The study, led by O. A. Elebute of the Department of Surgery at the College of Medicine, University of Lagos, together with a multidisciplinary team spanning Lagos University Teaching Hospital, Duke University, Baylor University, the University of Edinburgh, McGill University and Nationwide Children’s Hospital, deployed the Surgeons OverSeas Assessment of Surgical Need, or SOSAS, tool. SOSAS is a structured household questionnaire designed specifically to measure the burden of surgical disease in low- and middle-income countries, where hospital records capture only a fraction of the true disease landscape. In 2016, the team surveyed 856 households in Ikorodu Local Government Area, covering 3,984 individuals: 1,986 adult informants answering on their own behalf and 1,998 children represented through parental or guardian responses.

The survey’s design reflected a deliberate conservatism. Disability was recorded only when an informant explicitly attributed functional impairment to a surgical condition, rather than allowing interviewers to infer it. Mortality questions covered the twelve months preceding the interview, and for the 43 deaths for which individual age data were available, the researchers calculated years of life lost, or YLL, using the World Health Organization’s 2015 life table for Nigeria. This metric, a cornerstone of the Global Burden of Disease framework, quantifies the gap between the age at death and the age to which a person could have expected to live under standard mortality conditions.

What the team found was striking in its asymmetry. Forty-six deaths were reported across the surveyed population, 32 among adults and 14 among children, but for 36 of those deaths, 78.3 percent, the cause could not be ascertained. The crude all-cause death rate stood at 11.5 per 1,000 persons, with a 95 percent confidence interval of 8.7 to 15.4. The total years of life lost amounted to 1,681.3 years, averaging 39.1 years per death, a figure that underscores how much potential life is extinguished when people die young in a community where life expectancy is already constrained.

On the morbidity side, the survey catalogued 169 classified pathology entries among adults, and the dominant category was unexpected to some observers: conditions of the extremities, meaning disorders of the arms and legs, accounted for 91 entries, or 53.8 percent of all classified surgical pathology. This finding aligns with a growing recognition in global surgery research that musculoskeletal problems, from untreated fractures to chronic infections and deformities, represent an enormous and underappreciated share of surgical need in resource-limited settings, where road traffic injuries and occupational hazards are common and orthopedic capacity is thin.

Yet the disability data told a quieter story. Only 20 adults, or 1.0 percent of the adult sample, and 4 children, or 0.2 percent of the child sample, reported perceived disability attributable to a surgical condition. When the researchers ran an exploratory calculation of years lived with disability, or YLD, using representative disability weights and a conservative one-year duration assumption for affected respondents, the total came to just 1.55 years. Combining this with the mortality burden produced a total of 1,682.9 disability-adjusted life years, or DALYs, equivalent to 422.4 per 1,000 persons. More than 99 percent of that total consisted of years of life lost rather than years lived with disability.

This overwhelming dominance of mortality over morbidity in the DALY calculation is the study’s most consequential technical finding, and the authors are careful to explain why it demands caution rather than celebration. Because 78.3 percent of reported deaths had unascertained causes, the team could not estimate any surgically attributable mortality at all. The DALY figure therefore represents a floor, not a ceiling, for the community’s surgical disease burden. If any of those 36 unexplained deaths were caused by surgically treatable conditions, such as strangulated hernias, obstructed labor, appendicitis, or trauma, the true surgical share of the burden would be higher than the study could detect. Household informants, even when cooperative and well-intentioned, often cannot reconstruct the biomedical cause of a death that occurred months earlier, particularly in settings where many people die at home without formal medical certification.

The low rate of perceived disability raises a parallel methodological question. The SOSAS tool’s strict criterion, requiring informants to explicitly link functional impairment to a surgical condition, is designed to avoid inflating estimates, but it may also undercount disability in communities where chronic limitations are normalized, attributed to other causes, or simply not framed in terms of surgery. A person living with an untreated clubfoot, a chronic burn contracture, or a painful hernia that limits heavy labor may not spontaneously identify their condition as a surgical problem, even though a surgeon would recognize it as one. Cross-national SOSAS studies in Sierra Leone, Nepal, and Uganda have reported higher disability prevalence, suggesting that local framing, awareness, and stigma all shape what households are willing or able to report.

For the researchers, the policy implications are clear even amid the data limitations. The findings support improved access to timely surgical care, stronger referral pathways that can move patients from community health posts to facilities with operating capacity, and, critically, better community mortality surveillance. Without reliable cause-of-death information, planners cannot know how many deaths in a given year were preventable through surgery, and the global movement to embed surgical care within universal health coverage, championed by the Lancet Commission on Global Surgery, depends on exactly this kind of population-level evidence. The 422.4 DALYs per 1,000 persons measured in Ikorodu, even as a conservative lower bound, provides a benchmark against which future interventions, from trauma system development to hernia repair campaigns, can be evaluated.

The study also carries a broader lesson for the science of measuring unmet surgical need. Household surveys like SOSAS are among the few tools capable of reaching populations that never present to hospitals, and their findings repeatedly reveal that the burden of surgical disease in low-resource settings is far larger than operative logs suggest. But this Lagos survey demonstrates that the same instruments face real constraints: mortality attribution is fragile, disability perception is culturally mediated, and conservative assumptions can dramatically compress estimated burden. The authors’ call for community mortality surveillance, systems that systematically record and verify deaths and their causes at the neighborhood level, is thus not merely a technical recommendation but a prerequisite for understanding whether surgical care, one of the most cost-effective interventions in medicine, is reaching the people who die without it. In Ikorodu, as in much of the world, the silent toll of untreated surgical conditions remains largely uncounted, and this study is a step toward making the invisible visible.

Subject of Research: Population-level burden of untreated surgical conditions, mortality and disability in Lagos, Nigeria

Article Title: A community survey of reported deaths and perceived disability associated with potentially untreated surgical conditions in a rural–urban population in Lagos, Nigeria: a SOSAS survey

Article References: Elebute, O. A., Odugbemi, T. O., Bankole, O. B., Makanjuola, A., Alabi, E. O., Abazie, O., Ademuyiwa, I. Y., Okusanya, B., Onwuka, A., Smith, E. R., Tran, T., Gupta, S., Ots, R., Harrison, E. M., Poenaru, D., Seyi-Olajide, J. O., Ladipo-Ajayi, O., Alakaloko, F. M., Bode, C. O., … Ademuyiwa, A. O. (2026). A community survey of reported deaths and perceived disability associated with potentially untreated surgical conditions in a rural–urban population in Lagos, Nigeria: a SOSAS survey. BMC Public Health. https://doi.org/10.1186/s12889-026-29936-z

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29936-z

Keywords: global surgery, SOSAS survey, Nigeria, Lagos, surgical conditions, years of life lost, disability-adjusted life years, household survey, public health, low- and middle-income countries, mortality surveillance, disability

The scale of the problem provides urgent context for the research. Globally, cervical cancer is the fourth most common cancer among women, with an estimated 662,000 new cases and 349,000 deaths reported in 2024. In Nigeria, it is the second most common cancer in women, contributing approximately 15,000 new cases and nearly 10,000 deaths annually. Human papillomavirus, the primary etiologic agent of cervical cancer, is a common sexually transmitted infection with more than 100 genotypes, including 13 high-risk types linked to cervical carcinogenesis. HPV types 16 and 18 alone account for about 70 percent of cervical cancer cases worldwide. Persistent infection with high-risk HPV can progress to precancerous lesions, invasive cervical cancer, and ultimately death, making early detection and vaccination critical tools in interrupting this trajectory.

Despite the proven benefits of HPV vaccination and screening, uptake in Nigeria remains strikingly low. Only 8.7 percent of women aged 18 to 69 have ever been screened, mainly due to limited awareness, cultural beliefs, stigma, and inadequate access to affordable services. HPV self-collection, though promising as a convenient, private, and empowering alternative to clinic-based pelvic examinations, is still emerging and underutilized, constrained by low awareness, limited self-efficacy, minimal provider recommendations, and scarce kit availability. Evidence demonstrates that HPV self-collection is equally effective at detecting high-grade cervical precancer and can substantially increase screening uptake. HPV vaccination continues to be a key element in primary prevention for eligible adolescents, lowering the risk of HPV infection and cervical cancer by as much as 90 percent. Notably, Nigeria recently achieved 71 percent first-dose HPV vaccination coverage among girls aged 9 to 14, immunizing nearly 12 million girls, a remarkable public health achievement that contrasts sharply with the persistent barriers to screening.

The study employed semi-structured, in-depth interviews lasting 45 to 60 minutes, conducted privately and in a culturally appropriate manner in English or Yoruba. Participants were recruited through purposive sampling from community-based settings including schools, marketplaces, churches, mosques, and health facilities across Lagos State, which has an estimated population of about 21 million distributed across 20 Local Government Areas. The research team, trained in semi-structured qualitative interviewing techniques and culturally sensitive research practices, applied the Consolidated Criteria for Reporting Qualitative Research to ensure rigorous and transparent reporting. Thematic analysis was guided by the PEN-3 Cultural Model, which organizes health behavior influences into three domains: Cultural Identity, Relationships and Expectations, and Cultural Empowerment. Data collection continued until saturation was reached, assessed separately within each age group, and coding was performed by two independent researchers who met regularly to resolve discrepancies.

The results revealed significant variations in knowledge about HPV and cervical cancer across age groups. Many younger participants had never heard of HPV, with statements like, “I have never heard about it,” and “This is like the first time I am hearing about it.” Among older women, knowledge was similarly limited, with one participant stating, “I don’t know anything about cervical cancer,” and another explaining, “It is cancer that occurs in the women in their private parts.” A few participants who were health professionals demonstrated accurate understanding, while some older women expressed confidence and self-efficacy in managing their health needs independently, with one 39-year-old stating, “I can do it myself as long as I am taught.” Conversely, others expressed hesitation, admitting, “I don’t think I can do it; I’d rather go to the hospital.”

Family influence emerged as a central theme shaping health decisions in both age groups. For HPV vaccination, girls reported that recommendations from the health ministry (86 percent), health providers (86 percent), and family and friends (64 percent) strongly influenced their decisions. Younger participants indicated that decisions about vaccinations heavily depended on family approval, with one stating, “Yes, they will have to allow me, for me to take it.” Among older participants, male partners played a pivotal role as either facilitators or barriers, with one woman noting, “Men can encourage us, like reminding you and all that,” while another stated, “If my husband says no, then I can’t go.” Some participants reported that family opinions would not ultimately prevent them from seeking preventive services, with one 35-year-old explaining, “It is necessary so I’ll make him understand… I will lecture him on why it is important.” For HPV self-collection, adult women prioritized messages from health providers (96 percent) and health ministry officials (89 percent).

Misinformation, stigma, and spiritual beliefs created significant barriers to prevention behaviors across both groups. Some participants voiced concerns about vaccine safety and quality within the Nigerian health system, with one stating, “You know Nigeria and expired vaccine, I don’t really trust Nigeria.” Misinformation about the vaccines was shared, including the belief that “the vaccine may prevent me from having children.” Among older participants, misconceptions about cervical cancer origins were evident, with beliefs such as “maybe somebody put it on the chair… It’s a curse,” and fears that self-collection samples “may use it for ritual… people are afraid.” Stigma towards reproductive health was demonstrated through statements like, “Women don’t want to talk about things that affect the private part,” and “Some people think it’s an abomination.” One participant reflected reliance on spiritual protection, stating, “I am not praying to get that kind of sickness… the sickness will not know me.”

Financial constraints and accessibility emerged as prominent structural barriers. Younger participants expressed concerns about the cost of vaccines, noting a narrow affordability range of 3,500 to 5,000 naira per dose, with one stating, “Cost, if it’s too expensive, then I can’t.” Older participants indicated willingness to pay small amounts, with one explaining, “I want it to be free… but maybe 500,” and another adding, “If it’s free, I’ll take my daughter for the vaccine, but I can only pay maybe 200 naira per dose.” While low costs were preferred, some participants were willing to pay more, typically 500 to 1,000 naira, and in a few cases up to 10,000 naira, depending on perceived importance and financial capacity. Participants across both groups expressed a strong preference for affordable, accessible vaccines and self-collection kits available at health facilities and pharmacies, with proximity and trust in the service provider being recurring themes.

Trust in healthcare providers and formal institutions emerged as a central determinant of HPV vaccine acceptance and self-collection participation. Participants expressed strong preferences for receiving services in trusted settings such as hospitals, pharmacies, and schools. Younger participants articulated a desire for vaccinations at recognizable healthcare facilities, with one stating, “I would prefer to get it from my hospital. I would least prefer an outreach like this.” Older participants echoed this sentiment, emphasizing the importance of local health facilities for accessibility, with remarks like, “I would prefer it at the pharmacy because it is nearby,” and “They should make it closer to the market.” Some participants expressed preference for hospitals over pharmacies, with one noting, “I prefer to get it from the hospital. I don’t know about these pharmacy people; they can just give you anything.”

The study’s findings carry significant implications for designing culturally grounded cervical cancer prevention strategies in Nigeria and similar low-resource settings. The researchers emphasize that future HPV prevention efforts should be community-based and family-inclusive, engaging parents, spouses, religious leaders, and community gatekeepers to ensure cohesive, informed, and sustained uptake of vaccination and self-collection services. Endorsements from health ministries, religious leaders, and high-profile public figures could enhance the perceived legitimacy of HPV vaccination. Equipping clinicians and pharmacists to actively recommend HPV vaccination and self-collection may enhance confidence in these preventive interventions. The authors suggest promoting positive cultural values, such as emphasizing cancer control rather than HPV as a sexually transmitted infection, and highlighting the maternal role in health decision-making. Addressing misinformation and stigma through targeted, socio-culturally appropriate educational initiatives within schools, faith-based institutions, and media platforms can help dispel misconceptions, normalize cervical cancer prevention, and support informed decision-making. The study acknowledges limitations including self-reported data subject to social desirability bias, a sample limited to Lagos State, and underrepresentation of younger adolescents due to consent and logistical issues. Nevertheless, the findings underscore that addressing structural, social, and cultural factors is crucial for increasing HPV vaccine coverage and promoting equitable cervical cancer prevention in Nigeria.

Subject of Research: Cultural and social facilitators and barriers influencing HPV vaccination and HPV self-collection preferences among Nigerian girls and women

Article Title: Her health, her choice: a PEN-3 exploration on facilitators, and preferences for HPV vaccinations and HPV self-collection among Nigerian girls and women

Article References: Olusanya, O. A., Kabutey, P., Koledowo, A., Wapmuk, A., Kokelu, E., Gbaja-biamila, T., Ojo, T., Akinsolu, F., Nwaozuru, U., Obi-Jeff, C., Anikamadu, O., Musa, A. Z., Kalulu, P., Veluri, R., Ong, J. J., Zhang, L., Smith, J. S., Xian, H., Azuogu, B., … Iwelunmor, J. (2026). Her health, her choice: a PEN-3 exploration on facilitators, and preferences for HPV vaccinations and HPV self-collection among Nigerian girls and women. Frontiers in Cancer Control and Society, 4, Article 1790326. https://doi.org/10.3389/fcacs.2026.1790326

Image Credits: AI Generated

DOI: 10.3389/fcacs.2026.1790326

Keywords: HPV vaccination, cervical cancer, HPV self-collection, Nigeria, PEN-3 Cultural Model, qualitative research, cervical cancer screening, health behavior, Lagos, cultural beliefs, women's health, misinformation

The research team, led by Folake O. Echebiri and including Akeem A. Abayomi, Najeem O. Oladosu, Kehinde O. Olayinka, and Babajide I. Alo, conducted monthly sampling at ten locations across the Lagos coastal waters over a six-month period that spanned both the dry and wet seasons. At each station, they measured a suite of physicochemical parameters at two depths, the surface and mid-water, capturing total phosphorus, dissolved reactive phosphorus, dissolved inorganic nitrate, salinity, dissolved oxygen, turbidity, temperature, and pH. This dual-depth, multi-season design allowed the investigators to separate the vertical structure of the water column from the seasonal signals imposed by the region’s pronounced rainfall regime, a distinction that is critical for understanding how nutrients move through a system where riverine discharge and oceanic exchange compete for influence.

The headline result is striking: chlorophyll-a concentrations were consistently higher in surface waters than at mid-depth, and they rose markedly during the wet season. Mean concentrations reached 35.51 micrograms per liter at the surface and 29.19 micrograms per liter at mid-water during the rainy months, values that place Lagos coastal waters firmly in the range associated with eutrophic conditions. Chlorophyll-a serves as a proxy for phytoplankton biomass, and when it climbs to these levels it signals that microscopic algae are proliferating on a plentiful supply of nutrients. In moderation, phytoplankton form the base of the marine food web and support the fisheries that feed millions of people in the Lagos region. In excess, they can deplete oxygen, shade out submerged habitats, and in some cases produce blooms of cyanobacteria that pose risks to both wildlife and human health.

The seasonal pattern that emerged from the data points directly to freshwater as the dominant driver. During the wet season, heavy rainfall swells the rivers, lagoons, and drainage channels that empty into the coastal zone, delivering a pulse of nutrients washed from urban catchments, agricultural land, and atmospheric deposition. The researchers found significant seasonal differences in temperature, salinity, total phosphorus, and dissolved oxygen, all of which are consistent with a water column being diluted and fertilized by land-derived runoff. Salinity drops as freshwater floods the nearshore zone, while phosphorus concentrations rise, providing precisely the conditions under which fast-growing phytoplankton can capitalize on the sudden abundance of a limiting nutrient. The team identified these elevated nutrient inputs associated with freshwater inflows as a major driver of enhanced primary productivity in the system.

Yet the study also demonstrates that season alone does not explain the distribution of algal biomass. Spatial variability among the ten sampling stations significantly influenced chlorophyll-a concentrations, revealing that local conditions matter enormously in a coastal environment as heterogeneous as Lagos. Some stations, presumably those closer to major discharge points or areas of intense catchment activity, sustained higher algal productivity than others, a pattern the authors attribute to the role of local anthropogenic pressures in shaping eutrophic conditions. In a megacity where industrial effluent, untreated sewage, and stormwater converge on a narrow coastal strip, the geography of pollution is as important as the calendar of the rains. This spatial heterogeneity means that management interventions cannot be uniform; they must be targeted at the specific hotspots where nutrient loading is most intense.

The physical dynamics of the water column add another layer of complexity. The vertical gradient in chlorophyll-a, with surface concentrations exceeding those at mid-depth, reflects the fact that phytoplankton require light for photosynthesis and therefore concentrate in the sunlit upper layer. Turbidity, which the study measured alongside the nutrient variables, modulates this light availability, and in a sediment-laden coastal system the interplay between turbidity and nutrient supply can determine whether a given pulse of phosphorus translates into algal growth. The authors conclude that eutrophication in Lagos coastal waters is regulated by the combined effects of nutrient enrichment, hydrodynamic conditions, and spatial heterogeneity, a three-factor framework that echoes findings from other tropical and subtropical coastal systems, from the Arabian Gulf to the lagoons of West Africa, where similar studies have linked freshwater discharge to phytoplankton dynamics.

The consequences of this sustained eutrophication extend well beyond the water chemistry. The study notes that excessive primary productivity is reducing the capacity of Lagos coastal waters to deliver critical ecosystem services, including navigation and fisheries. Dense algal blooms can clog waterways and fishing gear, while the decomposition of the resulting organic matter consumes dissolved oxygen, creating conditions that stress fish and shellfish populations. Low-oxygen events, or hypoxia, are a well-documented consequence of nutrient over-enrichment in coastal seas worldwide, and the significant seasonal differences in dissolved oxygen recorded in this study suggest that Lagos waters may be moving along a trajectory that other eutrophic systems have followed, one that ends in seasonal dead zones if nutrient inputs are not curtailed.

The Lagos findings also carry a broader scientific significance. Coastal eutrophication is one of the most widespread forms of marine pollution on the planet, and tropical megacities represent some of the most challenging environments for its management, combining rapid population growth, inadequate wastewater infrastructure, and intense seasonal hydrology. Previous work by members of the same research group has documented nitrogen and phosphorus loading to the Lagos Lagoon from both wet and dry atmospheric deposition, and has traced the influence of human population and built-up area on sediment nutrient cycling in estuarine basins. The new study extends this body of work into the coastal waters themselves, closing the loop between catchment processes, nutrient delivery, and the biological response of the receiving marine environment.

For the researchers, the practical message is clear: continuous monitoring of key water quality indicators and of nutrient inflows through coastal inlets is essential for identifying eutrophication hotspots and supporting effective management strategies in tropical coastal ecosystems. Because the study shows that chlorophyll-a distribution is shaped by both season and location, monitoring programs that sample only occasionally or at a handful of sites risk missing the episodes and places where degradation is most severe. The authors argue that sustained observation, ideally at the inlets through which land-derived nutrients reach the sea, would give managers the information needed to intervene before blooms become crises, whether through improved wastewater treatment, control of runoff, or the protection of the hydrodynamic flushing that helps disperse nutrient loads.

As Lagos continues to grow, the pressure on its coastal waters will only intensify, and the study by Echebiri and colleagues provides both a warning and a roadmap. The warning is that freshwater-driven nutrient enrichment is already pushing primary productivity to levels that impair the services the coast provides. The roadmap is the demonstration that the problem is traceable, measurable, and spatially specific, which means it is, in principle, manageable. The research was partly funded by the Tertiary Education Trust Fund through the National Research Fund, and the data generated during the study are available from the corresponding author on request, an openness that may help other researchers and managers across the Gulf of Guinea confront the same challenge in their own coastal waters.

Subject of Research: Seasonal and spatial variability of chlorophyll-a and nutrients in eutrophic tropical coastal waters

Article Title: Freshwater driven seasonal and spatial variability of chlorophyll-a and nutrients in Lagos coastal waters

Article References: Echebiri, F. O., Abayomi, A. A., Oladosu, N. O., Olayinka, K. O., & Alo, B. I. (2026). Freshwater driven seasonal and spatial variability of chlorophyll-a and nutrients in Lagos coastal waters. Environmental Monitoring and Assessment, 198(10), Article 1077. https://doi.org/10.1007/s10661-026-15910-0

Image Credits: AI Generated

DOI: 10.1007/s10661-026-15910-0

Keywords: chlorophyll-a, eutrophication, Lagos, coastal waters, nutrients, freshwater inflow, water quality, phosphorus, phytoplankton, tropical ecosystems, dissolved oxygen, Environmental Monitoring and Assessment

The research, published in Frontiers in Public Health, is described as the first qualitative study of its kind conducted in Lagos, Nigeria’s sprawling commercial megacity. Researchers from the University of York’s Department of Health Sciences interviewed eight faith leaders drawn from six different religious traditions, asking them how they understood hypertension and whether the networks that gather around places of worship could play a meaningful role in tackling it. The choice of method matters. Rather than measuring outcomes or testing an intervention, the team set out to map the perspectives, motivations and reservations of the people who would have to make any faith-based health partnership work on the ground. What emerged from those conversations was neither simple enthusiasm nor reflexive resistance, but something far more nuanced: a group of community leaders with a strikingly sophisticated grasp of why their congregants fall ill in the first place.

Perhaps the most striking finding is that the faith leaders interviewed did not frame high blood pressure purely as a spiritual matter, a framing that outside observers might have expected and that has often been used to justify excluding religious actors from formal health planning. Instead, they offered what the researchers characterize as a sharp critique of the structural conditions that drive cardiovascular disease in their communities. They pointed directly to poverty, to the chronic stress of daily survival in a demanding urban environment, to inadequate public infrastructure, and to systemic failures of governance that leave ordinary people without reliable access to care. In other words, these leaders were already diagnosing the social determinants of health with a precision that mirrored the language of public health scholarship, even if they had never been invited into the rooms where policy is made.

Dr Abayomi Sanusi, the study’s lead author from the University of York’s Department of Health Sciences, said the findings build on earlier work suggesting that promoting health through faith institutions holds unrealized potential to support and supplement healthcare systems. According to Sanusi, the interviews revealed that rather than viewing cardiovascular issues purely through a spiritual lens, faith leaders offer a pointed analysis of current health system deficiencies. He also noted that the leaders expressed a strong willingness to open their doors to routine screening, health education and medical referral programmes. That willingness is significant because it inverts a common assumption: the barrier to faith-based health collaboration, the study suggests, may lie less with religious communities than with the health sector’s own habits of engagement.

That caveat emerged clearly in the leaders’ accounts of past experience. While many had participated in health initiatives run by researchers, government agencies or non-governmental organizations, they consistently described those collaborations as one-sided. Initiatives, they reported, often acted in an extractive manner, taking access, trust and resources from local congregations without leaving behind sustainable health infrastructure or giving anything back to the communities that had been served. A screening drive might arrive, collect data, photograph its activities and depart, leaving no equipment, no follow-up pathway and no lasting capacity within the congregation that had hosted it. From the leaders’ perspective, their institutions were being used as conduits rather than partners, and the goodwill that made each successive campaign possible was being spent faster than it could be replenished.

Professor Su Golder, also of the University of York’s Department of Health Sciences, framed the problem in structural terms. It is evident, she said, that faith leaders are already acting as sophisticated diagnosticians of health system failure, yet they remain structurally excluded from official state and national hypertension strategies. She attributed that exclusion to a failure to recognize religious authority as a legitimate public health asset. The observation cuts to the heart of a long-standing tension in global health: institutions that can mobilize millions of people, that enjoy deep reservoirs of community trust and that possess physical infrastructure in nearly every neighbourhood are routinely left out of national non-communicable disease planning, which tends to flow exclusively through clinics, hospitals and formal government channels.

The stakes of that exclusion are considerable. Hypertension is often called a silent condition because it can progress for years without symptoms, damaging blood vessels and organs while the person affected feels perfectly well. Detecting it requires little more than a blood pressure cuff, a trained hand and a few minutes of time, which makes screening one of the most scalable interventions in all of medicine. The difficulty lies in creating regular, repeated, trusted opportunities for that simple act to happen, particularly among adults who may work long hours, live far from clinics, distrust formal institutions or simply never think to get checked. Places of worship, by contrast, are visited weekly or more often by enormous cross-sections of the adult population, including older people and those least likely to present at a clinic, making them theoretically ideal venues for sustained screening and education programmes.

The York team is careful, however, to argue that simply parachuting health campaigns into religious venues would repeat the mistakes of the past. To effectively curb hypertension in Lagos, the study concludes that health authorities must move beyond treating faith institutions as convenient access points to the community. Instead, the researchers call for genuine, reciprocal partnerships that treat religious figures as equal stakeholders, with a real voice in design, implementation and evaluation. The study sets out practical implications for researchers, practitioners, funders and government officials: health interventions should be co-designed with faith networks from the outset, and models of care should be tested so that key health resources are drawn from, and remain within, the community they serve. Reciprocity, in this framing, is not a courtesy but a design requirement for sustainability.

The study’s final recommendation reaches further than any single screening campaign. Faith institutions, the researchers argue, should be embedded into long-term national health policy, giving religious networks a permanent, recognized role in the architecture of hypertension prevention and care rather than a temporary one in donor-funded projects. Achieving that, they caution, requires commitment from all partners from the beginning, along with a genuine understanding of how effective faith leaders can be in supporting and promoting healthy lives. For a country where one in three adults carries elevated blood pressure and where the formal health system is stretched thin, the message of the research is at once modest and radical: the most trusted health communicators in many Nigerian communities are already in place, already willing, and already waiting to be treated as partners rather than gateways.

Subject of Research: The role of faith leaders and religious institutions in hypertension screening, education and prevention partnerships in Lagos, Nigeria

Article Title: Faith leaders offer untapped key to hypertension crisis, research shows

Article References: Faith leaders offer untapped key to hypertension crisis, research shows. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: hypertension, faith leaders, Nigeria, Lagos, public health, cardiovascular disease, University of York, community health, health partnerships, screening, social determinants of health, Frontiers in Public Health

The guideline in question is the WHO Guideline: recommendations on digital interventions for health system strengthening, known as WHO-GRDI. Released in 2019, it distils the global evidence on nine categories of digital health intervention, from birth and death notification and drug stock management to telemedicine, targeted client communication, patient tracking, health worker decision support and digital training. The problem, the researchers argue, is that guidelines like this are written for the world in general, not for any particular health system in particular. In countries where electricity is unreliable, networks drop and health workers are already stretched thin, an unadapted guideline can sit on a shelf. Guideline adaptation — a systematic, participatory process that preserves the integrity of the original recommendations while customising them for local laws, resources and culture — is widely seen as a faster and cheaper alternative to developing new guidelines from scratch, yet detailed accounts of how to do it for mental health systems have been scarce.

The team structured the entire project around the Knowledge to Action cycle, a widely used implementation science framework that moves from identifying a problem, through adapting knowledge to local context, to implementing, monitoring and sustaining change. Lagos was a deliberately pragmatic choice. The state already runs the Mental Health in Primary Care programme, or MeHPriC, which operationalises the WHO’s mhGAP strategy in 57 designated flagship primary health centres, each staffed with doctors, nurses, midwives, community health extension workers, pharmacy technicians and counsellors. MeHPriC had already demonstrated clinical and cost-effectiveness in treating depression, anxiety, substance use disorders and epilepsy, but its processes were largely manual, with only scattered use of SMS messages, WhatsApp and emergency phone lines.

The project unfolded in four phases: planning, adaptation, implementation and evaluation. In the planning phase, the researchers established a Local Steering Committee of project members and independent local experts in digital intervention, guideline development, programme implementation and qualitative research, alongside a separate Stakeholders’ Forum drawing in psychiatrists, psychologists, primary care workers, technology providers, policymakers and nongovernmental organisations. Early dissemination through existing unions of nurses, midwives, community health workers and general practitioners helped secure cooperation from the outset. Ethics approval came from both the Lagos State University Teaching Hospital and the WHO itself.

The adaptation phase began with a hard-nosed assessment of whether Lagos was even ready. The team reviewed Nigeria’s mental health law, national mental health policy, task-shifting policy and National Health ICT Strategic Framework, and mapped existing digital health projects through the WHO’s Digital Health Atlas and a Nigerian digital health dashboard. The connectivity picture was surprisingly strong: by August 2021 Nigeria had more than 188 million active mobile lines, over 140 million people accessing the internet by phone, 48 percent broadband penetration and a call setup success rate of 98.9 percent. Notably, of 12 reviewed digital health projects in Nigeria, none focused on mental health — confirming the unmet need. Five independent raters then appraised the WHO-GRDI itself using the AGREE-II instrument, the international standard for guideline quality, scoring it 79.3 percent overall, with particularly strong marks for editorial independence and clarity. An 11-member Contextualization and Adaptation Panel of mental health specialists, primary care experts, policymakers, technology providers and linguists then worked through multiple rounds of structured feedback and formal consensus to produce a locally tailored draft, which was externally reviewed by professional bodies and 60 consulted stakeholders.

The adapted guideline emerged with eight rather than nine recommendations. Birth and death notification were merged into a single recommendation, since Lagos facilities record live deliveries, stillbirths and deaths with the same staff and systems. The word telemedicine was dropped entirely as ambiguous to local workers, and health worker decision support was relabelled clinical decision support. During planning workshops, stakeholders used the Theoretical Domains Framework to surface barriers and facilitators, then ranked the recommendations using a modified Delphi technique. Five were judged feasible for a pilot within the project’s timeline: drug stock notification, client-to-health-provider communication, health worker supervision and communication, targeted client communication and clinical decision support. The rest were set aside for want of infrastructure or priority.

The pilot itself ran for three months in five randomly selected flagship primary health centres, one from each administrative district. In each clinic, 11 health workers already involved in MeHPriC received mobile phones or tablets preloaded with project materials, and 55 health workers plus five supervising mental health specialists were trained over two weeks. Evaluation used validated implementation science instruments: the Acceptability of Intervention Measure, Intervention Appropriateness Measure and Feasibility of Intervention Measure, each scored on five-point Likert scales, supplemented by a perceived effectiveness rating and the 12-item Organizational Readiness for Implementing Change scale completed by health workers and managers. Altogether, 150 clients, 50 health workers, a five-member mental health team and five health managers participated in the assessment.

The headline results were encouraging. Recommendations on drug stock notification, health worker supervision and communication, and targeted client communication scored high across the board — perceived effectiveness between 80.0 and 92.0 percent, acceptability between 80.5 and 91.0 percent, appropriateness between 84.0 and 90.0 percent and feasibility between 81.0 and 90.0 percent. Organizational readiness was uniformly high, with a mean ORIC score of 55.62 out of 60, and no significant difference between frontline workers and managers. But two recommendations fell short. Client-to-health-provider communication scored between 65.6 and 73.4 percent, and clinical decision support between 78.0 and 79.0 percent on acceptability and effectiveness. The qualitative data explain why. Workers felt that emergencies such as suicidal crises demand face-to-face contact, worried about guilt and clinical liability if a remote patient deteriorated, and resented unpaid work extending beyond their capacity. On decision support, many found the electronic mhGAP guide too prescriptive and felt that checking a device in front of a patient undermined the patient’s self-esteem and the therapeutic relationship. Practical complaints about electricity, network connectivity, device safety and the need for more training rounded out the concerns.

The authors draw three main lessons for anyone attempting similar work in a low- or middle-income country. First, robust stakeholder engagement before, during and after adaptation is essential, and existing professional networks are the most efficient conduit for it. Second, policymakers should ensure a digital strategy, supporting infrastructure, legislation, governance frameworks and training plans are in place before attempting implementation of guideline recommendations. Third, integrating new recommendations into an already functioning programme — as the team did with MeHPriC’s existing mobile phone backup — makes the manual-to-digital transition far smoother. The team has prepared evidence briefs for Lagos policymakers and plans continued policy dialogues. The study does carry limitations: Lagos is Nigeria’s most developed state, the pilot was short at three months, and not all WHO-GRDI recommendations were implemented. Still, the authors argue the work offers valuable information for adapting and implementing the WHO-GRDI and other health systems guidelines, and they call for further research embracing the views and experiences of end-users to understand the balance between the generalizability and local adaptability of health systems guidelines. An ongoing feasibility trial of the electronic mhGAP app in Nepal and Nigeria is expected to inform the next round of implementation decisions.

Subject of Research: Adaptation and pilot implementation of the WHO guideline on digital interventions for strengthening mental health systems in Lagos State, Nigeria

Article Title: Adaptation and pilot implementation of the WHO guideline on digital intervention to strengthen mental health systems in Lagos state, Nigeria

Article References: Adewuya, A. O., Abdulmalik, J., Abimbola, S., Oladipo, O. E., Dahiru, A., Shettima, F., Fasawe, A., Fahim, C., Marten, R., Yangchen, S., & Straus, S. (2026). Adaptation and pilot implementation of the WHO guideline on digital intervention to strengthen mental health systems in Lagos state, Nigeria. Health Research Policy and Systems, 24(S1), Article 74. https://doi.org/10.1186/s12961-026-01463-8

Image Credits: AI Generated

DOI: 10.1186/s12961-026-01463-8

Keywords: WHO-GRDI, digital health, mental health systems, Nigeria, Lagos, guideline adaptation, implementation science, primary health care, mHealth, mhGAP, low- and middle-income countries, health policy