Publications
2026
John Olajide Olawepo, Ezeanolue EE, U, et al. Testing community-based strategies to increase hypertension screening in Nigeria: a protocol for an effectiveness-implementation hybrid type III cluster-randomized trial
Hypertension is a major risk factor for cardiovascular disease and stroke, with a growing burden in Nigeria. Limited access to blood pressure (BP) screenings, low awareness, and barriers to healthcare drive low diagnosis rates. Community-based screenings for other conditions have been successful and could improve diagnosis and care linkage. This study evaluates the effectiveness of a community-based screening and referral intervention to increase hypertension detection and facilitate connections to healthcare.
Methods: This cluster-randomized effectiveness-implementation hybrid type III trial in Nigeria tests the implementation and effectiveness of a community-based BP screening intervention. There are two arms: 1). Core: community screenings supported by mobile health technology with referral to a healthcare facility for participants with at least one elevated BP reading, and 2.) Core+ (enhanced): additional support from community health advisors to help participants link to healthcare facilities. Participants with elevated BP will be informed about medication vouchers if diagnosed with hypertension and prescribed medication. Community gathering sites hosting screenings leverage local engagement structures. The study will assess the proportion of individuals identified to have elevated BP, rates of linkage to healthcare facilities, and factors influencing intervention uptake and sustainability.
Discussion: To address gaps in hypertension detection and management utilizing community-based strategies, findings will provide insights into the feasibility and effectiveness of implementing a scalable, community-driven approach to hypertension screening and linkages to healthcare in Nigeria. If successful, this model could be adapted to other resource-limited settings in the United States and globally to improve detection and reduce hypertension-related complications.
(DOI: 10.1016/j.cct.2026.108367)
Idemili-Aronu N, Jemisenia JO, et al. Barriers and facilitators to research data collection in resource-limited settings: a qualitative study of research coordinators in the Nigeria Implementation Science Alliance Network
The increasing global burden of long-term illnesses necessitates high-quality data to inform effective interventions, particularly in low-resource settings. Despite the critical role of data collectors in health research, their lived experiences and challenges remain understudied, especially in low- and middle-income countries (LMICs) like Nigeria. This study explored the experiences, barriers and facilitators encountered by field researchers working with individuals living with long-term illnesses.
Methods: A qualitative, descriptive phenomenological design was employed, involving in-depth interviews with 12 research coordinators across 12 healthcare facilities in Nigeria. Participants were purposively selected from the Nigeria Implementation Science Alliance-Model Innovation and Research Centres. Data were analysed using Colaizzi's phenomenological method, with thematic analysis to identify key patterns.
Results: Field researchers described both rewarding experiences and significant obstacles. While they found value in contributing to impactful research, they faced emotional strain from engaging with sensitive narratives. Key barriers included low health literacy, cultural and religious constraints, hesitation to engage in the study and logistical constraints such as unreliable infrastructure. Facilitators included prefield training, trust-building and support systems. Recommendations emphasised ethical adherence, continuous skill development, context-appropriate incentives and streamlined data collection tools.
Conclusions: The study underscores the need for systemic support for data collectors, including mental health resources, adaptive methodologies and institutional policies that address logistical and emotional issues. These findings advocate for participant-centred, ethically sound research practices to enhance data quality and collector well-being in long-term illness studies.Future research needs to evaluate interventions to optimise data collection processes in LMICs.
(DOI: 10.1136/bmjopen-2025-107637)
Chigbu CO,Dim CC, et al. Cervical cancer screen-and-treat services at HIV treatment sites in Nigeria: findings from the ICON-3 Practice Based Research Network
Cervical cancer remains a major public health concern in Nigeria, particularly among women living with HIV (WLHIV). While treatable if detected early, many WLHIV do not access cervical cancer screening and treatment services. Accordingly, the Accelerating Cervical Cancer Elimination through the integration of Screen-and-treat Services (ACCESS) Study aims to test implementation strategies to enhance cervical cancer screening and treatment among WLHIV in 12 Nigeria Implementation Science Alliance Model Innovation and Research Centers (NISA-MIRCs) of the ICON-3 Practice Based Research Network. METHODS: Prior to the trial commencement, we conducted a baseline cross-sectional study to assess cervical cancer screening, pre-cancer treatment, and referral for suspected cancer treatment at the 12 NISA-MIRCs. Data were obtained from electronic medical records and analyzed with descriptive statistics. RESULTS: Out of 23,409 WLHIV who visited the sites during a six-month period (March to August 2023), 13,518 (57.7%) were eligible for screening, but only 4,499 (33.3%) were screened. The South West had the highest screening rate (65.5%), while the North West had the lowest (22.4%). Of the 112 WLHIV (2.7%) who screened positive with visual inspection with acetic acid (VIA), 73.2% were treated on-site. Twenty-three (0.5%) of those screened had suspected cancer, out of which 15 (65.2%) were referred to an oncology center. CONCLUSIONS: The results show significant gaps in cervical cancer prevention services in Nigeria and considerable regional disparities. There is a need for implementation research studies, such as ACCESS, to identify effective strategies for improved cervical cancer screening and treatment among WLHIV in Nigeria.
(DOI: 10.1186/s12913-026-14167-0)
Idemili-Aronu N, Okoli IA, et al. Healthcare providers' awareness, perceptions and experiences in integrating palliative care for women with HIV and cancer in Nigeria: a qualitative study on barriers and facilitators
Women living with HIV face an increased risk of cancer due to compromised immune systems, necessitating integrated care approaches that include palliative care (PC). However, in resource-limited settings such as Nigeria, significant gaps in integrating PC into community healthcare persist, resulting in suboptimal outcomes for women managing HIV and cancer conditions. Understanding the barriers to and facilitators of PC integration from the perspective of healthcare providers is essential for improving care delivery. METHODS: A qualitative study was conducted across Nigeria’s six geopolitical zones, involving 24 healthcare providers from primary and secondary facilities affiliated with the Nigeria Implementation Science Alliance-Model Innovation and Research Centers (NISA-MIRCs). Key informant interviews (KIIs) and in-depth interviews (IDIs) were used to collect data, which were analyzed thematically via NVivo 14. RESULTS: Key barriers included distance to healthcare facilities, inadequate training and resources, sociocultural stigmas, and fragmented care systems. The facilitators highlighted were healthcare worker incentives, community engagement, patient education, and infrastructural improvements. The participants advocated for holistic and standardized integration of PC into healthcare services to enhance patient outcomes. CONCLUSION: Significant gaps in the integration of PC into community healthcare systems in Nigeria impede the delivery of holistic care to women managing HIV and cancer. Addressing these gaps requires targeted policy interventions, healthcare worker training, and resource allocation to improve access to and delivery of PC services. These findings provide actionable insights for strengthening PC infrastructure in resource-limited settings.
(DOI: 10.1186/s12913-026-14029-9)
2025
Segun-Omosehin OA, Omiye JA, et al. Evaluating the digital health technology landscape in sub-Saharan Africa and its implications for cardiovascular health
Digital health technologies (DHTs) and novel artificial intelligence tools have already begun to transform healthcare in many parts of the world. Non-communicable diseases (NCDs) are on the rise in sub-Saharan Africa, with cardiovascular disease accounting for the largest NCD burden. Digital technologies can accelerate healthcare transformation and improve healthcare delivery in sub-Saharan Africa. This article explores digital technologies in sub-Saharan Africa and potential applications in the field of cardiovascular medicine.
(DOI: 10.1038/s44325-025-00055-9)
Onyeka TC, Olakunde B, et al. Closing the gap between implementation science and policy in Nigeria: lessons from the Nigeria implementation science alliance using a nominal group technique
Knowledge translation in healthcare has been of keen interest to researchers, practitioners, policymakers and administrators as it seeks to confront complex health issues within communities by closing the gap between knowledge generation through research and knowledge application. A paucity of information exists regarding nature of the relationship between Nigerian implementation science researchers and policymakers in the sphere of knowledge translation. This study aimed to identify and discuss barriers to successful engagement between implementation researchers and policymakers as well as to identify strategies for successful engagement between both parties in Nigeria.
Methods: A modified Nominal Group Technique was conducted with 259 diverse health research stakeholders attending the 7th Nigeria Implementation Science Alliance conference in Abuja, Nigeria, to identify barriers to knowledge translation in Nigerian healthcare settings.
Results: Lack of interest in non-aligned priorities of implementation researchers and policymakers, knowledge and capacity gap in stakeholder engagement, and non-existence of engagement framework were ranked as the top three barriers. Developing and sustaining an effective engagement framework, aligning researcher-policymaker interests through collaborative research projects, and joint capacity-building were ranked the topmost facilitators of researcher-policymaker engagement.
Conclusion: This study highlights key barriers to research-to-policy engagement in Nigeria, namely the need for structured engagement frameworks, alignment of priorities, and targeted capacity development, and proposes actionable strategies to address them. Sustainable impact will depend on dedicated financing, governance reforms, and institutional changes, supported by long-term partnerships and robust evaluation systems to advance knowledge translation and improve health outcomes.
(DOI: 10.3389/frhs.2025.1629317)
Adamu AA, Nnaji CA, et al. Towards making immunization programmes in Africa more successful: a primer on implementation research
There is a protracted lag in efforts to widen access and uptake of routine vaccination services in Africa. As a result, vaccine-preventable diseases continue to remain a major public health challenge. The increasing adoption of implementation research in global health is an opportunity for immunization programmes to leverage new tools in tackling long-standing implementation barriers to vaccination efforts. Implementation research in immunization programmes can strengthen how contextual barriers hindering vaccination efforts are identified and addressed with sustainable, context-appropriate, and practical strategies. In this primer, which is targeted at country-level immunization decision-makers and implementers, we discussed the meaning of implementation research and the value addition it can bring in fast-tracking programmatic success when integrated into all aspects of the immunization landscape.
Idemili-Aronu N, Olakunde BO, et al. Barriers and Facilitators to Cancer Clinical Trial Participation: Perspectives of Patients in the ICON-3 Practice-Based Research Network, Nigeria
Africa faces a growing burden of cancer yet remains under-represented in global cancer clinical trials. This disparity limits the generation of population-specific evidence needed to improve cancer outcomes. Recruitment and retention in cancer clinical trials are particularly challenging because of various systemic and individual barriers in Nigeria. This study explores patients' perspectives on barriers and facilitators to recruitment and retention in cancer clinical trials.
Methods: A convergent parallel mixed-methods design was used, which comprised a cross-sectional survey and a descriptive qualitative approach. Participants were recruited from multiple oncology centers and secondary facilities within Nigeria's ICON-3 Practice-Based Research Network. Quantitative data were collected through interviewer-administered questionnaires, whereas qualitative data were gathered via semistructured interviews and analyzed thematically.
Results: A total of 317 patients participated in the quantitative survey, 18 of whom participated in interviews. Barriers included limited understanding of clinical trials, logistical challenges such as transportation and visit frequency, distrust in researchers and the health care system, and lack of family support. Facilitators included effective communication, incentives, flexible research visits, and culturally tailored interventions.
Conclusion: To optimize cancer clinical trial participation in low-resource settings, interventions must be tailored to local contexts, addressing structural and cultural barriers. Enhanced communication, community involvement, and supportive policies can significantly improve trial participation and outcomes.
(DOI: 10.1200/GO-25-00181)
Olakunde BO, Itanyi IU, et al. Willingness to use female permanent contraception among married women and male partners´ support in Benue, Nigeria
There is a paucity of community-based studies on the acceptability of female permanent contraception (FPC), particularly among men. We examined the willingness of married women to use FPC and their male partners to support its use in Nigeria.
Methods: we conducted a cross-sectional study among pregnant women and their male partners who participated in the Healthy Beginning Initiative (HBI) program in Benue, Nigeria. The HBI was an integrated, feasible, and culturally adaptive platform for screening, linkage, and follow-up of pregnant women attending churches. Data on sociodemographic characteristics and reproductive intentions were collected from 10,168 pregnant women and 6,766 male partners independently through pre-tested semi-structured interviewer-administered questionnaires. We performed univariate and multivariate logistic regression analyses to examine factors associated with the willingness to use FPC among women and male partners to support the use of FPC. Our analysis was restricted to married participants.
Results: of the 10,046 married women and 6,759 men included in this study, 80% and 87% indicated willingness to use and support the use of FPC, respectively. In the adjusted model, women with no formal, primary, and secondary education (vs tertiary education) and those with an income level of ≤ ₦20,000 (vs > ₦50,001) had significantly higher odds of willingness to use FPC, while women with no living children (vs ≥ 5) and 0-2 desired children (vs ≥ 5) had significantly lower odds of intending to use FPC. Except for no formal education and the number of living children, similar factors were associated with the willingness of married men to support the use of FPC.
Conclusion: there was a high willingness to use or support the use of FPC among married women and men in this study. Increasing access to FPC services in this setting may improve its informed and voluntary uptake.
Olakunde BO, Idemili-Aronu N, Friebel-Klingner TM, et al. Optimizing Recruitment and Retention in Cancer Clinical Trials in Low-Resource Settings: Barriers and Facilitators From Nigerian Provider's Perspectives
The under-representation of African countries in cancer clinical trials continues to widen the cancer health disparity. In this study, we assessed health care workers' perspectives on recruitment and retention in cancer clinical trials in Nigeria.
Methods: This study was a convergent parallel mixed-methods design, using a survey for quantitative analysis and focus group discussions (FGDs) for further qualitative investigation. The health care providers that participated in the study were drawn from the ICON-3 Practice-based Research Network across the six geopolitical zones in Nigeria.
Results: Of the 42 providers, 35 completed the survey and 25 participated in the FGDs. The most cited (agreed or strongly agreed) patient-related barriers were lack of understanding of cancer clinical trials (83%), cultural barriers (77%), and lack of financial compensation for study visits (77%). The most cited provider-related barriers were negative attitude of the clinical team (89%), lack of training in good clinical practice (89%), and an overwhelming clinical workload (86%). On trial-related barriers, about 71% agreed or strongly agreed that lack of trial publicity was a barrier. Over 90% of the respondents agreed or strongly agreed that several factors, including the friendliness of the study team (97%) and clarity in the presentation of trial information (97%), are important facilitators. The FGDs unveiled additional themes, including systems-related barriers such as lack of infrastructure, limited research collaboration, and prolonged ethical approval process, and capacity building and community engagement as potential facilitators.
Conclusion: Our study provides providers' perspectives on the barriers and facilitators to the recruitment and retention of participants in cancer clinical trials in a low-resource setting and highlights the need for culturally appropriate recruitment strategies.
(DOI: 10.1200/GO-24-00308)
Ezeanolue EE, Olakunde BO, Itanyi IU, et al. Recruitment and engagement of a cohort of women living with HIV in Nigeria: Baseline characteristics from the Nigeria Implementation Science Alliance. PLOS Glob Public Health
Nigeria has a high burden of mother to child transmission (MTCT) of HIV. There is paucity of large-scale prospective cohort studies to provide insight into the reasons for the abysmal MTCT indices. This paper describes the baseline characteristics of women living with HIV who signed consent to participate in future clinical or implementation trials. The Nigeria Implementation Science Alliance (NISA) developed an open multicentre prospective cohort of women of reproductive age living with HIV, drawn from 12 facilities across the six geo-political regions of Nigeria. Research Electronic Data Capture system was used for the informed consent process. Socio-demographic and clinical information of participants were accessed through the clinics' Electronic Medical Records. We calculated descriptive statistics, summarizing categorical variables using frequencies and percentages.
(doi:10.1371/journal.pgph.0004028)
Onyeka T, Zakieh A, Gitonga I, et al. A scoping review exploring cancer survivorship in Africa
The scope of cancer survivorship in Africa remains largely unexplored. This scoping review aims to describe current survivorship-related factors and care delivery characteristics in Africa, and to provide insights that can inform a more systematic integration of survivorship care into the broader cancer care continuum.
(doi:10.1007/s11764-025-01805-5)
2024
Hepatitis B vaccine birth dose coverage among hepatitis B-exposed and hepatitis B-unexposed infants: evidence from the Healthy Beginning Initiative program in Benue State, Nigeria.
Nigeria offers universal hepatitis B birth-dose vaccine (HepB-BD) for the prevention and control of hepatitis B (HepB). While prior studies suggest low coverage of HepB-BD in Nigeria, there is a paucity of evidence on the association between the uptake of HepB-BD and maternal HepB status. This study aimed to determine HepB-BD coverage and the associated factors among infants of HepB-positive and -negative women in Nigeria.
Health education to promote knowledge about sickle cell disease and newborn screening in pregnant women: a community-based pilot study using the Healthy Beginning initiative
Abstract Background Pregnancy presents a critical period for any maternal and child health intervention that may impact the health of the newborn. With low antenatal care attendance by pregnant women in health facilities in Nigeria, community-based programs could enable increased reach for health education about sickle cell disease (SCD) and newborn screening (NBS) among pregnant women. This pilot study aimed to assess the effect of education on the knowledge about SCD and NBS among pregnant women using the Healthy Beginning Initiative, a community-based framework.
Methods A pre-post study design was used to evaluate knowledge of SCD and NBS in a convenience sample of 89 consenting pregnant women from three communities. Participants were given surveys prior to and following completion of a health education session. McNemar’s test was used to compare the proportion of participants with correct responses. The level of significance was taken as p<0.05.
Results Compared to pre-test values, post-test values showed that participants understood that SCD is hereditary (93.3% vs. 69.7%), both parents must have at least one gene for someone to have SCD (98.9% vs. 77.5) and blood test is the right way to know if one has SCD (98.8% vs. 78.7%). Also, a large proportion of participants (post-test~89.9%; compared to pre-test~23.6%) understood that the chance of conceiving a child with SCD was 25% for a couple with the sickle cell trait (SCT). Knowledge of the possibility of diagnosing SCD shortly after birth was highly increased in the post test phase of the study when compared to the pre-test phase (93.3% vs. 43.9%, respectively). Concerning the overall knowledge scores, those with high level of knowledge significantly increase from 12.6% pretest to 87.4% posttest (p=0.015).
Mobile Apps to Support Mental Health Response in Natural Disasters: Scoping Review
Abstract
Background:Disasters are becoming more frequent due to the impact of extreme weather events attributed to climate change, causing loss of lives, property, and psychological trauma. Mental health response to disasters emphasizes prevention and mitigation, and mobile health (mHealth) apps have been used for mental health promotion and treatment. However, little is known about their use in the mental health components of disaster management.
Objective:This scoping review was conducted to explore the use of mobile phone apps for mental health responses to natural disasters and to identify gaps in the literature.
Methods:We identified relevant keywords and subject headings and conducted comprehensive searches in 6 electronic databases. Studies in which participants were exposed to a man-made disaster were included if the sample also included some participants exposed to a natural hazard. Only full-text studies published in English were included. The initial titles and abstracts of the unique papers were screened by 2 independent review authors. Full texts of the selected papers that met the inclusion criteria were reviewed by the 2 independent reviewers. Data were extracted from each selected full-text paper and synthesized using a narrative approach based on the outcome measures, duration, frequency of use of the mobile phone apps, and the outcomes. This scoping review was reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews).
Results:Of the 1398 papers retrieved, 5 were included in this review. A total of 3 studies were conducted on participants exposed to psychological stress following a disaster while 2 were for disaster relief workers. The mobile phone apps for the interventions included Training for Life Skills, Sonoma Rises, Headspace, Psychological First Aid, and Substance Abuse and Mental Health Services Administration (SAMHSA) Behavioural Health Disaster Response Apps. The different studies assessed the effectiveness or efficacy of the mobile app, feasibility, acceptability, and characteristics of app use or predictors of use. Different measures were used to assess the effectiveness of the apps’ use as either the primary or secondary outcome.
Conclusions:A limited number of studies are exploring the use of mobile phone apps for mental health responses to disasters. The 5 studies included in this review showed promising results. Mobile apps have the potential to provide effective mental health support before, during, and after disasters. However, further research is needed to explore the potential of mobile phone apps in mental health responses to all hazards
Immune response to hepatitis B vaccine among children under 5 years in Africa: a meta-analysis
Abstract
Background:Hepatitis B virus (HBV) infection in Africa is mostly acquired before the age of 5 years through vertical or horizontal routes. While all the countries in the World Health Organization African region have introduced HBV vaccination into their national immunization programs, the rate of protective immune response to HBV vaccine among children in Africa has not been systematically synthesized. In this study, we estimated the HBV vaccine seroprotection rate (defined as anti-HBs titer ≥ 10 IU/L) and the associated factors among under-five children who completed a primary series of HBV vaccination in Africa
Methods:We systematically searched PubMed, Web Science, and Scopus databases from inception to May 2022 for potentially eligible studies. The pooled seroprotection rate was estimated using a random-effects model with Freeman-Tukey double arcsine transformation and the associated factors were examined using odds ratio estimated by the DerSimonian and Laird method.
Results:From the 1063 records identified, 29 studies with a total sample size of 9167 under-five children were included in the meta-analysis. The pooled seroprotection rate was 89.23% (95% CI 85.68-92.33%, I2 = 95.96%, p < 0.001). In the subgroup analyses, there was a significant difference in the rate by the assay method, vaccine dose, and vaccine combination. HIV-positive children had lower odds of achieving seroprotection when compared with HIV-negative children (OR = 0.22, 95%CI 0.12-0.40).
Conclusions:The majority of under-five children in Africa achieved seroprotection after completing three or four doses of HBV vaccine. However, the rate was lower among children living with HIV. This calls for interventions to timely identify and address nonresponse to HBV vaccine, particularly among immunosuppressed children.
Digital psychiatry in Nigeria: A scoping review
Background: Mental healthcare workforce shortage in Nigeria poses a major obstacle to mental health services scale-up. Digital psychiatry may provide a veritable platform to bridge treatment gaps. Aim: To provide an overview of quantity and range of peer-reviewed publications on digital psychiatry in Nigeria.
Setting: A comprehensive literature search encompassed all original, peer-reviewed research articles on digital psychiatry in Nigeria. PubMed, Google Scholar, and a direct exploration of relevant journal article reference lists were utilised. Inclusion criteria covered peer-reviewed original articles conducted in Nigeria between January 2013 and January 2023, regardless of quality. Exclusions comprised case reports, reviews, dissertations, and abstracts. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines were adhered to, while methodological framework of Arksey and O’Malley was used to describe the review.
Results: Fourteen studies meeting inclusion criteria exhibited two primary research areas: implementation and intervention. Most studies focused on intervention strategies, showcasing efficacy of digital devices in enhancing outcomes in depression and clinic appointments. Implementation studies indicated favorable acceptance by both clients and healthcare practitioners. Conclusion: Digital technology seems acceptable to Nigerian patients and clinicians. Policies to operationalise provision of digital healthcare services will have positive impact in addressing unmet mental health needs. Finally, the quality of the evidence from majority of studies has to be enhanced, and additional studies are required to uncover gaps in some regions of the country.
Contribution: This research demonstrates that, despite some drawbacks, digital methods of providing mental healthcare are practical in Nigeria. Keywords: digital psychiatry; digital healthcare; telemedicine; mental health services; Nigeria.
Comparative effectiveness of implementation strategies for Accelerating Cervical Cancer Elimination through the integration of Screen-and-treat Services (ACCESS study): protocol for a cluster randomized hybrid type III trial in Nigeria
Abstract Background Despite the increased risk of cervical cancer (CC) among women living with HIV (WLHIV), CC screen‑ ing and treatment (CCST) rates remain low in Africa. The integration of CCST services into established HIV programs in Africa can improve CC prevention and control. However, the paucity of evidence on efective implementation strategies (IS) has limited the success of integration in many countries. In this study, we seek to identify efective IS to enhance the integration of CCST services into existing HIV programs in Nigeria.
Methods Our proposed study has formative and experimental activities across the four phases of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Through an implementation mapping conducted with stakeholders in the exploration phase, we identifed a core package of IS (Core) and an enhanced package of IS (Core+) mostly selected from the Expert Recommendations for Implementing Change. In the preparation phase, we refned and tailored the Core and Core+ IS with the implementation resource teams for local appropriateness. In the implementation phase, we will conduct a cluster-randomized hybrid type III trial to assess the comparative efectiveness of Core versus Core+. HIV comprehensive treatment sites (k = 12) will be matched by region and ran‑ domized to Core or Core+ in the ratio of 1:1 stratifed by region. In the sustainment phase, we will assess the sustainment of CCST at each site. The study outcomes will be assessed using RE-AIM: reach (screening rate), adoption (uptake of IS by study sites), IS fdelity (degree to which the IS occurred according to protocol), clinical intervention fidelity (delivery of CC screening, onsite treatment, and referral according to protocol), clinical efectiveness (posttreat‑ ment screen negative), and sustainment (continued integrated CCST service delivery). Additionally, we will descrip‑ tively explore potential mechanisms, including organizational readiness, implementation climate, CCST self-efcacy, and implementation intentions
In-hospital psychoeducation for family caregivers of Nigerian children with cancer (The RESCUE Study)
Abstract
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.
Cholera outbreaks among children in sub-Saharan Africa
Abstract
Purpose of review
We review current knowledge on the burden, impact and prevention of cholera among children who bear the brunt of cholera outbreaks in sub-Saharan Africa.
Recent findings
Several studies have shown that recent outbreaks of cholera among African children are related to minimal progress in basic sanitation and infrastructural development. Poor hygiene practices such as open defecation and indiscriminate disposal of feces are still common in many parts of Africa
Summary
Cholera case fatality rates in sub-Saharan Africa remain unacceptably high. Children are disproportionately affected and bear the brunt of the disease. Controlling outbreaks of cholera among African children will require a synchronous implementation of the five levels of disease prevention.
Olawepo JO, O'Brien K, Papasodoro J, et al. Retention in Care Among People Living with HIV in Nigeria: A Systematic Review and Meta-analysis
In 2021, Nigeria had an estimated 1.9 million people living with the human immunodeficiency virus (PLHIV) and 1.7 million (90%) on antiretroviral therapy (ART). Study Design: A systematic review and meta-analysis.
Methods: This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. We searched PubMed, Embase, PsychINFO, CINAHL, Global Index Medicus, and Cochrane Library. Studies were included if they reported on ART retention in care among PLHIV in Nigeria. The random-effects meta-analyses were used to combine the studies that had complete retention data. The I2 statistic was used to assess the heterogeneity of the studies. A sensitivity analysis was then done by conducting a leave-one-out analysis. Afterward, data were analyzed using STATA version 18.
Results: The search yielded 966 unique articles, of which 52 studies met the inclusion criteria for the meta-analysis, and four experimental studies were split into their component arms. The total number of study participants was 563,410, and the pooled retention rate was 72% (95% CI: 67%, 76%; I2=99.9%; n=57). Sub-analysis showed that the Southeast region of Nigeria had the highest retention of 86% (95% CI: 78%, 92%), and the South-South had the lowest retention (58%; 95% CI: 38%, 79%).
Conclusion: In Nigeria, the pooled ART retention rate is less than optimal to achieve the UNAIDS goal of 95%, thus developing new models for ART retention is needed.
(DOI: 10.34172/jrhs.2024.153)
Idemili-Aronu N, Onyeka TC, Okenwa UJ, et al. Knowledge, attitudes, and barriers: Palliative Care services for women with HIV in resource-limited settings
Women living with HIV (WLWH) in low- middle-income countries (LMICs) face increased mortality risks from comorbidities despite progress in antiretroviral therapy. Palliative care (PC) is vital for these patients, yet its integration in LMICs, such as Nigeria, is suboptimal due to unique challenges.
Objective: This study investigated the knowledge, perceived barriers, and facilitators influencing PC integration into routine HIV care within healthcare (HC) settings.
Methodology: A cross-sectional survey was conducted among WLWH in twelve HC facilities throughout Nigeria. Data collection involved surveys focused on PC knowledge, attitudes, facilitators, and barriers. Logistic regression analyses were employed to examine the data.
Results: This study revealed significant gaps in knowledge and attitudes towards PC among HIV + women at NISA-MIRCs. Over 90% were unaware of PC services, but many saw its potential to offer hope (55%) and improve quality of life (56.5%). The key predictors of PC knowledge included education, occupation, religion, having fewer children, urban residence, type of residence, and having a high income (p < .05). Despite the willingness to access PC, barriers such as negative HC worker attitudes, perceived high cost, and limited decision autonomy could hinder integration. Facilitators included low-cost services, positive HCW attitudes, physician recommendations, and perceived necessity for personal well-being.
Conclusion: Knowledge gaps, diverse attitudes, and significant barriers highlight the need for targeted PC interventions for WLWH. Tailoring educational programs, addressing cost barriers, and improving healthcare infrastructure are crucial to enhancing PC accessibility and quality. These findings can guide policymakers and HC practitioners toward more effective and inclusive care strategies.
(DOI: 10.1186/s12904-024-01558-5)
Olakunde BO, Itanyi IU, Onyeka TC, et al. Hepatitis B vaccine birth dose coverage among hepatitis B-exposed and hepatitis B-unexposed infants: evidence from the Healthy Beginning Initiative program in Benue State, Nigeria
Nigeria offers universal hepatitis B birth-dose vaccine (HepB-BD) for the prevention and control of hepatitis B (HepB). While prior studies suggest low coverage of HepB-BD in Nigeria, there is a paucity of evidence on the association between the uptake of HepB-BD and maternal HepB status. This study aimed to determine HepB-BD coverage and the associated factors among infants of HepB-positive and -negative women in Nigeria.
Methods: the study was a secondary analysis of data from the Healthy Beginning Initiative program conducted between June 2016 and October 2018 in Benue State, Nigeria. The analysis was restricted to data from a cohort of 6269 mothers who had HepB screening during pregnancy and completed the HepB infant immunization question in the post-delivery survey. The association between the coverage of HepB-BD and maternal HepB status, sociodemographic characteristics, and obstetric factors were determined using crude and adjusted relative risks.
Results: about 10% of the women tested HepB positive. The coverage of HepB-BD was 64% (63.2% among infants of HepB-positive mothers and 63.8% among HepB-negative mothers). The likelihood of infants of HepB-positive mothers receiving HepB-BD was not significantly different from infants of HepB-negative mothers (aRR=0.97, 95%CI= 0.92-1.04). Among HepB-positive mothers, infants of mothers younger than 20 years (aRR=1.49, 95%CI=1.03-2.16) or those who received antenatal care (aRR=1.41, 95%CI=1.16-1.71) were more likely to receive HepB-BD, while mothers with no previous pregnancies (aRR=0.73, 95%CI=0.59-0.91) were less likely to receive HepB-BD. Among HepB-negative mothers, infants of less-educated mothers were less likely to receive HepB-BD (aRR=0.96, 95%CI=0.92-0.99), whereas infants of mothers who received antenatal care (aRR=1.23, 95%CI=1.16-1.31) or had an institutional delivery were more likely (aRR=1.29, 95%CI=1.23-1.36) to receive HepB-BD. Conclusion: our findings highlight the need to improve HepB-BD uptake, particularly among HepB-exposed infants who are at risk of perinatal transmission of HepB.
Ezenwosu OU, Olawepo JO, Lacroix-Willliamson LJ et al. Health education to promote knowledge about sickle cell disease and newborn screening in pregnant women: a community-based pilot study using the healthy beginning initiative
Pregnancy presents a critical period for any maternal and child health intervention that may impact the health of the newborn. With low antenatal care attendance by pregnant women in health facilities in Nigeria, community-based programs could enable increased reach for health education about sickle cell disease (SCD) and newborn screening (NBS) among pregnant women. This pilot study aimed to assess the effect of education on the knowledge about SCD and NBS among pregnant women using the Healthy Beginning Initiative, a community-based framework.
Methods: A pre-post study design was used to evaluate knowledge of SCD and NBS in a convenience sample of 89 consenting pregnant women from three communities. Participants were given surveys prior to and following completion of a health education session. McNemar's test was used to compare the proportion of participants with correct responses. The level of significance was taken as p < 0.05.
Results: Compared to pre-test values, post-test values showed that participants understood that SCD is hereditary (93.3% vs. 69.7%), both parents must have at least one gene for someone to have SCD (98.9% vs. 77.5) and blood test is the right way to know if one has SCD (98.8% vs. 78.7%). Also, a large proportion of participants (post-test ~ 89.9%; compared to pre-test ~ 23.6%) understood that the chance of conceiving a child with SCD was 25% for a couple with the sickle cell trait (SCT). Knowledge of the possibility of diagnosing SCD shortly after birth was highly increased in the post test phase of the study when compared to the pre-test phase (93.3% vs. 43.9%, respectively). Concerning the overall knowledge scores, those with high level of knowledge significantly increase from 12.6% pretest to 87.4% posttest (p = 0.015).
Conclusion: The health education intervention was associated with significant improvement on almost all measures of SCD knowledge. Focused health education for pregnant women using community structures can improve knowledge of SCD and NBS.
Olakunde BO, Ifeorah IM, Adeyinka DA et al. Immune response to hepatitis B vaccine among children under 5 years in Africa: a meta-analysis
Hepatitis B virus (HBV) infection in Africa is mostly acquired before the age of 5 years through vertical or horizontal routes. While all the countries in the World Health Organization African region have introduced HBV vaccination into their national immunization programs, the rate of protective immune response to HBV vaccine among children in Africa has not been systematically synthesized. In this study, we estimated the HBV vaccine seroprotection rate (defined as anti-HBs titer ≥ 10 IU/L) and the associated factors among under-five children who completed a primary series of HBV vaccination in Africa.
Methods: We systematically searched PubMed, Web Science, and Scopus databases from inception to May 2022 for potentially eligible studies. The pooled seroprotection rate was estimated using a random-effects model with Freeman-Tukey double arcsine transformation and the associated factors were examined using odds ratio estimated by the DerSimonian and Laird method.
Results: From the 1063 records identified, 29 studies with a total sample size of 9167 under-five children were included in the meta-analysis. The pooled seroprotection rate was 89.23% (95% CI 85.68-92.33%, I2 = 95.96%, p < 0.001). In the subgroup analyses, there was a significant difference in the rate by the assay method, vaccine dose, and vaccine combination. HIV-positive children had lower odds of achieving seroprotection when compared with HIV-negative children (OR = 0.22, 95%CI 0.12-0.40).
Conclusions: The majority of under-five children in Africa achieved seroprotection after completing three or four doses of HBV vaccine. However, the rate was lower among children living with HIV. This calls for interventions to timely identify and address nonresponse to HBV vaccine, particularly among immunosuppressed children.
Olakunde BO, Itanyi IU, Olawepo JO et al. Comparative effectiveness of implementation strategies for Accelerating Cervical Cancer Elimination through the integration of Screen-and-treat Services (ACCESS study): protocol for a cluster randomized hybrid type III trial in Nigeria
Despite the increased risk of cervical cancer (CC) among women living with HIV (WLHIV), CC screening and treatment (CCST) rates remain low in Africa. The integration of CCST services into established HIV programs in Africa can improve CC prevention and control. However, the paucity of evidence on effective implementation strategies (IS) has limited the success of integration in many countries. In this study, we seek to identify effective IS to enhance the integration of CCST services into existing HIV programs in Nigeria.
Methods: Our proposed study has formative and experimental activities across the four phases of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Through an implementation mapping conducted with stakeholders in the exploration phase, we identified a core package of IS (Core) and an enhanced package of IS (Core+) mostly selected from the Expert Recommendations for Implementing Change. In the preparation phase, we refined and tailored the Core and Core+ IS with the implementation resource teams for local appropriateness. In the implementation phase, we will conduct a cluster-randomized hybrid type III trial to assess the comparative effectiveness of Core versus Core+. HIV comprehensive treatment sites (k = 12) will be matched by region and randomized to Core or Core+ in the ratio of 1:1 stratified by region. In the sustainment phase, we will assess the sustainment of CCST at each site. The study outcomes will be assessed using RE-AIM: reach (screening rate), adoption (uptake of IS by study sites), IS fidelity (degree to which the IS occurred according to protocol), clinical intervention fidelity (delivery of CC screening, onsite treatment, and referral according to protocol), clinical effectiveness (posttreatment screen negative), and sustainment (continued integrated CCST service delivery). Additionally, we will descriptively explore potential mechanisms, including organizational readiness, implementation climate, CCST self-efficacy, and implementation intentions.
Discussion: The assessment of IS to increase CCST rates is consistent with the global plan of eliminating CC as a public health threat by 2030. Our study will identify a set of evidence-based IS for low-income settings to integrate evidence-based CCST interventions into routine HIV care in order to improve the health and life expectancy of WLHIV.
Ubesie AC, Odimegwu CL, Ezeanolue EE et al. Cholera outbreaks among children in sub-Saharan Africa
We review current knowledge on the burden, impact and prevention of cholera among children who bear the brunt of cholera outbreaks in sub-Saharan Africa.
Recent findings: Several studies have shown that recent outbreaks of cholera among African children are related to minimal progress in basic sanitation and infrastructural development. Poor hygiene practices such as open defecation and indiscriminate disposal of feces are still common in many parts of Africa.
Summary: Cholera case fatality rates in sub-Saharan Africa remain unacceptably high. Children are disproportionately affected and bear the brunt of the disease. Controlling outbreaks of cholera among African children will require a synchronous implementation of the five levels of disease prevention.
2022
Building a national framework for multicentre research and clinical trials: experience from the Nigeria Implementation Science Alliance
There is limited capacity and infrastructure in sub-Saharan Africa to conduct clinical trials for the identification of efficient and effective new prevention, diagnostic and treatment modalities to address the disproportionate burden of disease. This paper reports on the process to establish locally driven infrastructure for multicentre research and trials in Nigeria known as the Nigeria.
Awareness of HIV serostatus by sex partners of women living with HIV in North-Central Nigeria: Correlates and predictive analyses
Non-communication of HIV status among sex partners is a notable hurdle in halting transmission, largely due to socio-cultural factors. This study aimed to predict the determinants of male partners’ awareness of women’s serostatus. A total of 8825 women of reproductive age living with HIV who were clients at five comprehensive HIV treatment centres in Benue State, North-Central Nigeria were surveyed between June and December 2017, and 6655 reported having a sexual partner at the time of the survey selected for analysis. A regression model was used to estimate the determinants of male partner awareness of serostatus from the perspective of women. Conditional marginal analyses were conducted to evaluate the marginal effects of identified predictors on the probability of outcomes. Partners of married women were found to have greater odds of being aware of their spouse’s serostatus (adjusted OR (aOR): 3.20; 95%CI: 2.13-4.81) than non-married partners. Similarly, the odds of male partner awareness increased with the years women had been on antiretroviral therapy (aOR: 1.13; 95%CI: 1.07-1.20). The probability of partners of married respondents being aware of their spouse’s HIV serostatus was 97%. The conditional marginal effects of being educated to primary or higher level were 1.2 (95% CI: -0.2 to 2.7) and 1.8 (95% CI: 0.09-3.4) percentage points higher respectively when compared with women with no formal education. Being unemployed or being a trader significantly decreased the probability of partners being aware of respondents’ serostatus when compared with farmers; conditional marginal effects of -6.7 (95% CI: -12.0 to -1.4) and -3.9 (95% CI: -5.7 to -2.2) percentage points, respectively. The study found that relationship status and girl-child education are factors that can improve communication of HIV status to sex partners. Policies and interventions aimed at improving the social determinants of health, and social support for healthy communications in relationships, are recommended to reduce HIV transmission between sex partners.
Achieving HIV epidemic control through integrated community and facility-based strategies: Lessons learnt from ART-surge implementation in Akwa Ibom, Nigeria
Abstract
This study examines the lessons learnt from the implementation of a surge program in Akwa Ibom State, Nigeria as part of the Strengthening Integrated Delivery of HIV/AIDS Services (SIDHAS) Project. In this analysis, we included all clients who received HIV counseling and testing services, tested HIV positive, and initiated ART in SIDHAS-supported local government areas (LGAs) from April 2017 to March 2021. We employed descriptive and inferential statistics to analyze our results. A total of 2,018,082 persons were tested for HIV. Out of those tested, 102,165 (5.1%) tested HIV-positive. Comparing the pre-surge and post-surge periods, we observed an increase in HIV testing from 490,450 to 2,018,082 (p≤0.031) and in HIV-positive individuals identified from 21,234 to 102,165 (p≤0.001) respectively. Of those newly identified positives during the surge, 98.26% (100,393/102,165) were linked to antiretroviral therapy compared to 99.24% (21,073/21,234) pre-surge. Retention improved from 83.3% to 92.3% (p<0.001), and viral suppression improved from 73.5% to 96.2% (p<0.001). A combination of community and facility-based interventions implemented during the surge was associated with the rapid increase in case finding, retention, and viral suppression; propelling the State towards HIV epidemic control. HIV programs should consider a combination of community and facility-based interventions in their programming.
2021
Hepatitis B infection and risk factors among pregnant women and their male partners in the Baby Shower Programme in Nigeria: a cross‐sectional study
Cross-sectional study assessing the seroprevalence of Hep B virus in a cohort of 16 920 pregnant women and their male partners in northcentral Nigeria. Rapid HBsAg antibody test was used for Hep B diagnosis. Demographic, socio-economic and behavioural information was collected through interviewer-administered questionnaires and evaluated as determinants of Hep B status and couple status discordance using logistic regression.
Utilizing a church-based platform for mental health interventions: Exploring the role of the clergy and the treatment preference of women with depressionand challenges to integrating mental health into HIV programs in a low- and middle-income country: insights from the Nigeria implementation science Alliance
Training lay people to deliver mental health interventions in the community can be an effective strategy to mitigate mental health manpower shortages in low- and middle-income countries. The healthy beginning initiative (HBI) is a congregation-based platform that uses this approach to train church-based lay health advisors to conduct mental health screening in community churches and link people to care. This paper explores the potential for a clergy-delivered therapy for mental disorders on the HBI platform and identifies the treatment preferences of women diagnosed with depression.
Improving uptake of prevention of mother-to-child HIV transmission services in Benue State, Nigeria through a faith-based congregational strategy
Nigeria has low antiretroviral therapy (ART) coverage among HIV-positive pregnant women. In a previous cluster-randomized trial in Nigeria, Baby Shower events resulted in higher HIV testing coverage and linkage of pregnant women to ART; here, we assess outcomes of Baby Shower events in a non-research setting.
A systematic review and meta-analysis of the prevalence of hepatitis B virus infection among pregnant women in Nigeria
Nigeria has a high burden of hepatitis B virus (HBV) infection, commonly acquired through vertical transmission. However, there is a lack of an efficient surveillance system for monitoring and understanding the epidemiology of HBV among pregnant women. Building on a previous review on the prevalence of HBV in Nigeria (2000-2013), we conducted a systematic review and meta-analysis of HBV prevalence among pregnant women in Nigeria.
Community based screening for sickle haemoglobin among pregnant women in Benue State, Nigeria: I-Care-to-Know, a Healthy Beginning Initiative
Haemoglobin genotype screening at prenatal care offers women an opportunity to be aware of their genotype, receive education on sickle cell disease (SCD) and may increase maternal demand for SCD newborn screening. In developed countries, most pregnant women who access prenatal care and deliver at the hospital receive haemoglobin genotype screening. In settings with low prenatal care attendance and low hospital deliveries, community-based screening may provide similar opportunity for pregnant women. We assessed the feasibility and acceptability of integrating haemoglobin genotype screening into an existing community-based HIV program.
Utilizing a church-based platform for mental health interventions: exploring the role of the clergy and the treatment preference of women with depression
Abstract
Background:Training lay people to deliver mental health interventions in the community can be an effective strategy to mitigate mental health manpower shortages in low- and middle-income countries. The healthy beginning initiative (HBI) is a congregation-based platform that uses this approach to train church-based lay health advisors to conduct mental health screening in community churches and link people to care. This paper explores the potential for a clergy-delivered therapy for mental disorders on the HBI platform and identifies the treatment preferences of women diagnosed with depression.
Methods:We conducted focus group discussion and free-listing exercise with 13 catholic clergy in churches that participated in HBI in Enugu, Nigeria. These exercises, guided by the positive, existential, or negative (PEN-3) cultural model, explored their role in HBI, their beliefs about mental disorders, and their willingness to be trained to deliver therapy for mental disorders. We surveyed women diagnosed with depression in the same environment to understand their health-seeking behavior and treatment preferences. The development of the survey was guided by the health belief model.
Results:The clergy valued their role in HBI, expressed understanding of the bio-psycho-socio-spiritual model of mental disorders, and were willing to be trained to provide therapy for depression. Majority of the women surveyed preferred to receive therapy from trained clergy (92.9%), followed by a psychiatrist (89.3%), and psychologist (85.7%).
Conclusion:These findings support a potential clergy-focused, faith-informed adaptation of therapy for common mental disorders anchored in community churches to increase access to treatment in a resource-limited setting.
Keywords:Church; Nigeria; clergy; global mental health; perinatal depression.
2020
Sero-prevalence and determinants of Hepatitis B among a cohort of HIV-infected women of reproductive age in Nigeria
This was a cross-sectional study of HIV-infected women of reproductive age in Benue State, Nigeria. Participants were eligible for the study if they were HIV-infected women (ages 18-45 years) receiving care from any of the selected study sites. A global rapid hepatitis B surface antigen (HBsAg) antibody test strip was used to test for HBsAg in plasma. A pretested questionnaire was used to collect data on sociodemographic, clinical and lifestyle characteristics of participants. We estimated prevalence of HBV infection and used multivariable logistic regression to determine factors associated with the infection at a significance level of <0.05.
Opportunities and challenges to integrating mental health into HIV programs in a low- and middle-income country: insights from the Nigeria implementation science Alliance
In Nigeria, there is an estimated 1.9 million people living with HIV (PLHIV), 53% of whom utilize HIV care and services. With decreasing HIV-related deaths and increasing new infections, HIV with its associated comorbidities continue to be a key public health challenge in Nigeria. Untreated, comorbid mental disorders are a critical but potentially modifiable determinant of optimal HIV treatment outcomes. This study aimed to identify the challenges and opportunities related to integrating mental health care into existing HIV programs in Nigeria.
High prevalence of undiagnosed Hypertension among Men in North Central Nigeria: Results from the Healthy Beginning Initiative
The prevalence of hypertension in Nigeria is high and growing. The burden and risk factor distribution also vary by geographical zone. Information about prevalence, risk factors and disease status awareness are needed to guide evidence based public health response at the national and sub- national levels.
2019
Towards the elimination of mother-to-child transmission of HIV in Nigeria: a health system perspective of the achievements and challenges
Abstract
Despite its scaled-up response for prevention of mother-to-child transmission of HIV (PMTCT), Nigeria still contributes the greatest number of infants infected with HIV worldwide. Drawing on our knowledge, and review of policy documents and research papers, we explored the achievements and challenges in the elimination of mother-to-child transmission of HIV in Nigeria using the WHO's health systems framework. We found that Nigeria has increased the number of PMTCT sites, decentralized and integrated PMTCT care for expanded service delivery, adopted task-shifting to address the shortage of skilled healthcare providers, explored alternative sources of domestic funding to bridge the funding gap and harmonized the health management information system to improve data quality. Some of the challenges we identified included: difficulty in identifying HIV-infected pregnant women because of low uptake of antenatal care; interrupted supplies of medical commodities; knowledge gaps among healthcare workers; and lack of a national unique identifying system to enhance data quality. While there have been some achievements in the PMTCT program, gaps still exist in the different blocks of the health system. Elimination of mother-to-child transmission of HIV in Nigeria will require the implementation of feasible, culturally acceptable and sustainable interventions to address the health system-related challenges.