Abstract

1. TITLE:EFFECT OF THE MODEL LOCAL GOVERNMENT AREA PROGRAM ON PRESCRIBING AND TREATMENT OF MAJOR CHILDHOOD DISEASES IN RURAL NIGERIAAmos ABU (PhD), University of Lagos, Nigeria. Email: aabu_medgeounilag@yahoo.com • 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)

2. 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.

3. 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

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. Seasonal Pattern of ARI & Diarrhoea

10. 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 non-model 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”.

11. 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.

12. 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.