Table of Contents
Title Page i
Approval Page ii
Dedication iii
Certification iv
Acknowledgements v
Table of contents vi
List of Tables ix
List of Acronyms x
Abstract xi
CHAPTER ONE Introduction
Background to the Study 1
Statement of the Problem 9
Purpose of the Study 10
Research Questions 11
Hypotheses 11
Significance of the Study 11
Scope of the Study 14
CHAPTER TWO Review of Related Literature
Conceptual framework 15
•Child health services (CHs), objectives and components 15
•Availability and adequacy of CHs 22
•Utilization of CHs 23
•Primary health centre 24
•Factors associated with utilization of CHs 25
A diagrammatic schema showing conceptual frame work of availability,
adequacy and utilization of child health services 28
Theoretical Framework 29
• The three delays model (TDM) 29
• Health belief model (HBM) 30
• Health- Seeking behaviour model 31
Diagrammatic schema showing theoretical frame work of availability,
adequacy and utilization of child health services 32
Empirical Studies on Availability, Adequacy and Utilization of CHs 33
Summary of Literature Review 42
CHAPTER THREE Methods
Research Design 44
Area of the Study 44
Population for the Study 45
Sample and Sampling Techniques 45
Instrument for Data collection 46
Validity of the instrument 47
Reliability of the instrument 47
Method of data collection 47
Method of Data Analysis 48
CHAPTER FOUR Results and Discussion
Results 49
Summary of Major Findings 69
Discussion of Major Findings 71
Availability of child health services 71
Adequacy of child health services 71
Utilization of child health services 72
Differences in the availability, adequacy and level of utilization of CHs 73
Summary, Conclusions and Recommendations 75
CHAPTER FIVE: Summary, Conclusions and Recommendation
Summary 75
Conclusions 78
Recommendations 79
Limitation of the Study 80
Suggestions for Further Studies 80
References 81
Appendices 89
Appendix A: Letter of Introduction 89
Appendix B: Local Government, Primary Health Care Centres and
Population of Child Bearing Mothers in Nsukka Health District 90
Appendix C: List of Functional PHC in Nsukka Health District 91
Appendix D: Availability, Adequacy and Utilization of CHs questionnaire 92
Appendix E: Instrument (AAUCHSQ) Reliability Test Analysis 96
Appendix F: Analysis of Availability, Adequacy and Utilization of (CHs) 106
List of Tables
- Availability of Child Health Services 49
- Adequacy of Child Health Services 50
- Level of Utilization of Child Health Services 52
- Level of Utilization of CHs According to the Mother’s Educational
Level of Attainment 54 - Level of Utilization of CHs According to Mothers Occupation 56
- Level of Utilization of CHs by Mothers According to their
Residential Location 58 - Available CHs in PHCs in Nsukka Health District According to Location 59
- Adequacy of CHs in PHCs in Nsukka Health District According to Location 60
- Summary of ANOVA in the Level of Utilization of Child Health
Services According to Level of Education 62 - Scheffe’s Post-Hoc Analysis of Group Mean Scores Based on
Level of Education in Utilization of Growth Monitoring 63 - Scheffe’s Post-Hoc Analysis of Group Mean Scores Based on
Level of Education in Utilization of Immunization Services 64 - Summary of ANOVA in the Level of Utilization of Child Health
Services According to Mothers Occupation 65 - Summary of t-Test analysis on No Significance Difference in Level
of Utilization of CHs According to Location 66 - Summary of Chi-Square (x2) Analysis Testing the Null Hypothesis of
No Significance Difference in the Level Availability of CHs in PHCs
According to Location 67 - Summary of t-Test Analysis of No Significance in Adequacy of
CHs According to Location 68
List of Acronyms
AHRQ Agency for Health Care Research and Quality
AIDS Acquired Immune Deficiency Syndrome
BCG Bacillus Camette Guerrin
CHs Child Health Services
DPT Diphtheria Pertusis and Tetanus
FMOH Federal Ministry of Health
HBM Health Belief Model
L.G.A Local Government Area
MCH Maternal and Child Health
NPI National Programme on Immunization Tuberculosis
ORT Oral Rehydration Therapy
PHC Primary Health Care
SPSS Statistical Package for the Social Sciences
TDM Three Delay Model
TB Tuberculosis
UNICEF United Nations Children’s Fund
WHO World Health Organization
Abstract
The purpose of the study was to find out the availability, adequacy and utilization of child health services in Primary Health Care Centres in Nsukka Health District, Enugu State. To achieve the purpose of the study, eight specific objectives with corresponding research questions were posed and five hypotheses postulated to guide the study. The Descriptive survey research design was used for the study. The population for the study consisted of 3882 mothers (3666) and health service provider (216). The multi-stage sampling procedure was used to draw a sample of 474 mothers (366) and health providers (108) for the study. The instrument for data collection was the availability, adequacy and utilization of child health services questionnaire (AAUCHSQ) designed by the researcher. Cronbach’s Alpha statistic and Kuder Richardson 20 (KR-20) were used to establish the reliability of the instrument. Means and percentage were used to analyze descriptive data, while null hypotheses were tested using t-Test, Chi-Square and ANOVA statistics. The criterion mean for adequacy and utilization was 2.50. The major findings of the study were as follows: All the child health services were available in primary health centres, All the child health services were adequate ( = 2.98, SD = .92). Mothers of different level of education utilized child health services effectively (no formal education ( = 2.93) primary education ( = 2.80), secondary school education ( = 2.85) tertiary education ( = 2.81)). Mothers of different occupation utilized child health services effectively farming ( = 2.67), trading ( = 2.81), public/civil servant ( = 2.89), cloth weaving/hair dressing ( = 2.82), house wives ( = 2.81) and student ( = 2.67). Mothers in both urban ( = 2.96) and rural ( = 2.65) utilized child health services effectively. All the components of child health services were available in both urban and rural primary health centres. All the child health services were adequate in both urban ( = 3.14) and rural ( = 2.96). There was no significant difference in the level of utilization of child health services according to level of education at .05. There was significant difference in the level of utilization of growth monitoring services and immunization services according to level of education. There was no significant difference in the level of utilization of; growth monitoring, curative services, ORT and immunization services while there was significant difference in the level of utilization of nutritional services according to mothers’ occupation. There was no significant difference in the level of utilization of growth monitoring, nutritional services, curative services and immunization service according to residential location of mothers. There were significant differences in the level of availability of growth monitoring, nutritional services, curative services, ORT and immunization services. There was also no significant difference in the level of adequacy of growth monitoring, nutritional services and immunization services according to mother’s residential location while there were significant difference in the level of utilization of curative services and ORT according to residential occupation of mothers. The researcher recommended that government should see that primary health centres are located equally in both urban and rural areas, and that health workers should strengthen their teaching on the utilization of all the components of CHs especially growth monitoring and curative services.
CHAPTER ONE
Introduction
Background to the Study
People seek to improve quality of life in both developed and developing countries. Unfortunately, most people in developing countries live in overcrowded houses with inadequate sanitation and unsafe water supply. Infectious disease and malnutrition are common especially among children. Death rate is high and life expectancy is low. World Health Organization – WHO (2002) estimated that ten million children under the age of five years die each year from complications arising from childhood diseases and 80 per cent of these deaths occur in Sub-Saharan Africa. The ratio of infant mortality in the region is one of the highest in the world reaching a proportion of 113 per 1000 live births (World Bank, 2004). In Nigeria, the Federal Ministry of Health-FMOH (2007) reported that about 5.3 million children are born annually that is 11.000 per day. One million of these children die before the age of 5 years. The ministry further submitted that Nigeria’s infant mortality rate (528 per day) is one of the highest in the world. Infant mortality and under five mortality are 100 and 201 per 1000 live births respectively, and these deaths are from preventable causes such as malaria, pneumonia, diarrhoea, measles and HIV & AIDS. One explanation for poor health outcome among children is the non-use of available child health services by sizable proportion of mothers. Haddad (2005) Stated that the cost and utilization of health services in developing countries clearly showed that the utilization of available child health services is very low in developing countries. This according to Haddad is influenced by culture, economics, access, perceptions and lack of knowledge of mothers on existing child health services.
Stanfield (2004) noted that child health services is an integral part of Primary Health Care, which is concerned with the provision of accessibly integrated biopsychological health care services by the health care personnel. The author maintained that the health care personnel are accountable for addressing a large majority of personal health needs, developing a sustained partnership with patients and participating in the context of family and community. Onuzulike (2005) asserted that child health services are the total care and services rendered to children 0-5 years in order to maintain healthy living. Turmen (2006) described child health services as the provision made to improve optimal growth and development in infancy and childhood through disease prevention, good nutrition and health supervision.
Health care has been defined by William (2003) as the prevention, treatment and management of illness and preservation of mental well-being through the services offered by the medical, nursing and allied health profession. Hatch and Shiel (2006) described child health activities as services which focus on the well-being of children from conception and is concerned with all aspects of children’s growth and development and with the unique opportunities that each child has to achieve his or her full potentials as a healthy adult. Child health services in this study refer to the efficient strategies provided by health workers in order to promote health of the child and prevent diseases, disabilities and deaths through simple cost-effective measures. They are services meant to ensure as much as possible that every child lives and grows healthy.
Services are defined as a system provided for by a government or official organisation for the need of the public (Rundel, 2005). Services are provisions made for the public to use as much as they need in order to benefit from them (Pelto, 2005). Pelto added that services help to improve the health of the public especially Health Care Services. Health care services which are provided for the children is referred to as child health services (CHs). According to Ama (2001), comprehensive child health services must encompass all the following: immunisation services, growth monitoring services, nutritional services, health education, oral rehydration therapy (ORT), curative services and outreach services. These are the components of CHs.
Child health services are meant to ensure as much as possible that every child live and grows up in a healthy environment and receives adequate nourishment for healthy living. To ensure effective child health services, each primary health centre must provide the components or activities of child health care services. Gabr (1985) outlined certain activities to be provided for children within the PHC centres. The activities include, immunisation of all children against the six preventable diseases such as measles, poliomyelitis, whooping cough, tetanus and diphtheria and pertusis; growth monitoring and development using a standardised chart aimed at assessing the physical development of the child; health education for mothers on general child’s health; using oral rehydration therapy (ORT) in treating diarrhoea of any aetiology; treatment of identified minor diseases in the family and community. The author also mentioned other activities to be provided outside the primary health centres. These activities include promotion of breast feeding in preventing malnutrition and diarrhoea in children; use of locally and culturally acceptable foods during weaning period; and outreach services which are planned and carried out. In the context of this study, the components of child health services to be carried along include; immunisation, growth monitoring, ORT, nutrition and curative services. These are chosen because they are the services provided within the health centers of which information can be accessed.
Brunner and Sadder (2002) described immunisation as intentional introduction of weakened micro-organism in a small dose into the body to stimulate sensitive reaction that brings about immunity against the invasion of such organism in larger amount. Ajayi (2005) pointed out that administering life attenuated micro-organism produces antigen – antibody reaction that gives the body active immunity to diseases. Lacus and Gilles (2006) stated that immunization of children is one of the most cost effective public health interventions and each child should be immunized against common communicable diseases which vaccine is available. Immunization is routinely offered against tuberculosis, tetanus, whooping cough, diphtheria, poliomyelitis and measles. The choice of vaccine and the immunization schedule should be selected on the basis of local epidemiological situations and on the most practicable routine. During child immunization the health workers perform other child health services such as growth monitoring.
Growth monitoring is an important indication of child health in health care facilities. Growth monitoring, according to UNICEF (2004), is aimed at observing the physical growth and development of the child. It helps to detect growth failure at early stage for proper management. Akinsola (2004) asserted that growth monitoring is important during the first five years of child’s life because it is during this period that the child grows rapidly, physically and its social behaviour and mental attitude are also formed. The foundations are formed mentally and physically for building up the personality of the child. Monitoring a child’s progress helps to compare it with a standard growth chart. When a child progress is observed over a period of time, it is quite possible to detect a disease or abnormality at an early stage and prompt treatment can be administered. This helps to prevent disabilities, diseases and malnutrition. Akinsola (2004) maintained that, weighing is the easiest and most accurate methods of monitoring the growth of a child if the child’s age is known; his weight can be compared with a standard weight of a normal child of his age and of the same group. Even when his age is not known his weight can still be recorded regularly, (monthly) on a chart. By measuring and recording a child’s weight regularly on a single card, a growth curve for that child can be made. This curve can quickly reveal any significant changes in the child’s pattern of growth and so appropriate action can be taken promptly. Growth monitoring helps the health worker to give professional advice on malnutrition in children, hence improvement in nutritional services are among the services children should receive.
Nutritional education is an integral part of CHs which is meant to give the mothers the opportunity of early development of insight into the nutritional requirements of children. Through nutritional education, mothers learnt how to promote good nutrition, prevent nutrition diseases and seek immediate medical attention (Bennette, 2004). Pelto (2005) described nutrition education as a process by which nutritional information is successfully imparted in such a way that the recipient is motivated to make use of the information for the promotion and maintenance of the family’s or community’s nutritional status. Nutrition in children may be categorized into four; intra-uterine nutrition, complementary feeding, post weaning and exclusive breast feeding. Improvement in nutrition will help to reduce the need for curative services among children.
Curative services are concerned with appropriate treatment of diseases and injuries. The aim is to prevent death and disability resulting from common childhood diseases and injuries so that all children can have the opportunity of healthy growth and development (Akinsola, 2004). In Nigeria, one major health problem which has been tackled with great success is diarrhoea which is a major killer of children. With the introduction of ORT, the high mortality rate which often accompanies diarrhoea among children has been drastically reduced. Today, nearly every Nigerian mother knows how to prepare and administer oral rehydration fluid.
Bryce and Mansach (2000) described ORT as life saving oral fluid of sodium and water. They pointed out that since its inception in 1979 it has rapidly become a corner stone in the programme for control of diarrhoea diseases. They maintained that it is the most potentially significant medical advancement in the 20th century. Similarly, WHO (2002) reported that rapid decline in child mortality is attributed to ORT, which mothers can simply use at home. It is cheap and always available to save children from dehydrations and death and require no special expertise to operate. All the components of CHS are directed at the prevention of ill health in children, promotion of their health and achievement of child health objectives.
The objective of child health services is to prevent the major causes of death, disability and diseases during childhood. Similarly, Lacus and Gilles (2006), stated that the objectives of CHs are to promote the health of children; ensure that they achieve the optimal growth and development both physical and mental; protect children from major hazards through specific measures (immunization, chemoprophylaxis, dietary supplements) and through improvement in the level of care provided by the mothers and the family; treat diseases and disorders with particular emphasis on early diagnosis. The aim is to provide an effective remedy at an early stage before dangerous complication occur. Bennette (2004) asserted that the objective of child health services is to prevent the childhood killer diseases, save children from death due to rapid dehydration as a result of diarrhea, assess the nutritional status of children and give prompt attention to those malnourished and those having poliomyelitis, monitor the growth pattern of children especially the under-five children and encourage breast feeding. To achieve the objectives of child health services, such services must be available.
