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Background: Clinical deterioration in critically ill patients is a common phenomenon that can occur several hours before an adverse outcome. Early detection of subtle changes in vital signs, such as alterations in pulse rate and blood pressure, is crucial for preventing adverse events. However, these are not often recognized early enough to prompt quick intervention. The use of warning scores or assessment systems in the management of the critically ill in Nigeria has not been well evaluated. We assessed the association between the National Early Warning Score (NEWS) system and outcomes particularly mortality among the critically ill at the Jos University Teaching Hospital (JUTH), Nigeria., Methodology: This study is a retrospective study involving adults admitted to the medical and surgical wards between January 2021 and July 2021. Patient medical records were used to obtain data such as socio-demographics, and vital signs, which were used to compute the NEWS variable, diagnosis, length of stay, outcomes, and complications. Patients were classified as low, medium, and high-risk based on their NEWS scores within the first 24 hours of admission and 24 hours prior to the outcome of interest (death or discharge)., Results: A total of 405 patients were included in this study. Patients with low, medium, and high-risk NEWS scores within the first 24 hours of admission, had an 11.1%, 9%, and 17% chance of death respectively. In the NEWS score high-risk group 24 hours prior to outcome (death or discharge), the risk of mortality increased to 20.6% and there was a four-fold increase in odds of death., Conclusion: Our results showed that the NEWS score predicted outcome and may suggest that the implementation of the NEWS score as a routine tool for monitoring inpatients at the Jos University Teaching Hospital could help to detect patients at risk of adverse events., (Copyright © 2023 Nigerian Medical Association.)

Health workers have to balance their own welfare vs. that of their patients particularly when patients have a readily transmissible disease. These risks become more consequential during an outbreak, and especially so when the chance of severe illness or mortality is non-negligible. One way to reduce risk is by reducing contact with patients. Such changes could be along the intensive or extensive margins. Using data on primary care outpatient encounters during the early months of the Covid-19 pandemic, I document important changes in the intensity of provider-patient interactions. Significantly, I find that adherence to clinical guidelines, the probability that routine procedures such as physical examinations were completed, and even the quality of information given by health providers, all declined sharply. I present evidence that these effects likely reflect risk mitigation behavior by health providers., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: The COVID-19 pandemic has led to hundreds of thousands of deaths worldwide., Aims: Being a novel viral disease, we sought to evaluate the knowledge and practice of doctors and nurses in a tertiary hospital regarding the disease., Subjects and Methods: Using a self-administered questionnaire, respondents were asked questions on the cause, clinical features, and prevention of COVID-19., Results: : We studied 409 respondents (238 doctors and 171 nurses) with a mean age of 34 ± 7 years and a median length of experience of five (IQR 2-9) years. The mean knowledge score was 9.6 ± 1.2 out of a maximum of 12 points with 337 (82.4%) respondents having good knowledge. The majority of respondents (62.8%) had not been trained on infection prevention and control since the outbreak of the pandemic. Only 95 (23.2%) had seen COVID-19 Standard Operating Procedures (SOP) displayed in the hospital. The use of the personal protective equipment (PPE) kit comprising the N-95 mask, face shield, gown, and shoes was seen by 194 (47.4%) respondents in recent times. A total of 397 (97.0%) respondents felt they were at an increased risk of contracting COVID-19 relative to the general populace. Measures taken to prevent COVID-19 included: wearing of face mask (68.7%), hand gloves (78.2%), frequent use of hand sanitizers (84.1%), frequent hand washing (84.8%), the daily wash of uniforms and ward coats (44.5%), daily cleaning of footwear (31.7%), and avoidance of taking home clothing and footwear worn in the hospital (54.2%)., Conclusion: Despite having good knowledge of transmission and clinical features of SARS-CoV 2, the utilization of protective measures by HCW in this study is unsatisfactory., Competing Interests: None

The COVID-19 pandemic has put severe pressure on health care systems worldwide. Although attention has been focused on COVID-19 hospitalizations and deaths, some experts have warned about potentially devastating secondary health effects. These effects may be most severe in low- and middle-income countries with already weak health care systems. This study examines the effect of the COVID-19 pandemic on early infant deaths, a question that is currently unsettled. We present new evidence from Nigeria showing that early infant deaths have significantly increased during the pandemic. Using data on the birth outcomes of a large and diverse cohort of pregnant women enrolled in a prospective study and a quasi-experimental difference-in-differences design, we found a 1.1-percentage-point (22 percent) increase and a 0.72-percentage-point (23 percent) increase, respectively, in stillbirths and newborn deaths. Our findings show that the health effects of the pandemic extend beyond counted COVID-19 deaths. If these findings generalize to other low- and middle-income countries, they may indicate that the hard-won gains in child survival made during the past two decades are at risk of being reversed amid the ongoing pandemic. Policies addressing disruptions to health services delivery and providing support to vulnerable groups-specifically to households with pregnant women-will be critical as the pandemic continues.

This paper documents important mental health spillovers in the context of a program that offered pregnant women modest cash incentives to use pre- and perinatal health care services. Program participation was randomized and the payments were made after the birth of the child (and after the completion of an endline mental health assessment). I present causal evidence that the program led to improvements in mothers' mental health. The effect size ranges from a 1-3 percentage point reduction in postpartum depression measured using the Edinburgh Postnatal Depression Scale. I present suggestive evidence that these beneficial effects on mental health may be related to program-induced improvements in child health. These results provide novel evidence that programs designed to improve birth outcomes may generate unanticipated spillover effects on mental health., (© 2021 Rand Corporation. Health Economics published by John Wiley & Sons Ltd.)

During a health pandemic health workers have to balance two competing objectives: their own welfare vs. that of their patients. Intuitively, attending to sick patients during a pandemic poses risks to health workers because some of these patients could be infected. One way to reduce risk is by reducing contact with patients. These changes could be on the extensive margin, e.g., seeing fewer patients; or, more insidiously, on the intensive margin, by reducing the duration/intensity of contact. This paper studies risk avoidance behavior during the Covid-19 pandemic and examines implications for patient welfare. Using primary data on thousands of patient-provider interactions between January 2019 and October 2020 in Nigeria, I present evidence of risk compensation by health workers along the intensive margin. For example, the probability that a patient receives a physical examination has dropped by about a third. I find suggestive evidence of negative effects on health outcomes.

Background: Stroke is the second leading cause of death worldwide. Stroke mortality has been shown to be higher in blacks in multiracial studies. It is also a very important cause of disability with its attendant deterioration in the quality of life in survivors., Objective: The study sought to determine the risk and prognostic factors associated with stroke in Jos, North Central Nigeria., Methods: A prospective cohort study of stroke patients that were followed up for 90 days to determine outcomes. The stroke patients were admitted into the neurology unit of Jos University Teaching Hospital between September 2016 and August 2018., Results: We recruited a total of 246 subjects comprising 131 (53.3%) males aged 59.5 ± 13.1 years and 115 (46.6%) females aged 56.7 ± 14.2 years. Obesity, hypertension, dyslipidaemia and alcohol consumption were the commonest risk factors identified. The 90-day case fatality rate of stroke was 22%. Elevated glycated haemoglobin (p = 0.001), loss of consciousness at presentation (p <0.001), atrial fibrillation (p= 0.022), cardiac disease (p < 0.001) and HIV infection (p = 0.001) were significantly associated with poor outcome for stroke. Furthermore, subjects with a high NIHSS had three times the risk of death compared with those with low scores (RR = 2.93; 95% CI = 2.38 - 3.61, p <0.001)., Conclusion: The prognosis of stroke was poor. The predictors of poor stroke outcome were coma, HIV infection, cardiac disease, high NIHSS and total cholesterol., Competing Interests: The authors certifies that there is no conflict of interest in connection with the submitted article, (Copyright © 2021 by West African Journal of Medicine.)

Ninety-nine percent of global maternal deaths occur in low- and middle-income countries. The high mortality rates are often attributed to a large portion of births occurring outside of formal health care facilities. This has prompted the creation of programs to promote the use of formal delivery care. However, poor-quality care in health facilities in low- and middle-income countries is well documented. It is not clear that shifting births into health facilities in these settings necessarily leads to better-quality care. We present results from a randomized controlled trial in Nigeria that evaluated a conditional cash transfer intervention that paid pregnant women to deliver in a health facility. We found that the intervention led to a 41 percent increase in facility deliveries. We also found improvements in the quality of delivery care (as a result of more births taking place in formal health care settings) and in overall satisfaction with care. We found no evidence of a reduction in preventable complications that led to maternal deaths, though we found some improvements in self-reported health. Our results indicate that promoting facility deliveries can improve the quality of care received, even in settings where formal care quality is poor. However, modest quality improvements might not be sufficient to substantially improve health outcomes.

Households in poor countries are encouraged (and sometimes coerced) to increase investments in formal health care services during pregnancy and childbirth. Is this good policy? The answer to a large extent depends on its effects on child welfare. We study the effects of a cash transfer program in Nigeria in which households were offered a payment of $14 conditioned on uptake of health services. We show that the transfer led to a large increase in uptake and a substantial increase in child survival driven by a decrease in in-utero child deaths. We present evidence suggesting that the key driver is prenatal health investments.

This paper examines the association between health facility quality, subjective perceptions, and utilization of obstetric care. We draw on unique survey data from Nigeria describing the quality of care at rural primary health care facilities and the utilization of obstetric care by households in the service areas of these facilities. Constructing a quality index using the detailed survey data, we show that facility quality is positively related to perceptions of quality and utilization. Disaggregating quality into structural, process and outcome dimensions, we find a consistently strong relationship only between utilization and structural measures of quality. The results suggest that efforts to improve quality may involve a trade-off between investing in dimensions that are more easily observed by households, which will influence utilization, and investing in dimensions that are more closely related to outcomes., Competing Interests: The authors have declared that no competing interests exist.

High rates of home births in developing countries are often linked to high rates of newborn deaths, but there is considerable debate about how much of this is causal. This paper weighs in on this question by analyzing data on the timing of birth, health care utilization, and mortality for a sample of births between 2009-2014 in 7021 rural Nigerian households. First, we show that timing of birth is strongly linked to use of institutional care: women with a nighttime birth are significantly less likely to use a health facility because of the difficulties associated with accessing care at night. In turn, this is associated with a sharp increase in the rate of newborn mortality at night. Leveraging variation in household proximity to a health care facility that offers 24-h coverage, we show that this increase in mortality is plausibly due to lack of formal health care at the time of birth: infants born at night to households without a nearby health care facility that offers 24-h coverage, experience an increase in mortality equivalent to about 10 additional newborn deaths per 1000 live births. In contrast, when households have a nearby health facility that provides care at night, there is no detectable increase in mortality. These results suggest that well-designed policies to increase access to (and quality of) formal care at birth may lead to significant reductions in newborn deaths., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Haematologic malignancies cause significant morbidity and mortality and are not uncommon in resource-limited-low income countries. However, the types, pattern of presentation and treatment outcomes vary across regions. We assessed the presentation and overall survival over an 11-year period in adult patients presenting with haematologic cancers in Jos, North Central Nigeria., Materials and Methods: This retrospective outcome study evaluated patients who presented with haematologic malignancies between 2005-2015 at the Jos University Teaching Hospital (JUTH), Jos. Variables of interest were abstracted through chart reviews. Descriptive statistics were used to evaluate baseline and follow-up parameters. Overall survival (OS) was assessed using Kaplan-Meier method., Results: Sixty patients, contributing 25,994 person-days of follow-up were evaluated. The mean age was 43+17 years and 61.7% were males. Thirty-one patients (51.7%) presented with leukemia, 45.0% with lymphoma, and 3.3% with multiple myeloma. Forty-two (70.0%) presented with advanced disease, 5 (5.2%) were HIV positive and 4 (6.7%) had died at the end of follow-up. OS was 84.3% (95% CI: 58.1-94.7). Survival differed by disease group (p=0.01) and having fever at presentation (p=0.02)., Conclusion: We found long-term OS to be impacted by disease type and status of fever at presentation. Disease-specific Strategies to improve early diagnosis and therapies are needed to ensure optimal outcomes in Nigerian patients.

Background: The incidence of non-communicable diseases (NCDs) is rising globally, with its attendant morbidity and mortality, especially in developing countries. This study evaluated the prevalence of NCDs and their risk factors among members of a university community., Methods: All employees of the university were invited to the University health clinic for screening, using the World Health Organisation's STEPwise approach to NCDs., Results: A total of 883 (521; 59.0% males) employees with a mean age of 44 ± 10 years were studied. The median (IQR) number of NCD risk factors was three (two to three) per participant. The most common NCD risk factors were inadequate intake of fruit and vegetables (94.6%; 95% CI: 92.8-95.9), physical inactivity (77.8%; 95% CI: 74.9-80.5%) and dyslipidaemia (51.8%; 95% CI: 48.4-51.6%). Others included obesity (26.7%; 95% CI: 23.9-29.8%), alcohol use (24.0%; 95% CI: 21.3-27.0%) and cigarette smoking (2.9%; 95% CI: 2.0-4.3). Hypertension was the most common NCD (48.5%; 95% CI: 45.1-51.8%), followed by chronic kidney disease (13.6%; 95% CI: 11.4-16.1) and diabetes mellitus (8.0%; 95% CI: 6.4-10.1). There was no gender-specific difference in the prevalence of NCDs., Conclusion: This study identified that NCDs and their modifiable risk factors are highly prevalent in this community. Workplace policy to support the adoption of healthy living is needed.

Background: The lack of availability of skilled providers in low- and middle- income countries is considered to be an important barrier to achieving reductions in maternal and child mortality. However, there is limited research on programs increasing the availability of skilled birth attendants in developing countries. We study the implementation of the Nigeria Midwives Service Scheme, a government program that recruited and deployed nearly 2,500 midwives to rural primary health care facilities across Nigeria in 2010. An outcome evaluation carried out by this team found only a modest impact on the use of antenatal care and no measurable impact on skilled birth attendance. This paper draws on perspectives of policymakers, program midwives, and community residents to understand why the program failed to have the desired impact., Methods: We conducted semi-structured interviews with federal, state and local government policy makers and with MSS midwives. We also conducted focus groups with community stakeholders including community leaders and male and female residents., Results: Our data reveal a range of design, implementation and operational challenges ranging from insufficient buy-in by key stakeholders at state and local levels, to irregular and in some cases total non-provision of agreed midwife benefits that likely contributed to the program's lack of impact. These challenges not only created a deep sense of dissatisfaction with the program but also had practical impacts on service delivery likely affecting households' uptake of services., Conclusion: This paper highlights the challenge of effectively scaling up maternal and child health interventions. Our findings emphasize the critical importance of program design, particularly when programs are implemented at scale; the need to identify and involve key stakeholders during planning and implementation; the importance of clearly defining lines of authority and responsibility that align with existing structures; and the necessity for multi-faceted interventions that address multiple barriers at the same time.

Background: Hepatocellular carcinoma is a leading cause of cancer-related death in Africa, but there is still no comprehensive description of the current status of its epidemiology in Africa. We therefore initiated an African hepatocellular carcinoma consortium aiming to describe the clinical presentation, management, and outcomes of patients with hepatocellular carcinoma in Africa., Methods: We did a multicentre, multicountry, retrospective observational cohort study, inviting investigators from the African Network for Gastrointestinal and Liver Diseases to participate in the consortium to develop hepatocellular carcinoma research databases and biospecimen repositories. Participating institutions were from Cameroon, Egypt, Ethiopia, Ghana, Ivory Coast, Nigeria, Sudan, Tanzania, and Uganda. Clinical information-demographic characteristics, cause of disease, liver-related blood tests, tumour characteristics, treatments, last follow-up date, and survival status-for patients diagnosed with hepatocellular carcinoma between Aug 1, 2006, and April 1, 2016, were extracted from medical records by participating investigators. Because patients from Egypt showed differences in characteristics compared with patients from the other countries, we divided patients into two groups for analysis; Egypt versus other African countries. We undertook a multifactorial analysis using the Cox proportional hazards model to identify factors affecting survival (assessed from the time of diagnosis to last known follow-up or death)., Findings: We obtained information for 2566 patients at 21 tertiary referral centres (two in Egypt, nine in Nigeria, four in Ghana, and one each in the Ivory Coast, Cameroon, Sudan, Ethiopia, Tanzania, and Uganda). 1251 patients were from Egypt and 1315 were from the other African countries (491 from Ghana, 363 from Nigeria, 277 from Ivory Coast, 59 from Cameroon, 51 from Sudan, 33 from Ethiopia, 21 from Tanzania, and 20 from Uganda). The median age at which hepatocellular carcinoma was diagnosed significantly later in Egypt than the other African countries (58 years [IQR 53-63] vs 46 years [36-58]; p<0·0001). Hepatitis C virus was the leading cause of hepatocellular carcinoma in Egypt (1054 [84%] of 1251 patients), and hepatitis B virus was the leading cause in the other African countries (597 [55%] of 1082 patients). Substantially fewer patients received treatment specifically for hepatocellular carcinoma in the other African countries than in Egypt (43 [3%] of 1315 vs 956 [76%] of 1251; p<0·0001). Among patients with survival information (605 [48%] of 1251 in Egypt and 583 [44%] of 1315 in other African countries), median survival was shorter in the other African countries than in Egypt (2·5 months [95% CI 2·0-3·1] vs 10·9 months [9·6-12·0]; p<0·0001). Factors independently associated with poor survival were: being from an African countries other than Egypt (hazard ratio [HR] 1·59 [95% CI 1·13-2·20]; p=0·01), hepatic encephalopathy (2·81 [1·72-4·42]; p=0·0004), diameter of the largest tumour (1·07 per cm increase [1·04-1·11]; p<0·0001), log α-fetoprotein (1·10 per unit increase [1·02-1·20]; p=0·0188), Eastern Cooperative Oncology Group performance status 3-4 (2·92 [2·13-3·93]; p<0·0001) and no treatment (1·79 [1·44-2·22]; p<0·0001)., Interpretation: Characteristics of hepatocellular carcinoma differ between Egypt and other African countries. The proportion of patients receiving specific treatment in other African countries was low and their outcomes were extremely poor. Urgent efforts are needed to develop health policy strategies to decrease the burden of hepatocellular carcinoma in Africa., Funding: None., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Informal health providers ranging from drug vendors to traditional healers account for a large fraction of health care provision in developing countries. They are, however, largely unlicensed and unregulated leading to concern that they provide ineffective and, in some cases, even harmful care. A new and controversial policy tool that has been proposed to alter household health seeking behavior is an outright ban on these informal providers. The theoretical effects of such a ban are ambiguous. In this paper, we study the effect of a ban on informal (traditional) birth attendants imposed by the Malawi government in 2007. To measure the effect of the ban, we use a difference-in-difference strategy exploiting variation across time and space in the intensity of exposure to the ban. Our most conservative estimates suggest that the ban decreased use of traditional attendants by about 15 percentage points. Approximately three quarters of this decline can be attributed to an increase in use of the formal sector and the remainder is accounted for by an increase in relative/friend-attended births. Despite the rather large shift from the informal to the formal sector, we do not find any evidence of a statistically significant reduction in newborn mortality on average. The results are robust to a triple difference specification using young children as a control group. We examine several explanations for this result and find evidence consistent with quality of formal care acting as a constraint on improvements in newborn health.