CURRENT MANAGEMENT OF SYNDEMICS IN NIGERIA BY DRCICI Edit

MANAGEMENT OF
SYNDEMICS
BY
DR JOY CHINYERE NWAOGWUGWU
DEPARTMENT OF
PUBLIC HEALTH AND COMMUNITY MEDICINE
2ND MARCH, 2022
1
OUTLINE
• List of Abbreviations
• Definition of Terms
• Introduction
• Criteria of a Syndemic
• Types of Syndemic interaction
• Examples of syndemics
• Syndemics in Nigeria
• Public health implications/significance of the concept
• Syndemic-oriented approach to disease prevention
• Challenges
• Recommendations
• Conclusion
2
LIST OF ABBREVIATIONS
• AIDS: Acquired Immuno-Deficiency Syndrome
• HAI: Healthcare Associated Infections
• HIV : Human Immunodeficiency Virus
• IBBSS: Integrated Biological And Behavioral
Surveillance Survey
• MDR-TB: Multi-Drug Resistant Tuberculosis
• PCSI: Program Collaboration and Service
Integration
• SAVA: Substance Abuse Violence AIDS
• VIDDA: Violence, Immigration related stress,
Depression, Diabetes and Abuse.
3
DEFINITION OF TERMS
• Co-morbidity: a disease or condition that coexist with
but is independent of another disease or condition
• Endemic: the constant presence and/or usual
prevalence of a disease or infectious agent in a
population within a geographical area
• Epidemic: an increase, often sudden, in the number of

cases of a disease above what is normally expected in
that population in that area.
4
DEFINITION OF TERMS…
• Iatrogenic syndemic: A syndemic interaction caused
or exacerbated by medical treatment; or medical
treatment for one disease is weakened by the actions
of another disease.
• Pandemic: It refers to an epidemic that has spread
over several countries or continents, usually affecting
a large number of people.
• Program collaboration: This is a mutually beneficial
and well-defined relationship entered into by two or
more programs, organizations, or organizational units
to achieve common goals.
5
• Program collaboration and service integration:
This is a mechanism for organizing and blending
interrelated health issues, activities, and prevention
strategies to facilitate comprehensive delivery of
services
• Service integration: This is a distinct method of
service delivery that provides persons with seamless
services from multiple programs or areas within
programs without repeated registration procedures,
waiting period or other administrative barriers.
6
• Syndemics: The aggregation of two or more concurrent
sequential epidemics or disease clusters in a population
in which there is some level of deleterious biological or
social interface that exacerbates the prognosis and
burden of the disease or health condition
• Syndemic interaction: The co-occurrence of social and
health conditions, including socio-psychological, socio-
biological, and psycho-biological interactions, which
worsen the condition of the person or population
afflicted
7
INTRODUCTION
• Syndemics was originally developed by the medical
anthropologist Merrill Singer in the mid-1990s who
first recognized the first syndemic, the SAVA
(Substance Abuse, Violence, and AIDS) syndemic,
among inner city Hartford residents in the United
States (US).
• He found that a collection of tightly interwoven
factors such as poverty, lack of adequate housing,
family instability, drug-related violence, and
inequitable health care, fueled the increased risk of
AIDS among this population.
(Tsai, 2019) 8
INTRODUCTION…
• Singer conceptualized the conditions comprising the
SAVA syndemic as issues working in conjunction to
exacerbate all three components simultaneously.
• Conventional frameworks in medicine and public
health, such as comorbidity and multi-morbidity,
often overlook the effects of social, political, and
ecological factors.
(Tsai, 2019)
9
INTRODUCTION…
• Syndemics goes beyond common medical concepts of
comorbidity and multi-morbidity because it is
concerned with the health consequences of
identifiable disease interactions and the social,
environmental, or economic factors that promote such
interaction and worsen disease.
• The theory of syndemics improves on conventional
frameworks in both theoretical and practical terms by
illuminating how macro-level social factors promote
disease clustering at the population level and impact
disease pathologies at the individual level.
(Mendenhall, Kohrt & Norris et. al.,2017) 10
INTRODUCTION…
• Syndemics involve the adverse interaction of diseases
of all types (e.g. infections, chronic non-
communicable diseases, mental health problems,
behavoural conditions, toxic exposure, and
malnutrition).
• They are most likely to emerge under conditions of
health inequality caused by poverty, stigmatization,
stress, or structural violence because of the role of
these factors in disease clustering and exposure and in
increased physical and behavioural vulnerability
(Mendenhall, Kohrt & Norris et. al.,2017)
11
CRITERIA OF A SYNDEMIC
Three criteria set the boundaries that define what constitutes
a syndemic;
• the clustering of two or more diseases or health
conditions, such as infections, mental health problems,
and/or non-communicable diseases within a specific
population;
• biological interactions among the health conditions that
lead to an increased health burden in the affected
population;
• and contextual and social factors that create the
conditions for clustering and/or for interaction that
worsen health outcomes.
(Singer et al, 2017) 12
CRITERIA OF A SYNDEMIC…
FIRST CRITERION
• The first criterion of a syndemic is that the co-occurrence of
two or more health problems has epidemic proportions in a
specific population.
• To identify a syndemic, epidemic patterns of comorbidities,
the clusters of diseases or health conditions must be
established
• Clustering of disease therefore refers to both the individual
level, where health problems co-occur, and the population
level where patterns of co-occurrence are identified.
(Singer et al, 2017)
13
SECOND CRITERION
• The second criterion of a syndemic refers to the
relationship between the clustering health problems:
Diseases and health conditions are considered
intertwined.
• This means that the natural course of one disease is
altered due to the presence of another co-occurring
disease or condition.
14
SECOND CRITERION…
• In a syndemic, the biological interaction of two or
more diseases in individuals and within a population
amplifies the disease burden: working together, they
lead to more illness or disability, or a more rapid
health decline in individuals than if there was no
clustering of disease.
• At the population level, this amplification leads to a
disproportionate increase of morbidity or mortality
within the population.
15
THIRD CRITERION
• The key role of the social context is the third criterion
a syndemic has to meet
• The interaction of social conditions in the causal
pathways to clustering and interaction must be
demonstrated.
• The spread, clustering, and adverse interactions are
shaped by encompassing social conditions such as
structural violence, poverty, stress, and
stigmatization.
16
• These may all amplify the vulnerability of
disadvantaged individuals and populations by
increasing susceptibility, reducing immunological
functions, and limiting people's resources to prevent
the negative spirals from happening
17
TYPES OF SYNDEMIC INTERACTION
There are six types of syndemic interaction among

diseases, they include;
• Enhanced contagiousness
• Accelerated virulence
• Alterations of the physical body
• Alterations of the emotions
• Gene assortment
• Iatrogenic factors
18
TYPES OF SYNDEMIC
INTERACTION…
Enhanced contagiousness
• One disease promotes the contagiousness of another
disease by helping it to gain access to vulnerable
areas of the body.
• This type of interaction occurs, for example, between
syphilis and HIV when the disruption of the
multilayered epithelial barrier and genital - tract
ulceration produced by the former supports sexual
transmission of the latter.
19
TYPES OF SYNDEMIC
INTERACTION…
Accelerated virulence
• In the case of the HIV–tuberculosis syndemic, HIV
increases the virulence of Mycobacterium
tuberculosis due to immunosuppression thereby
allowing the infectious agent of tuberculosis to freely
replicate
20
TYPES OF SYNDEMIC
INTERACTION…
Alterations of the physical body
• Changes in the body caused by one disease can also
promote the invasion of another disease.
• For example, schistosomiasis is known to facilitate
HIV infection.
• In a study involving 500 sexually active women in
Zimbabwe, an association was found between having
genital lesions caused by Schistosoma haematobium
infestation and being HIV positive.
(Colley, Bustinduy & Secor et. al., 2014)
21
TYPES OF SYNDEMIC
INTERACTION…
• This finding suggests profoundly heightened
susceptibility to HIV in women with
schistosomiasis genital lesions that serve as
entry points for HIV.
(Colley, Bustinduy & Secor et. al., 2014)
22
TYPES OF SYNDEMIC
INTERACTION…
Alterations of psychological states
• Events such as trauma, stress, internalisation of social
rejection, and the embodied experience of social stigma
through a stigmatized illness or disease related,
stigmatized identity can have both psychosocial and
biological effects on disease–disease interaction and
adverse health outcomes.
• Exposure to violence, for example, can trigger an
increase in the severity of asthma.
23
TYPES OF SYNDEMIC
INTERACTION…
Gene assortment
• In influenza A virus, continual gene
assortment allows the constant generation of
new strains, some of which present a
substantial risk for transmissibility across
species, pathogenicity, and pandemic potential.
24
TYPES OF SYNDEMIC
INTERACTION…
Iatrogenic syndemic
• This form of syndemic interaction involves the
various ways in which the efficacy of a drug
administered for a particular disease can be
reduced by the actions of another disease.
• An instance of this pattern is seen in the case
of the measles and HIV syndemic.
25
TYPES OF SYNDEMIC
INTERACTION…
• Researchers in sub-Saharan Africa have found
that HIV significantly reduces the efficacy of
the measles vaccination, leading to primary
and secondary vaccine failure among HIV-
infected children and a high mortality rate.
(Moss & Strebel, 2011)
26
TYPES OF SYNDEMIC…
• Countersyndemics:
When one biological trait, disease, behaviour, or social
condition provides a protective benefit against other
disease interactions, as seen in the protection from
potentially lethal Rocky Mountain spotted fever that can
be conferred after exposure to Rickettsia amglyommii.
(Singer et al.,2017)
27
TYPES OF SYNDEMICS…
• Unintended countersyndemic:
When efforts to treat one disease improves the
elimination of another.
• Eco-syndemics:
Extreme weather contributes to severe conditions
that foster migration, the breakdown of built
environments, and metabolism of pathogenic
organisms that result in increased rates of growth and
cell division, as well as other interactions.
(Singer et al.,2017)
28
TYPES OF SYNDEMIC…
• Syndemics of war
War and conflict are traumatic biosocial events
that compromise existing conditions and health-
care access, thereby increasing the likelihood of
disease clustering and syndemic interaction.
(Singer et
al.,2017)
29
FACTORS AFFECTING SYNDEMIC
SOCIAL FACTORS
o Rapid developing technology.
o Changing political conditions.
o Expanding patterns of globalization.
o Stigmatisation.
o Poverty.
o Altering demographics and changing social
behaviour.
(Fronteira, 2021)
30
FACTORS AFFECTING SYNDEMIC…
ENVIRONMENTAL FACTORS:
Environmental factors is subdivided into;
• Social environment: Culture, gender, education,
race, income, occupation, standard of living,
stigmatisation, security, mass media, health care
social care system, national health research
systems.
(Fronteira, 2021)
31
• Biotic environment: susceptibility of human

host( age, sex, genetics, behaviour and life style,
mental health, nutritional status and immune status).
• Abiotic environment: sunlight, temperature,
humidity, pollution.
(Fronteira, 2021)
32
BIOLOGICAL FACTORS:
o Breakdown of public health protective services.
o Microbial adaptation.
o Malnutrition.
o Exposure to multiple infective microorganism.
o Host susceptibility.
(Fronteira, 2021)
33
EXAMPLES OF SYNDEMIC
• SAVA syndemic (Substance Abuse, Violence and
AIDS)
• The Hookworm, Malaria and HIV/AIDS syndemic
• The Chagas disease, Rheumatic heart
disease and Congestive heart failure syndemic
• The STD, HIV and TB syndemic
• The Malnutrition and Depression syndemic
• The Whooping cough, Influenza and Tuberculosis
syndemic
(Singer et. al., 2017)
34
EXAMPLES OF SYNDEMIC…
• The HIV incidence, substance use, mental health,
childhood sexual abuse, and intimate partner violence
syndemics
• The HIV infection, mental health and substance abuse
syndemic.
• The stress and obesity syndemic
(Singer et. al., 2017)
35
EXAMPLES OF SYNDEMICS…
SAVA SYDEMIC
• The first syndemic identified is known as SAVA
syndemic; a specific syndemic that was
first identified amongst inner city populations in
the USA in the 1990s.
• In SAVA, interactions between the conditions,
substance abuse, Violence and AIDS, exacerbate
the burden of disease.
36
SAVA SYNDEMIC
• Epidemiological data suggests that alcohol and illicit
drugs make people more susceptible to infection, by
causing immunosuppression
• Additionally, illicit drugs accelerate the progression
to symptomatic AIDS in people with HIV.
37
SAVA SYNDEMIC
• Also substance abuse including binge consumption
of alcohol increases the risk of intimate partner
violence and sexual risk taking with consequent
HIV infection
• This context is characterized by high rates of
unemployment, poverty, homelessness, lack of
social support networks, gang violence, healthcare
inequality, and many other social factors that
contribute to the inner city health crisis in the US.
38
• Such conditions of structural disadvantage find
expression in individual life histories characterized
by domestic abuse, neglect, family
difficulties, interpersonal violence, and economic
problems.

39
HIV-MDR-TB SYNDEMIC
• Another syndemic is the HIV Multidrug resistant
Tuberculosis syndemic, the HIV-MDR-TB syndemic.
• It is emerging around the world, but particularly
worrying in southern Africa.
• At the biological level, HIV and TB potentiate one
another.
• HIV predisposes the patient to a TB co-infection by
impairing the patient's immune system.
40
HIV-MDR-TB SYNDEMIC
• However, the co-infection also accelerates the further
deterioration of immunological functions, which increases
the risk of progression to active disease, AIDS.
• The earliest identified syndemics include HIV/AIDS as a
component because this disease is often an integral
component in disease interactions and is greatly affected by
social and structural conditions such as poverty,
marginalization, gender inequality, malnutrition, and
stigma.
41
• A few examples of HIV-related syndemics identified
to date include:
– HIV– sexually transmitted infection interactions,
for which women are at particular risk because of
the combined effects of biological factors and
social inequalities,
– HIV–drug-use–risky sexual behaviour–stigma
syndemic among men who have sex with men, and
– HIV– malnutrition–food insecurity syndemic, as
seen in subsaharan Africa.
42
VIDDA SYNDEMIC
• Syndemics are not limited to infectious diseases as the
VIDDA syndemic is an example of how
noncommunicable diseases and health conditions
cluster and interact.
• This syndemic unites Violence, Immigration,
Depression, Type 2 diabetes, and Abuse as mutually
exacerbating factors in the health of Mexican
immigrant women in the USA.
43
SYNDEMICS IN NIGERIA
• The SAVA syndemic is seen among gay,
bisexual and other men who have sex with
men (GBMSM) in Nigeria
• Nigerian gay, bisexual and other men who
have sex with men (GBMSM) experience
negative psychosocial health problems, which
may increase their risk for HIV infection.
(Ogunbajo et al., 2019)
44
SYNDEMICS IN NIGERIA…
• The SAVA syndemic is also seen among People
Who Inject Drugs (PWID) in Nigeria.
• Nigeria has among the highest rates of drug
trafficking and drug use in West Africa as well as
HIV, hepatitis and TB, suggesting significant
increased risk for PWID and an important
contribution of injection drug use to epidemics of
infectious diseases.
(UNODC, 2019)
45
• Healthcare Associated Infections (HAI) program data from
2016 to 2017 suggest an increasing HIV epidemic among
PWID: HIV positivity was three times higher among
PWID: 11%: (women: 20%; men: 8%) than in the most
recent Integrated Biological and Behavioural Surveillance
Survey (2014) study: 3.4% (women: 13.6%; men: 2.9%).
• PWID and service providers reported almost universal
sharing of injection equipment, opioid overdoses as well as
emotional, physical and sexual violence.
(Veen et al, 2021)
46
COVID-19 AND HIV SYNDEMIC IN NIGERIA
• Travel restriction as a measure to manage COVID-19
pandemic made it difficult for individuals to visit
health care facility for HIV testing and also for
PLHIV(People living with HIV) during time of crisis.
• HIV program was negatively affected by the current
COVID-19 pandemic due to ongoing disruption in
patients access to HIV services.
(Horton, 2020)
47
• Older adult with underlying disease like HIV are
immunosenescence which makes them at risks of
contracting COVID-19.
• Home quarantine and travel restriction as a
management measure for COVID-19 led to gender
based violence and sexual abuse which predisposed
the victims to contracting HIV which could in turn
lead to mother to child transmission of
HIV(MTCT).
(Bassey, 2020)
48
• Communities in the rural areas were ignored in
pandemic responses and this rural areas have low level
of literacy, healthcare services, all of which were
possible barriers to care delivery especially when
dealing with diseases like HIV.
• Financial constraints and unemployment continue to
prevail during the COVID-19 pandemic, resulting in
the patients’ limited access to ART treatment and
facility based care.
(Bassey, 2020)
49
• All attention shifted to the COVID-19 pandemic as
more health care workers were transferred from
other sections of the health care services to
COVID-19 centers, this cause a decline in the
health care services including HIV services.
• The short term consequence include; limited access
to drugs and loss of follow-up.
• The long term consequence include; drug
resistance, increased HIV incidence, weakening of
the health system.
(Bassey, 2020; Oladele et al., 2020)50
• With the global and national economic effect of
COVID-19, donor funding for HIV/AIDS such as US
President’s Emergency Plan for AIDS Relief
(PEPFAR) and the Global Fund to Fight AIDS,
Tuberculosis and Malaria (the Global Fund) were
redirected to COVID-19.
• This reduced funding on the HIV response would
have short and long term consequences.
(Oladele et al., 2020)
51
PUBLIC HEALTH SIGNIFICANCE OF
THE SYNDEMIC APPROACH
• Health-care systems can have an iatrogenic role by
exacerbating, or even precipitating, syndemics.
• Health intervention for one condition can cause the
emergence of another, and overlooking the
underlying biological effects of one condition on
another can negatively affect health outcomes.
52
THE SYNDEMIC APPROACH…
• The syndemic approach is an approach in which
health systems focus on providing holistic medical
care as opposed to care focused on singular disease
outcomes.
• Adding the social element into clinical care can
improve patient outcomes by recognizing the
underlying social, economic, and psychological
factors impede treatment.
• It also incorporates diagnostics and routine care into
one medical visit, saving the patient time and money.
53
• Recognition of syndemics promotes the need to build
strong health systems that are accessible, affordable,
and available for vulnerable populations worldwide.
• By addressing the social and economic drivers of
health inequities, the distribution of suffering and ill
health globally can be radically reduced.
54
• The syndemic approach provides powerful strategies
for recognising how social, political, and ecological
factors create and perpetuate structural vulnerabilities
that contribute to syndemic emergence and
exacerbation.
• Second, a syndemic framework enables
understanding of how certain individuals, families,
and communities (and not others) are consigned to
harmful environments that make them vulnerable to
syndemics with concrete effects on social and
biological wellbeing.
55
• Third, this syndemic knowledge makes it possible to
intervene effectively at both the policy and clinical
levels.
• By addressing both the roots of illness (inequality) and
the treatment of symptoms (clinical care), syndemic
intervention can strengthen strategies of prevention and
care by considering the full scope of syndemic
vulnerabilities, rather than treating disorders individually
and ignoring the complex contexts in which they occur.
56
• The syndemics approach can thus make a valuable
contribution to how researchers, clinical practitioners,
and policy makers think about and intervene in health
inequities and inequalities across populations.
• A syndemic approach requires the identification of
social policies and clinical care that address the
confluence of these mutually exacerbating conditions.
57
• Attention to syndemic interactions reveals the need to
build strong health systems that are accessible,
affordable, and available for vulnerable populations.
• Further, health systems that take syndemic
interactions into account will be designed to optimise
wellbeing of whole persons and address underlying
social and structural causes rather than asking
clinicians to treat individual diseases in isolation.
58
• The provision of patient-centred medical care that
incorporates diagnostics and routine care within a
single clinical encounter can save patients valuable
time and money and improve patients' outcomes by
working to overcome underlying social, economic,
and psychological impediments to treatment
regimens.
59
Syndemic-oriented approach to disease
prevention/control
• Certain populations are at elevated risk for multiple
diseases, this common risks suggest the need for
common solutions and enhanced collaboration among
related prevention programs.
• Also these disease conditions share many social,
environmental, behavioral, and biological
determinants and are often managed by the same or
similar organizations
(CDC, 2009)
60
prevention/control…
• Understanding the local epidemiology, as well as
understanding risks and the service needs of the
communities served are essential components of
developing appropriate, comprehensive services and
thereby enhancing quality, public health impact and
cost-effectiveness.
• A syndemic-oriented approach first defines the
population in question, identifies the conditions that
create and sustain health in that population, examines
why those conditions might differ among groups and
determines how those conditions might be addressed
in a comprehensive manner. 61
• The Center for Disease Control (CDC) in 2007
introduced the concept of Program Collaboration and
Service Integration (PCSI) as a way to conceptualize,
implement, and deliver holistic, evidence-based
prevention services and risk reduction messages to
appropriate populations in clinical settings
• The focus on PCSI to ensure that individuals receive
the best preventive service and treatment possible
whenever they interact with providers of health
services.
(CDC, 2009)
62
• The rationale is to maximize opportunities to screen,
test, treat, or vaccinate those in need of these
services; improve the health of populations
negatively affected by multiple diseases; and enable
service providers to adapt to and keep pace with
changes in disease epidemiology and new
technologies.
(CDC, 2009)
63
Goal of PCSI
• Preventing infection and disease among persons at
risk
• Interrupting disease transmission through prompt
diagnosis and adequate treatment
• Ensuring access to high-quality, culturally appropriate
services and key messages for marginalized,
underinsured and uninsured at-risk populations
• Monitoring infections in the population (e.g., case
surveillance)
(CDC, 2009) 64
Principles of PCSI
• Appropriateness:
– The integration of prevention services must make
epidemiologic and programmatic sense and should
be contextually appropriate.
• Effectiveness:
– Preventive services or interventions have to be
effective in order to conserve prevention
resources which are far too limited to be wasted
on ineffective or unproven interventions or
settings
(CDC, 2009) 65
Principles of PCSI…
• Flexibility:
– This is the ability to respond to changes in disease
epidemiology, demographic changes, advances in
technology, and policy/political imperatives.
• Accountability:
– This is done by tracking appropriate indicators that
reflect operational performance and comparing
them against previously defined key performance
standards thereby creating a continuous feedback
loop that facilitates iterative process improvement.
66
Principles of PCSI…
• Acceptability:
– To be effective, PCSI must be accepted by service
providers, as well as by the persons they serve.
– The objective of PCSI is to empower the provider
to provide all the services that are needed, thereby
increasing the health and satisfaction of service
recipients.
– For example, there is evidence that offering
hepatitis vaccination may increase acceptance of
STD and HIV testing and other prevention services
67
• The objective of service integration is to provide key
prevention interventions that can be combined
quickly and easily to create comprehensive evidence-
based prevention services.
• Benefits include
– Provision of prevention service providers with
greater flexibility when responding to changing
disease epidemics or policy/political priorities by
allowing them to build upon existing program
infrastructures (e.g., human, information
technology, financial) of multiple programs; and
– It Lowers the total cost of service provision.
68
Service integration has two main goals:
• To make it easier for persons to access needed
services by providing them with a single point of
entry (such as a community health center in an inner-
city area that also provides services such as welfare
assistance, economic development assistance, and
adult education); and
• To increase HCWs’ knowledge about available
resources that are shared with other programs or
agencies, and thereby minimize duplication of
services while allowing each program or agency to
continue specializing in its own area of expertise.
69
Three levels of service integration at the client–provider
interface have been proposed
• Level 1: Nonintegrated Services
• Level 2: Core Integrated Services
• Level 3: Expanded Integrated Services
(CDC, 2009)
70
• Level 2: Core Integrated Services:
o A basic package of services that integrates two or
more prevention services, including screening,
testing, or treatment services into clinical care.
• Examples of typical Level 2 integrated services
include
o TB clinics in which routine HIV testing is provided to
persons with latent and active TB and their contacts;
(CDC, 2009)
71
o STD clinics that offer routine HIV testing and
hepatitis B vaccination to all persons seeking care;
o Emergency departments that routinely offer opt-out
HIV testing to all newly admitted patients;
o Family-planning services that offer routine chlamydia
screening to all women younger than 26 years.
(CDC, 2009)
72
Level 3: Expanded Integrated Services:
• A comprehensive package of best and promising
evidence-based practice of syndemic prevention,
screening, or treatment services that are integrated
into general health and social services.
• Examples include
o Comprehensive HIV/AIDS, viral hepatitis, STD and
TB screening, diagnosis, and treatment services, with
referral to specialized services and primary care, if
required;
(CDC, 2009) 73
Level 3: Expanded Integrated Services…
o Comprehensive sexual and reproductive health and
behavioral risk assessment, including assessment of
drug use, mental health, and risk of intimate partner
violence;
o Comprehensive reproductive health services,
including pregnancy testing and contraceptive
services;
(CDC, 2009)
74
o Specialized or social services, such as social case
management and housing, drug addiction counseling,
and mental health services;
o Health education and provision of targeted risk-
reduction information; and
o Referral to other specialized and prevention services
(e.g., behavioral interventions to help reduce or
eliminate high-risk behaviors), as indicated
(CDC, 2009)
75
Role of the Public Health Physician
• Monitor community members’ health status to
identify and solve community health problems.
– Enhanced surveillance and evaluation capacity
(e.g., reduce redundant systems, track
comorbidity) or capability (e.g., provide cross-
training for data managers).
– Develop common reporting and data-collection
instruments.
(CDC, 2009)
76
Role of the Public Health Physician …
• Diagnose and investigate health problems and health
hazards in the community.
– Identify populations and settings that are a high priority for
multiple programs, and develop a joint approach to
providing outreach, testing, and risk-reduction services.
• Inform, educate, and empower people about health
issues
– Develop communication channels
– Develop and test integrated prevention messages for
diseases with common risk factors.
77
• Mobilize community partnerships and action to
identify and solve health problems.
– Ensure targeted communities are represented in planning,
implementation, and evaluation of activities across
programs.
• Advocate for policies and plans that support
individual and community health efforts.
– Advocate for the integration of policies related to
syndemics and their risk factors
(CDC, 2009)
78
• Link people to needed personal health services.
– Identify opportunities for integrated prevention
programs, risk reduction messages and testing
where individuals, groups, or networks would
benefit from counseling and testing for two or
more diseases (e.g., HIV/AIDS, viral hepatitis,
STD, and TB) in a clinical, behavioral intervention
or outreach setting.
(CDC, 2009)
79
• Ensure the competency of the public and personal
healthcare workforce.
– Train and retrain front-line HCWs to identify risk
factors or other diseases, or make referrals for
further evaluation when appropriate.
– Train and retrain HCWS to conduct testing,
screening, and partner services.
– Develop internal cross-program communication
mechanisms to keep all staff up-to-date on all
programs.
(CDC, 2009) 80
• Evaluate the effectiveness, accessibility, and quality
of personal and population-based health services.
– Develop mechanisms to track the outcomes of combined
interventions.
– Determine the population-level impact of PCSI on various
syndemics
• Conduct research to identify innovative solutions to
health problems.
– Identify and support research to devise effective PCSI
models.
(CDC, 2009)
81
Challenges to the Syndemic approach of
disease prevention in Nigeria
• Paucity of research and literature on syndemics
ongoing in the country
• Inadequate awareness of the concept of
syndemics among the government and health
care workers in Nigeria.
• The best practices for the integration of services
and the simultaneous treatment of syndemics is
still a challenge leaving intervention measures
still in the experimental stages.
82
RECOMMENDATION
TO THE PUBLIC HEALTH PHYSICIAN
• Advocate, advise and educate various
stakeholders on current syndemics and roles
they play in its prevention
• Increased surveillance and research on
evolving disease epidemiology and risk factors
83
RECOMMENDATION…
TO THE HEALTH SECTOR
• Retraining and training of clinicians on use of
syndemic approach (especially the social
context) in healthcare.
84
RECOMMENDATION
TO GOVERNMENT
• Provision of funding for research on use of
syndemic models in addressing health
challenges of marginalized populations in the
country.
85
CONCLUSION
• The syndemics approach has the potential to affect health
policy by drawing attention to how social, economic, and
environmental factors affect the health of human beings,
provided that these factors are not separated in analysis
from disease emergence or comorbidity.
• It provides a very different orientation to clinical medicine
and public health by showing how an integrated approach
to understanding and treating diseases can be far more
successful than simply controlling epidemic disease or
treating individual patients.
86
CONCLUSION…
• Adopting PCSI as a framework for managing
syndemics ensures the delivery of holistic,
evidence-based prevention services and risk
reduction messages to appropriate populations
in clinical settings
87
REFERENCES
• Colley, D. G., Bustinduy, A. L., Secor, W. E., & King, C. H.
(2014). Human schistosomiasis. Lancet (London,
England), 383(9936), 2253–2264. https://
doi.org/10.1016/S0140-6736(13)61949-2
• Edem Bassey A., Chidubem Olisaeloka L., Adebisi Y. A.
(2020). Identifying the Gaps in HIV prevention and
treatment during the COVID-19 pandemic in Nigeria, Int J
Infect. Onine ahead of print. 8(109546).
doi:10.5812/iji.109546.
• Fronteira et al. (2021). The SARS-COV-2 Pandemic: A
syndemic perspective, one health.2(100228).
https://doi.org/10.1016/j.onehlt.2021.100228.
88
REFERENCES…
• Mendenhall, E., Kohrt, B. A., Norris, S. A., Ndetei,
D., & Prabhakaran, D. (2017). Non-communicable
disease syndemics: poverty, depression, and diabetes
among low-income populations. Lancet (London,
England), 389(10072), 951–963. https://
doi.org/10.1016/S0140-6736(17)30402-6
• Merrill S., Nicola B., Bayla O., Emily M.(2017).
Syndemics and the biosocial conception of health.
Lancet; vol389: pp41-50. Available from www.the
lancet.com [Assessed 6th of April 2021].
89
REFERENCES…
• Moss, W. J., & Strebel, P. (2011). Biological
feasibility of measles eradication. The Journal of
infectious diseases, 204 Suppl 1(Suppl 1), S47–S53.
https://doi.org/10.1093/infdis/jir065
• Oladele et al. (2020). The impact of COVID-19 on
HIV financing in Nigeria: a call for proactive
measures. BMJ Global Health. 5(002718). doi:
10.1136/bmjgh-2020-002718.
90
REFERENCES…
• Ogunbajo, A., Oke, T., Jin, H., Rashidi, W., Iwuagwu,
S., Harper, G., Biello, K. and Mimiaga, M., 2019. A
syndemic of psychosocial health problems is
associated with increased HIV sexual risk among
Nigerian gay, bisexual, and other men who have sex
with men (GBMSM). AIDS Care, 32(3), pp.337-342.
• Richard Horton. (2020). COVID-19 is not a
pandemic. The Lancet. 396(10255).
https://doi.org/10.1016/S0140-6736(20)32000-6.
91
REFERENCES
• Singer, M., 2009. Introduction to Syndemics. 1st
ed. San-Francisco: Jossey-Bass.
• Singer, M., Bulled, N., Ostrach, B. and
Mendenhall, E., 2017. Syndemics and the
biosocial conception of health. The Lancet,
389(10072), pp.941-950.
• The Lancet. (2017). Syndemic: Health in
Context. Science direct. 389(10072): pp881.
http://doi.org/10.1016/50140-6736(17)30640-2.
92
REFERENCES…
• Tsai A. C. (2018). Syndemics: A theory in search of data
or data in search of a theory?. Social science &
medicine, volume 206, pp117–122.
https://doi.org/10.1016/j.socscimed.2018.03.040
• Veen, S., Trout, C., Cenival, M. and Emmanuel, G.
(2021). Opportunities to address the growing
“syndemics” of HIV, sexually transmitted infection,
stigma, violence and substance abuse among people who
inject drugs in Nigeria. [Online]. Heartlandalliance.org.
Available at: https://
www.heartlandalliance.org/international/wp-content/uplo
ads/sites/15/2018/05/Exec-Summ-and-Full-Report-HR-Ni
geria.pdf/ 93
REFERENCES…
• Whenayon S.A, Olumuyiwa O., Odusanya, R .A. (2020).
COVID-19 out break situation in Nigeria and the need for
effective engagement of community health workers for
epidemic response. Global Bio Security. 1(4).
• Yadav U.N et al.(2020). A Syndemic Perspective on the
Management of Non-Communicable Diseases Amid the
COVID-19 Pandemic in low and middle income countries.
Front. Public Health. vol8: pp25. https.//doi.org//
10.3389/fpubh.2020.00508.
• https://www.thelancet.com/action/showPdf?pii=S0140-673
6%2817%2930640-2
94
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FOR LISTENING
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MANAGEMENT OF

• Epidemic: an increase, often sudden, in the number of

There are six types of syndemic interaction among

• Biotic environment: susceptibility of human

(Oladele et al., 2020)

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