West Africa Journal of Medicine

LETTER TO THE EDITOR: Remarks on the Correlation between the EU-TIRADS Score and the Definitive Histology of Thyroid Nodules Operated on in Lomé

2026-02-05T15:59:50+00:00

Thyroidology is a dynamic discipline that deals with the disorders and therapeutic options of the delicate butterfly gland, the thyroid, which may 1-4 require a graceful approach. We read a great deal of the article entitled "Correlation between the EU-TIRADS score and the definitive histology of 5 thyroid nodules operated on in Lomé". This study aimed to evaluate the diagnostic performance of the European Thyroid Imaging Reporting and Data System (EU-TIRADS) ultrasound score in the evaluation of thyroid nodules, a common diagnostic problem in resource-limited countries. A total of 134 medical records were collected for the study, and the average age was 42.28 ± 12.93 years, and 94% were women. The frequency of thyroid cancer was 8.96%, with papillary carcinoma being the predominant type, accounting for 91.6% of the cancers. On the sonographic evaluation, the distribution of nodules was exhibiting: 24 nodules (18%) were classified EU-TIRADS 2, while 72 (54%) EU-TIRADS 3, 19 (14%) EU-TIRADS 4, and 19 (14%) EUTIRADS 5. We believe that this study provides essential data on the utility of the EU-TIRADS classification in a sub-Saharan African context and could contribute to the adaptation of existing algorithms for the management of thyroid nodules in contexts where cytological examination is not a common practice. As such, the strengths of the article are: i) The study focuses on a standard diagnostic problem in resource-limited countries: thyroid nodules; ii) It evaluates the diagnostic performance of the EU-TIRADS, a standardized diagnostic tool; iii) The study calculated and presented the key diagnostic performance metrics for EUTIRADS, such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy; iv) This allows for a quantitative evaluation of the system's usefulness; v) The results are compared to existing literature; vi) The discussion section clearly compares the study's results with those of other studies conducted in different geographical locations; and vii) The conclusion emphasizes that the EUTIRADS score could be a good tool for recognizing benign nodules, particularly in contexts where cytological examination is limited. It is still imperative and inevitable in order to carry out the cytopathologic examination of each indicated and suspected thyroid nodule. Nonetheless, the flaws of the study are: i) The study has a retrospective design; ii) It introduces inherent limitations such as the potential for bias in data collection and the possibility of missing information; iii) The variability of ultra sound equipment and its interpretation could be a limitation; iv) The fact that the ultrasounds were performed in different centers by different radiologists could have led to variability in image acquisition and the EU-TIRADS classification; v) The adaptation of the French TIRADS system to EU-TIRADS could also introduce bias; vi) The relatively small sample size for malignant cases might be a weakness; vii) Although 134 medical records were analyzed, the number of malignant cases is relatively small; viii) It could limit the statistical power of some analyses, particularly within the specific EU-TIRADS categories. ix) The lower malignancy rate in the high EUTIRADS categories compared to some literature data is a contradiction; x) The malignancy rate found for the EUTIRADS 5 in this study (36.8%) is lower than that reported in some other publications; xi) The PPV of the study is low (21.05%), which means that a positive EU-TIRADS result suggesting malignancy has a relatively low probability of actually being malignant; xii) the study is geographically limited to a single center (Lomé, Togo); and xiii) The outcomes may not be directly generalizable to other resource-limited settings or to populations with different prevalence rates of thyroid diseases or different access to healthcare. This issue merits further investigation. We thank 5 Foma et al. for their valuable study on EU-TIRADS in Thyroidology. Bene diagnoscitur bene curatur.

ORIGINAL: Assessing the Correlation of Protein C and Protein S Levels with Stroke Severity and Functional Outcomes in Adults with Ischaemic Stroke

2026-02-05T16:16:01+00:00

Background: Protein C, a vitamin K-dependent anticoagulant, regulates thrombin generation with its cofactor, protein S. Deficiencies in these proteins predispose individuals to thrombophilia, which may contribute to ischemic stroke. However, data on their role in Nigerian populations remain limited.

Objectives: To compare serum levels of protein C and protein S between adults with acute ischemic stroke and matched healthy controls; to assess associations between these deficiencies and stroke severity; and to evaluate their relationship with functional outcomes.

Methods: A hospital-based, cross-sectional case-control study was conducted involving 100 ischemic stroke patients and 100 age- and sex-matched healthy controls. Serum protein C and S levels were measured using enzyme-linked immunosorbent assay (ELISA). Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), while functional outcomes were measured using the Barthel Index and Modified Rankin Scale (mRS) on days 7, 14, and 30. Statistical analysis was performed using SPSS version 25, with significance set at p < 0.05.

Results: Among 200 participants (59 males, 41 females per group), the mean age of stroke patients was 61.24 ± 13.30 years. Median time to presentation was 48 hours. Protein C levels were significantly lower in stroke patients, while Protein S showed no significant difference. A weak positive correlation was observed between Protein C levels and stroke severity (rs = 0.201, p = 0.045), whereas Protein S did not show such a correlation. The functional outcome showed no significant association with either protein.

Conclusion: Protein C deficiency may serve as a marker for stroke severity but has limited predictive value for functional outcomes. Further research is needed to clarify its pathophysiological role in ischemic stroke.

ORIGINAL: Assessment of the Initial Acquisition of Streptococcus mutans in Infants Born to Pregnant Women Attending the Lagos University Teaching Hospital

2026-02-06T15:43:47+00:00

Aim: Streptococcus mutans has been strongly associated with dental caries. The mother, the primary caregiver in the first year of life is the most significant source of the bacteria. The presence of S. mutans in infants from birth to 6 weeks of life was assessed.

Methodology: Prospective study of 24 women enrolled during their third trimester. Socio-demographic characteristics, oral hygiene, dietary practices and obstetric characteristics obtained using investigator-administered questionnaire. Saliva samples collection from neonates at birth and six weeks, investigated by cultural microbial analysis and polymerase chain reaction to detect S. mutans specific species genes.

Results: Total of 24 mother-child pairs assessed. Mothers mean age; 31.29 (+/- 4.6) years. Neonates' mean gestational age; 38.79 (+/-1.4) weeks, with 14 (58.3%) females and 10 (41.7) males. Microbiological culture analysis of the saliva sample of the neonates showed that 25% of the neonates had S. mutans at birth and 25% had it at 6 weeks post-delivery. Approximately 25% of salivary samples from the neonates showed S. mutans upon cultural analysis and correlated with the presence of the bacteria in 41.7% of the samples using Polymerase chain reaction. Streptococcus mutans detected at birth in 60% of neonates were identical to that of the mothers.

Conclusion: Maternal transmission is the primary source of S. mutans acquisition. Culture analysis of oral fluid revealed presence of viable and cultivable S. mutans in neonates asserting the acquisition of these species at birth and their presence before tooth eruption.

ORIGINAL: Knowledge, Risk Perception and Prevention against Diphtheria among Caregivers of Children under-fives in Chikun Local Government Area, Kaduna State, Nigeria

2026-02-06T11:41:47+00:00

Background: Diphtheria, a re-emerging public health threat, is a vaccine-preventable acute respiratory infection caused by toxigenic strains of Corynebacterium diphtheriae. Caregivers of this most vulnerable group must be knowledgeable of the disease, its risk factors, and preventive measures to curb its spread.

Objectives: To determine the knowledge, risk perception and prevention against diphtheria among caregivers of under fives.

Method: A cross-sectional descriptive study was conducted in January 2024. A total of 288 caregivers of children under five years of age were selected using a multi-stage sampling technique, and data were collected using an interviewer-administered questionnaire. The data were analyzed using SPSS version 27, and results were presented in tables. The chi-square test was used to test for association between the socio-demographic variables and dependent variables, and the level of statistical significance was set at a p-value of <0.05.

Results: The median age of the respondents was 32 ± IQR 10.8 years. About half (51.7%) of the respondents had good knowledge of diphtheria, positive perception of the risk of the disease was reported in 77.1% of the respondents and 75.6% had good practice of the preventive measures against the disease. A quarter (26.8%) of the respondent's children took the complete 3 doses of the pentavalent vaccine.

Conclusion: Despite positive diphtheria prevention behaviors, the identified gap in pentavalent vaccination coverage indicates a significant need for community immunization programs. Investigating the factors contributing to this low coverage is crucial for developing effective strategies to strengthen immunization programs.

ORIGINAL: Enzymatic and Non-enzymatic Antioxidants as Related to Immediate Hospital Outcomes in Term Nigerian Babies with Perinatal Asphyxia

2026-02-06T12:11:43+00:00

Background and objectives: Antioxidants are often released to neutralise free radicals and oxidants generated in babies with perinatal asphyxia (PA). This study aims to determine the enzymatic and non-enzymatic antioxidants in babies with PA and the relationship between these antioxidants and hospital outcome at the Wesley Guild Hospital (WGH), Ilesa, Nigeria.

Methods: Consecutive term babies with or without asphyxia (defined as 5th minute Apgar score <7) were consecutively recruited into a comparative cross-sectional study at the labour ward of the WGH over a nine-month period. Babies were appropriately managed and outcome of hospitalisation documented. Five ml of cord blood was collected from the babies and analysed for enzymatic and non-enzymatic antioxidants using chromatography methods (Water Incorporate, California, U.S.A). Data obtained were analysed using SPSS version 21.

Results: A total of 168 babies (84 for each group) were recruited with male to female ratio of 1.2:1. Sixty-one (72.6%), 23 (27.4%) had moderate and severe PA respectively. Cord blood antioxidants were lower in babies with PA. The enzymatic [glutathione peroxidase r = -0.298, p=0.006, glutathione transferase r=-0.222, p=0.042] and non-enzymatic [TAS, r=-0.316, p=0.003] antioxidants showed negative correlation with the length of hospitalization. However, no significant relationship was observed between the antioxidants and severity of asphyxia, as well as mortality among babies with PA.

Conclusion: Low cord blood antioxidants (TAS and glutathione enzymes) may be useful indicators of increased length of hospital stay in Nigerian term babies admitted with PA.

ORIGINAL: Evaluation of Microalbuminuria Level to Determine Diabetic Nephropathy Among Type 2 Diabetic Patients in Zaria, Nigeria

2026-02-06T12:22:49+00:00

Background: Microalbuminuria was reported to be elevated in diabetic nephropathy and high levels of this biomarker correlates with progressing nephropathy, decline in e-GFR and consequently renal failure in some patients. A descriptive cross-sectional study was conducted to evaluate the level of microalbuminuria in type 2 diabetic patients and its correlation with renal function.

Method: One hundred Type-2 diabetic patients and an equal number of apparently healthy, age and sex-matched controls were recruited. Urinary albumin and serum creatinine was measured using FIA and Jaffe kinetic methods respectively. Data was analysed using SPSS version 22.0 with level of significance at p < 0.05. Urinary albumin creatinine ratio (u-ACR) was calculated, serum creatinine was used to calculate e-GFR using Cockcroft and Gault formula; while Mann-Whitney test was used to compare difference between the two means.

Results: The u-ACR (3.15 (7.8, 1.3)) mg/mmol was found to be significantly higher in patients than controls (p = 0.000) while serum creatinine (74.00 (86.0, 67.0) μmol/L was found to be significantly lower in patients than controls (p = 0.000). Pearson's correlation showed significant negative correlation between u-ACR and e-GFR (r = - 0.318, p = 0.001) and between serum creatinine and e-GFR (r-value = - 0.546, p-value = 0.000), while a significant positive correlation between u-ACR and serum creatinine (r-value = 0.281, p = 0.005) among patients.

Conclusion: The concentrations of microalbuminuria was higher in type 2 diabetic patients, and it may be used to assess renal function.

ORIGINAL: Prevalence and Risk Factors of Contrast Induced Nephropathy in Maiduguri, Northeastern Nigeria

2026-02-06T12:34:00+00:00

Background: Contrast-induced nephropathy (CIN) is the third leading cause of acute kidney injury (AKI) in developed countries. With the increase in contrast-based radiologic studies in developing countries, its contribution to the burden of AKI is increasing. However, there are few researches conducted in this part of the world on AKI due to contrast administration. This study was aimed at determining the prevalence and risk factors of CIN in a tertiary health facility in northeastern Nigeria.

Methods: This prospective study was conducted at the Radiology department of the University of Maiduguri Teaching Hospital, Maiduguri, North eastern Nigeria. The study population consisted of 150 consenting adult patients referred for investigations involving contrast administration. Sociodemographic variables were obtained from each patient, and blood samples were collected before contrast administration, at 24, 48 and 72 hours after contrast administration and analyzed for creatinine. Serum creatinine obtained was used to calculate glomerular filtration rates (eGFR) using the CKD-EPI Creatinine 2012 Equation. Contrast induced nephropathy was defined as an absolute increase in serum creatinine ≥0.5mg/dl or ≥25% increase from baseline within 48 to 72 hours after administration of contrast media (CM).

Results: The prevalence of CIN was 30% (45 patients), and risk factors were; advancing age (OR=1.346, p=0.009), volume of contrast (OR=2.037, p=0.001), high serum creatinine at base-line (OR=1.601, p=0.006) and low eGFR at base-line (OR=1.767, p=0.003).

Conclusion: Contrast induced nephropathy is a common complication of radiologic contrast studies in Maiduguri, northeastern Nigeria. Risk factors identified were advanced age >60 years, large volume of contrast >60ml, baseline serum creatinine >150µmol/l and GFR <60ml/minute/1.73m2.

ORIGINAL: Prevalence of Psychosis Spectrum Symptoms, Association with Quality of Life and Caregiver Burden in Yoruba Nigerians with Parkinson's Disease: A Matched Case Control Study

2026-02-07T17:12:21+00:00

Background: Up to 60% of persons with idiopathic Parkinson's disease (PD) will develop psychosis spectrum symptoms at some point during the course of illness. These symptoms are often undetected by attending physicians but are associated with great distress to patients and their caregivers.

Objectives: To investigate the prevalence and association of positive psychosis symptoms with quality of life (QoL) and caregivers' burden among clinic attendees with PD at two tertiary general hospitals in South western Nigeria.

Method: A case-control study was conducted between February 2023 to June 2024. Cases (N=150) were neurology outpatients with PD. Controls (N=150) were neurologically healthy individuals matched for age, sex, education, and outpatient status. Psychosis, QoL, and caregiver burden were assessed using the Scale for the Assessment of Positive Symptoms (SAPS), PD-QoL questionnaire (PDQ-8), and Caregivers Strain Index (CSI), respectively. Adjusted odds ratios (aO.R) and standardized coefficients (aCoeff.) were estimated using regression analyses. Estimates were within 95% confidence intervals (C.I).

Results: Psychosis symptoms were present in 28% of cases. Hallucinations were the most frequent symptom (16.7%). Cases with Psychosis were more likely to be ≥60years (88.1%, p=0.020), ever users of alcohol (78.6%, p=0.012), had higher mean motor-severity scores (51.1±15.7, p<0.001), and probable dementia (21.4%, p=0.001). In unconditional logistic regression analyses, cases had approximately five-point increase in the independent odds psychosis (aOR=4.92, 95% C.I=2.20, 10.99), and two-point increase in the independent odds of requiring social support (aOR=1.95, 95% C.I=1.19, 3.21).

Conclusion: The near five-point increase in the odds of psychosis spectrum symptoms in PD and their greater requirement for social support underscores the need for multidisciplinary approaches that include not only neurologists but psychiatrists, and social workers.

ORIGINAL: Rubella IgG Immunity: Spatial Distribution, Euclidean Distance Analysis, Correlates and Predictors among Women of Reproductive Age, Southwest Nigeria

2026-02-07T18:53:12+00:00

Background: Rubella is a leading cause of preventable congenital abnormalities. Paucity of data exists on the national morbidity burden of rubella infection, particularly among women of reproductive age in Nigeria. Added to this is the absent immunization policy on rubella vaccination in Nigeria.

Objectives: To determine the spatial and Euclidean distribution, correlates and predictors of rubella immunity among women of reproductive age in Ekiti state, southwest Nigeria.

Methods: A community-based cross-sectional survey for rubella IgG antibodies among women of reproductive age selected using multi-stage sampling technique. Data was collected quantitatively using interviewer-administered semi-structured questionnaire. Blood sample was collected for qualitative assay of rubella IgG. Global Positioning System (GPS) co-ordinates of sampled households were recorded. Euclidean distance tool in the ArcGIS environment analyzed the proximity to established rubella IgG negative areas. Data entry and analysis was through the use of Statistical Product and Service Solutions (SPSS) 23 and level of statistical significance was set at p-value < 0.05.

Result: The mean age of the women was 30.5±7.9 years. A total of 482 (84.1%) had negative rubella IgG serology. There was wide spread immunity gap. Educated respondents (p=0.009), higher number of inhabitants in households (p=0.011), ever married (p<0.001) and prior vaccination history (p<0.001) were associated with rubella immunity. Secondary education (aOR=2.47; p=0.046) and urban location (aOR=0.45; p=0.003) were predictive of rubella immunity (p<0.05).

Conclusion: The rubella immunity gap cuts across both rural and urban areas with a potential for disease spread in the Euclidean-determined proximal areas. To reduce the wide spread immunity gap, increase herd immunity, the Federal Government of Nigeria needs to introduce rubella vaccination in the National Immunization. KEYWORDS: Rubella Immunity, Spatial Distribution, Correlates, Predictors, Women, Nigeria.

RETROSPECTIVE CROSS-SECTIONAL STUDY: Spectrum of Rheumatic and Musculoskeletal Diseases in a Rheumatology Clinic in Nigeria: A Report of the First 5000 Patients

2026-02-07T19:14:07+00:00

Background and objectives: Rheumatic and musculoskeletal diseases (RMDs) are important causes of morbidity, disability, and mortality worldwide, including in sub-Saharan Africa. However, the spectrum of RMDs in this region has not been well documented due to a lack of data. This is particularly true since many of the diseases observed were previously considered rare among Africans. This study aims to identify the various RMDs seen in a private rheumatology facility in Lagos, Nigeria.

Method: The case records of the first 5,000 consecutive patients diagnosed with RMDs between January 2004 and May 2022 were reviewed. Diagnoses were made using standard rheumatology guidelines/consensus, societal guidelines, or clinical evaluation. Data analysis was performed using the Statistical Package for Social Sciences (SPSS) version 26.

Results: The mean ± SD age of the 5,000 patients was 52.33 ± 16.15 years, with a female-to-male ratio of 1.7:1. The frequency of the common RMDs were degenerative joint diseases (54.16%), followed by inflammatory arthritis (14.52%), soft tissue rheumatism (13.28%) and connective tissue diseases (10.32%). Females were more commonly affected in all categories except crystal arthropathies and spondyloarthropathy. Septic arthritis, metabolic bone diseases, and orphan diseases were rarely seen, at 0.26%, 0.28%, and 0.82% of the total, respectively.

Conclusion: This study, which includes arguably the largest cohort of RMD patients in sub-Saharan Africa, revealed a wide spectrum of RMDs, contrary to previous assumptions that RMDs are rare among Africans. As this is a hospital-based study, large population-based studies are recommended to determine the burden of RMDs in the community to guide policy implementation and resource allocation.

EDITORIAL: Antioxidant Depletion in Asphyxiated Neonates, Neuropsychiatric Burden in Parkinson's Disease, and Public Health Vulnerabilities: The Need for Proactive Healthcare Delivery

2026-02-05T15:45:15+00:00

We welcome our readers to another edition of the West African Journal of Medicine. This issue brings together a diverse set of articles that deepen the understanding of health and disease across the lifespan, spanning the unborn child, the newborn, the adult, and the elderly.

A recurring theme running through the various papers in this issue is the challenge of unseen vulnerabilities, i.e., clinical, biochemical, immunologic, and behavioural burdens that remain silent until they produce significant morbidity. Across diverse populations and disease contexts, these studies illuminate the hidden layers of risk that shape health outcomes in our environment, and the urgent need for earlier recognition, stronger surveillance, and more preventive health strategies. The reports on protein C and S levels in stroke, microalbuminuria as early diabetic nephropathy, and contrast-induced nephropathy elucidate hidden physiological threats that precede overt disease. The documentation of early Streptococcus mutans acquisition in infants and the review of rheumatology clinic patients highlight how early detection and long-term surveillance are essential in conditions that unfold gradually over time.

The study by Ojagbemi et al. provides insight into the often-overlooked neuropsychiatric burden of Parkinson’s disease (PD). In the case–control study across two tertiary hospitals, the authors demonstrate that psychosis spectrum symptoms are both common and clinically significant in PD. Nearly one in three patients experienced psychosis, with hallucinations being the most frequent feature. The study identifies key correlates such as older age, alcohol use, more severe motor impairment, and probable dementia. Crucially, psychosis in PD was linked to worse quality of life and greater caregiver strain, highlighting a dual burden that affects both patients and their support systems, as had been demonstrated in other climes.^{1, 2}

However, in our setting, where caregiving is informal and resources are limited, these findings carry profound implications. With PD patients showing five-fold increased odds of psychosis relative to controls, the authors make a compelling case for a more proactive, multidisciplinary approach that integrates neurology, psychiatry, and social support into routine PD care.

A similar message emerges from the work by Kuti et al., which revealed important biochemical vulnerabilities among neonates with perinatal asphyxia. In the comparative cross-sectional study of 168 newborns, the authors demonstrate that both enzymatic and non-enzymatic antioxidants are significantly depleted in asphyxiated infants compared with healthy controls. Markers such as total antioxidant status (TAS), glutathione, glutathione peroxidase, and glutathione transferase were notably lower, reflecting increased oxidative stress at birth. Although antioxidant levels did not correlate with PA severity or mortality, the study makes a compelling observation: lower antioxidant concentrations were associated with longer hospital stays. The findings highlight an opportunity for improved prognostication and possibly targeted antioxidant-supportive strategies.

In the public health domain, Durowade et al. reveal another hidden vulnerability, i.e., a widespread rubella susceptibility among women of reproductive age. Their community-based survey, the study reports a striking 84% rubella IgG seronegativity, which indicates a widespread immunity gap. Their spatial analysis shows that this vulnerability is not localised, but rather, it is diffuse, widespread, and distributed across both urban and rural communities, which makes a potential outbreak both possible and dangerous. It is quite concerning that the findings further showed that one-third of seropositive women were pregnant. This silently places unborn children at risk of congenital rubella syndrome. The authors’ message is unmistakable: without a proactive rubella immunisation policy, this immunologic vulnerability will continue to exact a preventable toll. This highlights the need to intensify ongoing measures that will promote widespread availability and coverage of the rubella-containing vaccines across the length and breadth of the country in order to protect mothers and newborns.³

Together, these contributions paint a compelling picture showing that a substantial portion of the disease burden in our region thrives in the shadows, undetected, underestimated, or under-addressed. They remind us that our most serious threats often emerge long before overt clinical illness becomes visible.

In low- and middle-income regions, including sub-Saharan Africa, these vulnerabilities are exacerbated by limited diagnostic capacity, under-resourced surveillance systems, sociocultural delays in care-seeking, and lack of effective preventive public health policies. This edition of the journal, therefore, highlights the urgent need for a more proactive, predictive, and prevention-oriented healthcare model. This emphasises upstream action to reduce preventable disease burdens in LMICs.⁴ In essence, the future of healthcare delivery in our region depends on our ability to think proactively, detect early, and intervene early and holistically. As our collective scientific work continues to shed light on these hidden layers of vulnerability, we move closer to a healthcare system that is not only reactive but truly preventive.

We extend our deep appreciation to all authors whose scholarship enriches this edition. We also encourage clinicians, researchers, and public health professionals across the region to continue submitting high-quality manuscripts that advance understanding, challenge assumptions, and improve patient care. Your work remains vital to shaping the evolving landscape of medicine in West Africa. Welcome once again to this edition, and we look forward to the continued growth of our scientific community through your contributions.

Prof G.E Erhabor

Editor in Chief

REFERENCES

Eichel HV, Heine J, Wegner F, Rogozinski S, Stiel S, Groh A, Krey L, Höglinger GU, Klietz M. Neuropsychiatric symptoms in Parkinson’s disease patients are associated with reduced health-related quality of life and increased caregiver burden. Brain sciences. 2022;12(1):89.
Segal GS, Xie SJ, Paracha SU, Grossberg GT. Psychosis in Parkinson’s disease: current treatment options and impact on patients and caregivers. Journal of geriatric psychiatry and neurology. 2021;34(4):274-9.
WHO Africa. Nigeria launches large-scale vaccination campaign to protect 106 million children against measles, rubella and polio [Internet]. Available from: https://www.afro.who.int/countries/nigeria/news/nigeria-launches-large-scale-vaccination-campaign-protect-106-million-children-against-measles. Accessed 2025 Dec 4.
Egwuaba EU, Sunday BA. Challenges In Health Care Delivery, Health-Seeking Behaviour And Implementing Social Behavioral Strategies In Awka, Nigeria. GVU Journal of Management and Social Sciences. 2025;10(1):218-33.