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ORIGINAL ARTICLE
Year : 2023 | Volume
: 30
| Issue : 1 | Page : 61-69
Ophthalmology residency training in Nigeria: The trainers' perspective
Bolajoko Abidemi Adewara1, Adenike Odunmorayo Adeoye1, Oluwaseun Olaniyi Awe1, Tolulope Olufunke Oyedun2, Mobolade Olasunkanmi Akinde2
1 Department of Ophthalmology, Obafemi Awolowo University; Department of Ophthalmology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
2 Department of Ophthalmology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
Correspondence Address:
Bolajoko Abidemi Adewara
Department of Ophthalmology, Obafemi Awolowo University, Ile-Ife
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/npmj.npmj_272_22
Introduction: Periodic evaluations are an indispensable part of any training programme. This study assessed ophthalmology residency training in Nigeria from the perspective of ophthalmology trainers. Materials and Methods: This was a nationwide web-based survey of ophthalmology trainers at the 30 institutions accredited by the National Postgraduate Medical College of Nigeria from April 2021 to June 2021. Trainers were invited to complete a Google form via E-mail and WhatsApp. Data were collected on the characteristics of trainers and the training programme. Results: One hundred and fifty-eight (71.2%) out of 222 trainers responded to the survey comprising 67 (42.4%) males and 91 (57.6%) females, amongst whom were 97 (61.4%) subspecialists. The mean age (±standard deviation) was 51.47 ± 8.61 years (range, 38–75 years). Most respondents rated human resources (trainers and support staff) as 'much more' than adequate (n = 30, 19%), the volume of surgery as 'less or much less' than adequate (n = 82, 51.9%), the conduct of examinations as 'good' or better than good (n = 120, 75.9%) and impact of emigration of ophthalmologists on training as 'very negative' (n = 36, 22.8%). Overall, 94 (59.4%) respondents rated the quality of training as 'good' or better than good. Respondents recommended improving funding and training resources, revising the current conduct of examinations, increasing the use of appropriate technology and improving remunerations and national security. Conclusions: The majority of ophthalmology trainers rated ophthalmology residency training in Nigeria as 'good' but rated 'volume of surgery' as inadequate for training. Recommendations were made to improve the quality of training, revise examination practices and reduce the negative impact of emigration.
Keywords: Educational assessment, emigration, Nigeria, ophthalmology, residency training programme
Globally, approximately 2.2 billion people have vision impairment. Of these, one billion cases could have been prevented or are yet to be addressed. Furthermore, the prevalence of vision impairment in low- and middle-income regions is estimated to be four times higher than in high-income regions.[1] Nigeria, a lower-middle-income country with more than 206 million people, has a prevalence of severe vision impairment of 1.5% and blindness of 4.2% amongst people aged 40 years and above.[2],[3]
A shortage of trained human resources is considered to be one of the greatest challenges to reducing the global burden of unaddressed vision impairment.[1] Nigeria has approximately 700 ophthalmologists, which is below the World Health Organization's recommended minimum requirement of one ophthalmologist per 250,000 population.[4],[5] This deficiency could worsen over time due to population expansion and the significant trend of emigration of Nigerian physicians to more developed countries.[6] Ophthalmologists are the leaders of the eye care team; therefore, efforts to train and maintain an adequate number are essential to reduce the burden of vision impairment and blindness in Nigeria.
Post-graduate medical training is the bedrock of speciality care in many countries of the world, including Nigeria. Ophthalmology residency training is a post-graduate medical training pathway to produce specialists in ophthalmology. In Nigeria, this training is regulated and standardised by the Faculty of Ophthalmology of the National Postgraduate Medical College of Nigeria (NPMCN).[5] Similarly, the West African College of Surgeons (WACS) performs this function for the West African sub-region.[7] The certification required to be an ophthalmology trainer is being a fellow of at least 4 years post-qualification of either of these training colleges.[7],[8] The training is for a minimum of 5 years,[9] and fellows of the NPMCN who are at least 8 years post-qualification are eligible for appointment as examiners as long as they are active in clinical practice and involved in training at an accredited training institution.[10]
The NPMCN conducts two examinations (Parts I and II) for ophthalmology residents. The Part I examination takes place after the completion of 24 months of junior residency training. It consists of three sections including a screening examination (multiple-choice question computer-based test), followed by essay questions, and clinical examinations (objective structured clinical and practical examinations). The Part II examination takes place after the completion of 36 months of senior residency training, of which the last 12 months are dedicated to subspeciality training. It consists of three sections including clinical examinations (objective structured practical examinations), viva voce and dissertation defence. The computer-based screening examination for the Part I examination takes place at ten centres across Nigeria twice a year, while the other examinations take place at a single centre in the Southwest zone of the country twice a year.[10]
Periodic evaluations help to identify areas for improvement and are an indispensable part of any training programme. Globally, some countries have been able to identify areas for improvement in their ophthalmology training programmes through such evaluations. In Brazil,[11] there were reports of training deficiencies in ophthalmic pathology, refractive surgery and orbit. In Saudi Arabia,[12] a considerable number of barriers to accomplishing high-quality research projects were identified. A limited number of available training positions, lack of adequate teaching by attending physicians and difficulty in securing a job after training were noted in China.[13] In Portugal,[14] a significant curtail in surgical experience was observed during the COVID-19 pandemic. Extreme variability of ophthalmology training in clinical and surgical skills was noted in India.[15] In South Africa,[16] staff shortages, large patient numbers and old and broken-down infrastructure or equipment were common. In Nigeria,[17] an assessment of ophthalmology training was conducted amongst ophthalmology trainees who expressed a need for further improvement in surgical and diagnostic skills transfer, availability of quality ophthalmic resources and a well-structured training programme.
Although the evaluations were able to identify areas for improvement in these countries, they were majorly done amongst ophthalmology trainees or recent ophthalmology graduates (within 5 years post-qualification). Thus, the perspectives of ophthalmology trainers are not well documented. However, the perspectives of ophthalmology trainers could contribute to creating a more holistic assessment of the areas of improvement in the ophthalmology residency training programme. This is because of their experience as trainers and some as examiners who have passed through the training programmes themselves.
This study aimed to determine the sociodemographic and professional characteristics of ophthalmology trainers in Nigeria, assess ophthalmology residency training in the country from their perspective and identify ways to improve the training programme.
Materials and MethodsEthics
Ethical approval for the study was obtained from the Health Research Ethics Committee of the Institute of Public Health, Obafemi Awolowo University, Ile-Ife, Nigeria, with protocol number IPHOAU/12/1653 approved on 15 April 2021. Respondents had to electronically provide informed consent to participate in the study before proceeding to complete the survey questionnaire. The study adhered to the tenets of the Helsinki Declaration.
Study population
This was a web-based survey of ophthalmology trainers in Nigeria across all the thirty institutions accredited for ophthalmology residency training by the NPMCN. In this study, an ophthalmology trainer was defined as an ophthalmologist of at least 4 years post-fellowship involved in the training of ophthalmology residents at an accredited health institution in Nigeria. All ophthalmologists who were trainers of ophthalmology residents at institutions in Nigeria accredited by the NPMCN were eligible to participate in the study. Three trainers who were involved in developing the survey questionnaire and five trainers who participated in the pilot survey were excluded from the study.
Methods
The survey was conducted from 26 April 2021 to 26 June 2021. The list of training institutions in Nigeria accredited by the NPMCN and the E-mail addresses of all ophthalmology trainers at these institutions were sourced from the NPMCN database. An electronic semi-structured questionnaire with 30 questions was developed based on a review of the NPMCN uniform criteria and guidelines for accreditation of training institutions,[8] and the NPMCN Ophthalmology Curriculum and Logbook,[9] and designed using the Google Forms web application. The questionnaire was then pilot-tested on five trainers who were randomly selected from each of the five geopolitical zones of Nigeria with accredited training institutions. The questionnaire was finalised after incorporating feedback received from the pilot survey.
Sample size calculation
The Yaro Tamane formula for calculating sample size from a population of known size (n = N/1 + N(e)2) was used.[18] A 95% confidence level and 50% level of variability were assumed. The population size (N) obtained from the online database of the NPMCN was 222 ophthalmology trainers, and the level of precision (e) was 0.05. To account for possible non-responders, the calculated sample size was increased by 10%. Hence, a sample size of at least 158 respondents was necessary for this study.
Data collection
Invitations to complete the survey questionnaire were sent to ophthalmology trainers via E-mail and posted on WhatsApp groups of ophthalmology trainers. The invitations contained an electronic link to the survey questionnaire on the Google Forms web application and a cover letter informing them of the title of the study, the objectives of the study and the assurance that all their responses would be kept confidential. Informed consent to participate in the study was provided by respondents electronically via the Google Forms web application as a prerequisite to commence filling out the questionnaire. Follow-up E-mails were sent to non-responders at 2-week intervals for the duration of the study. The authors had no physical contact with the participants. The responses from the survey were automatically generated and anonymously integrated by the Google Forms web application. Data were downloaded as a single Microsoft Excel spreadsheet from the Google Forms platform and exported to IBM SPSS version 25 software (IBM Corp. Armonk, New York, U. S. A.) for further analysis.
The questionnaire
The questionnaire contained four sections that consisted of multiple-choice, 5-point Likert-type scale and open-ended questions. Specifically, the first section included five questions on the sociodemographic characteristics of trainers. The second section included eight questions on the professional characteristics of trainers. The third section included six questions on the perspective of trainers on the adequacy of resources for ophthalmology residency training at their different institutions. The fourth and last section included 11 questions on the perspective of trainers on the challenges of ophthalmology residency training in Nigeria. Three of the 11 questions asked trainers to provide recommendations on how to improve ophthalmology residency training, improve the conduct of ophthalmology fellowship examinations and how to reduce the emigration of Nigerian ophthalmology trainers and trainees.
'Dissertation supervisors' were ophthalmology trainers of at least 5 years post-fellowship who had or were currently supervising an ophthalmology resident's dissertation for the award of the ophthalmology fellowship of the NPMCN or the WACS. 'Examiners' were ophthalmology trainers that examined candidates at the fellowship examinations for the NPMCN or the WACS. 'Human resources' referred to the number of trainers and support staff. 'Infrastructure' referred to the facilities for training such as wards, clinics, theatres, laboratories, radiology suites, libraries, internet facilities and basic amenities (electricity, water and waste disposal). 'Equipment' referred to core or support equipment and instruments required for training and skills acquisition. 'Structured training programme' referred to structured lectures, tutorials, bedside sessions, opportunities for skill acquisition, evaluations, feedback, etc.[8]
Analysis
Quantitative data analysis was done for continuous and categorical variables. Descriptive statistics were calculated for responses to questions on the sociodemographic characteristics of trainers, professional characteristics of trainers, the perspective of trainers on the adequacy of resources for ophthalmology residency training and the perspective of trainers on the challenges of ophthalmology residency training in Nigeria. Categorical data were reported as frequencies with percentages. The comparison between 'years post-qualification as an ophthalmologist' and trainers' overall rating of the quality of ophthalmology residency training in Nigeria was presented using a table. The relationship between examiners and non-examiners' ratings of the current conduct of ophthalmology fellowship examinations in Nigeria was analysed using the likelihood ratio Chi-square test. Continuous data were analysed as means with standard deviations (SDs), median with interquartile range (IQR) and range (minimum to maximum). The level of significance was set at P ≤ 0.05.
Qualitative data analysis was done for responses to open-ended questions that required trainers to provide recommendations. A standard content analysis of all the responses was conducted. Responses to each question were analysed separately. Responses were read to understand the key ideas. Recommendations were subsequently grouped using colour codes into the main themes. The most common recommendations were then identified and reported under each theme.
ResultsThere were 30 accredited training institutions across five geopolitical zones in Nigeria. This translated to a training institution-to-population ratio of about 1:6.9 million persons. One hundred and fifty-eight out of 222 ophthalmology trainers across all the 30 accredited institutions completed the survey giving a response rate of 71.2%. They comprised 51 (92.7%) out of 55 trainers from 10 institutions in the Southwest zone, 34 (64.2%) out of 53 from five institutions in the Southeast zone, 30 (62.5%) out of 48 from six institutions in the Northwest zone, 23 (60.5%) out of 38 from six institutions in the North Central zone and 20 (71.4%) out of 28 from three institutions in the South-South zone. The Northeast geopolitical zone did not have any training institution accredited by the NPMCN at the time of this study.
The mean age (±SD) of all the respondents was 51.47 ± 8.61 years (range, 38–75 years). There were more female respondents (n = 91, 57.6%) than male respondents (n = 67, 42.4%), and the majority (n = 113, 71.5%) of the respondents were from federal government-owned institutions [Table 1]. One hundred and six (67.1%) respondents were dissertation supervisors comprising 46 (29.1%) males and 60 (38%) females, and 73 (46.2%) respondents were examiners comprising 31 (19.6%) males and 42 (26.6%) females. The mean number of years post-qualification as an ophthalmologist for examiners was 20.29 ± 7.67 years (median, 20 years; IQR, 11; range, 7–36 years), and the mean for non-examiners was 11.95 ± 8.89 years (median, 9 years; IQR, 12; range, 4–46 years).
Table 1: Sociodemographic and professional characteristics of ophthalmology trainersThe specialisations/main areas of interest for the respondents included glaucoma (n = 29, 18.4%), paediatric ophthalmology (n = 28, 17.7%), vitreo-retinal surgery (n = 19, 12%), comprehensive ophthalmology (n = 18, 11.4%), oculoplastics (n = 17, 10.8%), community ophthalmology (n = 16, 10.1%), medical retina (n = 14, 8.9%), cornea and external diseases (n = 10, 6.3%), cataract surgery (n = 4, 2.5%), neuro-ophthalmology (n = 2, 1.3%) and low vision and rehabilitation (n = 1, 0.6%). Twenty-nine (18.4%) respondents had some formal training in communication skills and 39 (24.7%) respondents had some formal training in medical education.
Overall, respondents rated human resources (n = 30, 19%) as 'much more than adequate' in their institutions but rated the volume of surgery (n = 17, 10.8%) as 'much less than adequate' [Table 2]. Some resources were rated as 'less' and 'much less' than adequate by respondents. However, the order of these resources varied based on the respondent's institution type. The order for federal institutions (n = 113, 71.5%) comprised volume of surgery (n = 60, 53.1%), followed by equipment (n = 51, 45.1%), infrastructure (n = 35, 31%), human resources (n = 15, 13.3%) and structured academic programme (n = 7, 6.2%). The order for state institutions (n = 32, 20.3%) comprised volume of surgery (n = 21, 65.6%), followed by infrastructure (n = 15, 46.9%), equipment (n = 14, 43.8%), human resources (n = 13, 40.6%) and structured academic programme (n = 3, 9.4%). Only one respondent (33.3%) from a mission hospital reported the volume of surgery, equipment and structured academic programme as 'less than adequate'. None of the resources was rated as 'less than adequate' or worse by respondents from private institutions (n = 10, 6.3%).
Table 2: Responses to the question ‘from your perspective, how adequate are each of the following five resources in your institution?’The majority (n = 120, 75%) of respondents rated the conduct of ophthalmology fellowship examinations in Nigeria as 'good' or better. However, non-examiners tended to rate the conduct of examinations poorly compared with examiners (P < 0.001) [Table 3]. In addition, more than half (59.4%) of the respondents rated the overall quality of ophthalmology residency training in Nigeria as 'good' or better [Table 4].
Table 3: Responses to the question ‘how will you rate the current conduct of ophthalmology fellowship examinations in Nigeria?’
Table 4: Responses to the question ‘overall, how will you rate the quality of ophthalmology residency training in Nigeria?’Some respondents considered residency training in their institutions to be 'extremely challenging' and 'very challenging' for surgical skills transfer (n = 5, 3.2% and n = 31, 19.6%), research training (n = 6, 3.8% and n = 26, 16.5%), soft skills transfer (n = 4, 2.5% and n = 16, 10.1%), clinical skills transfer (n = 1, 0.6% and n = 10, 6.3%) and refraction training (n = 1, 0.6% and n = 6, 3.8%), respectively. Other challenges reported by respondents (multiple responses) included residents with a poor attitude to work and learning (n = 133, 84.2%), residents with learning difficulties (n = 68, 43%), personal stress-related physical health issues (n = 49, 31%), personal stress-related mental health issues (n = 15, 9.5%), verbal abuse from residents (n = 10, 6.3%) and physical abuse from residents (n = 1, 0.6%). Also, the impact of emigration of ophthalmology trainers and trainees on ophthalmology residency training at their institutions was perceived by respondents as very negative (n = 36, 22.8%), negative (n = 80, 50.6%), neither negative nor positive (n = 37, 23.4%) or positive (n = 5, 3.2%).
There were 126 (79.7%) participants who responded to the question 'What are your recommendations to improve ophthalmology residency training in Nigeria?' The recommendations were generally focused on improved funding and the provision of adequate resources for training. The most common recommendations were grouped under four main themes, which were to improve the structure of the training programme, improve training support, improve the volume of surgeries and surgical skills transfer and provide adequate infrastructure and equipment for training. The main themes and most common recommendations are summarised in [Figure 1].
Figure 1: Summary of the main themes and most common recommendations to the question 'What are your recommendations to improve ophthalmology residency training in Nigeria?'There were 122 (77.2%) participants who responded to the question 'What are your recommendations to improve the conduct of ophthalmology fellowship examinations in Nigeria?' Twenty-six (21.3%) respondents gave recommendations related to improving the preparations for examinations and 96 (78.7%) respondents gave recommendations related to revising the examination format including using simulators for the practical examination sections. The main themes and most common recommendations are summarised in [Figure 2].
Figure 2: Summary of the main themes and most common recommendations to the question 'What are your recommendations to improve the conduct of ophthalmology fellowship examinations in Nigeria?'There were 132 (83.5%) participants who responded to the question 'What are your recommendations to reduce the emigration of Nigerian ophthalmology trainers and trainees?' Recommendations included employing more ophthalmologists, providing more accredited training centres, better remuneration for staff, providing a good working environment and retirement package, improving national security and improved accessibility to insurance schemes.
DiscussionThis nationwide survey aimed at highlighting the perspectives of ophthalmology trainers in Nigeria on the adequacy and challenges of ophthalmology residency training. It also elicited trainers' recommendations on how to improve the training in general, as well as reduce the emigration of ophthalmologists. The respondents included more than 70% of all the ophthalmology trainers in Nigeria who were spread across five geopolitical zones in the country.
The number of health institutions accredited for ophthalmology residency training in Nigeria translated to a training institution-to-population ratio of 1:6.9 million persons based on Nigeria's World Bank estimated population of about 206 million as of 2020.[3] This figure suggests some degree of accessibility to high-quality eye care. However, there is still room for improvement as this figure was comparable to 1:6.8 million for all sub-Saharan African countries,[19] but lower than 1:2.9 million calculated for the United States using 114 institutions by Camacci et al.,[20] and a population of 331.5 million in 2020.[21] Furthermore, the Northeast geopolitical zone in Nigeria did not have an accredited training institution. The NPMCN would need to correct this geographical maldistribution of accredited training institutions to prevent some communities from being underserved in terms of high-quality eye care provision as well as opportunities for residency training in ophthalmology.
In addition, the accredited training institutions were largely owned by the federal and state governments and there were more resources rated as 'less than adequate' in the government-owned institutions compared to the private and mission-owned institutions. This could be because government-owned institutions have funding difficulties as reported by Monsudi et al.[5] and Babalola.[22] Advocacy for improvements in budgetary allocations to health care and medical training, an increase in public–private partnerships, and the accreditation of more private institutions could help to reduce these funding challenges.
Overall, the proportion of respondents with subspeciality training was almost double that of general ophthalmologists. This suggests that significant strides have been made in subspeciality training when compared to an earlier study that reported a lower proportion of 54% of trained subspecialists in Nigeria between 2017 and 2018.[23] The subspeciality ophthalmology fellowships offered by the International Council of Ophthalmology and the Commonwealth Eye Health Consortium could also have contributed to this improvement.[24] But, there were some divergent views on the need for ophthalmic subspeciality training in Nigeria. Some respondents advocated for more directed subspeciality training for residents while others said an emphasis on comprehensive ophthalmology training was what is needed to first address the basic eye problems in Nigeria. However, a compromise could also be reached where residents spend longer durations in cataract and glaucoma rotations relative to other subspeciality rotations. Further research may be required to investigate the merits and demerits of these divergent views.
Overall, more than half of the respondents rated the ophthalmology residency training in Nigeria as 'good', 'very good' or 'excellent'. This finding may be because more than two-thirds of the trainers considered the structured academic programme, human resources and infrastructure to be adequate. Thus, these resources may currently be regarded as the strengths of the training programme. However, this finding differs slightly from the perspective of ophthalmology trainees in Nigeria who suggested that improving the structure of the training programme was needed.[17] Moreover, the adequacy of human resources could be temporary due to the constant threat posed by the persistent emigration of physicians from Nigeria.[6]
The institutions' resources deemed to be 'less than adequate' and 'much less than adequate' by respondents overall, were 'volume of surgery' followed by 'equipment'. This finding is at variance with the overall assessment of ophthalmology residency training as 'good' or better and conversely suggests that ophthalmology trainees may have suboptimal surgical skills training. Furthermore, this finding was supported by reports from other studies in Nigeria on training challenges due to inadequate volume of surgery,[22],[25] and unavailability of equipment,[5],[23],[25] as well as the suggestion for the improvement in the volume of ophthalmic surgeries by ophthalmology trainees in Nigeria.[17] Therefore, there is an urgent need to find solutions to increase the volume of surgeries and provide adequate equipment for training to optimally address these weaknesses in the training programme.
The provision of comprehensive health insurance schemes for patients was proffered as a way to improve the inadequate volume of surgeries. Nigeria has a national health insurance scheme that was established in 1999 and became operational in 2005. However, the scheme serves just about 4% of the Nigerian population.[26] Hence, there is an urgent need to improve the coverage of this insurance scheme in Nigeria. Other recommendations included sponsored community surgical outreaches, the use of simulators to enhance the acquisition and honing of trainees' surgical skills, the use of audiovisuals to record surgeries and provide feedback, as well as other technologies for surgical skills transfer. These recommendations are worthy of consideration because some have been shown to have produced favourable results by other researchers.[27],[28],[29],[30]
Most of the respondents rated surgical skills transfer as the most challenging aspect of training. The challenges with surgical skills transfer could be a consequence of the inadequate volume of surgeries as highlighted by respondents in this study. In addition, the challenge of surgical skills transfer could have been further worsened due to the general reduction in non-critical eye care services during the recent COVID-19 pandemic.[31],[32] Respondents have recommended the early integration of trainees into surgical training as well as the use of simulators to enhance surgical skills transfer, similar to findings by Annoh et al.[27]
The most common recommendations to improve the conduct of ophthalmology fellowship examinations in Nigeria were themed around revisions in the examination format. A specific improvement would be for examinations to be made more objective by using appropriate simulators for the practical examination sections. The use of technology in the residency training programme to enhance learning was also recommended by respondents. This was also noted by Al-Khaled et al.[33] who proposed that web-based modules and resources, artificial intelligence-based systems and telemedicine programmes would augment current curricula for ophthalmology trainees.
The availability of human resources appeared to be one of the strengths of the ophthalmology residency training programme. However, most respondents felt that the persistent and increasing emigration of trainers and trainees has had a 'very negative' or 'negative' impact on ophthalmology residency training in Nigeria. Furthermore, the current national security challenges in Nigeria could worsen this emigration over time if not resolved in a timely fashion.[34] Improving the remunerations of both ophthalmology trainers and trainees as was cited by Nentwich et al.[35] could help to combat this trend.
The findings from this study were based on the perspectives of ophthalmology trainers in Nigeria and may be inherently subjective in nature. Nevertheless, the study has provided useful information on the areas of improvement, as well as recommendations for policy change needed for the ophthalmology residency training programme in Nigeria.
ConclusionsMost ophthalmology trainers perceived that the overall quality of ophthalmology residency training in Nigeria was 'good'. However, it was considered that government-owned institutions had less adequate resources compared to private and mission-owned institutions due to funding challenges. 'Human resources' was rated to be 'much more' adequate than other resources while 'volume of surgery' was rated to be 'much less' adequate than other resources. 'Surgical skills transfer' was deemed to be the most challenging aspect of training, while the emigration of trainers and trainees was majorly considered to have had a negative impact on ophthalmology residency training in Nigeria. The main recommendations to improve ophthalmology residency training in Nigeria have been highlighted in this study. These recommendations could inform changes in policy that would improve training programmes as well as the provision of eye health services in Nigeria and other countries.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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