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Stakeholder meeting report for ENHANCE CVH: a trial to improve maternal and child cardiovascular health in Nigeria

Year: 2025
Type: article
Abstract: According to the Global Burden of Disease 2019 Study, Nigeria has the fourth-highest rate of maternal mortality globally, with an estimated 528 deaths per 100 000 live births (compared with 24 fatalities per 100 000 in the United States).1 Because of this high mortality rate and its large population, Nigeria accounts for 23% of all maternal deaths worldwide.2 Hypertensive disorders of pregnancy (e.g. chronic hypertension, gestational hypertension, pre-eclampsia, eclampsia, haemolysis, elevated liver enzymes and low platelets syndrome, and pre-eclampsia superimposed on chronic hypertension) constitute a significant contributor to this burden, as they are estimated to be present in 17% of all pregnant women in Nigeria and are responsible for 32% of maternal fatalities in Nigeria.3 At the same time, Nigeria is undergoing a nutrition transition that is causing high and rapidly rising rates of obesity or overweight, which have reached age-standardized prevalence rates of 20%–33% among women aged 20 to 40 years.3,4 Compared with women of normal weight, obese or overweight women are more likely to experience a hypertensive disorder of pregnancy and are more prone to gain excess weight during pregnancy and to maintain the same weight for a year following delivery.5 Evidence-based interventions are urgently needed to reduce the burden of maternal morbidity and mortality and improve maternal health in Nigeria. To respond to this need, the Enhancing Intergenerational HeAlth in Nigeria: Peripartum as Critical Life StagE for Cardiovascular Health (ENHANCE CVH) trial seeks to test the effectiveness and implementation of an adapted behavioural health intervention delivered through a home visiting programme to improve maternal and child health. The trial is funded through a 5-year grant from the National Heart, Lung, and Blood Institute. The ENHANCE CVH team includes investigators from the University of Abuja (Nigeria), Cardiovascular Research Unit, University of Abuja Teaching Hospital (Nigeria), Washington University in St. Louis (USA), New York University (USA), and Parents as Teachers National Center (USA). The study is part of a larger effort co-ordinated by the Global Alliance for Chronic Disease to address the rising prevalence of non-communicable diseases in resource-limited contexts at critical life stages. The ENHANCE CVH study is a type 2 hybrid effectiveness-implementation, cluster-randomized trial (1:1) that will be conducted in 40 primary healthcare centres (clusters) in the Federal Capital Territory of Nigeria, Abuja. The study team will recruit 1000 mother-child dyads to compare the effect of an adapted Parents as Teachers home visiting program plus Healthy Eating Active Living Taught at Home (PAT + HEALTH) intervention on maternal and child cardiovascular health metrics such as peripartum weight, and behavioural health delivered through home visits. The intervention is modelled after a successful, evidence-based home visiting intervention developed by investigators at Washington University in St. Louis and Parents as Teachers National Center in the United States. The ENHANCE CVH study includes: (i) stakeholder mapping and interviews to adapt the intervention, (ii) training of community health extension workers (CHEWs) and community health nurse educators using a train-the-trainer model, (iii) recruitment of first trimester pregnant women who are obese, and (4) parent education via home visits through pregnancy and up to 24 months post-partum. The primary effectiveness outcome will be change in maternal weight at 18 months. Secondary effectiveness outcomes include measures of maternal and child cardiovascular health. Implementation outcomes will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. In April 2024, the ENHANCE CVH team organized and hosted its inaugural multi-sectoral stakeholder meeting to facilitate dialogue, collaboration, and multi-level policy coherence among partners from health, government, policy, non-profit, and media among other sectors. The hybrid meeting was attended by 61 stakeholders, including representatives from the Nigeria Federal Ministry of Health, Primary Healthcare Development Agency, Federal Capital Territory Public Health Department, Safety and Welfare, Abuja Municipal Area Council, Pharmacists Association of Nigeria, Society of Obstetricians and Gynecologists, and Institute of Cardiovascular Diseases, Ibadan, among others. Implementing partners included primary care physicians and community health extension workers (Figure 1). Enhancing Intergenerational Health in Nigeria: Peripartum as Critical Life Stage for Cardiovascular Health study team members and stakeholders in April 2024 The inaugural meeting engaged key stakeholders during the study’s formative period with the aim of introducing the study to them, evaluating their perceptions of maternal and child cardiovascular health in Nigeria, and seeking feedback on the study design. Discussions emphasized the large and rising burden of maternal cardiovascular diseases in Nigeria, its impact on perinatal and transgenerational health outcomes, and the increasing need for evidence-informed and sustainable interventions adapted to the local context. Participants reported that the intervention was feasible, acceptable, appropriate, and timely, and the study represented an opportunity for capacity building in improving maternal and child cardiovascular health. The meeting was designed to foster trust among stakeholders and provide an opportunity for engagement and dialogue to work collaboratively towards the success of the project. Prior to the meeting, the ENHANCE CVH team conducted formative research to explore stakeholders’ knowledge and perceptions on the relevant contextual factors that may influence the acceptability, feasibility, and appropriateness of the adapted HEALTH intervention. The study team conducted key informant interviews and focus group discussions with policymakers, implementers such as health administration staff, physicians and nurses, and community opinion leaders in the Federal Capital Territory. The interviews and focus groups captured data on the facilitators, barriers, and context of the study. Key findings included the acceptability and appropriateness of the study, the need for tailoring the proposed intervention to the local context, such as emphasizing locally available foods, focusing health education training modules on relevant topics, using community centers for some patients as alternatives to home visits, and devising strategies to reach hard-to-reach populations. Concerns were raised regarding safety and security during home visits, and stakeholders recommended using local village communication channels to raise community awareness about the study. In summary, the ENHANCE CVH trial is an important opportunity to address the large and growing burden of high maternal morbidity and mortality in Nigeria by improving maternal and child cardiovascular health. Multi-sectoral stakeholder engagement will be critical to the success of the study, including beyond the initial funding period, and this report represents an initial step towards that goal. ENHANCE CVH Study Team: Victor G. Davilá Román, Charles Goss, Julia López, Mansi Agarwal, Zainab Mahmoud, Kenneth Schechtman, Cindy Schwarz, Rachel Tabak, Guhan Iyer, Lisa de las Fuentes, Debra Haire-Joshu, Cecilia Naa Nartey, Mark Huffman (Washington University, St. Louis, USA), Angela Aifah, Olugbenga Ogedegbe (New York University, New York, USA), Allison Kemner, Tiedra Marshall, Patty Velasquez, Roschel Servantes, Constance Gully (Parents as Teachers, St. Louis, USA), Godwin Akaba, Anthony Orji, Dennis Isah, Clementina Okoro, Vincent Ugochukwu, Emmanuel Okpetu, Lamkur Shedul, Kasarachi Omitiran, Nanna Ripiye, Ucheoma Nwaozuru, Adaora Okechukwu, Nneka Onwu, Ekundayo Ocholi, Olubunmi Ojji, Chinwe Chidebe, Dike Ojji (University of Abuja, Abuja, Nigeria); Chisom Obiezu-Umeh (Northwestern University); Ucheoma Nwaozuru (Wake Forest University); David Dowdy (Johns Hopkins University); Kathryn Lindley (Vanderbilt University). Collaborators: University of Abuja; Cardiovascular Research Unit, University of Abuja Teaching Hospital; Washington University In St. Louis; New York University Grossman School of Medicine; Parents As Teachers National Center; Federal Capital Territory Abuja, Public Health Department; Institute of Cardiovascular Diseases Ibadan, Director, Public Health, Federal Ministry of Health, Area Councils Services Commission, Federal Capital Territory, Abuja, Health Departments for Abuja Municipal Area Council, Abaji Area Council, Bwari Area Council, Kwali Area Council, Kuje Area Council; Public Health Department, Federal Capital Territory; Federal Ministry of Health Safety And Welfare; Pharmacists Association Of Nigeria; Dietician Association of Nigeria; Nigerian Cardiac Society; Society of Obstetricians and Gynecologists of Nigeria. Our special appreciation goes to the Federal Ministry of Health of Nigeria, Abuja State Primary Health Care Development Agency, ENHANCE-CVH DSMB Members, ENHANCE-CVH Advisory Board Members, University of Abuja, including the Vice Chancellor, and Cardiovascular Research Unit, University of Abuja Teaching Hospital, including the Chief Executive M.D.H. has received travel support from the World Heart Federation and consulting fees from PwC Switzerland. MDH has an appointment at The George Institute for Global Health, which has a patent, license, and has received investment funding with intent to commercialize fixed-dose combination therapy through its social enterprise business, George Medicines. MDH has pending patents for heart failure polypills. The other authors have no disclosures. This study is funded by National Heart, Lung, and Blood Institute, USA (grant number: R01HL168771). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
DOI: 10.1093/eurheartj/ehaf288
Language: English
Field: Medicine
Open Access status: bronze
OpenAlex ID: W4411224674
FWCI:
Cites: 5
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