What Are the Contextual Enablers and Impacts of Using Digital Technology to Extend Maternal and Child Health Services to Rural Areas? Findings of a Qualitative Study From Nigeria

Background: Strengthening health systems to improve access to maternity services remains challenging for Nigeria due partly to weak and irregular in-service training and deficient data management. This paper reports the implementation of digital health tools for video training (VTR) of health workers and digitization of health data at scale, supported by satellite communications (SatCom) technology and existing 3G mobile networks. Objective: To understand whether, and under what circumstances using digital interventions to extend maternal, newborn and child health (MNCH) services to remote areas of Nigeria improved standards of healthcare delivery. Methods: From March 2017 to March 2019, VTR and data digitization interventions were delivered in 126 facilities across three states of Nigeria. Data collection combined documents review with 294 semi-structured interviews of stakeholders across four phases (baseline, midline, endline, and 12-months post-project closedown) to assess acceptability and impacts of digital interventions. Data was analyzed using a framework approach, drawing on a modified Technology Acceptance Model to identify factors that shaped technology adoption and use. Results: Analysis of documents and interview transcripts revealed that a supportive policy environment, and track record of private-public partnerships facilitated adoption of technology. The determinants of technology acceptance among health workers included ease of use, perceived usefulness, and prior familiarity with technology. Perceptions of impact suggested that at the micro (individual) level, repeated engagement with clinical videos increased staff knowledge, motivation and confidence to perform healthcare roles. At meso (organizational) level, better-trained staff felt supported and empowered to provide respectful healthcare and improved management of obstetric complications, triggering increased use of MNCH services. The macro level saw greater use of reliable and accurate data for policymaking. Conclusions: Simultaneous and sustained implementation of VTR and data digitization at scale enabled through SatCom and 3G mobile networks are feasible approaches for supporting improvements in staff confidence and motivation and reported MNCH practices. By identifying mechanisms of impact of digital interventions on micro, meso, and macro levels of the health system, the study extends the evidence base for effectiveness of digital health and theoretical underpinnings to guide further technology use for improving MNCH services in low resource settings. Trial Registration: ISRCTN32105372

Impact of using eHealth tools to extend health services to rural areas of Nigeria: protocol for a mixed-method, non-randomised cluster trial

Introduction: eHealth solutions that use internet and related technologies to deliver and enhance health services and information are emerging as novel approaches to support healthcare delivery in sub-Saharan Africa. Using digital technology in this way can support cost-effectiveness of care delivery and extend the reach of services to remote locations. Despite the burgeoning literature on eHealth approaches, little is known about the effectiveness of eHealth tools for improving the quality and efficiency of health systems functions or client outcomes in resource-limited countries. eHealth tools including satellite communications are currently being implemented at scale, to extend health services to rural areas of Nigeria, in Ondo and Kano States and the Federal Capital Territory. This paper shares the protocol for a 2-year project (‘EXTEND’) that aims to evaluate the impact of eHealth tools on health system functions and health outcomes. Methodology and analysis: This multisite, mixed-method evaluation includes a non-randomised, cluster trial design. The study comprises three phases—baseline, midline and endline evaluations—that involve: (1) process evaluation of video training and digitisation of health data interventions; (2) evaluation of contextual influences on the implementation of interventions; and (3) impact evaluation of results of the project. A convergent mixed-method model will be adopted to allow integration of quantitative and qualitative findings to achieve study objectives. Multiple quantitative and qualitative datasets will be repeatedly analysed and triangulated to facilitate better understanding of impact of eHealth tools on health worker knowledge, quality and efficiency of health systems and client outcomes. Ethics and dissemination: Ethics approvals were obtained from the University of Leeds and three States’ Ministries of Health in Nigeria. All data collected for this study will be anonymised and reports will not contain information that could identify respondents. Study findings will be presented to Ministries of Health at scientific conferences and published in peer-reviewed journals. Trial registration number: ISRCTN32105372; Pre-results

A Linguistic (Discourse) Analysis of AROKO as Mon-verbal Communication among the Yoruba

Using the linguistic (discourse) analysis, this study finds that aroko- an aspect of nonverbal communication that “speaks the loudest”- is fast losing its steam among the new generation of the Yoruba of South West Nigeria. Culture bestrides every facet of a people’s life, their social, religious, intellectual, artistic, linguistic and philosophical manifestations. Cultural determinists have argued that culture is the basic determinant of a man’s social behavior. This paper examines the use of aroko (non-verbal communication) among the Yoruba. The inference from the study is that aroko forms a veritable part of the linguistic behavior amongst the Yoruba, especially when compared with other nationalities across the globe. It finds that aroko is widely used in all nooks and crannies of Yoruba land. However, it is discovered that the use of aroko is fast losing its steam among the new generation of the people in focus. A case is therefore made for the rejuvenation of such cultural traits for the advancement of Yoruba cultural values

An institutional survey of female genital mutilation in Lagos, South-West, Nigeria

Background: Female genital mutilation (FGM) as a procedure can have serious physical and psychological health consequences in girls and women.Objectives: To determine the prevalence of FGM and the socio-demographic factors which influence the practice among women in Lagos State.Methods: This was a cross-sectional descriptive study carried out at the Lagos University Teaching Hospital (LUTH) with eligible participants recruited by  consecutive sampling method. Relevant data were collected using a structured questionnaire and physical inspection of the external genitalia was performed on each respondent to confirm the presence and type of FGM. All quantitative data were entered in the computer and analysed using SPSS version 17 for windows.  Descriptive statistics were computed for all relevant data.Results: The prevalence of FGM in the study was 56.3% with the largest proportion of the respondents with FGM being women aged 60years and above. The Yoruba ethnic group had the lowest prevalence of FGM (44.2%), while the highest  prevalence was found among the Ibos (93.1%) (p=0.025). An almost similar  proportion of Christians (53.3%) and Muslims respondents (62.4%) had physical evidence of FGM (p=0.074). Higher levels of maternal education was significantly related to reduction in practice of FGM (p=0.002).Conclusion: There is an urgent need for a better analysis and understanding of the socio-demographic mechanisms sustaining the practice of FGM in Nigeria.Keywords: Complications, education, external genitalia, Ibo, prevalence, socio-demographic factor

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

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

A Review of Fetomaternal Outcome of Preterm Prelabour Rupture of Membranes in a Tertiary Hospital in Lagos, South-west, Nigeria

Preterm prelabour rupture of membranes(PPROM) is an important obstetric complication. It accounts for a third of all preterm deliveries with associated increased risks of fetomaternal and neonatal morbidity and mortality. To review the fetomatermal outcome of PPROM in a tertiary hospital in Lagos, South-west, Nigeria. This is a descriptive retrospective designin which cases of PPROM were identified from the Labour ward records and their case notes retrieved. Relevant information were extracted from those case notes and the neonatal unit records. Data was analyzed using Epi-info statistical software package. The rate of PPROM in this study was 2.2%. The mean age of the women was 31.3 ± 2.4years with the unbooked women constituting 50.2% of the cases and women with parity of 2 or less accounting/or 83.3% of them. The mean gestational age at delivery was 32. 7 ±2.4weeks. Caesarean section was the mode of delivery in 49.3% of cases, 8.1 % of the women had clinical evidence of choriamnionitis, 4.9% had puerperal sepsis while 1 maternal death was recorded. Ninety four percent (94%) of the births were livebirths while 6% were stillbirths. Low birth weight was noted in 79.1% and birth asphyxia was observed in 7.4%. Neonatal Unit admission was necessary in 72.5% of the livebirths. Perinatal mortality in this study was 17%. PPROM is an important cause of adverse fetomaternal outcome with increased perinatal and maternal morbidity and mortality. Adequate antenatal care should be advocated so that appropriate risk assessment can be done and intervention provided where applicable. Neonatal units should also be equiped to be able to render necessary care for these preterm neonates thereby reducing the morbidity and mortality asscociated with PPROM.Keywords: PPROM, preterm deliveries, fetomaternal outcom

Effects of selenium supplementation on pregnancy outcomes and disease progression in HIV-infected pregnant women in Lagos: A randomized controlled trial

Objective To examine the effects of selenium supplementation on pregnancy outcomes and disease progression among HIV-infected pregnant women in Lagos. Methods A randomized, placebo-controlled trial conducted among HIV-positive pregnant women between September 2018 and August 2019. At enrollment, 90 women were randomly assigned into each treatment arm to receive either a daily tablet of 200 μg elemental selenium or a placebo. Relevant participants' sociodemographic and clinical data were collected at enrollment and delivery. Results Women in the selenium arm had a significantly lower risk of preterm delivery (relative risk [RR] 0.32, 95% confidence interval [CI] 0.11–0.96) and a non-significant reduction in the risk of delivering term neonates with a low delivery weight (RR 0.24, 95% CI 0.05–1.19). Supplemental selenium does not increase the risk of perinatal death and adverse drug events. Conclusion The study reported a beneficial effect of prenatal selenium supplements on the risk of preterm delivery with no further reduction in risk among HIV-infected women who used the supplements for more than 14 weeks. Trial registration Pan African Clinical Trial Registry (PACTR201809756724274)

Rationale and Design of the Diet, CKD, and Apolipoprotein L1 Study in Low-Income and Middle-Income Countries

IntroductionDiet, chronic kidney disease (CKD), and Apolipoprotein L1 (APOL1) (DCA) Study is examining the role of dietary factors in CKD progression and APOL1 nephropathy. We describe enrollment and retention efforts and highlight facilitators and barriers to enrollment and operational challenges, as well as accommodations made in the study protocol.MethodsThe DCA study is enrolling participants in 7 centers in West Africa. Participants who consented were invited to complete dietary recalls and 24-hour urine collections in year 1. We conducted focus groups and semistructured interviews among study personnel to identify facilitators and barriers to enrollment as well as retention and operational challenges in the execution of the study protocol. We analyzed emerging themes using content analyses.ResultsA total of 712 participants were enrolled in 18 months with 1256 24-hour urine and 1260 dietary recalls. Barriers to enrollment were the following: (i) a lack of understanding of research, (ii) the burden of research visits, and (iii) incorporating cultural and traditional nuances when designing research protocols. Factors facilitating enrollment were the following: (i) designing convenient research visits, (ii) building rapport and increased communication between the research team and participants, and (iii) cultural sensitivity - adapting research protocols for the populations involved. Offering home visits, providing free dietary counseling, reducing the volume of study blood collection, and reducing the frequency of visits were some changes made in the study protocol that increased participant satisfaction.ConclusionAdopting a participant-centered approach with accommodations in the protocol for cultural adaptability and incorporating participant feedback is vital for carrying out research in low-income and middle-income regions