Joshua D. Adeniyi

Factors associated with coverage in community‐directed treatment with ivermectin for onchocerciasis control in Oyo State, Nigeria

Community‐directed distribution with ivermectin (CDTI) has been adopted by the African Programme for Onchocerciasis Control (APOC) as its main strategy for achieving sustained high coverage in endemic communities. This article describes the coverage results achieved when CDTI was introduced in four local government areas of Oyo State, Nigeria. Using a household survey after the second distribution, researchers documented that 68.6% of the community overall received the drug, and as did 85.0% of those who were eligible (not pregnant, not sick and at least 5 years of age). Six factors were associated with having received ivermectin. Four were personal characteristics: being male, being at least 35 years of age, belonging to the Fulani ethnic minority, having taken the drug at a previous distribution. Two village characteristics were smaller size, as measured by number of houses, and use of the central place mode of distribution as opposed to house‐to‐house. In‐depth interviews with village leaders and volunteer community‐directed distributors (CDDs) and focus group discussions among villagers provided qualitative data to help interpret the findings. Women in many villages felt excluded from decision making. The concerns of migrant farm workers living in Yoruba farm settlements were not well understood by health staff or the majority population. The main factor associated with receiving the ivermectin was having received it before, and qualitative comments about side‐effects and beliefs about orthodox drugs indicated that issues of personal preferences, not addressed in a household coverage survey, need to be explored further. The findings can provide guidance in re‐orienting health workers to the importance of fostering participation and cohesion among all segments of the community, especially the inclusion of women and minority groups.

The Influence of Cultural Perception of Causation, Complications, and Severity of Childhood Malaria on Determinants of Treatment and Preventive Pathways

A cluster sample of 2,052 mothers and other caregivers of children from southwest Nigeria was studied. Qualitative and quantitative methods of data collection were employed, including semi-structured questionnaires, focus groups, in-depth interviews, and parasitological investigation forms/blood smears. “Too much work” (17.7%) and “too much sun” (12.6%) were the two most-often mentioned causes of malaria. Malaria was not perceived as a serious disease. Convulsions and anemia are not perceived as complications of malaria and are preferentially treated by traditional healers. Fifty-eight and one-half percent of children with malaria were treated at home. Choice of drugs used was based on previous experience and advice from various members of the community. Fathers (53.5%) and mother (32.5%) decided on where ill children received treatment. Mothers (51.5%) paid for the drugs more often than fathers (44.6%). Symptoms described as “iba lasan,” which means “ordinary fever,” conform to the clinical case definition of malaria. Cultural practices that are likely to influence appropriate treatment-seeking include cultural perception of malaria as ordinary fever, wrong perceptions of severe malaria, and fathers role as decision maker.

Community involvement in social marketing: guineaworm control.

Social marketing as a health education strategy has the potential for encouraging the adoption of new health technologies. The focus on the individual, though, holds the risk of victim blaming. This can be overcome if the consumers/community are involved in the four major components of the marketing strategy-product design, price, distribution and promotion. The community of Idere, Nigeria, has recently been involved in marketing a monofilament nylon cloth filter to prevent the water-borne helminthic disease, guineaworm. Local tailors produced the filters. Volunteer primary health workers debated pricing, sold the product and educated each consumer. Coverage in those neighborhoods and farm settlements where primary health workers were resident was nearly double that of other sections showing the value of local action to market health changes.

Illness Behavior in Guineaworm Disease

Guineaworm, a waterborne helminthic disease, affects a large portion of the population in Idere, Nigeria. Although preventive health education interventions are experiencing success, it is slow due to the low economic status of the community. In the meantime people suffer and seek treatment. The decision-making process during illness with guineaworm does not fit neatly into individual psychosocial theoretical models. Concepts of the disease and potential remedies are strongly influenced by the local culture. In the process of studying these cultural influences, suggestions for new models have arisen. These suggest a mediating role for health education between traditional and Western scientific viewpoints in promoting efficacious illness behavior in endemic tropical diseases.

The Role of Patent Medicine Sellers in Home Management of Childhood Malaria: A Situational Analysis of Experience in Rural Nigeria

Patent medicine sellers (PMS) play an important role in supplying the medication needs of the community particularly antimalaria. A situational analysis of the role of PMS in home management of malaria was carried out in four rural local government areas in Southwestern Nigeria using both cross sectional and observational study methods. The results showed that patent medicine stores constituted 76.2% of the medicine shops in the areas. The PMS provided not only drugs but also consultation services. Malaria constituted the commonest fever for which drugs were purchased. The most commonly mentioned drug best for malaria was the 4 aminoquinolone. Many (55.4%) of the PMS have received some form of training on malaria treatment. However, this was carried out in many instances (41.9%) by the shop owners to the apprentice PMS or shopkeepers. Health personnel were mentioned as trainers by only 27% of the PMS. The use of guidelines provided by PMS was infrequent and only 13.8% could produce the guideline at the time of survey. PMS would like to have more training on causes and recognition of malaria and antimalaria dosages. These topics were least taught. The rural PMS is important to the management of malaria. If quality training and supervision is provided to them, home management of malaria should improve.

Community Response to Social Marketing: Filters for Guineaworm Control

Guineaworm is a tropical helminthic disease which is responsible for much disability in rural areas from African to South Asia. Control interventions focus mainly on improving the quality of water supply at the health promotion level of prevention. This includes such technologies as dug wells, cloth filters, and chemicals added to pond water. Each technology has an appropriate health education strategy to aid in its promotion. The community of Idere in rural Nigeria was chosen to test the social acceptability of a new monofilament nylon cloth water filter. A social marketing strategy was used that built upon an existing primary health care program that utilized volunteer primary health workers (PHWs). The PHWs proved effective in marketing the filters in Idere as one-third of households in monitored areas purchased a filter during the six-month sales period in 1985–86. Those who bought filters were more likely to live in hamlets/family compounds where PHWs resided, belong to a modern religion, and have a preventive orientation toward health. Those who did not buy complained mostly of lack of money, but other overt and inferred reasons included attitudes that filters were inferior to wells, traditional beliefs that guineaworm cannot be prevented and availability of cheaper but ineffective alternatives. Filters were found to be a particularly useful technology in the smaller, isolated farm hamlets surrounding the main town. Recommendations are made to improve the marketing strategy through modifications in filter design, price, distribution, and promotion.

Organizational development as a health education strategy to maintain community involvement in PHC management.

Primary Health Care programs should not stop with the training of PHWs. Not only do these village-based workers need regular supervision; they also need continual access to the resources required for them to carry out their duties. Formal health agencies have had difficulties in meeting these demands for supervision and management on the scale required to bring health to all in even the remotest hamlet. There is consequently a need to look for ways that a community can manage its own PHC program. Efforts to develop a PHW Association in Idere, Nigeria, have shown that self-management is a realistic goal. They have also shown the need for health educators to focus on organizational and leadership development as part of their contribution to primary health care.

MONITORING USE OF MONOFILAMENT NYLON WATER FILTERS FOR GUINEAWORM CONTROL IN A RURAL NIGERIAN COMMUNITY

Guineaworm, a disabling waterborne helminthic disease, has been targeted for eradication from endemic areas of Africa and South Asia. One short-term intervention consists of filtering pond water through a clean cloth. Monofilament nylon cloth has been found to be more effective in straining out the vector-various species of the small crustacean, cyclops—than local cotton cloth, though the former is more expensive. A concern with any new technique is whether the community will accept the idea and subsequently use it properly. Previous reports in this series have documented the process by which the rural community of Idere, Nigeria, through its volunteer primary health workers, was involved in production, distribution, and education concerning filters. One-third of households in monitored sections of the community bought filters, while others thought that filters could not prevent the disease, cost too much, or were inferior to other solutions (e.g., wells). This report looks at filter use and factors associated with use and durability. Monthly monitoring visits by a field assistant served to identify problems and reinforce correct and continued filtration. Mobility of the population between farm and town hampered regular use. Difficulty in understanding the nature of the nearly invisible vectors meant that users did not perceive tiny holes in their filters as dangerous. While filters were ultimately seen as useful in guineaworm eradication efforts, they should not take the place of more long-term community water supply interventions which will have a greater impact on community and womens development.

Improving recognition of onchocerciasis in primary care--1: Nonclassical symptoms.

The symptomatology of onchocerciasis appears to show some variations in different parts of the world, This may be related to race (Guderian et al. 1984; Molea et al. 1984), to the strain of parasite which is associated with the geography and vegetation type forest or savannah (Anderson et al. 1974), and to endemicity (Buck 1974), Despite these local variations, all published descriptions list three cardinal features: nodules, pruritus (with skin signs), and ocular manifestations. That many patients have microfilaria-positive skin snips without nodules, skin or eye changes is also documented (Duke & Anderson 1972), but there is a dearth of studies that look for other premonitory symptoms or signs which might be useful diagnostic indicators in early stages of the disease. This paper focuses on the diagnostic potential of other symptoms, particularly musculo-skeletal pain (MSP).

Improving recognition of onchocerciasis in primary care--2: Learning from a cultural perspective.

INTRODUCTION Control and treatment of endemic diseases are among the eight basic services expected of a community-based primary health care (PHC) programme (WHO/UNICEF 1978). A major consideration is that these services be delivered in a form that is relevant to the culture of the particular community being served. To achieve this end, health workers must have a thorough knowledge of how the local populace perceives and responds to endemic diseases. The way health workers have made use of local perceptions of onchocerciasis manifestations in a rural Nigerian community is the subject discussed here. In order to ensure timely treatment of a disease, it is not just the health worker who must be adept in recognizing signs and symptoms. The potential patient must also perceive that he has a problem. His perception must then lead to appropriate illness behaviour (Kirscht 1974) that is, seeking competent help to confirm the existence and nature of the problem. Patient perceptions and actions are influenced by a number of cultural factors. These include local concepts about what constitutes disease (Frake 1961) and what are the appropriate sources of diagnosis and care for a particular condition (Gould 1965, Press 1969). The time lapse between recognition and action also has cultural variations due to local ideas about seriousness (Rosenstock 1974) and self-image (King 1973).