Department of Population, Family and Reproductive Health
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Item Improving Health Outcomes By Strengthening Public Sector Capacity In Social And Behaviour Change Programming In Nigeria: A Qualitative Study.(BMJ Group, 2025-01-02) Ankomah, A.ABSTRACT Objective This paper examines the outcomes of the public sector capacity strengthening (PSCS) approach and how they contribute to the promotion of maternal, newborn, and child health, and nutrition (MNCH+N), family planning (FP) and malaria prevention-related outcomes. Design The qualitative study implemented from July to August of 2022 used the outcome harvesting methodology and key informant interviews to elicit information including most significant change (MSC) stories to evaluate project outcomes over 5 years (2017–2022). Setting The study was conducted in Sokoto, Kebbi, Nasarawa, Bauchi and Ebonyi states of Nigeria. Participants The study focused on public sector stakeholders who were exposed to the PSCS intervention and were selected from government agencies. Nine study participants were engaged per state, bringing the total number of participants to 45. Data were analysed thematically and elicited MSC stories were analysed for content. Results The PSCS approach empowered stakeholders at the individual level to disseminate MNCH+N, FP and malaria prevention messages, monitor health and social and behaviour (SBC) activities and increase the demand for health services. At the organisational level, the approach facilitated coordination of SBC activities, enabled training cascades and promoted adherence to health service guidelines. At the system level, it strengthened ward development committees to address health challenges. Challenges hindering stakeholders’ application of PSCS-acquired skills include inadequate workforce, negative attitudes of health workers, funding constraints, cultural barriers, lack of government ownership and limited accessibility. Conclusions This study shows that the PSCS approach is an effective model to scale up capacity for SBC in MNCH+N, FP and malaria prevention programmes. In response to documented supply-side challenges impeding the application of gained knowledge and skill, we recommend inclusive health worker recruitment, sensitisation programmes for health workers, government ownership, improved security, healthcare infrastructure and transportation systems.Item Laboratory Quality Audit in 25 Anti-Retroviral Therapy Facilities in North West of Nigeria(Open Journal of Clinical Diagnostics, 2014) Jegede, F.E.; Mbah, H.A.; Torpey, K.; et al.Introduction: A laboratory’s ability to consistently produce high-quality and reliable results hinges on adopting laboratory standards that guide daily practices to ensure steady quality improvement. Although assessment is an extremely rewarding exercise in health care quality improvement processes, it is always considered very time consuming and expensive in developing world set tings. A quarterly internal audit was conducted in 25 FHI360 supported Antiretroviral Treatment laboratories in the North West of Nigeria which can surely provide reference for other countries. Methodology: A checklist adapted from the World Health Organization/African Regional Office la boratory accreditation checklist was used to quantitatively evaluate 7 quality essentials (QEs). A team composed of technical staff from FHI360, State Ministry of Health and facility laboratory heads, conducted the audits, developed and monitored intervention plans. Information obtained with the checklist was captured in excel, validated and imported into Grappa Prism software ver sion 5.0 for analysis. Results: Most (92%) facilities were at secondary level with (8%) at tertiary level. The mean total score on all QEs across the facilities was 63.34 ± 9.77 in quarter (Q) 1, 68.8 ± 10.91 in Q2, 72.59 ± 8.02 in Q3 and 72.72 ± 9.16 in Q4 (p ≤ 0.0001). The most improved QE through Q1-Q4 was organization and personnel (32.2%), while signage/bench top reference had an 18.6% point decline. In ranking facilities based on differences of total scores between Q4 and Q1, Kachia General Hospital was the highest with 27 point increase. Considering the mean percentage score for all quarters per facility, 4 had ≥ 80%, 19 had between 60% - 80% and 2 had ˂60%. The total non-conformities cited for QI-Q4 were 185, 100, 78 and 64 respectively with highest recorded in internal and external quality control and the least in facility and safety. Conclusion: We recorded some improvement in most QEs confirming the benefits of internal audits, reviews and follow-up. However, much more is needed in terms of technical assistance, capacity building, mentorship, and commitment at facility and state level to meet minimum acceptable laboratory quality standards.Item Piloting Laboratory Quality System Management in Six Health Facilities in Nigeria(PLOS ONE, 2014) Mbah, H.; Ojo, E.; Torpey, K.; et al.Background: Achieving accreditation in laboratories is a challenge in Nigeria like in most African countries. Nigeria adopted the World Health Organization Regional Office for Africa Stepwise Laboratory (Quality) Improvement Process Towards Accreditation (WHO/AFRO– SLIPTA) in 2010. We report on FHI360 effort and progress in piloting WHO-AFRO recognition and accreditation preparedness in six health facility laboratories in five different states of Nigeria. Method: Laboratory assessments were conducted at baseline, follow up and exit using the WHO/AFRO– SLIPTA checklist. From the total percentage score obtained, the quality status of laboratories were classified using a zero to five star rating, based on the WHO/AFRO quality improvement stepwise approach. Major interventions include advocacy, capacity building, mentorship and quality improvement projects. Results: At baseline audit, two of the laboratories attained 1- star while the remaining four were at 0- star. At follow up audit one lab was at 1- star, two at 3-star and three at 4-star. At exit audit, four labs were at 4- star, one at 3-star and one at 2- star rating. One laboratory dropped a ‘star’ at exit audit, while others consistently improved. The two weakest elements at baseline; internal audit (4%) and occurrence/incidence management (15%) improved significantly, with an exit score of 76% and 81% respectively. The elements facility and safety was the major strength across board throughout the audit exercise. Conclusion: This effort resulted in measurable and positive impact on the laboratories. We recommend further improvement towards a formal international accreditation status and scale up of WHO/AFRO– SLIPTA implementation in Nigeria.Item Integrating cervical cancer screening with HIV care in a district hospital in Abuja, Nigeria(Nigerian Medical Journal, 2013) Odafe, S.; Torpey, K.; Khamofu, H.; et al.Background: Human immunodeficiency virus positive (HIV+) women have a higher risk of developing invasive cervical cancer compared with uninfected women. This study aims to document programmatic experience of integrating cervical cancer screening using Visual Inspection and Acetic Acid (VIA) into HIV care as well as to describe patients’ characteristics associated with positive VIA findings amongst HIV+ women. Materialsand Methods:Across‑sectional study analysed routine service data collected at the antiretroviral therapy (ART) and cervical cancer screening services. Our program integrated screening for cervical cancer using VIA technique to HIV care and treatment services through a combination of stakeholder engagement, capacity building for health workers, creating a bi‑directional referral between HIV and reproductive health (RH) services and provider initiated counselling and screening for cervical cancer. Information on patients’ baseline and clinical characteristics were captured using an electronic medical records system and then exported to Statistical Package for the Social Sciences (SPSS). Logistic regression model was used to estimate factors that influence VIA results. Results: A total of 834 HIV+ women were offered VIA screening between April 2010 and April 2011, and 805 (96.5%) accepted it. Complete data was available for 802 (96.2%) women. The mean age at screening and first sexual contact were 32.0 (SD 6.6) and 18.8 (SD 3.5) years, respectively. VIA was positive in 52 (6.5%) women while 199 (24.8%) had a sexually transmitted infection (STI). Of the 199 who had a STI, eight (4.0%) had genital ulcer syndrome, 30 (15.1%) had lower abdominal pain syndrome and 161 (80.9%) had vaginal discharge syndrome. Presence of lower abdominal pain syndrome was found to be a significant predictor of a positive VIA result (P = 0.001). Women with lower abdominal pain syndrome appeared to be more likely (OR 47.9, 95% CI: 4.8‑480.4, P = 0.001) to have a positive VIA result. Conclusion: The high burden of both HIV and cervical cancer in developing countries makes it a necessity for integrating services that offer early detection and treatment for both diseases. The findings from our study suggest that integrating VIA screening into the package of care offered to HIV+ women is feasible and acceptable.Item Implementing and Measuring the Level of Laboratory Service Integration in a Program Setting in Nigeria(PLOS ONE, 2014) Mbah, H.; Negedu-Momoh, O.R.; Torpey, K.; et al.Background: The surge of donor funds to fight HIV&AIDS epidemic inadvertently resulted in the setup of laboratories as parallel structures to rapidly respond to the identified need. However these parallel structures are a threat to the existing fragile laboratory systems. Laboratory service integration is critical to remedy this situation. This paper describes an approach to quantitatively measure and track integration of HIV-related laboratory services into the mainstream laboratory services and highlight some key intervention steps taken, to enhance service integration. Method: A quantitative before-and-after study conducted in 122 Family Health International (FHI360) supported health facilities across Nigeria. A minimum service package was identified including management structure; trainings; equipment utilization and maintenance; information, commodity and quality management for laboratory integration. A check list was used to assess facilities at baseline and 3 months follow-up. Level of integration was assessed on an ordinal scale (0 = no integration, 1 = partial integration, 2 = full integration) for each service package. A composite score grading expressed as a percentage of total obtainable score of 14 was defined and used to classify facilities (#80% FULL, 25% to 79% PARTIAL and ,25% NO integration). Weaknesses were noted and addressed. Results: We analyzed 9 (7.4%) primary, 104 (85.2%) secondary and 9 (7.4%) tertiary level facilities. There were statistically significant differences in integration levels between baseline and 3 months follow-up period (p,0.01). Baseline median total integration score was 4 (IQR 3 to 5) compared to 7 (IQR 4 to 9) at 3 months follow-up (p = 0.000). Partial and fully integrated laboratory systems were 64 (52.5%) and 0 (0.0%) at baseline, compared to 100 (82.0%) and 3 (2.4%) respectively at 3 months follow-up (p = 0.000). Discussion: This project showcases our novel approach to measure the status of each laboratory on the integration continuum.Item Evaluation of Laboratory Performance with Quality Indicators in Infectious Disease Hospital, Kano, Nigeria(2015) Jegede, F.E.; Mbah, H.A.; Aminu, M.; Yakubu, T.N; Torpey, KBackground: In January 2010, the implementation of quality management systems toward WHO AFRO laboratory accreditation commenced in the Antiretroviral Treatment Laboratory of the In fectious Disease Hospital, Kano, Nigeria. Quality improvement projects were instituted in 2011 in line with ISO 15189 requirements for accreditation of medical laboratory. In this study we eva luated the performance of the laboratory through some set of quality indicators (QI). Methodology: This was a retrospective study to evaluate laboratory QIs monitored from January 2011 to De cember 2013. The QIs were specimen rejection rate (SSR), turnaround time (TAT), proficiency testing performance (PTP) and client satisfaction survey (CSS). Data was collected into an excel file for analysis and percentage performance compared among years. SSR & TAT were evaluated with the Sigma scale. Results: A total of 7920 (2194 in 2011, 2715 in 2012, 3011 in 2013) speci mens were received for testing. 22 (0.28%) specimens were rejected and 81 (1.02%) specimens’ results were reported after the acceptable TAT, giving a Sigma level of 4.27 and 3.82 for SSR and TAT respectively. There was steady improvement in PTP: CD4+ from 67% in 2011 to 90% in 2013, hematology from 81% in 2012 to 83% in 2013, blood film reading 79% in 2011 to 83% in 2013 and chemistry from 90% in 2011 to 93% in 2013. HIV serology recorded 100% throughout. CSS increased from 59% in 2012 to 78% in 2013. However, there was no statistically significance dif ference reported for PTP and CSS over the years (P > 0.05). Conclusion: The study highlights the need to continuously evaluate QIs and calls for more effort to improve on PTP and focuses on un derstanding and improving on clients concerns.Item Prevalence of intestinal parasites among HIV/AIDS patients attending Infectious Disease Hospital Kano, Nigeria(Pan African Medical Journal, 2014) Jegede, E.F.; Oyeyi, E.T.I.; Bichi, A.H.; Mbah, H.A.; Torpey, K.Introduction: Intestinal parasitic infection has been a major source of morbidity in tropical countries especially among HIV patients. The aim of this study was to determine prevalence of intestinal parasites and its association with immunological status and risk factors among HIV infected patients in Kano, Nigeria. Methods: 105 HIV+ subjects and 50 HIV- controls were recruited into the studies from June to December 2010. Clinical information was collected using a questionnaire. Single stool and venous blood samples were collected from each subject. Stool examination and CD4+ count were performed. Results: Prevalence of intestinal parasites was 11.4% and 6% among the HIV+ and control subjects respectively with no statistically significant difference (p=0.389). Specifically, the following intestinal parasites were isolated from HIV+ subjects: Entamoebahistolytica (5.7%), hookworm (3.8%), Entamoeba coli (1%), Blastocystishominis (1%). Only Entamoebahistolytica was isolated among the control subjects. The mean CD4+ count of HIV+ and control subjects was 287 cells/ul and 691 cells/µlrespectively while the median was 279(Q1-120, Q3-384) cell/µl and 691(Q1-466, Q3-852) cell/µlrespectively with statistically significant difference (P= 0.021).Diarrhea and the absence of anti-parasitic therapy seem to be important risk factors associated with the occurrence of intestinal parasites among HIV+ subjects. A higher prevalence (14.5%) of intestinal parasites was observed in subject with CD4+ count 350cell/µl. Conclusion: Routine examination for intestinal parasites should be carried out for better management of HIV/AIDS patients.Item What Is the Economic Burden of Subsidized HIV/AIDS Treatment Services on Patients in Nigeria and Is This Burden Catastrophic to Households?(PLOS ONE, 2016) Etiaba, E.; Onwujekwe, O.; Torpey, K.; Uzochukwu, B.; Chiegil, R.Background A gap in knowledge exists regarding the economic burden on households of subsidized anti-retroviral treatment (ART) programs in Nigeria. This is because patients also incur non ART drug costs, which may constrain the delivery and utilisation of subsidized services. Methods An exit survey of adults (18+years) attending health facilities for HIV/AIDS treatment was conducted in three states in Nigeria (Adamawa, Akwa Ibom and Anambra). In the states, ART was fully subsidized but there were different payment modalities for other costs of treat ment. Data was collected and analysed for direct and indirect costs of treatment of HIV/ AIDS and co-morbidities’ during out-and in-patient visits. The levels of catastrophic health expenditure (CHE) were computed and disaggregated by state, socio-economic status (SES) and urban-rural location of the respondents. Catastrophic Health Expenditure (CHE) in this study measures the number of respondents whose monthly ART-related household expenditure (for in-patient and out-patient visits) as a proportion of monthly non-food expen diture was greater than 40% and 10% respectively. Results The average out-patient and in-patient direct costs were $5.49 and $122.10 respectively. Transportation cost was the highest non-medical cost and it was higher than most medical costs. The presence of co-morbidities contributed to household costs. All the costs were cat astrophic to households at 10% and 40% thresholds in the three states, to varying degrees. The poorest SES quintile had the highest incidence of CHE for out-patient costs (p<0.0001). Rural dwellers incurred more CHE for all categories of costs compared to urban dwellers, but the costs were statistically significant for only outpatient costs. Conclusion ART subsidization is not enough to eliminate economic burden of treatment on HIV patients. Service decentralization to reduce travel costs, and subsidy on other components of HIV treatment services should be introduced to eliminate the persisting inequitable and high cost burden of ART services. Full inclusion of ART services within the benefit package of the National Health Insurance Scheme should be considered.Item What Is the Cost of Providing Outpatient HIV Counseling and Testing and Antiretroviral Therapy Services in Selected Public Health Facilities in Nigeria?(Journal of Acquired Immune Deficiency Syndromes, 2012) Aliyu, H.B.; Chuku, N.N.; Torpey, K.; et al.Background: Limited data on actual cost of providing HIV/AIDS services in Nigeria makes planning difficult. A study was conducted in 9 public health facilities supported by the Global HIV/AIDS Initiative Nigeria. The objective was to determine the cost of outpatient HIV Testing and Counseling (HTC) and antiretroviral therapy (ART) services per patient. Methods: Two tertiary and 7 secondary facilities were purposively selected across the six geopolitical regions. Facilities were distrib uted in urban and rural settings. Utilization and cost data for a 12-month period (January to December 2010) were analyzed. Cost elements included consumables, human resources, infrastructure, trainings, facility management, and Global HIV/AIDS Initiative Nigeria technical support. Total costs were apportioned based on percentage utilization by services, and unit costs were derived by dividing resource inputs by service outputs. Data were analyzed using Microsoft Excel 2003. A sensitivity analysis was also conducted for key assumptions. Results: Mean costs for HTC and ART were US $7.4 and US $209.0, respectively. Costs were higher in Northern facilities (US $6.9, US $250.8), compared with Southern ones (US $6.7, US $194.7); and in tertiary facilities ($18.5, $338.4), compared with secondary ones ($6.3, $204.9). Major cost drivers for HTC and ART were human resources—ranging from 62% to 50%, and ARV drugs —ranging from 54% to 31%, respectively.Conclusions: Governments’ ability to negotiate lower priced antiretroviral drugs will be central to reducing the cost of ART. Additionally, use of lower cadre staff to provide HTC will reduce costs and improves efficiency.Item Patients’ demographic and clinical characteristics and level of care associated with lost to follow-up and mortality in adult patients on first-line ART in Nigerian hospitals(Journal of the International AIDS Society, 2012) Odafe, S.; Idoko, O.; Torpey, K.; et al.Introduction: Clinical outcome is an important determinant of programme success. This study aims to evaluate patients’ baseline characteristics as well as level of care associated with lost to follow-up (LTFU) and mortality of patients on antiretroviral treatment (ART). Methods: Retrospective cohort study using routine service data of adult patients initiated on ART in 2007 in 10 selected hospitals in Nigeria. We captured data using an electronic medical record system and analyzed using Stata. Outcome measures were probability of being alive and retained in care at 12, 24 and 36 months on ART. Potential predictors associated with time to mortality and time to LTFU were assessed using competing risks regression models. Results: After 12 months on therapy, 85% of patients were alive and on ART. Survival decreased to 81.2% and 76.1% at 24 and 36 months, respectively. Median CD4 count for patients at ART start, 12, 18 and 24 months were 152 (interquartile range, IQR: 75 to 242), 312 (IQR: 194 to 450), 344 (IQR: 227 to 501) and 372 (IQR: 246 to 517) cells/ml, respectively. Competing risk regression showed that patients’ baseline characteristics significantly associated with LTFU were male (adjusted sub-hazard ratio, sHR 1.24 [95% CI: 1.08 to 1.42]), ambulatory functional status (adjusted sHR 1.25 [95% CI: 1.01 to 1.54]), World Health Organization (WHO) clinical Stage II (adjusted sHR 1.31 [95% CI: 1.08 to 1.59]) and care in a secondary site (adjusted sHR 0.76 [95% CI: 0.66 to 0.87]). Those associated with mortality include CD4 count B50 cells/ml (adjusted sHR 2.84 [95% CI: 1.20 to 6.71]), WHO clinical Stage III (adjusted sHR 2.67 [95% CI: 1.26 to 5.65]) and Stage IV (adjusted sHR 5.04 [95% CI: 1.93 to 13.16]) and care in a secondary site (adjusted sHR 2.21 [95% CI: 1.30 to 3.77]). Conclusions: Mortality was associated with advanced HIV disease and care in secondary facilities. Earlier initiation of therapy and strengthening systems in secondary level facilities may improve retention and ultimately contribute to better clinical outcomes.