Inequity in access to childhood immunization in Enugu urban, Southeast Nigeria

BACKGROUND

The Nigerian National Programme on Immunization aims at increasing the immunization coverage of children under 1 year of age. However, there is still a gap between the national immunization targets and the immunization coverage rates, and data are rarely disaggregated according to socioeconomic status. As a result, there is a dearth of information about the coverage of subgroups, especially at the local level. This study determined the socioeconomic differentials in immunization coverage for children under 5 years and under 1 year in Enugu urban, Southeast Nigeria.

METHODS

This was a community-based, descriptive cross-sectional study in Enugu urban of Southeast Nigeria. A modified 30 × 7 cluster sampling design was adopted as the sampling method to select and interview 462 mothers of 685 children under the age of 5 years on their sociodemographic and economic characteristics and immunization status of their children. Principal components analysis in STATA software was used to characterize socioeconomic inequity.

RESULTS

Immunization coverage was as follows: Diphtheria, pertussis, tetanus third dose(DPT3), 3, 65.3%; oral polio vaccine 3, 78.0%; hepatitis B3, 65.2%; and measles, 55.8%. The full immunization rates for children 1-5 years and st year of life was selected as the reference group, the immunization rates in all other age groups decreased significantly. Using the same logistic regression model for children under 1 year of age, every added month of the child's life increased the full immunization coverage, and this was statistically significant (OR 2.752, 95% CI 2.304-3.418).

CONCLUSIONS

Full immunization coverage for children aged < 1 year was lower than the national target of 95%. There are differences in immunization coverage rates between different wealth quartiles in the area with the least poor benefiting more than the poorest, thus creating equity problems. Health managers need such community-based information about the vaccination status of their target population to plan and implement interventions that aim to improve immunization coverage in these areas.

BWS Experience in Integrating Cancer Care

Background and context: Nigeria, being the most populous African country has the highest cancer burden. Fragmentation of healthcare services leads to late presentation, inappropriate navigation, delay in diagnosis, intervention and an increased loss to follow-up. Aim: To have a harmonized and fast-tracked cancer diagnosis and management via providing an integrated cancer care and effective navigation to tertiary hospitals, when required. Strategy/Tactics: We set up a center to screen, diagnose and treat cancers in partnership with collaborators, at low cost to patients. Program/Policy process: The BWS (Breast Without Spot) Screening and Wellness Centre was set up in 2016 to offer cancer/NCD education, screening services for cancers and other noncommunicable diseases. A multidisciplinary volunteer team takes care of diagnostic ultrasound, ultrasound-guided biopsies, cryotherapy of premalignant cervical lesions, histopathology and chemotherapy. Where radiotherapy and surgery are indicated, patients are navigated appropriately to our collaborators in tertiary hospitals. Outcomes: 721 persons were seen. 112 men and 609 women, 14 men had PSA/DRE and 411 women had VIA and CBE. 58 women had sonomammography while 9 with suspicious masses had ultrasound-guided biopsies followed by histologic diagnosis and IHC for proven malignancy. In the women with proven breast cancer, 7 underwent chemotherapy while 8 were navigated to radiation therapy and surgery. What was learned: There is improved patient experience and compliance when there is an accessible “one stop” facility for their care. Early detection, prompt diagnosis and facilitated treatment improves prognosis. With prompt access to care, patients feel supported and eager to go through the entire cancer care process.

Bridging the Funding Gap for Oncology Services in LMIC: The BWS Cancer Patient Treatment Intervention Fund Project

Amount raised: #1,627,000 (Nigerian Naira) Background and context: With a large population and very limited resources, the economic burden of cancer in our country is enormous and cannot be tackled solely by the government. A high mortality rate among newly diagnosed patients is a direct result of poverty and lack of an effective health insurance coverage for cancer, among other reasons. Breast cancer accounts for two out of five women cancers, with a 70% mortality. Aim: To alleviate the financial burden of cancer treatment on indigent patients. Strategy/Tactics: We constituted the Cancer Patient Treatment Intervention Fund (CPTIF) board of partners and funders. We also inaugurated a fundraising event, the annual Go Pink Day Ball, and instituted crowd-funding schemes. Program process: Indigent patients diagnosed at BWS and designated health facilities are referred to CPTIF for financial support. The patient is reviewed for eligibility by the medical board. If approved by the CPTIF Board of Directors, the required funds are paid directly to the designated tertiary health facility where patient will be receiving the oncology services. Costs and returns: Between December 2017 and March 2018 a total of #1,627,000 (Nigerian Naira) was raised, a total of #750,950 has been spent on 7 patients at different levels of oncology services. The cost covered included laboratory tests, ultrasounds, biopsies chemotherapy and radiotherapy. What was learned: Financial assistance gave these patients a lifeline and zeal to go through the usually overwhelming cancer treatment process.

BWS Effort in Cancer Screening in Rural Communities

Background and context: Nigeria, being the most populous African country has the highest cancer burden. Most of the population reside in rural areas where there are no functional health centers. Life in these communities is marked by profound ignorance, superstition and stigma, concerning cancers. There is no cancer control plan in place in the country. Aim: BWS aims at increasing awareness of the need for prevention and early detection of cancers. Strategy/Tactics: Three-pronged approach of education, screening and vaccination, with navigation where required. Monthly education and cancer screening in rural communities. Provision of a navigation system of medical follow-up for patients with a positive screening result; establishing treatment and support care for patients and recruiting and training volunteers and local advocates for cancer awareness campaigns. Program/Policy process: Monthly education/enlightenment activities in various rural communities in southeast Nigeria. Dissemination of information on screening activities is done via church and other community groups; town criers, WhatsApp, radio and banners at strategic locations. Outcomes: A total of 1990 participants (1388 females and 602 males) were screened from January 2016 to December 2017. 1342 women had CBE, 96 were referred for mammography. 105 out 1041 females who had VIA with colposcopy were positive and 26 of them had cryotherapy. 426 girls and young women (9-26 years) received HPV vaccination. 12 out of 204 men who had PSA tests were positive and referred to urologists. Since the launch of project Rid Nigeria of Late Cancer Detection in 2016, BWS has acquired a physical infrastructure for daily screening and continued her monthly rural screening services. What was learned: Women need to take permission from their husbands to even get screened, therefore involvement of traditional rulers, local government chairmen, opinion molders, leaders of faith-based organizations, and local cancer advocates from the community, is helping to increase awareness and reduce stigmatization. Taking the screening to the community is helping combat “late presentation syndrome”. However, financing rural awareness and screening is quite a challenge without financial support.

Development and Evaluation of the Use of Local Materials for Medical Simulation in Cancer Education in Nigeria

Background: Lower competence and poorer training of healthcare professionals (HCP) are among the many limitations of cancer control in Nigeria. These manifest as deficiencies in advocacy, screening/diagnostic practices, and patient management. Medical simulation (MS) using models is an effective approach for sustainably improving the competence of HCP. Access to modern, silicone-based simulation models is limited in Nigeria. Cassava starch and papaya fruits are widely available in Nigeria and the tropics, but not widely used for MS. Aim: Study describes the development and evaluation of the use of locally-available materials (cassava starch and immature papaya) as MS models for Papanicolaou test and breast biopsy. Methods: Immature papaya fruits were harvested and using a sharp knife, the stalk was removed to reveal the moist cavity. The space housing the stalk was simulated as the external cervical os ( Fig 1 ). Dried cassava starch was sourced as waste from the pulp. About 100 g of starch was dissolved in a cup using cold water. Boiling water at 100°C was added to the cup and stirred into a thick gel. Gel was poured into a clear polythene bag and shaped into a broad-based dome, to simulate a breast. About 2 cm cuts of ripe plantain were embedded into the gel to simulate breast mass (Fig 2). Clinicians attending a cancer education course were trained on Papanicolaou test using the papaya model, and breast core-biopsy using the gel, respectively. Training also covered clinical breast (CBE) and pelvic examinations (PE). Pre and posttraining surveys with comments evaluating self-reported comfort levels were basis for comparison. Data analysis included descriptive statistics, Wilcoxon signed rank test, χ2 and thematic analysis. Results: Of the 92 course participants (physicians-36, nurses-16), 51 completed the course evaluation forms (response rate=55.4%; 51/92), and average number of years in practice was 8 (±5.2) years. Only 3 physicians had performed Tru-Cut biopsy previously. There was significant improvement in median self-reported comfort level for Tru-Cut (pre=2 {IQR 2-2}, post=4 {4-5}, P < 0.001). Significant improvements were also recorded for median comfort-levels on CBE (4 vs 5, P < 0.01) and PE (4 vs 5, P < 0.01). According to some participants, “it gives a visual view of organs that are not obvious. It is excellent” (#2). “it is very good semblance of a living structure; this goes to enhance hands-on practice” (#41); “simulation helps to build up confidence and improves precision prior to using actual patients” (#19); “excellent! it should be highly recommended for medical training” (#49). Conclusion: Locally-available immature papaya and cassava starch are good MS materials. Their use improved self-reported comfort levels in patient evaluation. Participants recommend widespread use of MS for continuing medical education and undergraduate training. Further studies should evaluate use of cassava starch for breast ultrasound training.[Figure: see text][Figure: see text]

Exploratory Use of Cloud Computing and Social Media for Prostate Cancer Advocacy in Nigeria

Background and context: Prostate cancer is the commonest cancer affecting Nigerian men, with worse outcome compared with men from the developed world. There is limited public awareness about prostate cancer in Nigeria. Oga Blue 4 Prostate Awareness (OB4PA) was created by a consortium of Nigerian nonprofits for prostate cancer advocacy (PCA). Aims: -Design PCA using videos, printed brochure and social media -Implement PCA in five Nigerian states -Evaluate the reach and impact of PCA campaign Program/Policy process: Community-based participatory process, involving the medical community, prostate cancer survivor, and the public was used. Multimedia teaching was used to enhance learning and retention; social media was used to engage groups and individuals. Content development involved iterative consultation among project leaders, medical experts and target audience, often on social media. High-quality teaching videos were recorded in English and Nigerian Pidgin languages. Videos ensured consistency and ease of broadcast. Videos were accessed by OB4PA partners through cloud computing (OneDrive). Facebook was used to promote the campaign, engage local audience, and for Facebook Live presentation. Local health professionals projected the video in appropriate language to audiences in religious and community groups. Brochure detailing clinical features and local service providers was distributed. Audience evaluation was obtained following each interaction. Outcomes: In 6 weeks, 20 presentations were made to 1800 persons. The Facebook Live presentation had 1500 views, reached 9302 people and was shared 107 times. A total of 25 Facebook posts were made, resulting in 628 like, 1908 video views, 160 shares, and reached 14,222 people. Almost all participants had positive feedback on the free and detailed advocacy. Most questions focused on the causes and prevention of prostate cancer, especially on the use of nutritional supplements. What was learned: Cloud computing enabled us to have one presenter; this eliminated the need to find a presenter for each organization. Audience appreciated simplified videos used in explaining the disease process and need for personalized early detection. Facebook live presentation attracted the most reactions on social media, with most comments showing that people liked the intervention. Audience feedback showed that adding advocacy cellphone video by a survivor helped demystify prostate cancer. Having the main presentation video in different file formats and sizes enhanced sharing on social media, as most Nigerians access the Internet on cell phones. Reliable access to projectors was challenging, especially in remote areas. Overall, use of cloud computing and social media were crucial in the success of the PCA project. Lessons from OB4PA informed the design of the current We Can, I Can Conquer Cervical Cancer Awareness project in Nigeria.

Increasing Cancer Awareness Through BWS Social Media Activities

Background and context: Information is key. The Nigerian Communications Commission released a statement in December 2017 that 98.3 million people in Nigeria use the Internet. The increasing number of people that use social media and the unlimited access is a reason to do some level of awareness on these platforms. A huge opportunity to pass information and save lives in the process will be missed by not engaging social media. Aim: To increase awareness for prevention and early detection of cancer via social media and forming an online community in the process. Strategy/Tactics: Creation of cancer-related engaging contents with words, pictures and videos such as general information about cancer, preventive measures among others to get the attention of the audience and consistent posting of these contents. Informing the general public of our free screening exercises and activities. Program/Policy process: Creation of a content calendar for our posts on specific days and times, targeting of online audience through age, sex and location among others considering the campaign we want to push at a given time. Outcomes: After 3 months, we had 48,765 reach and 17,223 impressions on Facebook, 47,599 impressions on Twitter and 15,177 impressions on Instagram from 30 posts each. A very significant increase in the number of people that showed up to our vaccinations, screenings and other activities/programs. Positive response from people who were reached via social media, they were thankful for the basic information they got which they had no idea about. Dozens of people volunteered to work for our organization to help get rid of cancer. What was learned: Social media enabled us to reach a good number of people easily. Our target audience was very grateful for the information they got. In summary, the use of social media in raising awareness and passing information was very effective.