FACULTY OF PUBLIC HEALTH
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Item Contextual factors influencing the roles of patent medicine vendors in the provision of injectable contraception services in Nigeria(Springer Nature, 2023) Adebayo, A. M.; Oluwasanu, M. M.; Okunade, F. T.; Ajayi, O. O.; Akindele, A. O.; Ajuwon, A. J.Background Patent medicine vendors (PMVs) play vital roles in the delivery of family planning services in Nigeria and other developing countries. There is a growing recognition of the need to integrate them into the formal health care system as a strategy to increase the contraceptive prevalence rate and achieve universal health coverage.Though promising, the success of this proposition is largely dependent on a critical analysis of the factors which influence their operations. This study was designed to identify the contextual factors influencing the provision of injectable contraceptive services by PMVs and the broader effects of their activities on the health system to inform similar interventions in Nigeria. Methods This was a qualitative study guided by the UK Medical Research Council’s Framework for Complex Interventions. Twenty-seven in-depth interviews were conducted among officials of the association of PMVs, health workers, government regulatory officers and programme implementers who participated in a phased 3-year (2015–2018) intervention designed to enhance the capacity of PMVs to deliver injectable contraceptive services. The data were transcribed and analyzed thematically using NVIVO software. Results The contextual factors which had implications on the roles of PMVs were socio-cultural and religious, the failing Nigerian health system coupled with government regulatory policies. Other factors were interprofessional tensions and rivalry between the PMVs and some categories of health care workers and increasing donors’ interest in exploring the potentials of PMVs for expanded healthcare service provision. According to the respondents, the PMVs bridged the Nigerian health system service delivery gaps serving as the first point of contact for injectable contraceptive services and this increased contraceptive uptake in the study sites. A negative effect of their operation is the tendency to exceed their service provision limits, which has spurred a planned tiered PMV accreditation system. Conclusions This study has highlighted the contextual factors which define the roles and scope of practice of PMVs involved in injectable contraceptive service provision. Strategies and interventions aimed at expanding the healthcare delivery roles of PMVs must be encompassing to address the broader contextual factors which underpin their capacities and functions.Item Temporal trends in overweight and obesity and chronic dease risks among adolescents and young adults: A ten-year review at a tertiary institution in Nigeria(Public Library of Science (PLoS), 2023) Oluwasanu, A. O.; Akinyemi. J. O.; Oluwasanu, M. M.; Oseghe, O. B.; Oladoyinbo, O. L.; Bello, J.; Ajuwon, A. J.; Jegede, A. S.; Danaei, G.; Akingbola, O.There is an increasing prevalence of obesity among college/university students in low- and middle-income countries, similar to the trend observed in high-income countries. This study aimed to describe the trend and burden of overweight/obesity and emerging associated chronic disease risks among students at the University of Ibadan (UI), Nigeria. This is a ten-year retrospective review of medical records of students (undergraduate and post-graduate) admitted between 2009 and 2018 at UI. Records of 60,168 participants were analysed. The Body Mass Index (BMI) categories were determined according to WHO standard definitions, and blood pressure was classified according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7). The mean age of the participants was 24.8, SD 8.4 years. The majority were ≤ 40 years (95.1%). There was a slight male preponderance (51.5%) with a male-to-female ratio of 1.1:1; undergraduate students constituted 51.9%. The prevalence of underweight, overweight, and obesity were 10.5%, 18.7% and 7.2%, respectively. We found a significant association between overweight/obesity and older age, being female and undergoing postgraduate study (p = 0.001). Furthermore, females had a higher burden of coexisting abnormal BMI characterised by underweight (11.7%), overweight (20.2%) and obese (10.4%). Hypertension was the most prevalent obesity-associated non-communicable disease in the study population, with a prevalence of 8.1%. Also, a third of the study population (35.1%) had prehypertension. Hypertension was significantly associated with older age, male sex, overweight/obesity and family history of hypertension (p = 0.001). This study identified a higher prevalence of overweight and obesity than underweight among the participants, a double burden of malnutrition and the emergence of non-communicable disease risks with potential lifelong implications on their health and the healthcare system. To address these issues, cost-effective interventions are urgently needed at secondary and tertiary-level educational institutions.Item Process evaluation of an intervention to improve access to injectable contraceptive services through patent medicine vendors in Nigeria: a mixed methods study(Springer Nature, 2021) Oluwasanu M. M.; Adebayo, A. M.; Okunade, F. T.; Ajayi, O.; Akindele, A. O.; Stanback, J.; Ajuwon, A. J.Background: The low utilisation of modern contraceptives in many low- and middle-income countries remains a challenge. Patent medicine vendors (PMVs) that operate in the informal health sector, have the potential to address this challenge. Between 2015 and 2018, the Population Council, in collaboration with the Federal and State Ministries of Health and the Pharmacy Council of Nigeria, trained PMVs in six states to deliver injectable contraceptive services. Outcome evaluation demonstrated increased client uptake of injectable contraceptive services; however, there is limited information on how and why the intervention influenced outcomes. This study was conducted to elucidate the processes and mechanism through which the previous intervention influenced women’s utilisation of injectable contraceptive services. Methods: The study utilised a mixed methods, convergent parallel design guided by the UK Medical Research Council framework. Quantitative data were obtained from 140 trained PMVs and 145 of their clients in three states and 27 in-depth interviews were conducted among relevant stakeholders. The quantitative data were analysed descriptively, while the qualitative data were analysed thematically. Results: The results revealed that even after the completion of the PMV study which had a time-bound government waiver for injectable contraceptive service provision by PMVs, they continued to stock and provide injectables in response to the needs of their clients contrary to the current legislation which prohibits this. The causal mechanism that influenced women’s utilisation of injectable contraceptives were the initial training that the PMV received; the favourable regulatory environment as demonstrated in the approval provided by government for PMVs to provide injectable contraceptives for the duration of the study; and the satisfaction and the confidence the female clients had developed in the ability of the PMVs to serve them. However, there were gaps with regards to the consistent supply of quality injectable contraceptive commodities and in PMVs use of job aids. Referral and linkages to government or private-owned facilities were also sub-optimal. Conclusion: PMVs continue to play important roles in family planning service provision; this underscores the need to formalize and scale-up this intervention to aid their integral roles coupled with multi-faceted initiatives to enhance the quality of their services.Item Perception of blindness and blinding eye conditions in rural communities(2006-06) Ashaye, A.; Ajuwon, A. J.; Adeoti, C.Purpose: The purpose of this qualitative study was to explore the causes and management of blindness and blinding eye conditions as perceived by rural dwellers of two Yoruba communities in Oyo State, Nigeria. Methods: Four focus group discussions were conducted among residents of Iddo and Isale Oyo, two rural Yoruba communities in Oyo State, Nigeria. Participants consisted of sighted, those who were partially or totally blind and community leaders. Ten patent medicine sellers and 12 traditional healers were also interviewed on their perception of the causes and management of blindness in their communities. Findings: Blindness was perceived as an increasing problem among the communities. Multiple factors were perceived to cause blindness, including germs, onchocerciasis and supernatural forces. Traditional healers believed that blindness could be cured, with many claiming that they had previously cured blindness in the past. However, all agreed that patience was an important requirement for the cure of blindness. The patent medicine sellers' reports were similar to those of the traditional healers. The barriers to use of orthodox medicine were mainly fear, misconception and perceived high costs of care. There was a consensus of opinion among group discussants and informants that there are severe social and economic consequences of blindness, including not been able to see and assess the quality of what the sufferer eats, perpetual sadness, loss of sleep and dependence on other persons for daily activities. Conclusion: Local beliefs associated with causation, symptoms and management of blindness and blinding eye conditions among rural Yoruba communities identified have provided a bridge for understanding local perspectives and basis for implementing appropriate primary eye care programs.Item Outcome of a research ethics training workshop among clinicians and scientists in a Nigerian university(2008-01) Ajuwon, A. J.; Kass, N.Background: In Nigeria, as in other developing countries, access to training in research ethics is limited, due to weak social, economic, and health infrastructure. The project described in this article was designed to develop the capacity of academic staff of the College of Medicine, University of Ibadan, Nigeria to conduct ethically acceptable research involving human participants. Methods: Three in-depth interviews and one focus group discussion were conducted to assess the training needs of participants. A research ethics training workshop was then conducted with College of Medicine faculty. A 23-item questionnaire that assessed knowledge of research ethics, application of principles of ethics, operations of the Institutional Review Board (IRB) and ethics reasoning was developed to be a pre-post test evaluation of the training workshop. Ninety-seven workshop participants completed the questionnaire before and after the workshop; 59 of them completed a second post-test questionnaire one month after the workshop. Results: The trainees came from a multi-disciplinary background including medicine, nursing, pharmacy, social science and laboratory science. The mean scores for knowledge of the principles of research ethics rose from 0.67 out of 3 points at pre-test to 2.25 at post-test (p < 0.05). Also, 42% correctly mentioned one international guideline or regulation at pretest, with most of those knowing of the Declaration of Helsinki. Trainees' knowledge of the operations of an IRB increased from 6.05 at pre-test to 6.29 at post test out of 7 points. Overall, participants retained much of the knowledge acquired from the workshop one month after its completion. Conclusion: The training improved participants' knowledge of principles of research ethics, international guidelines and regulations and operations of IRBs. It thus provided an opportunity for research ethics capacity development among academic staff in a developing country institution.Item Outcome of interventions to improve the quality of reproductive health services provided by private health facilities in selected states in Nigeria(2006) Ajuwon, A. J.; Okuribido, B.; Sadiq, A.; Ajibola, A; Delano, G. E.In Nigeria, as in many developing countries, the private health sector provides a significant proportion of reproductive health services. However, there are concerns about the quality of the reproductive health services provided by personnel operating in this sector. Few interventions exist to improve the quality of reproductive health services being provided by private practitioners. This three year intervention project, which was implemented in Oyo, Ogun and Gombe States, was designed to improve the capacity of personnel working in the private sector to deliver quality reproductive health service to their clients. One hundred and thirty nine privately owned health facilities participated in the project. Baseline data were collected from staff and clients using these facilities through self-completed questionnaires. A total of 458 nurses/auxiliaries were trained to improve their counseling and service delivery skills; 138 proprietors/proprietresses were trained on total quality management to enhance the quality of reproductive health service; and 84 physicians' knowledge were updated on reproductive health/family planning, and post-abortion care. Provision of contraceptive, drugs for treatment of sexually transmitted infections, supply of equipment and development of educational materials were the other components of the intervention. A follow-up survey was conducted three years after implementing the interventions to gauge outcome. At baseline, only 35.2% managed postpartum sepsis compared to 97.8% at follow-up. Thirty-nine percent provided post-abortion care at baseline the figure rose to 97.2% at follow-up. The proportion of respondents who reportedly provided family planning services increased from 39.5% at baseline to 43.0% at follow-up. Report of managernent of persons living with HIV/AIDS increased from 16.0% to 24.3% while counseling services increased from 36.1 % to 37.6%. At baseline, only 55% of the health workers reported that they had male condoms in stock, the figure rose to 88.2% at follow-up. Sixty-one percent of clients reported that it took 1- 5 minutes before being attended at follow-up, compared to 95% who claimed they spent about an hour before receiving care at baseline. The interventions improved availability and quality of reproductive health services provided by private health facilities. Similar interventions should be replicated to scale up the proportion of private health facilities that provide quality reproductive health services in the country.Item Indigenous surgical practices in rural southwestern Nigeria: implications for disease prevention(Oxford University Press, 1995) Ajuwon, A. J.; ||Brieger, W. R.; ||Oladepo, O.; Adeniyi, J. D.A qualitative, community-based study was conducted in the rural community of Ago Are in southwestern Nigeria to learn about indigenous surgical practices and their potential for disease transmission. Community leaders as key informants assisted in identifying two types of indigenous practitioner whose work involved blood contact, whose work was observed. The olola are surgeons who specialize in circumcision and making traditional facial-markings, while the generic term for healer, onisegun, performed gbeere, that is making incisions into which medicinal herbs are rubbed. Although the onisegun used a clean blade for his procedures, he rubbed the herbs into the cuts with his bare hands. The olola used the same knife for all operations and cleaned it simply by rinsing it in a bowl of water. The potential for HIV transmission between practitioner and clients and among clients during these procedures is discussed-as is the potential of health education for reducing the demand for female circumcision and training indigenous healers in hygienic methods.Item Evaluation of a school-based reproductive health education program in rural South Western,Nigeria(2007) Ajuwon, A. J.; Brieger, W. R.This quasi-experimental study compared the relative efficacy of teacher instructions alone, peer education alone, and a combination of these two on reproductive health knowledge, attitude, perceived self-efficacy and sexual practices among secondary schools students in the lbarapa district of Southwestern Nigeria. A baseline questionnaire was administered to a systematic sample of students in four schools that were randomized into four treatment arms: teacher instructions alone (E1), peer education alone (E2), combination of teacher instruction and peer education (E3), and control, The results were used to design the contents of the interventions, which were implemented for one academic session. A follow-up survey using the same sampling procedures as baseline was conducted to measure the outcome of the intervention. The control group had superior reproductive health knowledge at baseline. By follow-up survey however, all three intervention schools showed significant knowledge gains, while the control school students' mean score increased slightly. Increase in knowledge was greatest among E3 (+5.0 points), followed by E2 (+3.4), E1 (+1.4) and C (0.3). The intervention schools showed a significant positive shift in attitude towards use of contraceptives with mean increase of 0.6, 0.5, and 0.9 points in E1, E2 and E3 respectively. Scores that measured the students' perceived self-efficacy for safe sex increased significantly among E1 (from 10.8 to 11.8) and E3 (from 10.4 to 12.6). Reported condom use was significantly higher among E2 (from 16.7 % to 62.8%) (p<0.05) and E3 (from 22.8% to 53%) (p<0.05) compared to E1 (28.6% to 47.4%) (p>0.05) and control (from 25% to 45.8%) (p>O.05). Overall, the students from E3 showed more improvement in knowledge, attitude and self-efficacy, than their counterparts from E2 and E3 and control. Multiple intervention strategies have greater potential of improving reproductive health of studentsItem Ethical and methodological challenges involved in research on sexual violence in Nigeria(2008) Ajuwon, A. J.; Adegbite, O.Research on sexual violence is fraught with ethical and methodological challenges due to its sensitive nature. This paper describes the ethical and methodological challenges encountered in planning and conducting two exploratory studies on sexual violence that included in-depth interviews of eight female adolescent rape survivors in Ibadan and four married women in Lagos Nigeria who were raped, forced to perform sexual acts and sexually deprived. The first challenge encountered was an Institutional Review Board (IRB) requirement to obtain parental permission from adolescents, when such a requirement may place the adolescent at risk if a parent was a perpetrator of sexual violence. Using arguments emphasizing the Council for International Organization for Medical Sciences guidelines helped convince the IRB to provide a waiver of parental consent. Second, the privacy required to conduct in-depth interviews for rape survivors was difficult to achieve because five of the rape survivors were apprentices who work in public settings that which are typically used to conduct business In the informal sector. To overcome this challenge, interviews were conducted in safe locations, investigator's offices and homes of survivors. The culture of silence associated with sexual violence posed a challenge because it encourages perpetration of violence with impunity causing rape survivors to suffer in silence. None of the affected adolescents had sought judicial redress for rape despite availability of stringent punishment for this behaviour. Referral information was provided on where survivors could seek care. Interviews with the women could not be recorded on audio-tapes because of concerns that their partners might identify their voices from the tapes and punish them for this. Although research on sexual violence poses ethical and methodological challenges, it is not only desirable but also feasible to conduct such research in ways that ensure safety of participants.Item Sexual and reproductive health Knowledge, behaviour and education needs of In-School adolescents in northern Nigeria(2009-12) Adeokun, L. A.; Ricketts, O. L.; Ajuwon, A. J.; Ladipo, O. A.Adolescence is marked by progression from the appearance of secondary sexual characteristics to sexual and reproductive maturity. Curiosity about bodily changes is heightened. However, adolescents' perceived sexuality education needs have been poorly documented. A survey of 989 adolescents from 24 North-Eastern Nigerian secondary schools yielded information on socio-demographic characteristics, reproductive health knowledge, sexual activities and sexuality education needs. Of the interviewed respondents, 72% of females had experienced menstruation. Overall, 9% were sexually active, 3.1% knew when ovulation occurs, 47% knew pregnancy could result from first coitus and 56% knew of contraception. 84% opined that adolescents should be given sexuality education but only 48.3% had received any. Sexuality education should be provided for in-school adolescents through their preferred and reliable sources of information.