Transcript Poster presentation

TITLE:EFFECT OF THE MODEL LOCAL GOVERNMENT AREA PROGRAM ON PRESCRIBING AND TREATMENT
OF MAJOR CHILDHOOD DISEASES IN RURAL NIGERIA
Amos ABU (PhD), University of Lagos, Nigeria. Email: [email protected]
Abstract
Problem Statement: In 1988 the Government of Nigeria embarked on a rather ambitious
program aimed at 100% immunization coverage, promote the right prescription practices etc., on
selected local government areas to be models whose success would be replicated in other parts
of the country. An assessment was needed to evaluate the effectiveness of the program,
particularly in the area of rational drug prescription and treatment of childhood diseases.
Objectives: To assess the level of compliance by health care workers and mothers in the
prescription and acceptance of appropriate drugs in the treatment of diarrhea and Acute
Respiratory Infection (ARI); to compare the prescription in the intervention areas with the situation
in other areas; and to explore the impact of terrain and season on accessibility to appropriate
treatment.
Design: Questionnaires, a rapid assessment module, and focus group discussions and structured
observations were used to obtain information on the situation and treatment of childhood diarrhea
and ARI.
Setting and Population: All under five children (216) and available health facilities in eight
village clusters were studied for one year. The Area is typical of most rural Nigeria with dispersed
population.
Four villages a piece were selected from adjacent model and non-model areas for comparism.
The study area is in the south western region of Nigeria. It is characterized by rugged terrain that
is inundated during the wet season. The study focused on the behavior of health care workers and
mothers. The population is chiefly engage in farming, cottage industry and petty trading. The
study area is one of the model of the model regions for the vigorous implementation of primary
health program marked by profound intervention campaigns for the use of oral rehydration therapy
and appropriate treatment of childhood diseases in Nigeria.
Outcome Measures: Percentage of appropriate drug/treatment prescribed for diarrhea. and ARI
in children; knowledge by health workers and mothers of the message of the intervention;
compliance with appropriate use of the prescribed drugs; level of utilization of traditional herbs.
Results: Appropriate Prescribing Practices were more common in the model areas compared
with non-model areas. Considerable disparities were observed between model and non-model
areas in terms of drug prescription. In diarrhea treatment the use of ORT/SS was 48.6% and
29.3% for model and non-model areas respectively. The use of traditional herbs (57.3%) was the
most common in non-model areas while antibiotics (33.8%) were mostly use in model areas for
the treatment of ARI.
The result of MANOVA (multivariate analysis of variance) showed the
difference to be statistically significant (P<0.005). However, the level of irrational drug prescription
especially in non-government facilities is still high. The rates of acceptance and compliance by
mothers to appropriate drugs is low. This is particularly profound in the more remote villages and
during the wet season when itinerant drug peddlers are the only ‘doctors’ available. The
deliberate combination of appropriate drugs, inappropriate drugs and traditional herbs may
indicate that mothers are being by-passed by the programme.
Conclusion: The intervention seems to have been a measured success in the villages with
access to its program. However, the success rate dissipates in the remote villages and during wet
seasons when the activities of itinerant drug hawkers and use of traditional herbs are more
common. Addressing the specific needs and challenges of treating children in difficult terrains and
seasons are key to program success. There is a gap between intervention policy and practice
that requires urgent attention.
Study Funding: Council for Development of Social Sciences Research in Africa (CODESRIA)
Background and Setting
Nigeria has a population of 120 million and the largest in Africa.
However, infant and under-five morbidity and mortality rates are
unacceptably high especially in the rural areas that constitute 70%
of her population. Even more worrisome is that illness and death
result majorly from malaria vaccine preventable diseases, diarrhea
diseases and acute respiratory infection confounded by nutrition.
(UNICEF, 2002). The Nigerian national health policy released in
1988 was meant to signal a new era in social policy with primary
health care (PHC) as the cornerstone. In the face of scarce
resources that have been thinly dissipated to “all” with little success
and the manifest ambivalence in folk search for health care the need
to concentrate on at risk areas and groups (Talylor 1986, Araya
1992) became a very attractive option.
In 1988, the Federal Government of Nigeria selected 52 Local
Government Areas and designated them Model-PHC LGAs. PHC
services including purchase and distribution of appropriate drugs
were to be established, rendered and monitored in each of these
models. Baseline and situation reports were carried. Villages were
also mapped and houses numbered to facilitate easy identification
and visitation by health workers. Other activities include mass
mobilization and enlightenment campaigns at community levels and
capacity building of all categories of health workers. These activities
were sponsored by the Federal Government with a Grant of
$500,000 for each of the first 52 LGA models. This Poster is on the
assessment of LGA models in the area of substances used by
mothers in the treatment of the two most important diseases (Abu,
2002) ARI and Diarrhoea in rural Nigeria.
Background and Setting (cont.)
For this study a child is deem to have an episode of diarrhoe if (s)he
passes more than 3 waterly stools within 24 hours. On the other
hand, a child was diagnosed as having ARI when the following
symptoms are exhibited: purulent nasal discharge, sore throat,
earache or discharge or cough. Episodes of ARI were classified as
severe if accompanied by rapid breathing, wheezing, stridor, rales or
chest retractions.
The Study Area
This study was carried out in Oluyole and Ona Ora Local
Government Areas (LGAs) of Oyo State. The area is typical of most
rural settings in Nigeria with the population widely dispersed, and a
marked neglect of government in the provision of basic amenities.
The villages, however, differ in terms of access roads, access to
potable water, health and sanitation facilities among others. Ona
Ora LGA was purposely selected being adjacent to one of the model
LGAs where primary health care is being vigorously implemented.
The people are essentially peasant farmers. The women of the area
farm and are also involved in cottage industries such as food
processing and weaving. They also trade in agricultural products.
The majority of the people are of Yoruba ethnic group although there
is a considerable mixture of Nigerians from other parts of the
country. The study area is located south of Ibadan (Oyo State
Capital) between latitude 7o 051 N and 7o141N and longitude 3o
421E and3o 541E. The topography is that of an undulating lowland
that is drained by Rivers Ona and Awun. The climate is influenced
by the two major trade winds in Nigeria. Because the area is
located in the south-western part of the Country (See Fig. 1.1) it has
a long wet season lasting from April to October which
Background and Setting (Cont.)
alternates with a short dry season which last from November to
March. The rainfall regime is double peak with a mean annual
rainfall of about 12,300mm and annual temperature of 27oC. The
natural vegetation is semi-deciduous low land forest.
Four village clusters were randomly selected from the list of villages
in the two local government areas by the use of Table of random
numbers. They include Onipe, Olubi, Ibusogboro, Onigambari,
Elerin, Abayawo, Gbaleasun and Moleke (Fig. 1.1). All households
with children below the age of 45 months were selected. This was
done to ensure that none of the study children would exceed five
years at the end of the surveillance, which lasted for 12 months. The
field work was conducted between January 1994 and late March
1995.
Aim and Objectives
Aim
Although this paper emanates from a bigger study (See Abu, 2002),
the aim of this aspect of the study is to evaluate the impact of the
model local government area program on Prescribing and treatment
of Dairrhoa and Acute Respiratory Infection (ARI) in rural Nigeria.
Objectives
To assess the level of compliance by health care workers in drug
prescription.
To document the level of acceptance and use of appropriate drugs.
Based on the obtained results, make recommendation to all
stakeholders for the actualization of project objective.
To compare the prescribing in the model areas with the situation in
the non model area.
To explore the impact of terrain and season on accessibility to
appropriate treatment.
Methodology
A reconnaissance survey of the area was carried out between
January and February 1994. The main purpose was to get a first
hand knowledge of the villages and to enlist the support and
cooperation of all, especially mothers. In this task, series of
meetings were held with the local government hierarchy, the primary
health care (PHC) unit, village chiefs (Baales and Bales), household
heads and women. It was also during this period that households
with under-five children were identified for the study. These
households were also given an identification code during the period
under review. The training of field assistants was done during this
period thereby setting the stage for the survey proper. The survey
team comprised the researcher, one nurse, one community health
worker, one field assistant, an official of the local government and at
times a graduate of the social sciences. Three data collection
instruments comprising semi-structured questionnaires, longitudinal
surveillance, structured observation and focus group discussions
(FGD) were used. The data collection was done in 3 phases.
Phase 1: Interviewing
Semi-Structured Questionnaire were used to obtain a detailed
village and household level data. Information collected at village
level, include presence of basic amenities such as water, electricity,
schools, health facility and access roads. More detailed information
was collected at the household level covering a wide spectrum of
the
general environmental sanitation conditions, housing,
demographic and socio-economic characteristics of households,
especially of mothers of children under the age of 5. Information on
the health status and general characteristics of the study children
were also obtained.
Methodology (Cont.)
Phase 2: Longitudinal Surveillance
A participatory and observation approach to an evaluation of the
health situation of population of interest was employed. This phase
lasted for 12 months, March 1994 – February 1995. In this task,
rapid assessment methodology was employed to study households
with under five children for one year. One informant was trained and
stationed in each village. The eight assistants who were indigenes
or residents of the study villages visited all households every two
weeks. During these visits an inventory of observed behaviors and
practices such as feeding habits, treatment and illness behaviors of
mothers were recorded. In all, a total of 5784 bi-weekly child visits
were made. Throughout the duration of the surveillance, information
on the study children was collected and analyzed in an ongoing
manner
Phase 3: Focus Group Discussion (FGD) Session
At the end of 12 month rapid assessment survey, focus group
discussion (FGD) sessions were held in four villages. FGD is a
qualitative research method for eliciting descriptive data from
population subgroups (Morgan and Spanish, 1984; bender and
Ewbank, 1994). Usually a group of eight to twelve persons (in this
study, mothers) were gathered in a group to discuss a focused topic
– childhood diseases and treatment in this instance.
Secondary Data Sources
Clinic based data were obtained from two health centres namely,
Onipe and Onigambari. The main interest here is to identify the
major diseases, complaints and symptoms that often take under five
children in the study area to the existing health facilities and the type
of treatment prescribed.
RESULT 1:
INDICES OF DISEASE PROFILE
Point prevalence rates of 12.8% and period prevalence 23.70 of
diarrhoea was observed in the study area. Children of age 9 – 18
months have the highest incidence rates of diarrhoea. This age
cohort coincides with weaning practices in the study area.
Age specific incidence rates for ARI and Diarrhoea were higher in
Non Model areas than in Model areas for all age groups.In particular
the incidence of ARI rates tend to decrease with increasing age of
children.
The incidence rates of ARI was a high as 5.1 and 8.3 for model and
non model areas.
RESULTS 2: KNOWLEDGE, PRESCRIPTION &COMPLIANCE
Nurses, community health workers, patent medicine store owners,
itinerant drug sellers, older/experienced members of the family
prescribe drugs freely in both model and non-model areas.
Health workers and mothers in the model LGA showed superior
knowledge of ARI and Diarrhoea causes and prevention than their
counterparts in the non-model LGA.
However, this does not automatically translate in better prescription
and treatment practices per se.
It is highly probable that certain contextual circumstance
(accessibility, affordability cultural re-interpretation of illness) tend to
perpetuate the gap between knowledge and actual practice.
Specifically, in diarrhoea treatment the use of ORT/SS was 48.6%
and 29.3% for model and non-model areas respectively
Mothers perceived such dangerous signs of rapid/difficult breathing
convulsions, stidor/wheezing (ARI), sunken eyes, depressed
fontannelle, weakness, restllessness (Darrhoea) as ordinary
symptoms of ARI and Diarrhoea respectively.
Drugs prescribed and used for treating ARI include: Anti-biotics,
capsule, tablets, syrups, injections balm, herbs etc.
Seasonal Pattern of ARI & Diarrhoea
RESULTS 2: KNOWLEDGE, PRESCRIPTION &COMPLIANCE (Cont.)
The treatment of diarhoea include the use of tetracycline,
chloramphenicol, ampicillin, injections, antidiarrhoeas, herbs,
vitamins, amulets.
It is important to point out the volume and extent of inappropriate
prescription and treatment not only exceeds what the literature in
Nigeria suggests. We also observed deliberate combination of
appropriate drugs, inappropriate drugs traditional herbs in a shrewd
cocktail whose real outcome on child’s health is yet to be ascertain.
Late Reporting was common as most mothers especially in the non
model LGA first give homemade remedies such as ‘agbo’ tea etc.
Incomplete dosages are common as mothers stop treatment when
symptoms disappear.
The use of leftover medicines from earlier episodes of Illness by the
same child other members of the household was observed in both
model and non-model LGAs. It is more common in the latter.
The use of traditional herbs 57.3% was the most common in nonmodel areas while antibiotics 33.8% were mostly used in model
areas for treatment of ARI. The result of multivariate analysis of
variance showed the differences in various indices of knowledge,
prescription, treatment compliance to be statistically significant (P <
0.005).
RESULT 3 SEASONALITY IN TREATMENT:
This study reveals considerable seasonality in the treatment given to
children with the worst cases of irrational drug use in the wet season
for both model & non model areas alike.
The problem of accessibility is accentuated when lanes are
inundated and only itinerant drug sellers on motor bikes & bicycles
constitute the only doctors & pharmacists during the wet season.
The use of traditional herbs is prominent during wet season.
According to one of the FGD discussants: “…herbs can cure all
childhood diseases & protects against witchcrafts…we get herbs
from our backyard at no cost at all”.
Policy Implications
The findings of this study have several implication for project policy
formulation implementation and monitoring. Some are highlighted
below:
Equal/Proportionate attention needs to be given to the use of SSS
and O as paid to appropriate medicine prescribing.
There is great need to include itinerant medicine sellers in
enlightenment campaigns and training workshops.
The shrewd combination of modern medicine and traditional herbs,
balms, amulets and rational and irrationational use of medicines
tend to suggest that mothers are being by-passed over by the
intervention project.
The need for a more mother centred and clear and unambiguous
messages preferably, face-to-face enlightenment campaigns in the
appropriate treatment of ARI and Diarrhoea will loom large in the
context of the study area.
The activities of itinerant medicine sellers especially during the rainy
season as a major challenge and hazard to program success in the
context of the study area such impurity may be mitigated if drug
sellers and pharmacists are involved in the training programs to give
them appropriate drug prescription education for ARI and Diarrhoe.
Addressing the specific needs and challenges of treating children in
difficult terrains and seasons are pivotal to program success.
Conclusion
Under five children in Nigeria are fraught with unacceptably high
mortality and morbidity rates. The situation is not likely to abate in
view of the recent set backs recorded in the area of immunization.
Meanwhile, inappropriate use of medicine in the treatment of major
childhood diseases such as ARI and diarrhoea poses considerable
problem for child survival efforts. The results of this comparative
study between model LGA and Non model LGA are most instructive.
In all, significant variations exist between Model and Non Model
area in the area of drug prescription and treatment. Mothers in
program areas generally exhibiting more positive behavior in the
areas of disease perception, health seeking and treatment of sick
children. However, there is room for adjustment and improvement.
Before the strategy of the model LGA is replicated or extended,
there is the need to factor the topography, ecology, seasonality and
their possible inhibitions to program success. These considerations
may be very pivotal for project success or otherwise in communities
whose women are not as educated and therefore less willing to
adopt innovations in child care and treatment.
In conclusion, the gap between policy statements and practice tend
to stem from a failure to appreciate that beyond the readily
trumpeted behavioral socio-cultural factors, ecological factors
operating and community and household levels provide the context
for understanding disease occurrence and treatment in rural Nigeria.
Acknowledgements
I am grateful to the Council for Development of Social Sciences
Research in Africa (CODESRIA) for the Grant of this study.
Professor B. F. Iyun now of blessed Memory inspired and guided
this work.