Nigerian Health Journal

Interventions to Improve Health Literacy in Nigeria: Systematic review of effectiveness and policy recommendations

K.T. Olabanji — Mon, 23 Oct 2023 00:00:00 +0000

Background: Health literacy plays a crucial role in enabling individuals to navigate and make informed decisions within the healthcare system. It encompasses the ability to understand, interpret, and act upon medical information and instructions, as well as the capacity to source and analyse relevant health information for preventive measures and self-care. This paper explores the interventions aimed at improving health literacy in Nigeria and synthesizes policy recommendations for the Nigerian government.

Method: A systematic literature review based on the PRISMA methods was carried out to identify published interventions and reported effectiveness in the Nigerian population. A search strategy using key words health literacy and health interventions was executed in PubMed, Embase and African Index Medicus. A total of 268 records were screened for relevance and 18 were identified.

Results: Of the 18 reports identified, 13 interventions were effective, 3 interventions had mixed results reporting effectiveness in some domains and ineffectiveness in other important domains, while 2 interventions were not effective. The nature of effectiveness in the interventions was based on the outcomes as reported in the identified studies.

Conclusion: The health literacy situation in Nigeria provides a background into some of the challenges faced in achieving universal health coverage and promoting health in Nigeria. Low literacy rates, particularly in its many rural areas, the lack of functional, communicative, and critical health literacy competencies among many adults, as conceptualised in literature pose a significant obstacle to health literacy development in Nigeria. Many of the health literacy interventions have been effective to address various aspects of health literacy on a rather small scale. To comprehensively address the problem, collaborative efforts involving the government, healthcare professionals, non-governmental organisations, media, and the community are necessary.

Heavy Metal Exposure and Renal Impairment: A Systematic Review of Observational Studies

E. Iwunze, C. Kanu , C. Tobin-West , B. Ordinioha — Mon, 23 Oct 2023 00:00:00 +0000

Background: Environmental exposure to toxins has been strongly implicated in its multi-faceted etiology of chronic kidney disease, a serious public health problem affecting individuals, families, and communities. There is a need to synthesize available studies on the effect of heavy metal exposure on renal function, considering the rising global burden of kidney disease. The objective of this study is to determine the association between exposure to heavy metals and renal disease.

Methods: The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) were used to conduct the review. A comprehensive independent search, title, abstract, and full-text screening of available literature on Google Scholar, PubMed, and OAREScience was done between March 2021 and May 2021. The criteria for study inclusion were full-text articles published in English language in the last 20 years (2001-2020), and observational primary human studies reporting the association between heavy metal exposure and renal disease. The Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of the included studies.

Results: A total of 552 studies were identified following the search from the different databases. A total of 13 studies were finally included in the review. Heavy metals implicated in the studies include cadmium, lead, mercury, and arsenic, with ten studies showing environmental exposure as the primary source. Ten (10) studies showed an association between heavy metal exposure and renal impairment (p<0.05) while only 3 studies reported no association.

Conclusion: Environmental monitoring is needed to stem the tide of heavy metal exposure in view of the growing burden of chronic kidney disease.

Prevalence of Non-Communicable Diseases among HIV Positive Patients on Antiretroviral Therapy at a Tertiary Health Facility in Makurdi, North-Central, Nigeria

Mon, 23 Oct 2023 00:00:00 +0000

Background: Human immunodeficiency virus (HIV) treatment program has grown exponentially in Nigeria largely due to improved Antiretroviral therapy (ART) regimen which has changed the course of HIV/AIDs by enabling patients to live longer, raising concern of the co- existence of HIV with other chronic illnesses, notably non communicable diseases (NCDs). This study determined the prevalence of hypertension and diabetes mellitus among HIV positive patients in a tertiary institution in Makurdi, Northcentral Nigeria.

Methods: A cross-sectional study was conducted at the ART clinic among clients ≥ aged 21 years old living with HIV /or enrolled between October 2022, and March 30, 2023. The clients’ information was extracted from the register using a Proforma and all the clients who had attended their follow up clinic visit within the study period were included in the study. Data was analyzed using SPSS version 21.0. Categorical data were presented as frequencies and percentages.

Results: Among the 491 patients, 404 (82.3%) had HIV only and 87 (17.7%) had HIV and at least one comorbidity, namely DM and/or HTN. Hypertension was the most prevalent comorbidity affecting 15.5% of the patients while 1.0% of them were diabetic. The middle aged (30-49) patients, females (63.2%) had the highest prevalence of comorbidities and some of those with normal weight (35.6%) also had the highest prevalence of NCDs.

Conclusion: Non-communicable diseases are common among people living with HIV. There is need to encourage early diagnosis and treatment of noncommunicable diseases in HIV positive patients in Nigeria.

Pre- and post-donation ferritin level of blood donors attending University of Calabar Teaching Hospital, Donor Clinic in Southern Nigeria

I.M. Okafor, V.O. Abasi , H.U. Okoroiwu , C.O. Ogar — Mon, 23 Oct 2023 00:00:00 +0000

Background: While trying to save the patient via blood transfusion, the safety of the blood donor is paramount. This study evaluated the pre- and post- donation ferritin and packed cell volume (PCV) of donors attending University of Calabar Teaching Hospital.

Method: The study adopted descriptive longitudinal approach. A total of 18 donors with age range of 18 – 48 years were enrolled and followed up for 30 days post- donation. The serum ferritin was analyzed using ELISA method while the PCV was analyzed using the microhematocrit method. Difference between means was performed using repeated measure ANOVA while post hoc was done using Bonferroni adjustment. Prediction of return to baseline values were performed using logistic regression. Alpha value was placed at 0.05.

Results: There was a decline in ferritin and packed cell volume from pre- to post-donation. The decline in ferritin was imminent until day 14 when recovery was initiated. Significant difference was observed between the predonation ferritin and the rest of the days except day 30. There was also a decline in PCV from pre-donation all through with recovery noticeable after day 7. The PCV of the pre-donation was only comparable to the day 30 postdonation. Approximately 5.6% (n=1) of the subjects was iron deficient predonation. Approximately 25% (n=4) of the subject have returned to baseline PCV while 0% of the subjects have returned to baseline ferritin at day 30 post- donation.

Conclusion: For the safety of the donor, donation interval should be widened, and iron supplement followed up.

Medication Adherence and Health-Related Quality of Life amongst HIV Patients Receiving Care at Umuebule Cottage Hospital, Etche, Rivers State

L.O. Okwuonu, A. Ibidabo, J.E. Ifere — Mon, 23 Oct 2023 00:00:00 +0000

Background: HIV treatment is available, free, and accessible for individuals who are infected. The study is aimed at determining the levels of medication adherence and health related quality of life (HRQOL) among HIV patients receiving care at Umuebule Cottage Hospital, Etche, Rivers State.

Method: This cross-sectional study recruited 430 adult clients who have been on ART for at least one year using a convenient sampling method. An average of 10 patients visits the facility on clinic days. After explaining the purpose of study and obtaining consent, patients who met the eligibility criteria were recruited on each clinic day for a period of 12 weeks, until the sample size was reached. Data was collected using semi-structured interviewer administered validated questionnaire; Morisky Medication Adherence Questionnaire (MMAS-8) and WHO-Quality of LifeBREF(WHOQOL-BREF), after a pilot study on 30 PLHIV from Okomoko general hospital, Etche. Data was analyzed with IBM-SPSS Version 25.

Results: The mean age of respondents was 35.9±10.9 years, 59.3% of the respondents’ last viral load was suppressed, 19.1% had low level viremia, while (21.6%) were virally unsuppressed. Medication adherence levels were observed to be good (67.7%), poor (32.3%) respectively, while HRQOL of respondents were found to be poor (56.9%) and good (43.1%).

Conclusion: A significant proportion of the respondents adhere to their medication whereas most of them had poor HRQOL. There is need for hospital management to collaborate with social welfare organizations to support PLHIV to set up means of earning to enable them to provide their basic needs for improved HRQOL.

Pattern and Determinants of Outcomes of Neurological Emergencies admitted into Children Emergency Ward in a Tertiary Hospital in Port Harcourt, Nigeria

W. Wonodi , T.G. Okari — Mon, 23 Oct 2023 00:00:00 +0000

Background: Neurological emergencies are life-threatening central nervous system disorders, significantly contributing to childhood morbidity and mortality. The sequelae may be irreversible and may impact negatively on the quality of life of affected children and their families. This study identified the morbidity pattern and determinants of the outcomes of children with neurological emergencies in the Children Emergency Room (CHER) of the Rivers State University Teaching Hospital (RSUTH).

Method: A 4-year retrospective study was carried out in the CHER. Data on demography, diagnosis and outcomes of children with neurological disorders were extracted from the records. Data analysed with SPSS 24 were expressed in percentages and frequency tables.

Results: Of the 3040 children admitted in the CHER, 364(12%) aged 0-15 years had neurological emergencies, commoner among males (59.3%) and children aged less than five years (70.9%). Meningitis (40.2%) and febrile convulsion (28.2%) were the topmost diagnoses made. Raised intracranial pressure (17.4%) and head injuries (25.5%) were significantly more prevalent among children aged five years and above. The mortality rate was 61(16.8%) and more among adolescents (30.6%). All the mortalities took place within the first 48hours of admission especially among those with head injuries (46.5%) and perinatal asphyxia (95%), (p < 0.05).

Conclusion: Meningitis and febrile convulsion were the commonest neurologic emergencies seen in this study. Mortality rate was high, especially in the first 48 hours of admission and mainly from perinatal asphyxia and head injuries. Education on the prevention and management of neurologic emergencies should be strengthened.

Childhood Seizures: Assessment of the Knowledge, Attitude and Home Interventions among Patients attending a Paediatric Outpatient Clinic in Nigeria

W. Wonodi , U.C. Onubogu — Mon, 23 Oct 2023 00:00:00 +0000

Background: Most seizures in children occur outside the hospital and effective first aid would protect individuals from harm. Study assessed the knowledge, attitude and home-based interventions for childhood seizures.

Methodology: This was a descriptive cross- sectional survey conducted from 1st June to 31st December, 2021 among caregivers of patients in a Paediatric outpatient clinic. Interviewer-administered questionnaires were used to assess knowledge, attitude, and home intervention of childhood seizures. Data were analyzed using SPSS 24 and results presented as frequency tables, percentages and charts. P-values < 0.05 were considered significant.

Results: Out of 218 respondents, the commonest source of information on childhood seizures was from friends and relatives 126(73.2%). Fever was the commonest known cause. Only 15(6.9%) recognized seizure as a neurological disorder. Jerking of the body and clenching of the teeth were the commonest recognizable symptoms. The majority said seizures were contagious (176(80.7%) and children with seizures should not go to school 187(85.8%). The overall knowledge score was poor. Negative attitudes included avoidance 19(8.7%), isolation from playing with peers (15(6.9%) and from the public 17(7.8%). Common interventions during seizures were putting palm kernel oil in the mouth while only 25(29.4%) took the child to the hospital or laid him down away from harmful objects 25(29.4%). The practice of home intervention for seizures was good in only 11(5.0%) of respondents.

Conclusion: Knowledge, attitude and first aid home interventions for seizures were poor among caregivers in this study hence standard first aid management of seizures should be taught in schools and the community

Knowledge and Practice of COVID-19 Preventive Measures: Comparative Analysis of Medical and non-Medical Students University of Port Harcourt

I.A. Jegede , E. Iwunze , J.E. Ifere — Mon, 23 Oct 2023 00:00:00 +0000

Background: The influence of COVID-19 has impacted the education sector just like it has other sectors. This study examined the level of knowledge, attitude, and practice of COVID-19 preventive measures among medical and non-medical students of the University of Port Harcourt, Rivers State

Method: A comparative cross sectional study design using a selfadministered structured questionnaire involving a total of 406 students; medical (200) and non-medical (200), using multi-stage sampling. Frequency, percentages, means, and standard deviation were used to describe data where necessary. Chi-square and Fisher exact was used to compare knowledge, attitude, and practice of COVID-19 preventive measures between medical and non-medical students.

Results: The mean age of medical and non-medical students was 25.04 and 22.59 respectively. A total of 70% from medical students arm received COVID-19 vaccines while 15.5% of non-medical students arm. 152(73.8%) non-medical students and 123(61.5%) medical students had good knowledge of COVID-19. Positive attitude toward COVID-19 preventive measures was showed by 119(59.5%) medical students and 62(30.1%) nonmedical students. Concerning practice of COVID-19 preventive measures, 99(48.1%) medical students and 78(39.0%) non-medical students practiced appropriately. A chi-square test for association showed that gender, academic level, religion, accommodation status, vaccination status, geopolitical zone, and faculty of students were significantly associated with knowledge, attitude, and practice of COVID-19 preventive measures. Chisquare test also showed that knowledge of COVID-19 was significantly associated with the practice of COVID-19 preventive measures.

Conclusion: Non-Medical students had better knowledge than medical student although difference was not significant. Attitude was good and practice of COVID-19 preventive measures was poor among medical students, while poor attitude and poor practice among non-medical students was observed

Practice of Food Hygiene among Nursing Mothers attending UnderFive Clinics in a Rural Community in Edo State, Nigeria

O.I. Alenoghena , O.B. Asalu , O.A. Aigbiremolen — Mon, 23 Oct 2023 00:00:00 +0000

Background: Children under the age of five are prone to foodborne diseases, resulting from poor food hygiene because of their less effective immune systems. This study aimed to assess the knowledge, attitude and practice of food hygiene among nursing mothers attending under-five clinics.

Method: This study was a descriptive cross-sectional study, involving 330 nursing mothers attending the under-five clinic in health care facilities. Data were collected using interviewer-administered questionnaires and analyzed using Statistical Package for Social Sciences (SPSS) version 21. A p-value < 0.05 at 95% confidence interval was considered statistically significant.

Result: Eighty-two percent of the respondents had good knowledge of food hygiene; 95.2% had a good attitude and 82.7% demonstrated good practice. Knowledge on food hygiene was significantly associated with the age of the respondents (P=0.008) and their educational status (P=0.001), those with tertiary education doing better. Similarly, respondents with tertiary education had significantly better attitude (P=0.001 and practice (P=0.001). The predictors of knowledge on food hygiene were education status (odds ratio [OR] =0.249, 95% confidence interval [CI]: 0.126, 0.492) and occupation of the respondents (OR = 2.158, 95% CI: 1.156, 4.026). Educational status was also the predictor for positive attitude (OR =0.143, 95% CI: 0.031, 0.667) and practice of food hygiene (OR =0.394, 95% CI: 0.210, 0.738).

Conclusion: The knowledge, attitude and practice of food hygiene among the respondents was good. Predictors of knowledge included level of education and occupation. Government at the State and Local Government levels should organize regular health promotion on food hygiene.

Healthcare providers’ satisfaction with participation in private Health Insurance scheme in a city in the Southern Nigeria

M. Aloni-Alali , A.A. Alali , D.S. Ogaji — Mon, 23 Oct 2023 00:00:00 +0000

Background: Health insurance coverage in Nigeria is still very low as over 70% of health care expenditure is financed by out-of-pocket payment. Health care providers are critical participants in the private health insurance scheme, therefore, their perception and satisfaction with the scheme is fundamental in ensuring sustainability. This study assessed health providers’ satisfaction with private health insurance scheme in Port Harcourt Rivers State.

Method: A descriptive cross-sectional study which engaged a two-stage sampling method to recruit 60 participating health facilities and 180 responding health personnel by simple random sampling at each stage. A structured, pretested interviewer-administered questionnaire was used to collect data on the levels of satisfaction with the four major domains of satisfaction viz; billing rate, payment models, HMO administrative processes and claims management. Data was analysed using of SPSS, version 26. Characteristics of the responding facilities were tabulated and compared. Level of satisfaction was deduced by Likert Scale according to the domains of satisfaction. Regression analysis with p-value was set at less than or equal to 0.05 was used to determine the predictors of satisfaction with participation in health insurance. The level of satisfaction with negotiated billing rates, payment models, HMO administrative processes and claims management were analysed descriptively, and results were presented as means, standard deviation, frequencies and percentages, in tables, pie and bar charts.

Results: 68.3% of the respondents were females and 31.7% males. 37.8% were satisfied with billing rates, 76.1% preferred fee-for-service method of payment. 55.6% were satisfied with HMO administrative processes and 41.5% were satisfied with claims administration. Facilities that have been in operations for more than 10years were 1.5 times more likely to be satisfied with their participation in private health insurance scheme [OR = 1.52; 95% CI = 0.07-0.65] p value = 0.01

Conclusion: Health care providers’ satisfaction with participation in private health insurance scheme is barely above average. The HCWs were poorly satisfied with billing rates and claims administration by HMOs. There is a need to actively involve providers in the processes and operations of the health insurance scheme in Nigeria.

Knowledge of Cervical Cancer among Women of Reproductive Age in Ibadan North LGA, Oyo State, Nigeria

G.J. Oruikor , M.P. Durotoye , A.G. Jeremiah — Mon, 23 Oct 2023 00:00:00 +0000

Background: Nigeria has one of the highest rates of cervical cancer morbidity and mortality in Sub-Saharan Africa. Both the human papillomavirus vaccine (HPV) and cervical screening are effective prevention strategies against both HPV infection and cervical cancer. Lack of awareness, limited knowledge, limited decision-making agency, lack of spousal support and stigma are barriers to uptake of these preventive measures. Cervical cancer is a deadly disease claiming the lives of many women in developing countries due to late presentation which might be influenced by a lack of knowledge of the disease and its prevention.

Method: This descriptive study examined the knowledge assessment of cervical cancer among women of reproductive age (15-49), about cervical cancer, its prevention, and their utilization of Pap smear screening; using a convenience sample of 426 women in Ibadan North Local Government Area of Oyo State, Nigeria. Women voluntarily completed a structured questionnaire.

Result: Results showed that women who participated in the study were aware of cervical cancer (77%; n=328) but many (62.9%; n= 268) were unaware of Pap smears as the screening tests for cervical cancer. Although 41.3% (n=176) were knowledgeable about cervical cancer, risk factors and prevention, only 9.4% (n=40) had Pap smear tests done.

Conclusion: Health care professionals, need to intensify efforts to increase awareness about cervical cancer screening, and encourage women through the different clinics to use these services. The benefits of screening and early diagnosis of cervical cancer should be emphasized to enhance the utilization of cervical cancer screening services.

Assessment of Mothers' Knowledge and use of Oral Rehydration Therapy for Diarrhoea in Children under 5 Years in Ife, Nigeria

G.J. Oruikor , M.P. Durotoye — Mon, 23 Oct 2023 00:00:00 +0000

Background: Diarrhoea disease is the second leading cause of death in children under 5 years old, and is responsible for killing about 300, 000 children annually in Nigeria. Oral rehydration therapy (ORT) is the preferred treatment for fluid and electrolyte losses due to diarrhoea in children with mild to moderate dehydration. This study aimed to assess the knowledge and use of ORT in the management of diarrhoea in children under 5 years at Seventh Day Adventist Hospital (SDAH, Ife).

Method: A structured questionnaire was adopted for this study design and data was collected using a self-structured questionnaire both selfadministered and interviewer administered.

Results: Of 80 participants, 44 (55%) of the respondents had heard of ORT before this study, while 36 (45%) had not. 48 (60%) responded that they use oral rehydration solution while 32 (40%) of mothers said they had not used ORT. There was significant difference in both outcomes. The result revealed that there was significant difference in morbidity and mortality between mothers who use ORT and those who do not. But there was no significant difference between the knowledge of ORT compared with its use.

Conclusion: Appropriate knowledge of the therapy will positively influence its use which will drastically prevent morbidity associated with diarrhoea as well as contain the incidence of mortality.

Antibiotic Prescription Patterns in Paediatric Wards of Rivers State University Teaching Hospital, Southern Nigeria: A Point Prevalence Survey

Mon, 23 Oct 2023 00:00:00 +0000

Background: Antimicrobial resistance remains a threat to patient safety andhealthcare outcomes and largely arises from inappropriate antimicrobial prescriptions. This study aimed to determine the pattern of antibiotic prescriptions in the Paediatrics department of Rivers State University Teaching Hospital, Port Harcourt.

Method: A point prevalence survey was conducted in the Paediatric wards and Special Care Baby Unit (SCBU) on 13 November 2021. Records of all children admitted before or at 8:00 a.m. on the day of the survey were descriptively analysed using the protocol and web- based management system of the Global Point Prevalence Survey of Antimicrobial Consumption and Resistance, University of Antwerp.

Results: The antibiotic prevalence in this study was 77.4%. The most common indication(s) for antibiotic use in SCBU was infection prophylaxis (81.3%) and in paediatric wards: Pneumonia, Ear Nose Throat and Soft tissue infections accounted for (23.1%) each. Third- generation cephalosporins and aminoglycosides were predominantly used in all wards and were empirical-based prescriptions. Regarding antibiotic quality indicators of prescriptions: In SCBU: 19 (90.5%) had indication(s) for antibiotics documented, 10 (46.7%) were guideline compliant, and 1 (4.8%) had documented review/stop date. In the paediatric medical and surgical wards, 17(85.0%) vs. 4(100%) had indication(s) for antibiotics documented, 6(30.0%) vs. 0(0%) were guideline compliant, and 1(5.0%) vs. 4(100.0%) had a review/ stop date.

Conclusion: High prevalence of antibiotic use, suboptimal antibiotic quality indicators and absence of laboratory evidence for antibiotic prescriptions were observed in the paediatric units. There is a need to reorientate prescribers and institute strategic measures to improve antimicrobial stewardship.

A Comparative Cross-Sectional Assessment of the Preventive and Healthy Lifestyle Practices of Doctors in Port Harcourt, Rivers State

O. Otokunefor , E.I. Azi — Mon, 23 Oct 2023 00:00:00 +0000

Introduction: Lifestyle modification in relation to disease prevention and outcome has recently received increasing awareness around the world and in Nigeria. Poor lifestyle choices make people susceptible to many chronic illnesses including thirteen cancers. Medical doctors are gate keepers and educators of health.

Objectives: The aim of the study was to assess the level of knowledge of healthy living and preventive health among doctors in Port-Harcourt and ascertain the practices and to investigate the barriers and facilitators of healthy living among doctors in Port-Harcourt.

Methods: It was a comparative cross-sectional study with purposive sampling method. The tool used was an online questionnaire. MS Excel and SPSS was used for data analysis. Ethical approval was obtained from UPTH ethical committee.

Results: A total of 201 doctors participated. With 54.7% being females and 53.2% within the 30-40 years age group. Resident doctors accounted for 42.8%. 92% received some form of lifestyle education; seminars (48.1%), CME’s (47.0%), and social media (44.9%) were the top three. Just 15.2% knew what the daily portion of fruit was and 82.6% knew the cut off for obesity. 50% were aware of the recommended exercise frequency. 60% concluded that adults should sleep for 7-9 hours, however, 61.2% slept for 4-6 hours a day. 84.6% of respondents did not have a dedicated physician.

Conclusion: There is a knowledge gap among doctors which impacts everyday lifestyle choices regarding, diet, exercise and rest. More doctors need their own personal physicians and hospital management should establish strong lifestyle policies.

Care-Recipient Perspectives on the Responsiveness of Orthopaedic Surgical Services in a Tertiary Center in Nigeria

T.E. Diamond , D.S. Ogaji — Mon, 23 Oct 2023 00:00:00 +0000

Background: Responsiveness optimises the system-based approach to meeting legitimate demands by healthcare recipients. This study assessed the responsiveness of orthopaedic services at the University of Port Harcourt Teaching Hospital (UPTH) from the perspectives of the care recipients.

Methods: Descriptive cross-sectional study among 442 consecutively recruited recipients of orthopaedic services at UPTH from March to June 2020. Close-ended questionnaire with responsiveness conceptualised by five constructs: dignity, autonomy, confidentiality, quality of basic amenities and choice of care provider, each measured along 4-point response scale. The internal consistency reliability of the responsiveness scale was determined by the Cronbach’s alpha coefficient. Descriptive (frequency, percentages, bar charts) and inferential (ordinal logistic regression) statistics were conducted and p-values ≤ 0.05 were considered statistically significant.

Results: Response rate was 97.3% and the Cronbach’s alpha coefficient for the responsiveness scale was 0.83. Participants’ mean age was 38.5±14.8years with more being males (55.8%), privately employed (34.9%) and completed secondary education (82.5%). Proportion of respondents who gave excellent ratings across responsiveness domains were dignity (32.8%), autonomy (34.2%), confidentiality (26.3%), amenities (25.8%) and no excellent rating for choice of provider. Marital, employment and visit status were the most consistent factors associated with feedback on autonomy, choice of providers, confidentiality domains.

Conclusion: More orthopaedic patients were pleased with the level of autonomy and dignity than choice of providers and quality of basic amenities. There is the need for enhanced responsiveness of orthopedic services to meeting the unique needs of patients and achieving improved quality of care and patient outcomes.