85.7%, positive predictive value 100% and negative predictive value 98.8%. Attitude to testing was maintained on post-partum re-evaluation. CONCLUSION: The prevalence of HIV amongst unregistered parturients showed the importance of offering point-of-care HIV testing and intervention, especially in an environment where antenatal clinic attendance is poor. Rapid testing appeared to be acceptable and feasible in labour to prevent the mother-to-child transmission of HIV.

Bell's palsy in pregnancy and the puerperium: a report of five cases.

The incidence of idiopathic facial nerve palsy is higher during pregnancy and the puerperium than in nonpregnant women of childbearing age. An important association also exists between Bell's palsy and hypertensive disorders of pregnancy. We describe three patients with idiopathic facial nerve palsy in pregnancy and two in the puerperium. Two of these were associated with hypertensive disorder of pregnancy. This case report illustrates the fact that Bell's palsy is common in pregnancy and in the peurperium and often associated with hypertensive disorders of pregnancy.

Clinical audit of knowledge and practice of epidural labour analgesia amongst obstetricians in south-west Nigeria.

Epidural analgesia (EA) is the most ideal method for pain relief during labour. We sought to highlight the current knowledge and practice of the obstetricians regarding epidural labour analgesia (ELA). An audit was conducted amongst obstetricians in two teaching hospitals in the south west of Nigeria. Most of our respondents received lectures about ELA but about half of them rated the lectures as inadequate. Though 37.8% and 53.3% of respondents are of the opinion that there is interference with labour and increased incidence of instrumentation following epidural analgesia in labour respectively, however 84.4% agreed that the technique is not associated with adverse neonatal or maternal outcome and 97.8% will prefer their patients having epidural labour analgesia. We are of the opinion that education regarding ELA, both during and after obstetric speciality training, be improved, and well-established interpersonal relationship between obstetricians and anaesthetists will be needed to achieve this.

Health risks of obesity.

Obesity is becoming of interest as a non-communicable disease. There is however a dearth of information on obesity in this environment, as literature in developing countries is limited. Review of health risks of obesity is useful in order to increase the pool of available information in Nigeria and to draw attention to obesity and its attendant health risks.

Pre-induction cervical ripening: transcervical foley catheter versus intravaginal misoprostol.

The object of this study was to compare the effectiveness of the intravaginal Misoprostol and transcervical Foley catheters as pre-induction cervical ripening agents, to estimate the proportion of patients achieving vaginal delivery and to compare the complications of labour and foetal outcome between the two groups. The study was a prospective, randomised study of pregnant women, with singleton pregnancies who presented for antenatal care and delivery at the University College Hospital (UCH), Ibadan, Nigeria. Ninety-nine patients were invited to participate and ninety-six (96) agreed. No patient withdrew from the study. The patients were assigned by means of computer-generated random numbers to receive transcervical Foley catheters (Size 16F, with 30 ml balloon capacity) or 50 microg intravaginal Misoprostol (Cytotec tablet, Searle & Co., Chicago). Fifty (50) patients received intravaginal Misoprostol and Forty-six (46) received Transcervical Foley catheters. The proportions of nulliparous, primiparous and multiparous patients were 52, 20 and 28% in the misoprostol group and 43.5, 26.1 and 30.4%, respectively, in the Foley catheter group. The time to achieve a favourable cervical status was significantly shorter in the Misoprostol group, with 98.0% of the subjects attaining Bishop score > or = 6 within 6-12 hours of insertion of the study agent, in contrast to 69.0% of the subjects in the Foley catheters group (P<0.001). Thirteen (26.6%) and three (6.5%) patients in the Misoprostol and Foley catheters groups, respectively, went into labour while undergoing cervical ripening and all had uneventful vaginal deliveries (P<0.05). The induction-delivery interval did not differ significantly between the groups. The incidence of caesarean delivery was 6.0% in the Misoprostol group compared with 2.2% in the Foley catheter group (P=0.62). Instrumental vaginal delivery rates were similar in both groups. Overall, the mode of delivery did not differ significantly between the groups. The number of neonates with 1-minute Apgar score <7 did not differ significantly in both groups and no neonate had 5-minute Apgar score <7. Meconium stained liquor was noticed in 5 (Misoprostol) vs 2 (Foley catheters) patients in labour. None of the neonates had any features suggestive of meconium aspiration. Labour complications were mainly precipitate labour {2 (Misoprostol) vs 1 (Foley catheters) } and 1 patient with transient tachysystole (> or =6 contractions in 10 minutes for two consecutive 10-minute periods) in the Misoprostol group. Hyperstimulation was not noticed in any of the patients in either arm of the study groups. Intravaginal Misoprostol is as effective a pre-induction cervical ripening agent as transcervical Foley catheters, with added advantages of shorter duration of cervical ripening, reduced oxytocin requirement for induction of labour and greater acceptability to patients. The incidence of caesarean sections, other labour complications and the foetal outcome were similar with both methods.

Controversies in community based education.

An attempt has been made to discuss in broad terms the subject of Community based Education. The approach adopted has been to critically examine five major controversial issues from opposing standpoints. Drawing from the literature and personal experience some light was shed on the worrying questions of each issue. Working conclusions upon which individuals can further ponder were reached. It is hoped that this presentation will refreshen the knowledge of some, answer many of the objective questions of a number of faculty staff (traditional and innovative) and stimulate the interest of those not yet exposed to Community Based Education.

Psychiatric morbidity in a pregnant population in Nigeria.

Psychiatric morbidity among 240 pregnant women attending an antenatal unit was assessed by a two-stage screening procedure, using the General Health Questionnaire (GHQ-30) and Present State Examination Schedule (PSE). The prevalence of psychiatric morbidity was found to be significantly associated with younger age (< 24 years), being primigravid, married for less than 1 year, having an unsupportive husband, and a previous history of induced abortion. It is suggested that more attention needs to be paid to the mental health of pregnant women in developing countries (where pregnancy rates and the risks associated with pregnancy/delivery are much higher than in the developed countries) at the primary, secondary, and tertiary levels of health care.

Psychiatric morbidity in a gynaecology clinic in Nigeria.

Psychological disorders among 233 women attending a gynaecology out-patient clinic was assessed by a two-stage screening procedure, using the GHQ-30 and the PSE. The prevalence of psychiatric disorders was found to be 35.2%. Psychiatric morbidity was significantly associated with a history of induced abortion, previous marriages, having no children, complaints of menstrual abnormalities, chronic pelvic pain and having unsupportive husbands. It is suggested that more attention needs to be paid to the psychological health of patients with gynaecological disorders (in line with the biopsychosocial model of health care). This will ensure an overall improvement in the quality of care.

PIP: Many studies in developed countries show a high frequency of psychological distress among women attending gynecology clinics. The aim of this study is to assess the prevalence of psychiatric morbidity among 239 women attending a gynecology clinic at Ilorin Maternity Hospital in Nigeria. The aim also was to test the validity of using the 30-item version of the General Health Questionnaire (GHQ-30) as a screening tool. Clinical diagnoses were recorded according to the International Classification of Diseases-Ninth Edition (ICD-9). Psychiatric morbidity was determined according to the method of Deshpande. Literate respondents used a self-administered GHQ-30 and illiterate respondents were interviewed with the GHQ-30. The psychiatric interview was conducted by a research psychiatrist. Patients were grouped into 1) patients with symptoms diagnoses according to ICD-9, 2) cases with subdiagnostic syndromes, and 3) patients without significant psychiatric symptoms. A basic demographic profile of patients is given. Obstetrics and gynecologic data reveal that 31.3% were nulliparous, 44.5% had between 1 and 4 children, and 24.5% had 5-8 children. 64.4% reported regular menses, 21.9% reported scanty menstrual flow, and 64.4% had a normal flow. 17/6% reported a history of induced abortion, and 43.4% reported previous spontaneous abortion. 23.6% had primary infertility and 28.3% had secondary infertility; infertility was the most common complaint. A score of 5 or higher on the GHQ-30 indicated a psychiatric case. 35/2% were found to suffer from definite psychiatric morbidity. An additional 6.4% had severe psychiatric symptoms. Of the psychiatric diagnoses, 34.1% were for neurotic depression, 24.4% for anxiety, 25.7% for adjustment reaction, 12.2% manic depressive psychosis (depressed type), 2.4% phobic state, and 1.2% schizophrenia. Psychiatric morbidity was found to be unrelated to age, marital status, religion, education, occupational group, or duration of marriage. Symptoms such as irregular menses, pelvic pain, ad having no children were factors significantly associated with psychiatric morbidity; this pattern is supported in the developed country literature. Policy should be directed to a preventive and biopsychosocial model of health care.

Medical education in the community: a Nigerian experience.

PIP: Central to the curriculum of the University of Ilorin's medical school is the Community-Based Education and Service (COBES) program. This program is consistent with the emphasis of the government health care system on primary health care services targeted at problems such as poor nutrition, parasitic disease, and infection, especially among mothers and children. The CORES program, instituted in 1978, places medical students in both urban and rural clinics to impart awareness of the unique problems in each setting. In their 1st COBES posting, students study the demographic structure of the community and make a "community diagnosis." They organize a health education day and a public health action (e.g. immunization). At the end of this posting, students present suggestions for action to village leaders. The 2nd posting is centered around the World Health Organization's theme for that year. Postings 3 and 4 emphasize the development of clinical skills in basic primary care. At all times, students are taught to understand the impact of the local culture on the interpretation and treatment of illness. The COBES experience has stimulated numerous related developments, including establishment of an African Chapter of the Network of Community Oriented Institutions for Health Sciences, proposals for reforms in medical education by the 1989 African Inter-Ministerial Conference, and the introduction of similar programs at Ogun State and Bayero Universities.^ieng

The application of operational research (OR) procedures to maternal mortality from puerperal sepsis in a rural community.

An operation research (OR) procedure on maternal mortality from puerperal sepsis was carried out in Irepodun Local Government Area of Kwara State of Nigeria. The study involved ten focus groups discussion (FGD) in two districts of the Local Government Area. The findings were analysed from three broad perspectives, that is, consumers' views, providers' views and community decision takers' views. In general, the analysis revealed that the community knowledge of puerperal sepsis is poor. In addition, limited access and prohibitive cost of orthodox health care services prevented the community from full utilization of the few available health care centres in the community. The study also revealed that there is urgent need to introduce three key interventions for an improved maternity care in the community. These interventions are community health education, health institutions development and community participation in provision of ancillary services such as transportation.