Introduction

Age-friendly services are health services that address the unique needs and wants of older people so they can live healthy and active lives [1]. Presently, 14.8 million older persons live in Nigeria and at a growth rate of 3.2%, this number is expected to increase to 30 million by 2050, with women constituting 46% of this population” [2, 3]. Associated with the aging populations, non-communicable diseases (NCDs) have become a leading cause of morbidity, disability and mortality in all regions of the world, including in developing countries [4]. The burden of disease also includes age-related comorbidities including frailty, cognitive decline and multimorbidity [5]. In response, health care services need to be structured to be responsive to the needs of older adults to provide longitudinal primary care to prevent, diagnose and manage these comorbidities and improve the quality of life for this growing population [6, 7].

Primary Health Care centers (PHCs) are well positioned to provide person-centred and community-based care required to prevent or postpone morbidities associated with or more common with aging and reduce their impact on individuals, facilities and health systems [4, 8]. However current PHC-related services in Nigeria prioritize maternal and child healthcare, resulting in gaps in the structure and delivery of services needed by older adults [9, 10]. For example, despite a national action plan for the control of NCDs, its prevention, care and treatment are not currently included in the minimum service package for primary health care in Nigeria [7].

According to the World Health Organization (WHO), PHCs that are age-friendly should address three areas in their care for older adults: 1) information, education, communication and training for providers; 2) health care management systems; and 3) the physical environment [11]. PHCs should focus on adapting health care to the preferences and needs of older people, health promotion and the prevention of chronic conditions that result from aging [12]. These adaptations in service provision can empower older adults, involving them as partners in the care process, with goals to improve their quality of life, and ensure dignity in care [13]. Before the establishment of the National Senior Citizens Centre by the Nigerian federal government in 2017, there was no specific policy directly addressing the health needs of senior citizens. However, a more recent development is the approval of the National Policy on Ageing for Older Persons in Nigeria by the Federal Executive Council in February 2021, which emphasizes the importance of implementing age-friendly services, among other provisions, in Nigeria [14, 15]. Sustainable Development Goal 3, "Ensure Healthy Lives and Promote Well-being for All at All Ages," encompasses various actions aimed at improving the well-being of older adults. These actions are in line with essential aspects emphasized in the WHO Global Age-Friendly Guide, focusing on healthcare, active participation for healthy aging, and addressing welfare issues [16].

Some studies have identified enablers and barriers to providing age-friendly services in both high and low and middle income countries. For example, in an Australian health system, stakeholders highlighted barriers in delivering hospitals-based education and skills training; governance structures and leadership and working in multidisciplinary teams [17]. Enablers included valuing care of older people and their families; skilled compassionate staff working in effective teams; and care models and environments supporting older people across the system. Focus group data from clinician stakeholders in Canada reflected organizational level barriers and facilitators in five categories namely; education, environment, staffing, policies and other research projects [18]. In Uganda, low readiness for public health facilities to provide age-friendly care services were due to gaps in all of the health system building blocks; leadership, financing, human resources and health management information systems (HMIS) [19].

In Nigeria, high staff workload, administrative challenges, and mismatch with the needs of the aging patient population and existing resources and priorities have been identified as common barriers to service provision for chronic conditions that affect older adults in the PHCs [20]. Minimizing barriers to accessing primary health care and improving care provided for older adults would both enhance health outcomes, and reduce public health spending substantially [13]. Our previous study in comprehensive PHCs across Lagos, southwest Nigeria, found health care workers to be inadequately trained for the care of older persons, sub-optimal screening for conditions common among this population, and infrastructural gaps in the physical environment that should allow older people to move around independently, actively, safely and securely while receiving health care [21]. A study in Benin City, Nigeria, demonstrated a positive and supportive approach by health providers, maintaining helpful, friendly communication with older patients, explaining treatment processes and medication side effects as facilitators to provision of age-friendly services [22]. In Lagos, Nigeria, the promotion of age-friendly services was facilitated by healthcare providers acknowledging the importance of delivering suitable care for the elderly. The majority emphasized the need for compassionate staff in the care of older persons and expressed their readiness to undergo specialized training aimed at enhancing their skills and knowledge for effective [21]. To gain further insight into our findings, we aimed to explore further the barriers and facilitators to the delivery of age-friendly health services from the perspectives of PHC managers. These finding are important to inform the designing and testing of interventions to increase accessibility, acceptability and appropriateness of age-friendly PHCs in Lagos and in the region.

Materials and methods

Study site and participants

Lagos State is the most populous city in Africa with over 15 million residents across 57 local districts and 376 wards [24, 25]. There are over 300 PHCs across the wards and 57 of such PHCs are referred to as “flagship PHCs” because they have a full complement of health workers including medical doctors and offer 24-hour services [25]. The Lagos State Primary Health Care Board (PHCB) is tasked with the overall responsibility of primary health care management in the state. The board acts as a strategic link between the state and local councils in matters relating to primary health service improvement and delivery [26]. It is headed by the permanent secretary and who provides oversight functions through the principal officers of several directorates and the medical officers of health (MOH). The MOH oversees all the PHCs within a local council and each PHC facility is headed by an officer-in-charge.

This study was conducted among key informants recruited between May and September 2022. They included medical officers of health, principal officers of the PHC Board who are assistant directors or directors and board members. Participants were purposively selected based on their experience and position in the PHC system. Seventeen individuals who had direct oversight in PHC management and delivery were contacted via invitation letters and phone calls and asked to participate in the study; four declined due to lack of interest and a total of 13 stakeholders were interviewed. However, saturation of themes was achieved in our sample. The demographic characteristics of participants are included in Table 1.

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Table 1. Characteristics of interview participants (n = 13).

https://doi.org/10.1371/journal.pone.0288574.t001

Interviewer team.

Interviews were conducted by two researchers, A.O. and M.B., whom are both public health specialists with experience in qualitative research. Most of the participants were known to the interviewers as a result of the meeting in other public health meetings and related activities in the state. The participants knew the researchers were faculty members at the University of Lagos and were involved in public health research.

Results

Three-quarters of the participants were female (76.9%) and doctors (76.9%) (Table 1). Almost half (46.1%) were medical officers of health of the primary health care centers while 46.2% belonged to the management category in the primary health care board.

We identified fifteen major themes (Table 2). Ten of these were barriers to the delivery of age-friendly services while five were facilitators.

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Table 2. Summary of interview themes: Barriers and facilitators to the delivery of age-friendly health services (AFHS).

https://doi.org/10.1371/journal.pone.0288574.t002

Discussion

Our qualitative work found supporting evidence of the earlier quantitative findings of gaps in training and infrastructure, as well as identified new barriers to providing healthy aging care for older people in Lagos State as well as the presence of some facilitators. Majority of our respondents were female and this is not surprising. World Health Organization has reported that 70% global health workforce is female. In Nigeria, women constitute the majority of doctors (65%) and nurses (87%) [28]. Our respondents highlighted that older adults were not always a priority population for care at the PHCs but acknowledged the centrality of PHC’s role to provide accessible and affordable care across the lifespan. A review of the rising burden of non-communicable diseases among older adults indicates that these conditions might not be adequately addressed in primary health care systems that are primarily designed for acute care [29]. While the need to strengthen accessibility as well as the availability of PHC focused on older adults was recognized in this study there were a number of challenges that need to be addressed.

One important gap noted by some of the respondents was the lack of the existence of policies targeted at serving older adults in PHCs in Lagos State. However, it was stated that there were aspects of the national policies that implied the inclusion of older adults for care based on care for all adults with the main goal of social welfare. For example, according to the 1999 Nigerian Constitution, Section 16, sub-section 2(d), old age care and pensions, as well as sick benefits, will be provided to all citizens [30]. Similarly, existing policy documents in Uganda focus only on addressing the social needs of older adults [19]. The federal government of Nigeria introduced new policies such as the National Senior Citizens Centre in 2017, an agency to cater to the needs of senior citizens; and related matters were enacted and in due course, the National Policy on Ageing for Older Persons in Nigeria was approved by the Federal Executive Council in February 2021 [14, 15]. In addition to this, financial barriers from the PHC and limited financial resources among older adults were also identified. These barriers included low rates of uptake of programs designed to reduce these barriers. For example, the respondents also identified the poor coverage by the National Health Insurance Scheme (NHIS), reflections supported by data that only 5% of the population, mostly civil servants and younger individuals were enrolled in the program [31]. A review revealed that nations in Sub-Saharan Africa (SSA), such as Ghana, Mozambique, South Africa, Uganda, and Tanzania, have officially endorsed national policies addressing the aging population, while, Cameroon and Rwanda have formulated policies that are currently pending legislative approval for enactment into law [32].

Another important barriers was the staffing limitations and specifically workforce trained in the care for older adults was another reason given as an implementation barrier for Age- friendly Health Service (AFHS). These results reflect similar to findings from a quantitative survey in Benin City, Nigeria [22]. The lack of health manpower capacity is an issue of global public health concern and a major limitation to implementing important health policies across the lifespan [33]. In Nigeria, similar to in many countries in Africa, training in the care of older persons is still new. In Nigeria, it is not included in the undergraduate curriculum and only a few hospitals are accredited to offer training in geriatrics [34]. As a result, healthcare workers often do not have the knowledge and competency to address the emerging challenges in delivering care for older adults living with complex needs and this threatens the quality of care as well as trust in the healthcare system [35].

Many participants also noted the importance of moving beyond facility-based care to providing home services in the community to support older adults but there are no such formalized services for this age group in Nigeria [36]. This work would be important for both practice outreach as well as prompt attention to identifying and responding to emergency situations, as well as active outreach to prevent delay in disease complications. Learning from existing approaches that work will be important as well as leveraging strengths in community care. For example, in parts of the United States, community-based supports and services are designed to help community-dwelling older adults remain safely in their homes and delay the need for placing them in institutions [37]. Respondents also noted that many older adults lacked the social support in bringing older adults to the facility was also identified as a challenge. Studies have suggested that some of this weakened social support and this has been largely attributed to the change in family dynamics and traditional family structure in Nigeria as well as the lack of community-based support noted above [38].

An important barrier reported was that many of the PHCs were not designed and constructed to serve older adults, especially as regards physical accessibility. For example, some of the buildings that serve as PHCs were put up by the local council chairmen for the purpose of providing care in the community, and health providers regarded this as a starting point. In our preliminary study that assessed the facility readiness of selected PHCs for AFHS, we found that two-fifths of the PHCs did not have ramps at their entrances, and a third did not have a reception area near the entrance. In addition, 86.7% of the public toilets in the PHCs did not have grab bars, and 33.3% were not served by public transportation [21]. According to several of the participants, there was a current effort by the present state government to ensure donors complied with the building template provided. Furthermore, the participants were optimistic that funds were not a barrier to making recommended changes to older buildings if given the necessary information and expanded use of the available funding sources including increasing enrollment in insurance and the Basic Primary Health Care Provision Fund (BHCPF). Among the three principles proposed by World Health Organization (WHO) for AFHS, the physical environment has the most precise guidelines and is thought to be the least complex area of change [12].

While data are routinely recorded and reported at the PHCs, it was reported that they were not disaggregated for age for the older adult category, 60 years and above. One of our participants mentioned that the nationally designed reporting forms did not specify for those aged 60 years and above but classified adults as 18 years and above. This negatively affected the use of data to plan for the needs of older adults in the PHCs. However, routinely collected data is used to understand disease trends in the community and to restock drugs for facility use. On the contrary, outpatient department registers in Uganda had disaggregated data by age in all the selected health facilities in a study but geriatric data was not being used to improve service delivery [19]. A multi-country study on health data reporting in PHCs in five LMICs including Nigeria found that data was primarily collected in outpatient care, antenatal care, immunization, family planning, HIV and tuberculosis services only [39]. Although older adults vary greatly in terms of health status, the majority of them have at least one chronic condition and are prone to other age-related diseases such that the current data reporting system in the PHCs will exclude them from care [40, 41]. In comparison to high-income countries, data on aging and the well-being of older people in Low- or Middle- Income Countries (LMICs) are insufficient and might not be fully representative of the aging populations in the countries flagging the need to prioritize research for informed decision-making [42].

One of the key facilitators for the implementation of AFHS mentioned by our respondents was the establishment of the Basic Healthcare Provision Fund (BHCPF), a component of the National Health Act of 2014. It is predominantly funded by the Federal Government of not less than 1% of the Consolidated Revenue Fund (CRF), donor grants, and others [43]. Our respondents were positive that accessing the BHCPF would provide opportunities for investments in the PHCs but admitted that such funding may still not be targeted toward the care of older people. However this was also identified as missed opportunity identified was low use of the Basic Healthcare Provision Fund (BHCPF), PHCs which could support expanding and strengthening care for older adults. Our findings are supported by a study of the process of administration and disbursement of the BHCPF which highlighted some challenges such as poor accountability systems, high-level political interference, and lack of political commitment from the State to release funds for health activities [44].

Another facilitator mentioned by our participants while reflecting on the success of other PHC programs, is the existing PHC workforce that can be trained on the delivery of AFHS. This includes community health workers who can provide health awareness campaigns and home services for older adults while performing their routine duties in the community. Community health workers constitute the majority of the health workers in PHCs and their deployment to deliver essential health services has proven to be a well-established strategy to address the critical skilled health workforce [45, 46]. Several respondents also mentioned existing community outreach programs for non-communicable chronic conditions in older adults by the PHCs as a facilitator. Such care is offered during occasional outreaches comprising free screening and treatment of chronic conditions such as hypertension and diabetes. Recently, the Nigerian government focused on PHCs to tackle the rising non-communicable disease (NCD) burden by strengthening community health workers’ skills and competencies for NCD care delivery [46]. However, it has been noted that such roles are sometimes beyond the community health worker’s scope of practice and may be limited by access to adequate training and supervision [46].

To the best of our knowledge, this study is the first to explore barriers and facilitators to the delivery of age-friendly health services in Nigeria and one of few from Africa. We interviewed a multidisciplinary group of participants at high level of leadership in the PHC setting. Our studies had a number of limitations. Like all qualitative methods, results reflect the opinion and reflections of the respondents and their possible biases. We worked to limit bias by keeping questions open ended and ensuring anonymity throughout the process. Importantly we did not include older adults or their caregivers in this study due to resource limitations, so their important perspectives and experiences of care were not captured. However we plan to engage these groups in a follow-on study.

Conclusions

In conclusion, this study among PHC stakeholders recognizes the role of PHCs in the promotion of healthy aging in general. While barriers were identified, there were multiple opportunities to strengthen and prioritize primary care services for older adults in Lagos State.

We recommend that experts actively engage stakeholders and give priority to selecting, co-designing, and implementing interventions that directly address barriers while building on existing strengths to improve the delivery of age-friendly health services in Primary Health Care facilities in Lagos, Nigeria.

Supporting information

Acknowledgments

We thank all our interview participants for sharing their experiences, granting access to the research team, and for their time in responding to the survey.