Nigerian Healthcare Research Articles

How prepared is Nigeria digital payment for health workers? A landscape analysis

IntroductionStakeholders in the health sector have advocated for the optimization of digital payment channels in low-and-middle-income countries in order to improve program outcomes. We conducted a landscape analysis of the local context, challenges, and opportunities for digitized health worker payments in Nigeria.MethodsThis study was an exploratory qualitative case study with mixed-methods approach to data collection including; i) desk review, ii) interview of key informants and iii) engagement of stakeholders. In the desk review, the databases searched were MEDLINE (PubMed), Google Scholar and Google. For the qualitative interviews, 17 stakeholders were interviewed between May and July 2022. Audio recordings of interviews were transcribed and analyzed using thematic approach with the Nvivo software. At the stakeholders’ (n = 15) engagement, findings from the desk review and interviews were discussed and additional data collected.ResultsDigital payment systems for health personnel described in the reviewed documents included the direct disbursement mechanisms, direct bank transfers and mobile money. Among these-payment methods, direct bank transfer was the most prominent digital payment method. Also, there is a high level of acceptability of digitized means of payment of health workers among stakeholders in the Nigerian health sector. From the regulatory point of view, the Nigerian government has initiated a number of digital payment policies including the cashless policy. Other incentives for digitization of payments were: availability of credible financial institutions, improved financial accountability and transparency, previous experience of under-payment or non-payment of end beneficiaries, to avoid delays in payment and ensure timely retirement of funds. Challenges of digital payments included: delayed resolution of problems associated with digital payment such as failed transactions, cyber security, double payments, and unfriendly bank policies.ConclusionDigital payment system is being utilized, accepted and would be beneficial for payments for the Nigerian healthcare system. Harnessing its benefits of improved health workers’ performance and program outcomes by enacting appropriate policies is recommended.

Migration of Health Workers and Its Impacts on the Nigerian Health Care Sector: Protocol for a Scoping Review.

Health worker migration from Nigeria poses significant challenges to the Nigerian health care sector and has far-reaching implications for health care systems globally. Understanding the factors driving migration, its effects on health care delivery, and potential policy interventions is critical for addressing this complex issue. This study aims to comprehensively examine the factors encouraging the emigration of Nigerian health workers, map out the effects of health worker migration on the Nigerian health system, document the loss of investment in health training and education resulting from migration, identify relevant policy initiatives addressing migration, determine the effects of Nigerian health worker migration on destination countries, and identify the benefits and demerits to Nigeria of health worker migration. This study will follow the Joanna Briggs Institute methodology. A search strategy will retrieve published studies from MEDLINE, CINAHL, Embase, Global Health, Academic Search Premiere, and Web of Science. Unpublished studies will be sourced from dissertations and theses. A comprehensive search will involve keyword scans and citation searches. Exclusion criteria will filter out irrelevant studies, such as studies unrelated to the international migration of health workers and non-English language studies. A total of 2 independent reviewers will screen the titles and abstracts and then review the full text. Data will be extracted from the included studies using a data extraction tool developed for this study. The study selection process will be shown using a PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) flowchart. While the traditional risk of bias assessments is not applied to scoping reviews, the quality of included studies will be evaluated based on methodological transparency. The process of selecting studies will be shown using a PRISMA ScR flowchart, and information gathering will be done through a charting table that has been prepared in advance. We plan to collect data from January 2025 to March 2025 and present the results to examine publication patterns and study details. The final summary is expected to be released by the summer of 2025. It will provide an in-depth look at how health worker migration impacts the health care sector in Nigeria. This study holds immense potential to contribute to understanding health worker migration from Nigeria and inform policy and practice interventions to address its challenges. By synthesizing existing evidence, the scoping review will guide future research and policy efforts to mitigate the adverse effects of migration on health care systems and workforce sustainability. Furthermore, the results will aid in recognizing deficiencies in the existing literature; this will offer a defined path for specific policy measures and methods to retain health care workers effectively and thus support the sustainability of health care systems. PRR1-10.2196/62726.

Demistifying the role of job crafting on the morale of healthcare workers in Nigerian public hospitals

The mass exodus of healthcare workers from the Nigerian healthcare system highlights the urgent need to reevaluate the operational framework. This reevaluation aims to grant healthcare workers greater autonomy to improve their morale and address organizational issues like job dissatisfaction and high turnover. The inability to create new positions or redesign existing roles has contributed to these challenges, necessitating a comprehensive solution. Therefore, this study aims to investigate the impact of job crafting on the moral of healthcare workers in the Nigerian Public Hospitals. It buttressed its argument with Hackman & Oldham’s Job Characteristics Model. All the Doctors and Nurses in the public Secondary Hospitals also known as General Hospitals in Lagos State were used for this study, making a total population of 11,084. The sample size of 725 was determined using Morgan sample size determination table. Quantitative and qualitative methods of analysis were employed. The results of the study show that job crafting has a substantial impact on the morale of healthcare workers in public hospitals. Higher levels of morale and happiness are experienced by healthcare workers who participate in job crafting activities. The crucial elements of job crafting—relational, task, and cognitive—allow healthcare professionals to customise and remodel their work experiences in accordance with their preferences and values. The study recommends that structures be put in place that supports job crafting in the Nigerian healthcare system so as to give a high level of autonomy and flexibility to the healthcare workers thereby boosting their morale for effective and efficient performance.

A Cry for dignity: Verbal, physical, and emotional abuse experienced by postpartum women in Nigerian healthcare.

This study explores and describes the lived experiences of postpartum women of Obstetric Violence (OV) in selected secondary health facilities in Oyo State, Nigeria. The study utilized a qualitative research design. A purposive sampling technique was used to recruit thirty participants for the study. A Focus Group Discussion interview guide was used as an instrument of data collection. Thematic analysis was used in analyzing the data using Collaizi's seven stages of data analysis. The analyzed data on the OV experienced by postpartum women during pregnancy and childbirth generated five themes, which include verbal abuse, abandonment of care, physical abuse, non-dignified care, and non-consented care. Addressing OV requires targeted policies promoting respectful care, healthcare provider training on ethical practices and informed consent, and improved healthcare infrastructure. Empowering women and establishing accountability systems are critical for fostering a dignified and safe maternal healthcare environment.

Brain Drain in Nigerian Health Sector: An Unsung Epidemic

Brain drain in the Nigerian health sector is a critical issue that has drained Nigeria of skilled and competent healthcare professionals thereby placing a heavy burden on the Nigerian healthcare system. The paper aimed to describe some factors responsible for the increase in brain drain and thereby offer possible solutions to the problem. The theory of push and pull factors was used to describe the phenomenon. Push factors are unfavourable conditions that push people out of their domain country while pull factors are favourable conditions that attract citizens to migrate to developed countries. The consequences of brain drain in the health sector led to the shortage of skilled healthcare workers which places a heavy burden on those who remain leading to increased workload and burnout. The paper also highlighted various efforts the Nigerian government had put in place to mitigate the effects of brain drain in Nigeria such as implementation of the national health policy increased funding for the health sector and strengthening of healthcare institutions. Unfortunately the efforts are yet to yield positive impacts. However this paper has several possible recommendations aimed at reversing brain drain in the health sector which include improvement of working conditions and remuneration development of retention strategies to retain healthcare professionals and addressing socioeconomic factors that contribute to brain drain. The study concluded that brain drain in the Nigerian health sector is a significant challenge that requires urgent attention and a multifaceted approach. Only then can Nigeria hope to alleviate the unsung epidemic of brain drain in its health sector.

Post COVID-19: Advancing medical laboratory service integration in nigeria and progress towards establishing integration guideline

BackgroundThe Nigerian healthcare system, including medical laboratories, operates in a three-tiered structure across public and private sectors. Lessons from COVID-19 show the urgent need for a guideline to drive medical laboratory service integration. ProblemLack of operational guideline to drive the integration of laboratory services has resulted in siloed operations across different medical laboratories causing duplication of resources, coordination issues, and inefficiencies. AimTo highlight the development processes of medical laboratory service integration guideline and discuss its key provisions. MethodThe Medical Laboratory Services Division (MLSD), Federal Ministry of Health (FMoH) initiated the development of a national guideline for integrating medical laboratory services. Partnering with stakeholders and engaging two consultants, a technical workshop was facilitated in January 2024. The Consultants garnered the initial inputs stakeholders made at the five-day meeting. The inputs were collated and organized to produce the guideline. The guideline was circulated to participants and other stakeholders for review and feedback received was used to finalize the document. The MLSD with support from partners further held a three-day stakeholders’ meeting in May 2024 to validate the document before submitting it to the Health Minister for endorsement. ResultThe guideline sets standards for achieving medical laboratory services and systems integration across different medical laboratories. The contents of the guideline are enumerated and respective recommendations made under each element are highlighted. ConclusionThe implementation of the guideline will help harmonize services, improve access to diagnostics, streamline processes, reduce redundancies, optimize resource utilization, enhance communication, data sharing, and pandemic preparedness.

PSYCHOLOGICAL FACTORS INFLUENCING MIGRATION DECISIONS AMONG HEALTHCARE PROFESSIONALS IN NIGERIA

The mass migration of healthcare professionals from Nigeria, commonly referred to as “japa syndrome,” has left a significant gap in the country’s healthcare system. While economic and social factors in migration decisions are well-documented, the psychological dimensions remain significantly underexplored. This study aimed to identify key psychological factors and theoretical foundations explaining migration decisions and determine how these factors drive migration in Nigeria. This qualitative study was structured around two research questions: What psychological factors influence migration decisions? and how these psychological factors drive migration decisions and intentions. The study reveals that Nigerian healthcare professionals are driven by work-related stress, burnout, anxiety, and job insecurity, leading to migration for better opportunities abroad. These factors explained by Maslow's hierarchy of needs, push and pull theory, and cognitive dissonance theory, present a comprehensive understanding. The study suggests systemic changes to reduce migration pressures for healthcare workers, including stress management programs, improved working conditions, professional recognition, and effective retention strategies. Keywords: Healthcare, Healthcare Professionals, Migration, Psychological Factors.

Cultural and religious structures influencing the use of maternal health services in Nigeria: a focused ethnographic research

BackgroundCultural and religious structures encompass a set pattern of values, beliefs, systems and practices that define a community's behaviour and identity. These structures influence women's health-seeking behaviour and access to maternal health services, predisposing women to preventable maternal health complications. However, most maternal health policies have focused on biomedical strategies, with limited attention to women’s cultural challenges around childbirth. The overall aim of this paper is to provide a thick description and understanding of cultural and religious structures in Nigeria, their meaning and how they influence women’s use of maternal health services.MethodsRoper and Shapira’s (2000) focused ethnography comprising 189 h of observation of nine women from the third trimester to deliveries. Using purposive and snowballing techniques, 21 in-depth interviews and two focus group discussions comprising 13 women, were conducted in two Nigerian primary healthcare facilities in rural and urban area of Kogi State. Data was analyzed using the steps described by Roper and Shapira.ResultsUsing the PEN-3 cultural model, nine themes were generated. Positive factor, such as the language of communication, existential factor, such as religion, and negative factors, such as the use of prayer houses and lack of women’s autonomy, were either positive or negative enablers influencing women’s use of maternal health services. Additionally, women's perceptions, such as their dependency on God and reliance on cultural norms were significant factors that influence the use of maternal health services. We also found that the use of herbal medicine was a negative enabler of women’s access to facility care. At the same time, family support was also a positive and a negative nurturer that could influence how women use facility care. Finally, factors such as religion, Ibegwu, and male child syndrome were negative nurturers influencing women’s contraceptive use.ConclusionCultural and religious structures are significant factors that could promote or limit women’s use of maternal health services. Further studies are needed to understand culturally focused approaches to enhance women’s use of maternal health services in Nigeria.

Repositioning Nigerian education and healthcare system using quality library and information services

Repositioning Nigerian education and healthcare system using quality library and information services

Public acceptance of coercive measures in Nigerian mental health care.

For the first time, Nigeria has enacted a new mental health law that regulates the use of coercive measures in mental health care. The study aimed to investigate the extent to which the Nigerian public accepts the use of coercive measures in the treatment of people with mental health conditions and to understand the impact of stigma and other sociodemographic characteristics. A cross-sectional survey was conducted among 615 adult respondents from Nigeria's six geopolitical zones. The study instrument included a case-specific vignette, a social distance scale, and a brief sociodemographic form. Descriptive and inferential statistics were conducted with SPSS v.25 software. More than half of the study respondents agreed that the vignette character should be forced to go to the hospital if he refuses to go (65%, n = 400), and he should be forced to take medications at the psychiatric hospital (55.1%, n = 339). The least accepted coercive measure was Isolation (28.8%, n = 177). There were significant associations between social distance and the acceptance of involuntary admissions, forced medication, mechanical restraints, and isolation (p < .05). Social distance score was highest among respondents who agreed that the vignette character should be isolated (24.023 ± 5.503; F = 24.672, p < .001). The study highlights variations in public attitudes toward coercive psychiatric measures, within the Nigerian context compared to other countries. The lower acceptance rates for isolation as a coercive measure underscore the cultural importance of social interaction in Nigeria. The relatively recent implementation of Nigeria's Mental Health Act also suggests a potential gap in public knowledge regarding the criteria for coercive measures. Future research should aim to include diverse populations and consider longitudinal approaches to assess changes in public attitudes as awareness of mental health legislation increases.

Cost–benefit analysis of mammography screening: the perspective of Nigerian healthcare providers

IntroductionThere is no national breast cancer screening implemented in Nigeria. The National Cancer Control Plan (NCCP) has a goal of making screening services and early detection of cancer available for...

Pandemic and brain-drain in Africa: assessing the impact of the COVID-19 outbreak on ‘capital flight’ of Nigeria’s health workers

ABSTRACT Human Capital flight has become notable in the healthcare workforce in the post-COVID-19 era with a significant impact on effective healthcare delivery in Nigeria. This article examines the push and pull factors responsible for the drastic increase of human capital flight in the health sector during/after the COVID-19 pandemic. Relying on both primary and secondary methods of data collection applying interpretive qualitative method for data analysis, the study argues that stopping brain-drain in Nigeria will be a mirage if Nigerian healthcare professionals are not motivated with sufficient retention mechanisms through a significant pay increase and an enabling working environment, among other social benefits.

Perturbation Patterns of Bone Metabolism Secondary to COVID-19 Among Nigerian Healthcare Workers

&amp;lt;i&amp;gt;Background&amp;lt;/i&amp;gt;: Severe acute respiratory coronavirus-2 (SARS-CoV-2), the etiologic agent of coronavirus disease of 2019 (COVID-19) is known to affect several organ systems. However, the disease’s influence on bone metabolism is poorly characterized especially among native Nigerians. Consequently, the current study explored the effect of the disease on bone metabolism among Nigerian healthcare workers (HCWs). &amp;lt;i&amp;gt;Methods:&amp;lt;/i&amp;gt; This was a prospective longitudinal study conducted in the Department of Chemical Pathology of the Rivers State University Teaching Hospital among unvaccinated HCWs in Rivers State, Southern Nigeria. Eligible HCWs (n=96) were followed up from when they unwittingly had contact with SARS-CoV-2 infected/COVID-19 patients until they developed symptomatic RT-PCR-confirmed COVID-19. Demographic, anthropometric, clinical, and laboratory data were obtained before and at diagnosis/confirmation of COVID-19 among the eligible HCWs. Statistical analysis was done using descriptive/inferential statistics at a p-value of &amp;lt;0.05. &amp;lt;i&amp;gt;Results&amp;lt;/i&amp;gt;: At COVID-19 diagnosis, the HCWs had increased levels of inflammatory markers (procalcitonin, C-reactive protein, and D-dimer), raised bone resorption marker (s-CTX), but reduced bone formation marker (s-PINP) compared to the pre-COVID-19 parameters (p&amp;lt;0.001). These cardinal biochemical findings were more prominent among those with severe disease variant than those with non-severe disease variant (p&amp;lt;0.001). In addition, a negative correlation pattern was observed between these inflammatory markers and the bone formation marker, however, a positive correlation was observed between the inflammatory markers and the bone resorption marker (p&amp;lt;0.001). &amp;lt;i&amp;gt;Conclusion: &amp;lt;/i&amp;gt;The current finding indicates perturbation of bone metabolism, associated with increased bone resorption pattern, secondary to COVID-19 among the studied population. Hence, it is highly recommended that the evaluation of bone metabolism status be incorporated into the management protocols for COVID-19.

RANK-RANKL-OPG System in COVID-19: Examining the Pathway Among Healthcare Workers in Nigeria

&amp;lt;i&amp;gt;Background&amp;lt;/i&amp;gt;: Coronavirus disease 2019 (COVID-19) influences bone metabolism by altering the RANK-RANKL-OPG system. However, this has not been validated, especially among Nigerians. Consequently, the current study explored the influence of the disease on this vital skeletal pathway among Nigerian healthcare workers (HCWs). &amp;lt;i&amp;gt;Methods&amp;lt;/i&amp;gt;: This was a prospective longitudinal study conducted in the Department of Chemical Pathology of the Rivers State University Teaching Hospital among HCWs in Rivers State, Southern Nigeria. Eligible HCWs (n=76) with moderate RT-PCR-confirmed COVID-19 were recruited and compared with age and sex-matched healthy controls. Demographic, anthropometric, clinical, and laboratory data were obtained at baseline upon COVID-19 onset and followed up on days four and seven. Statistical analysis was done using descriptive/inferential statistics at a p-value &amp;lt;0.05. &amp;lt;i&amp;gt;Results:&amp;lt;/i&amp;gt; The HCWs with moderate COVID-19 had higher serum levels of pro-inflammatory markers (IL-1β, IL-6, TNF-α) and receptor activator of nuclear factor kappa beta ligand (RANKL) but lower serum levels of osteoprotegerin (OPG) t COVID-19 diagnosis compared to the healthy controls (p&amp;lt;0.05). Among the HCWs with positive COVID-19 status, an increasing trend of these inflammatory markers and RANKL was observed from day one to day four and day seven, but a decreasing trend of OPG levels was observed (p&amp;lt;0.05). On day seven following COVID-19 diagnosis among the HCWs, a positive relationship was established between serum RANKL and all the pro-inflammatory markers (p&amp;lt;0.001) while an inverse relationship was only observed between OPG and IL-1β pro-inflammatory marker (p&amp;lt;0.05). &amp;lt;i&amp;gt;Conclusion:&amp;lt;/i&amp;gt; The study findings corroborate the negative influence of COVID-019 on the RANK-RANKL-OPG system in favor of exaggerated osteoclastogenesis.

Urbanization factors and the vagaries of the rural health care industry in Nigeria: an analysis of the accessibility of healthcare services by older adults in the Nsukka Local Government Area

This study sought to determine the effects of urbanization on access to healthcare services by older adults in Nsukka Local Government Area. The Nigerian healthcare industry is organized under the three tiers of government: Federal, State and Local governments. As such, most of the healthcare facilities are located in urban areas while majority of older adults reside in different local governments in rural communities where there are a few of the facilities. This has led to poor utilization of medical services by older adults in rural areas. This study adopted a mixed method approach. While questionnaire was used to collect quantitative data, interviews were used to collect qualitative data for the study. Questionnaire survey was used to collect data from 1180 older adults between the ages of 60 years and above from six communities in the study area. Descriptive statistics and Chi square were used to analyze the data while frequency distribution tables and percentages were used to present the results. The research showed that there are inadequate health facilities for the older adults in rural communities in Nsukka LGA. It also found that the older adults suffered challenges arising from lack of medical doctors, nurses, equipments, and drugs for effective healthcare delivery. It is recommended that more efforts should be geared towards providing adequate health facilities and health workers by government at public hospitals in rural communities to increase accessibility and adequate utilization by the older adults.

Prevalence of methicillin-resistant Staphylococcus aureus in a Nigerian healthcare setting: Findings from Edo Specialist Hospital

Prevalence of methicillin-resistant Staphylococcus aureus in a Nigerian healthcare setting: Findings from Edo Specialist Hospital

Understanding the Impact of Cultural Factors on Healthcare Outcomes: A Data-Driven Comparison of US and Nigerian Healthcare Systems

Understanding the Impact of Cultural Factors on Healthcare Outcomes: A Data-Driven Comparison of US and Nigerian Healthcare Systems

Effective Strategies to Address “Japa Syndrome” among Nigerian Nurses for Better Workforce Retention

INTRODUCTION: The “Japa Syndrome” describes the increasing trend of Nigerian nurses emigrating for better opportunities abroad, exacerbating the challenges faced by the Nigerian healthcare system. This exodus, driven by poor working conditions, inadequate pay, and limited career prospects, has led to critical shortages in the nursing workforce and a decline in healthcare quality. Addressing these issues demands a thorough review of strategies to enhance nurse retention and stabilize the healthcare workforce in Nigeria. Therefore, this narrative review aims to synthesize existing literature on the factors contributing to “Japa Syndrome” among Nigerian nurses and to identify effective strategies to mitigate this trend. METHODS: A systematic search of peer-reviewed journals, government reports, and relevant literature published between 2018 and 2024 was conducted, focusing on nurse migration, workforce retention, and healthcare policy in Nigeria. Studies were selected for their relevance to the themes of “Japa Syndrome,” nurse retention strategies, and the sustainability of the healthcare workforce. The selected articles were analyzed to extract key themes, challenges, and proposed solutions for retaining nurses. RESULTS: The review revealed that the primary factors driving nurse migration include suboptimal working conditions, low wages, limited opportunities for career advancement, and insufficient institutional support. Retention strategies identified in the literature highlight the need for improved working environments, competitive remuneration, job security, and continuous professional development. Moreover, fostering a supportive workplace culture has been shown to reduce nurses’ intentions to migrate. CONCLUSION: The literature suggests that addressing “Japa Syndrome” requires a comprehensive and proactive approach by healthcare institutions, policymakers, and stakeholders. Strategies focusing on better working conditions, improved compensation, and enhanced career development are essential for retaining Nigerian nurses. These interventions are critical to ensuring a stable and sustainable healthcare workforce in Nigeria, essential for the future of the country’s healthcare system.

Relative Validity and Reproducibility of a Dietary Screening Tool in Nigerian Health Care

BackgroundHypertension and cardiovascular disease burden are rising rapidly in Nigeria. This trend is partly attributed to a transition from healthy to unhealthy dietary patterns. However, health care professionals lack a dietary screening tool to assess patient dietary intake and offer personalized dietary advice. ObjectivesWe aimed to develop and validate a food frequency questionnaire (FFQ) that can quickly and accurately assess regional dietary intake for use by health care professionals in a hospital setting in Port Harcourt, Nigeria. MethodsWe recruited 58 patients from a single hospital in Nigeria. The FFQ was administered at baseline and again after 3 wk. To evaluate the validity of the FFQ, we used 3 repeated and nonconsecutive 24-h dietary recalls (24DR) as a reference method. Spearman rank correlations, Wilcoxon signed-rank tests, cross-classification, intraclass correlation coefficients (ICCs), and Bland–Altman analysis were performed in R software version 4.3.1 to assess the relative validity and reproducibility. ResultsThe mean correlation coefficient (rs) between the FFQ and 24DR was 0.60 (P < 0.05), and ranged from 0.20 to 0.78. The Wilcoxon signed-rank tests indicated no significant differences in the 19 food groups queried (P > 0.05), except for fats and oils (P < 0.05). The exact agreement for classifying individuals into quartiles ranged from 17% for salt to 88% for processed meats and alcoholic drinks, with 90% of individuals classified into the same or neighboring quartile. Additionally, the Bland–Altman analysis demonstrated acceptable agreement, with >96% of observations within the acceptable limits of agreement for all food groups. For reproducibility, the ICC ranged from 0.31 for stew to 0.98 for fruit, with an mean ICC of 0.77 between the FFQs delivered 2 wk apart. ConclusionsOur results support the use of the FFQ as a valid and reliable tool for ranking intakes of certain food groups among patients in a hospital setting in Nigeria.The trial was registered at clinicaltrials.gov as NCT05973760.

An empirical study of job crafting and employees’ loyalty in the Nigerian healthcare system

Many factors have contributed to the continuous departure of workers from the Nigerian healthcare system since the COVID-19 outbreak. Therefore, this study aimed at examining the effect of job crafting on the loyalty of healthcare workers in public hospitals in Lagos, Nigeria. The study population was 11,084, comprising all the doctors and nurses in public hospitals in Lagos, with a sample size of 725 using the Morgan Sample Size Determination table. We collected primary data using a well-structured questionnaire and conducted analysis using structural equation modeling. The findings revealed a significant positive relationship between job creation and healthcare workers' loyalty in the public healthcare system. This implies that job creation influences health care workers' loyalty. This study suggests that the management of the public healthcare system should encourage and support job crafting while also building and encouraging positive relationships among healthcare workers to ensure their loyalty and effective service delivery.