Abstract
The
study was to evaluate RBM programme in Igbo-Eze South Local Government Area.
The study evaluated the availability and adequacy of RBM services, qualified
service providers, materials and health facilities, the factors that influenced
the utilization of RBM materials and the extent of utilization of RBM
materials, community participation and patient attendance in health facilities.
The factors evaluated in relation to the utilization of the materials and
services were weak health system, community participation, drug resistance,
discontinuity of programme and non vaccine development. To achieve the purpose
of the study twelve research question were posed and three null hypotheses were
postulated. The study adopted a descriptive survey research design. It covered
all the government health facilities. All the four LGA team members, 326
professional health staff, 26 RBM role model caregivers and 57
community/opinion leaders were used. There was no sampling as the entire
population was studied through the use of two sets of questionnaires and
programme data stored in the LGA headquarter and health facilities. Data collected
were analyzed quantitatively using frequency and percentages in respect of
research questions one and then while mean and standard deviation for research
questions two through nine and eleven and twelve. The student t-test hypotheses
and ANOVA were used to verify the three null hypothesis formulated for the
study at .05 level of significance. The data generated from programme records
were used to confirm information got from respondents. The study revealed that
artemisimin based combination therapies, intermitted preventive treatment in
pregnancy and insecticides treated bed nets distribution health education and
rapid diagnostic treatment were available while environmental techniques was
virtually absent. It also reveal that some RBM materials and service providers
were available and adequate. The study further revealed that majority of the
respondents indicated that majority of the factors influenced the utilization
of RBM services. The study further revealed that the utilization of these RBM
services did not differ by age, gender and occupation. Based on the major
findings and conclusion, it was recommended among others that environmental
health techniques should be incorporated into RBM control programme
intervention. More Doctors, Environmental Health Officers, Nurses should be
trained and employed for RBM control programme services delivery.
CHAPTER ONE
Introduction
Background to the Study
Malaria is a major public health problem and poses a major challenge as it impedes human and economic development. According to World Health Organization, WHO (2001) malaria is both a cause and consequence of leading causes of morbidity and mortality in the world including Nigeria today. It has proven to be the most horrendous and intractable among the health problems confronting countries in the sub-Sahara Africa. In Nigeria, the disease is responsible for sixty per cent of out patient visits to health facilities, thirty per cent childhood death, twenty five per cent death in children under one year and eleven per cent maternal deaths (Federal Ministry of Health (FMOH), 2007). FMOH, (2005) submitted that about fifty per cent of adult population in Nigeria experience at least one episode of malaria yearly while children under five years of age have up to 2-4 attacks of malaria annually. The financial loss due to malaria annually is estimated to be 132 billion Naira in form of treatment costs, prevention, loss of man-hours and so on. Yet, it is a treatable and completely evitable disease. Therefore, malaria contributes to both poverty and under development of Nigeria families and individuals because people spend huge part of their yearly income on prevention and treatment of malaria.
Malaria is an infectious disease caused by protozoa parasite plasmodium from the plasmodium family that can be transmitted by the sting of the anopheles mosquito (Beare; Taylor; Harding, Lewallen and Molyneux (2006). It is characterized by cycles of chills, fever, muscle aches and sweating that recur every few days. There can also be vomiting, diarrhea, coughing and jaundice of the skin and eyes. Historically, records suggested that malaria has infected human since the beginning of mankind. Today, approximately 40 per cent of the world’s population mostly those living in the world’s poorest country are at the risk of malaria. This present study adopt the definition of malaria as provided by Beare, Taylor, Harding, Lewallen and Molyneux (2006).
Based on the recognition of the unacceptable morbidity and mortality rates in Africa and the availability of number of evidence based on cost effective interventions, health reform was carried out in 1998 with the adoption of a health policy. Within the policy, malaria was to be controlled by using the concept and technology of Primary Health Care (PHC). The implementation of malaria control in the context of PHC strategy demands national commitment, community participation and intersectoral co-operation which are the diverse strength of expertise of Roll Back Malaria (RBM) partners. In an effort to combat the growing threat of malaria, RBM programme was launched in 1998 to reduce the burden due to malaria in Africa region by fifty per cent by the year 2010.
Roll Back Malaria (RBM) is a global partnership established in 1998 by World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations Development Programme (UNDP) and World Bank with the goal of halving the world’s malaria burden by 2010. RBM is an initiative to improve malaria control in the context of health sector reform (FMOH, 2009). It serves as a strategic approach to disease control, mitigation and the overall fight against malaria. In this study, it is a tool for executing health projects which are carried out in partnership with public, private, research institutions, professional Associations, UNICEF, WHO, UNDP and World Bank.
Nigeria hosted Africa summit on RBM in Abuja in the year 2000. The summit concluded with the signing of declaration and plans of Action. The declarations stated that at least 60 per cent of those suffering from Malaria should have access to affordable and appropriate treatment within 24 hours of the onset of symptoms. It further stated that at least 60 per cent of those at risk of malaria particularly pregnant women and children under 5 years of age should benefit from the most suitable combination of personal and community protective measures such as insecticide treated nets (ITNs) and other interventions which should be accessible and affordable to prevent infection and sufferings. As part of the declaration, it was also agreed that’ at least 60 per ‘cent of all pregnant women who were at risk of malaria especially those in their first and second pregnancies should have access to chemoprophylaxis and chemotherapy medicine (FMOH, 2002). WHO, UNICEF and UNDP promised reliab1e, sustainable case management, prevention, research, effective and affordable tools, human and institutional resources to fight against malaria scourge.
Also, in the declaration RBM partnership supports effort to tackle Malaria wherever it occurs but the burden of the disease and death falls mainly on two venerable groups. The venerable groups are children and pregnant women. As a result, the focus of RBM and its greater challenges are to reduce the burden of malaria in the two vulnerable groups in the African regions. The objectives of RBM are to reduce morbidity and mortality by keeping malaria under effective control (less than 2 per/1000 per year) so that it does not become a major public health problem. It also promised to halt malaria by 2010 and begun to reverse the incidence of malaria. It will help to strengthening community participation (Burton and Thomas 1990). The RBM objectives were targeted to achieve universal access and utilization of preventive measures and its sustenance. It also hope to accelerate development of surveillance system and achieve universal access to case management at health facility and community level. RBM in Nigeria anchors on three global strategic approaches for malaria control which are multi-pronged and of proven efficacy. These include prompt and effective case management, promotion of intermitted preventive treatment in pregnancy (IPTp) and multiple prevention with promotion of the use of insecticide treated nets, indoor residual spraying (IRS) and environmental management (FMOH, 2010).
Case management is the clinical management of malaria cases (i.e. diagnosis and treatment). Roll Back malaria partners have made concerted efforts to ensure that Nigerians especially children under five years and pregnant women have prompt access to effective treatment within 24 hours of the onset of malaria by working with pharmaceutical manufacturers to ensure that prepackaged drugs for malaria are produced and distributed (Foster, 1991). Health workers, patent medicine vendors and role model RBM caregivers have also been trained on home managements of malaria to ensure that vulnerable groups have access to effective treatment (Alfred, 2006).
Moreso, intermittent preventive treatment in pregnancy (IPTp) is the use of anti-malaria drugs given to pregnant women in treatment doses at predefined intervals after the first movement of baby in the womb to clear presumed burden of malaria parasites and provide significant protection against maternal anemia, mortality as well as low birth weight and abortion (Hill and Kazembe, 2006). IPTp is a curative dose of sulfadoxine – pyrimethamine (SP) given two times during pregnancy. This approach has been shown to be safe, inexpensive and effective. Therefore, IPTp is designated as the preferred approach to reduce the number of malaria parasites in pregnant women during critical periods of greatest foetal weight gain.
Again, multiple prevention is another strategy that use multiple preventive strategic approaches such as the use of insecticide treated nets (ITNs), indoor residual spraying (IRS) and environmental management. ITNs are designed in various shape, colours, and sizes to appeal to local tastes and meet local needs. These nets have insecticides incorporated into the fibre or bound around the fibre at factory stage. If treated with insecticides, the effectiveness of nets is greatly improved by generating a chemical halo that extends beyond the mosquito net itself. This tends to kill, or deter mosquitoes from biting or shorten the mosquito life span so that she cannot transmit malaria infection. Insecticidal Residual Spray is the application of long acting chemical insecticides on the inner walls, eaves, ceilings and roofs of all houses in a given area in order to kill the adult vector that transmit Malaria. Environmental management as a strategy is the act of rendering the environment unsuitable for mosquito breeding.
The strategies of RBM as contained in the Abuja declaration seek to ensure building and strengthening its partnership, contributing to health system reforms and integrating malaria control activities into PHC. They also included strengthening community and international participation, reducing mortality and morbidity rate due to malaria among children and pregnant women. They also pledged to reduce overall morbidity and mortality to ensure that malaria will not be public health problem (UNICEF/WHO, 2003).
Furthermore, initiating programme is one thing and implementing it objectively is another thing. There are some factors that may hinder RBM programme objectives. They are weak health system, community participation, drug resistance, discontinuity of programme and non-vaccine development (WHO, 2009).
Weak health system has been identified as a strong factor that influences RBM. Due to poor capacity of the health system with poor access to diagnosis and treatment, a lot of malaria cases are out-of reach by health services. Also, drugs have been critical in limiting morbidity and mortality but treatment coverage of population is well below the larger proportion of suspected case and death due to malaria.
Community participation has influenced RBM activities. RBM can only be effective when individuals and communities are actively involved. Ruebush, Zeissig, Klein & Godoy, (1992) states that if the communities are actively participating they will adopt and maintain healthy behaviour such as early recognition of symptom and signs of malaria, prompt treatment seeking, proper use of ITNs, appropriate use of anti:-malaria drugs and appropriate use of other vector control options. But if community participation is poor, the technical know-how will not reach the grassroot needed by RBM programme thereby frustrating partnership and intersectoral collaboration required by RBM programme (RBM, 2004).
Another key factor that influences RBM is drug resistances. Malaria burden have shown increasing levels of malaria morbidity and mortality due to widespread resistance of malaria parasites to conventional anti-malaria drugs (Sukwe, Kassankogno & Kabore, 2005). Spurious, counterfeit and substandard drugs have contributed to the situation. Consequently, diagnosis and treatment are often inappropriate thereby complicating health care delivery in their direction.
Also, discontinuity of programmes is another factor that influences RBM. A lot of strategies have been tried in attempt to interrupt malaria transmission but sometimes along the implementation, it stops either due to logistic, cost, or political problems. Development of vaccine has been a long-term objective of the research community but progress has been difficult. The above factors may have led to the increased morbidity and mortality due to malaria, despite all effort of RBM. Therefore, it is necessary to evaluate RBM multiple prevention strategy as to pinpoint whether RBM is progressing or not.
Evaluation is a process which attempt to determine systematically and objectively as possible the relevance, effectiveness and impact of activities relative to their objective (Egwu, 1996). To ensure good evaluation of RBM programme, availability, adequacy and extent of utilization of RBM materials should be properly assessed to provide useful feedback to the health care providers and care givers. Availability could be seen as whether something can be assessed or used while adequacy is the state of being sufficient for the purpose concerned. This does not suggest abundance or excellence or even more than what is absolutely necessary. Firefox (2010) defined extent as the point or degree which something extends. The point or degree could be the coverage, range, limit or scope to which something might extend, indicating utilization of RBM programme materials. Tochim (2006) defined evaluation as the systemic acquisition and assessment of information to provide useful feed back about some object.
Habicht, Victoria and Vaughan (1999) defined evaluation as systematic enquiry designed to provide information to decision makers and other parties interested in a particular programme, policy or intervention. Evaluation strengthens or improves the programme by examining the delivery of the programme, the quality of its implementation, the organizational context and personnel procedures and in puts. Evaluation can be seen as impact indicators which allow periodic assessment of the way in which strategies and implemented activities reached the planned objectives. Evaluation in this work is the measuring of outcome and impacts of intervention by the RBM programme. It is needed to document periodically whether defined strategies and implemental activities lead to expected results. Examples of outcomes are treatment seeking, coverage of ITNs while impacts are reduction of morbidity, mortality and economic losses.
Evaluation indicators fall into two groups – outcome based indicators and impact indicators. Outcome indicators are changes observed in coverage, adequacy and quality of interventions, services and practices of something. For example, the number of malaria victims who have been able to access timely treatment, the level of ITNs coverage among a particular target population and by measuring changes in the population knowledge, attitude and practice of the population to malaria. Impact based indicators means changes in health status as consequence of programme activities. For example, the reduction of mortality and morbidity or even the economic loses caused by malaria.
Remme, Binka and Nabarro, (2001) states that five indicators are considered so important by all RBM partners globally. It consists of two impact indicators and three outcome indicators. The two impact indicators are malaria death rate (Probable and confirmed cases) among target groups (under 5 years children and pregnant women) and number of severe and complicated malaria cases (Probable and confirmed) among target groups. For instance, in Nigeria malaria is responsible for the death close to 300,000 children annually as it cause 30 per cent of deaths in under five and 25 per cent of death in infants. Also, malaria is responsible for 11 per cent maternal mortality, at least 50 per cent of the population have one episode of malaria annually and about 60 per cent hospital attendance (FMOH, 2007). The three outcome indicators are – proportion of household having at least one ITNs, percentage of patients with uncomplicated malaria getting correct treatment at health facilities and community level according to the national guideline within 24 hours of onset of symptoms and percentage of health facilities reporting no disruption of stock of anti-malaria drugs as specified in the drug policy for more than one week within the previous three months. For example in the year 2005-2008 about 13.9 million ITNs/LLNs were distributed to various households in Nigeria (WHO/UNICEF, 2005). It shows estimate of national coverage of households with at least one net to be 30-35 per cent (Baker, 2000). This study used both outcome and impact based indicators. It will help both individuals and other Roll Back Malaria programme partners to make positive change in the RBM programme strategies. This positive change in the RBM programme may be influenced by some socio-demographic factors.
There are many socio-demographic factors that are associated with malaria epidemiology. The present study is concerned with the demographic factor of gender, age, and occupation.
Gender has been identified as strong factor that influences malaria epidemiology. Studies have indicated that men are more frequently exposed to the risk of acquiring malaria than female because of out door life they live. Park (2005) confirmed that males were more exposed to the bite of mosquito, especially those who were farmers. Although, females are more likely than males to practice protective health behavior.
Again, age has influence on malaria distribution. Malaria affect all ages but more dangerous on children below 5 years age though newly born infants have considerable resistance to infection with P. falciparum. This has been attributed to high concentration of foetal haemoglobin during the first few month of life.
Occupation exposes someone to malaria attack. Malaria is predominantly a rural disease and is closely related to agricultural practices. Igbo-Eze south is predominantly rural area who depends on farming to make their life needs. In farms, water holding weeds, shrubs trees and open receptacles provide ideal resting and breeding places for mosquitoes. Malaria are acquired in most instances by mosquitoes bites within the occupation environment (WHO, 2009).
