DEPARMENT OF PUBLIC HEALTH AND COMMUNITY MEDICINE

Background: School health services are essential for promoting pupils’ health, reducing preventable diseases, and supporting effective learning outcomes. However, their effectiveness is dependent on teachers’ awareness and engagement, as well as the availability of functional infrastructure. In many settings, these components remain weak, contributing to sustained transmission of communicable diseases such as malaria, diarrhoea, and respiratory infections among school children. Objective: This study assessed teachers’ knowledge and attitude, availability of school health facilities, and the burden of communicable diseases among pupils in Egor LGA to guide improvements in school health services. Methods: A descriptive cross-sectional study was conducted between March 2025 and May 2026 among 254 teachers and 245 pupils in primary schools in Egor LGA, Benin City, Edo State recruited via a multistage sampling technique. Data collected using a structured self-administered questionnaire was analysed with IBM SPSS 27.0 using descriptive and inferential statistics. Statistical significance was set at p < 0.05. Results: The mean age of teachers was 39.3 ± 9.4 years, while pupils had a mean age of 10.1 ± 2.0 years. Most teachers were female, 438 (73.0%), married, 460 (76.6%), and possessed a B.Ed/B.Sc degree, 147 (57.9%). Good knowledge of school health services was observed in 92 (54.1%) respondents and was significantly associated with years of teaching experience (p = 0.031) and school type (p < 0.01). Most teachers, 185 (72.8%), demonstrated a positive attitude towards school health services. School health infrastructure and preventive services were limited, with only 98 (38.6%) schools keeping pupils’ health records. Among pupils, 93 (38.0%) reported illness within the preceding three months, with malaria being the most common condition, 38 (40.9%). Most pupils had good hygiene indicators and normal nutritional status. Primary caregiver type significantly predicted child ill health (p = 0.001). Major barriers to implementation included shortage of trained personnel, 110 (44.0%), lack of health education programmes, 131 (52.6%), and low parental awareness of school health services. Conclusion: Most respondents had good knowledge and a positive attitude towards school health services. However, school health facilities were inadequate and communicable diseases were common among pupils, especially in public schools. Strengthening teacher training, improving infrastructure, and ensuring adequate funding and supervision are needed to improve implementation and reduce disease burden.

Introduction: Workplace violence (WPV) against healthcare workers is a major occupational and public health concern globally, with significant consequences on the safety, psychological well-being, job satisfaction, and productivity of healthcare personnel. Objective: This study assessed the prevalence, causes, and effects of workplace violence against healthcare workers in the University of Benin Health Services department, Benin City, Edo State. Methodology: A descriptive cross-sectional study design was adopted among healthcare workers in the University of Benin Health Services Department. A total population survey method was used, and data are collected using a structured questionnaire adapted from the International Labour Organization (ILO), International Council of Nurses (ICN), World Health Organization (WHO), and Public Services International (PSI) workplace violence research instrument, administered through both self-administered and interviewer-administered approaches. One hundred and sixty-five completed questionnaires are analyzed using IBM SPSS version 27.0, with descriptive and inferential statistics performed at a 95% confidence interval and a significance level of p < 0.05. Results: The lifetime prevalence of workplace violence among respondents was 35.2%, while 21.2% and 33.3% report experiencing physical violence and verbal abuse respectively within the six months preceding the study. Patients or clients constitute the major perpetrators of both physical violence (72.7%) and verbal abuse (72.7%). Professional category shows a statistically significant association with workplace violence (p = 0.003), with clinical staff experiencing a higher prevalence than non-clinical staff. The major perceived causes of workplace violence are the non-availability of doctors or nurses on call duty (72.7%) and the aggressive personality of perpetrators (70.9%). Post-traumatic stress disorder (63.1%) and loss of job satisfaction (53.3%) are the most commonly reported effects of workplace violence among respondents. Conclusion: Workplace violence occurs among healthcare workers in the University of Benin Health Services Department, with verbal abuse being more commonly reported than physical violence. Non-availability of healthcare workers on call duty and aggressive behaviour of perpetrators emerge as the major perceived causes, while post-traumatic stress disorder and loss of job satisfaction constitute the major effects. Strengthened institutional policies, improved staffing, and supportive interventions are needed to reduce workplace violence and improve healthcare worker safety.

Background: Task-shifting in primary healthcare was an initiative long adopted by the Federal Ministry of Health to assist in ensuring human resource maximization for universal health coverage especially across domains of reproductive, maternal, child health, family planning, and high prevalence communicable illness like tuberculosis and malaria. Despite its potential, only some states have adopted and begun implementation of the strategy, and among states that have adopted it like Edo State, the necessary assessment to understand the implementation level, acceptance, integration status and concerns of health workers about it locally, is limited. Aim: This study assessed the knowledge, perception and barriers to task-shifting among primary healthcare workers in Benin-City. Methods: A descriptive cross-sectional study was conducted among 120 healthcare workers selected using a multistage sampling technique. Data were collected using a structured, self and interviewer administered questionnaire covering socio-demographic characteristics, knowledge, perception, barriers and enablers to task-shifting. Data were analysed using SPSS version 27.0. Univariate analysis summarised means, frequencies, and percentages. Bivariate analysis using chi square tests determined associations between socio-demographic factors and respondents’ knowledge and perception. Binary logistic regression identified independent determinants of good knowledge and perception. Statistical significance was set at p < 0.05. Results: A total of 120 respondents participated, with a mean age of 35.9 ± 8.6 years, with females being 112 (93.3%), males 8 (6.7%). Those who demonstrated good knowledge were 37 (30.8%), and those with poor knowledge 83 (69.2%). Receiving training on task-shifting was found to be statistically significant and associated with knowledge, as those with prior training had good knowledge (59.9%) record than those without (17%) (χ²: 21.455; p < 0.001). Perception of task-shifting was mixed, as good and poor perception were almost equally distributed at 59 (49.2%) and 61 (50.8%) respectively. Age was significantly associated with perception, and was also a significant predictor of knowledge, with increasing age associated with reduced likelihood of positive perception (OR = 0.927; p = 0.024). Workers with 5 – 9 years of experience were also less likely to have positive perception of task-shifting (OR = 0.165, 95% CI: 0.031–0.872, p = 0.034). The barriers to task-shifting encountered most by respondents were inadequate training and knowledge gaps (mean score: 3.99 ± 1.19), lack of clear job description or role boundary (3.74 ± 1.28), inadequate supervision or monitoring (3.64 ± 1.28), lack of incentives or recognition (3.54 ± 1.33), resistance from higher cadres, shortage of staff and related issues were also mentioned as challenges/barriers. The enablers reported were adequate training, and supportive supervision (3.90 ± 1.42), availability of clear policy guideline (3.93 ± 1.42), teamwork and collaboration among cadres (3.77 ± 1.41), support from management and policy makers (3.79 ± 1.41). Conclusion: Primary healthcare workers in Benin-City had predominantly poor knowledge of task-shifting and the national task-shifting policy, coupled with mixed perception of task-shifting. Inadequate knowledge or training among staff, lack of clear job descriptions or roles, inadequate supervision or mentoring, lack of incentives or recognition were the identified barriers, while adequate training and supportive supervision, provision of policy guidelines, teamwork and inter-cadre collaboration, and support from management and policy makers were named among enablers. There should be concerted efforts to improve knowledge and perception of task- shifting through training and adequate supervision provision; this will also remove barriers to task-shifting.

BACKGROUND xiv Child injury and violence remain major public health problems, especially in low- and middle-income countries where children are often exposed to unsafe environments, poor supervision, and harmful disciplinary practices, and caregivers play a central role in preventing these occurrences. OBJECTIVE To assess child injury and violence prevention practices in Ovia North-East Local Government Area, Edo State, to provide evidence that will improve child injury and violence prevention practices and reduce the health burden caused by these injuries. MATERIALS AND METHODS A descriptive cross-sectional study was carried out among 572 primary caregivers of children aged 0– 17 years in Ovia North-East Local Government Area, Edo State. A multistage sampling technique was used to select respondents. Data were collected using a pretested, interviewer-administered structured questionnaire. Data analysis was done using IBM SPSS version 27. Descriptive statistics were presented as frequencies and percentages, while chi-square test and multivariate logistic regression were used to determine associations and predictors. Statistical significance was set at p < 0.05. RESULTS The majority of respondents were female (84.4%), married (81.3%), and aged 30–39 years (42.1%). All respondents were aware of child injury and violence. Overall, 64.9% had good knowledge, while 62.9% had a good attitude towards child injury and violence prevention. Falls, burns, and cuts were the most commonly identified forms of child injury, while physical abuse was the most commonly identified form of violence. Falls were also the most frequently reported injuries experienced by children under the caregivers’ care. A very high proportion of respondents reported witnessing violence against children, with physical abuse being the most common form observed. Overall, 71.7% of xv respondents had good preventive practices, although unsafe practices such as allowing unsupervised play and keeping medicines or hazardous substances within children’s reach were still noted. Factors significantly associated with child injury and violence prevention included age, education, marital setting, income, household size, and occupation. On multivariate analysis, age, education, and marriage type were significant predictors of knowledge, marriage type significantly predicted attitude, while occupation was a significant predictor for practice. CONCLUSION The study found that caregivers in Ovia North-East LGA generally had good knowledge, attitude, and practices regarding child injury and violence prevention. However, important gaps remain in specific areas of home safety and violence prevention. There is a need for sustained community-based health education, targeted caregiver support, and practical interventions aimed at improving child safety and reducing violence against children in the community. KEYWORDS: Child injury, child violence, Prevention, Caregivers, Knowledge, Attitude, Practices, Ovia North-East

Background: Human Immunodeficiency Virus (HIV) remains a critical public health burden, particularly in high-prevalence settings like Nigeria. Within this environment, clinical-year medical students represent a highly vulnerable demographic; their transition into hands-on patient care and the accompanying steep clinical learning curve frequently expose them to occupational hazards such as needle-stick injuries and mucosal splashes. Although Post- Exposure Prophylaxis (PEP) can reduce the transmission risk by over 80% if initiated within the critical 72-hour window, its clinical effectiveness is heavily contingent upon the trainees' underlying awareness, positive attitudes, and prompt health-seeking behaviours. Assessing the Knowledge, Attitude, and Practice (KAP) of these students is therefore vital for identifying hidden educational deficits and designing targeted, student-centred institutional safety interventions. Objective: The objective of this study was to explore the experiences of clinical-year medical students at the University of Benin regarding HIV post-exposure prophylaxis, specifically by evaluating their knowledge, attitude, practice, and the barriers limiting its utilisation. Methodology: A quantitative descriptive cross-sectional study design was employed. The study was conducted among clinical-year (400, 500, and 600-level) medical students at the University of Benin, Edo State, Nigeria. A multistage sampling technique was used to select 313 respondents. Data were collected via a pretested, self-administered online questionnaire xii (Google Forms). Responses were scored to formally categorize participants' knowledge, attitude, and practice into specific tiers (e.g., poor, fair, good). Data were analysed using IBM SPSS version 27.0, with statistical significance determined through Chi-square tests, Fisher’s exact tests, and binary logistic regression. Result: A total of 313 students participated (100% response rate), with a mean age of 23.03±2.40 years and a male majority (62.9%). While a high proportion (89.1%) were aware of PEP, detailed knowledge was grossly inadequate: 41.2% had poor knowledge, 43.8% had fair knowledge, and only 15.0% possessed good knowledge. Prior HIV testing emerged as the sole independent predictor of good knowledge (p < 0.001). Conversely, an overwhelming majority (90.4%) demonstrated a positive attitude toward PEP, which was significantly predicted by having a higher knowledge score (p = 0.007). Regarding practice, 8.3% reported a history of occupational exposure, but only 23.1% of those exposed actually initiated PEP, resulting in an overall poor practice rate of 88.5%. Major barriers to utilisation included a lack of knowledge regarding reporting protocols (86.6%), uncertainty about exposure risk (74.4%), and fear of stigma (74.1%). Conclusion: The study reveals a critical gap between high theoretical awareness and positive attitudes versus severely deficient practical knowledge and poor utilisation of HIV PEP among clinical-year medical students. Individual demographic factors did not significantly improve practice, indicating that the low utilisation is heavily driven by structural and informational barriers. To mitigate these occupational hazards, institutions must integrate formal PEP protocol training into the clinical curriculum, guarantee confidential reporting pathways, and ensure unrestricted 24-hour access to prophylaxis services. xiii Keywords: HIV, Post-Exposure Prophylaxis, Clinical-year Medical Students, Occupational Exposure, Knowledge Attitude and Practice, University of Benin, Nigeria

Introduction: Household air pollution (HAP) remains a major public health concern in low- and middle-income countries, particularly in Nigeria where biomass fuel use is still common. Under-five children are especially vulnerable due to their developing respiratory systems and increased exposure within household environments. Despite existing global data, there is limited community-specific evidence in peri-urban areas such as Ekosodin, Benin City. Objectives: This study aimed to determine the prevalence of household air pollution and respiratory symptoms among under-five children in Ekosodin, Benin City, Edo State. It also sought to identify common sources of HAP and assess the association between exposure and respiratory symptoms. Methodology: A descriptive cross-sectional study was conducted among caregivers of under￾five children using a multistage sampling technique. A minimum sample size of 298 was calculated, with 280 respondents participating. Data were collected using a structured interviewer-administered questionnaire and analyzed using IBM SPSS version 27. Chi-square test and logistic regression were used to assess associations at a significance level of p < 0.05. Results: The majority of households used cleaner fuels, with gas (61.1%) and electricity (14.6%) being the most common, although some still used firewood (12.9%) and kerosene (7.5%). Most households had ventilation (94.6%), but only 18.6% had smoke outlets. Cough was the most prevalent respiratory symptom (31.4%), while wheezing (8.6%) and shortness of breath (3.2%) were less common. Diagnosed respiratory illnesses such as pneumonia (2.9%) and bronchitis (2.9%) were relatively low. Significant associations were found between respiratory symptoms and use of unclean fuels (p = 0.018), child proximity to cooking areas (p < 0.001), indoor pollution sources such as mosquito coils (p = 0.001), place of cooking (p < 0.001), and indoor tobacco smoking (p = 0.002). xi Conclusion: Despite the predominant use of cleaner fuels, household air pollution exposure remains prevalent due to other contributing factors such as cooking location, poor smoke outlet availability, and indoor pollution sources. These factors significantly influence the occurrence of respiratory symptoms among under-five children. Interventions should focus on improving household environmental practices alongside promoting clean energy use

Background: Hepatitis B Virus (HBV) infection is a potential occupational biological hazard to medical and nursing students who are frequently exposed to blood and bodily fluids during clinical rotations, and the Hepatitis B vaccine is one of the most effective and safest prevention measures. Objectives: This study aimed to assess and compare the knowledge, attitude, and uptake of the Hepatitis B vaccination, including its determinants, among medical and nursing students at the University of Benin, Edo State, Nigeria. Methodology: A comparative cross-sectional study was conducted from December 2024 to March 2026, among 646 respondents, comprising 324 medical students and 322 nursing students. A multistage sampling technique was used to select students across preclinical and clinical levels. Data was collected using a pretested, structured, self-administered questionnaire and analysed using SPSS version 25. Bivariate (Chi-square) and multivariate (Binary Logistic Regression) analyses were utilised, with statistical significance set at p < 0.05. Results: The mean age of the respondents was 22.47 ± 2.72 years. Overall, 83.0% of respondents demonstrated good knowledge of Hepatitis B and its vaccination, while 17.0% had poor knowledge. Most respondents (91.0%) exhibited a positive attitude, which was strongly predicted by good knowledge (OR = 4.078; p < 0.001). However, actual vaccination uptake was critically low, with 73.8% of students remaining completely unvaccinated and only 10.7% having completed the three-dose series. Logistic regression showed that clinical exposure significantly predicted good knowledge (p < 0.001), while course of study predicted vaccination uptake, with medical students significantly more likely to be vaccinated than nursing students 15 (OR = 2.035; p = 0.022). Lack of awareness of vaccination centres (42.1%), vaccine cost (28.9%), and lack of time (26.4%) were reported as the major barriers to vaccination. Conclusion: Despite possessing high theoretical knowledge and a positive attitude towards the HBV vaccine, the actual vaccination practice among medical and nursing students is critically inadequate. Systemic barriers, specifically cost and logistical challenges, are the primary barriers preventing positive attitudes from translating into practice. Strengthening targeted awareness campaigns, subsidising vaccine costs, and integrating proactive vaccination policies into the curriculum will enhance uptake and optimise occupational safety during clinical training.

Background: Malnutrition among children under five years remains a critical public health issue in Nigeria, contributing substantially to under-five morbidity and mortality. Despite various interventions, limited evidence exists on the specific determinants of malnutrition in semi-urban settings such as Egor Local Government Area, Edo State, Nigeria. Objective: This study assessed the prevalence and determinants of malnutrition among children under five years in Egor LGA, specifically evaluating caregiver knowledge, feeding practices, sources of nutritional information, and socioeconomic factors influencing nutritional outcomes. Methods: A descriptive cross-sectional study was conducted among 400 caregiver- child pairs selected through multi-stage stratified systematic random sampling from primary healthcare centres, immunization clinics, and child welfare services in Egor LGA between January and March 2026. Data were collected using a structured interviewer-administered questionnaire covering sociodemographic characteristics, caregiver knowledge (27-point scale), child feeding practices (12-point scale), information sources, and household factors. Anthropometric measurements (weight, height/length, mid-upper arm circumference) were taken following WHO standardized protocols. Nutritional status was classified using WHO 2006 Child Growth Standards (Z-scores). Data were analysed using IBM SPSS version 25, with chi-square tests and multivariate binary logistic regression (p < 0.05 significance level). Results: The majority of caregivers were mothers (73.3%), aged 29–38 years (38.8%), with secondary (47.0%) or tertiary (41.5%) education. Good knowledge of child nutrition was demonstrated by 65.6% of caregivers, with 96.3% correctly identifying exclusive breastfeeding duration (6 months) and 91.3% knowing appropriate complementary feeding age (6 months). However, only 47.5% exhibited good feeding practices. A significant knowledge-practice gap was identified: caregivers with good knowledge were significantly less likely to have good feeding practices (AOR = 0.625, 95% CI: 0.409–0.955, p = 0.030). Health workers were the most utilized (94.5%) and trusted (44.8%) information source, yet only 13.0% had attended formal nutrition education. Overall malnutrition prevalence was 20.7% (underweight 14.5%, moderate malnutrition 4.0%, wasting 1.3%, stunting 1.0%). Recent child illness (AOR = 1.891, 95% CI: 1.101–3.250, p = 0.021) and good feeding practices (AOR = 2.042, 95% CI: 1.167–3.571, p = 0.012) were significant risk factors for malnutrition, while good caregiver knowledge (AOR = 0.419, 95% CI: 0.245–0.717, p = 0.001), male caregiver sex (AOR = 0.305, 95% CI: 0.112–0.831, p = 0.020), and household food insecurity (AOR = 0.382, 95% CI: 0.204–0.712, p = 0.002) were protective. Conclusion: Despite relatively high caregiver knowledge and lower malnutrition prevalence than national averages in Egor LGA, a substantial knowledge-practice gap persists, and child feeding practices remain suboptimal with low dietary diversity and high consumption of sugary drinks and packaged snacks. Health workers are trusted information sources but structured nutrition education is underutilized. Interventions must address economic and structural barriers limiting knowledge translation, integrate practical skills-based nutrition counselling into routine health services, and target modifiable risk factors including childhood illnesses.

BACKGROUND: Sexually transmitted infections (STIs) remain a major global public health problem, especially among youths, causing reproductive health, social, and economic challenges. They are caused by various bacteria, viruses, and parasites, with some curable infections and others requiring lifelong management. Untreated STIs can result in infertility, chronic pain, pregnancy complications, increased HIV risk, and certain cancers. Prevention includes abstinence, consistent condom use, vaccination, limiting sexual partners, and regular testing, though many youths do not practice these consistently. In Nigeria and sub-Saharan Africa, poor sexual health knowledge, misinformation, peer pressure, and risky behaviours continue to increase STI prevalence among young people. OBJECTIVES: This study assessed the knowledge, attitude, and preventive practices towards sexually transmitted infections (STIs) among young people in Ovia North East Local Government Area, Edo State, with the goal of identifying gaps and recommending effective interventions for STI awareness and prevention. METHODS: A descriptive cross-sectional study was conducted amongst 633 youths in Ovia North East LGA of Edo State Nigeria, selected by multistage sampling. Data were collected using a structured questionnaire adapted from validated tools administered via an online google form with required answers, and analyzed with IBM SPSS version 27. Descriptive statistics, chi- square and logistic regression identified predictors at 95% CI with significance at p < 0.05. RESULTS: A total of 633 respondents participated in the study with a 100% response rate. The mean age of respondents was predominantly within 20–24 years 490 (77.4%), while 364 (57.5%) were females and 621 (98.1%) were single. Majority of respondents had heard of sexually transmitted infections (STIs) 604 (95.4%), with schools (86.4%), social media (78.1%), and health workers (75.7%) as major sources of information. Overall, 593 (93.7%) respondents had good knowledge of STIs, while 481 (76.0%) demonstrated positive attitudes towards STI prevention and management. Preventive practices were generally high, with 604 (95.4%) having good preventive practices; however, only 199 (31.4%) had ever tested for STIs, and 183 (28.9%) had received STI vaccination. Among respondents, 72 (11.4%) reported experiencing STI symptoms, with itching (6.6%), discharge (4.9%), and painful urination (4.3%) being the most xiii common symptoms. Hospitals were the most preferred place for treatment 477 (75.4%), followed by private clinics 107 (16.9%). Despite this, overall utilization of appropriate treatment options was poor, as 586 (92.6%) had poor treatment utilization while only 47 (7.4%) had good treatment utilization. Significant predictors of good preventive practice included positive attitude towards STIs (OR = 2.617, p = 0.041), while predictors of good treatment utilization included increasing age (OR = 1.213, p = 0.026). CONCLUSION: Young people in the study area demonstrated high knowledge, positive attitudes, and good preventive practices regarding sexually transmitted infections. However, uptake of important preventive services such as STI screening and vaccination remained low, while utilization of appropriate treatment options was poor. This gap between knowledge and actual health-seeking behaviour suggests persistent barriers such as stigma, delayed treatment seeking, and limited access to youth-friendly sexual health services. Strengthening sexuality education, expanding confidential screening and vaccination services, and promoting early treatment-seeking behaviour are recommended to improve STI prevention and management among young people.

Background: Simulation-based learning is essential for preparing and training undergraduate students for their professional roles and enhancing their experiences and skills. Simulation-based learning (SBL), however, has not been widespread, despite its integration in the university curriculum. There is a gap in understanding how undergraduate students perceive and engage with simulation base learning. Objective: This study aims to assess the knowledge, attitude and practice of simulation based learning among undergraduate students in university of Benin. Subjects and Methods: A descriptive cross-sectional study design was utilized for this study using a self-administered questionnaire administered to 620 undergraduate students of university of Benin. Data collected was analyzed using IBM Statistical Package for Social Science (SPSS) 27.0. with statistical significance set at p<0.05 and 95% Confidence Interval. Categorical data was presented using frequency tables. Chi-square and Fischer’s Exact tests examined relationship between demographic characteristics and respondent’s knowledge, attitude, practice and challenges towards simulation-based learning. Results: The mean age and parity of respondents studied was 21.1 ± 3.1 years. In terms of sex, 54.8% of the respondents were male, and 45.2% were female. The tribal distribution of the respondents showed Benin (34.5%) with the highest proportion. Five hundred and twenty-five (84.7%) respondents were aware of simulation-based learning with 193 (36.7%) having good knowledge of SBL. Department and academic level were significant predictors of good SBL knowledge with respondents form Medicine and 600 level students showing a p-value of 0.042 and 1 respectively. In relation to attitude, 447 (85.1%) respondents had positive attitude towards simulation based learning while only 78 (14.9%) had negative attitude. Good knowledge and Academic level were significant predictors of attitude toward simulation-based learning with respondents from fourth-year having a coefficient of 0.836 with a p-value of 0.053, suggesting a near-significant positive influence on supportive attitudes, while respondents from sixth-year and respondents with good knowledge of SBL as reference category. In relation to practice, 53.9% (334) had participated in simulation-based learning activities, while 46.1% (286) had not. The academic level of study of respondents in their sixth year, good knowledge and attitude had a strong predictive value and significantly influenced participation of simulation-based learning. Conclusion: The study revealed that while awareness of simulation-based learning is high, over two-thirds of students showed limited understanding of its concepts, especially younger and less advanced students. Over four-fifths had a positive outlook on simulation-based learning, recognizing its value in enhancing knowledge and skills. Although more than half had participated in SBL activities, current engagement was lower, with only four-tenths actively involved. High-fidelity mannequins and virtual patients were commonly used, indicating a preference for realistic simulations. Notably, over one-fifth of respondents reported challenges, such as inadequate infrastructure, limited resources, technical issues, and time constraints, which hinder effective simulation-based learning implementation.