WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE
ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA PROGRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFzuQUE DE L'OUEST
EXPERT ADVISORY COMMITTEE Ad hoc Session Ouasadousou 1l - 15 March 2002
EAC.AD.7 Original: English December 2001
SOCIO-DEMOGRAPHIC STUDY IN THE PRU BASIN 1
TABLE OF CONTENTS
LIST OF TABLES J
LIST OF FIGURES J
ACKNOWLEDGEMENTS 4
ACRONYMS 5
EXECUTIVE SUMMARY 6
CHAPTER ONE: INTRODUCTION 9
1.0 The Study Background 9
1.1 Programme Achievements 9
1,.2 The Problem Statement 10
1.3 Objectives of the Study 10
. Major Objective 10
. Specific Objectives 10
1.4 Method of Data Collection l0
1.5 Field Problems 11
CHAPTER TWO: SOCIAL STRUCTURE OF THE COMMUNITIES t2
2.0 Introduction t2 2.1 Location t2 2.2' Geographical Features t2 2.3 The Population t2 2.4 Economic Activities 13 2.5 Social Infrastructure 13 2.6 Conclusion t4 2
CHAPTER THREE: FINDINGS 15
3.0 Introduction l5
3.1 Socio-demographic Characteristics of Respondents l5 3.1.0 Sex t5 3.1.1 Age 15 3.t.2 Educational Background l6 3. 1.3 Economic Activities l7 3.t.4 Religion 17 3.1.5 Duration of Residence t7
3.2 SettlementPatterns 17
3.3 Patterns of Population Movement 18
3.4 Organization of Treatment 19 3.4.0 Coverage 2t 3.4.1 The Community Distributors 27
3.5 Other Issues 27 3.5.0 Causes and Treatment of Oncho 28 3.5.1 Ivemectine 29 3.5.2 General Concerns 29
CHAPTER FOUR: CONCLUSION AND RECOMMENDATION 30
4.0 Findings 30 4.1 Recommendations 3l J
LIST OF TABLES
Table I Data Collection Techniques and Respective Respondents 11
Table 2 Age Distribution of Respondents t6 Table 3 Educational Background of Respondents r6
Table 4 Distribution of Ivermectine in Pru Basin (2000) 22
Table 5 Distribution of Ivermectine in Pru Basin (2001) 23 Table 6 Distribution of Ivermectine in Pru Basin (2000 - 2001) 24 Table 7 Perceived Health Problems of the Communities 28
LIST OF FIGURES
Figure I The Distribution Process 20
Figure 2 Treatment Rates for 2000 & 200L 25
Figure 3 Treatment Rates for 2000 & 2001 26 4
ACKNOWLEDGEMENTS
The production of this report would not have been possible without the support of many people and organisations. lt is in this regard that I want to cxpress my hr:art-fclt thanks to all who have assistcd in this task.
My thanks go to Dr. Boakye A. Boatin, the Director of OCP and to Dr. K. Siamevi of OCP Responsible Technical Officer, for their patience and for the confidence reposed in me. If it has taken too long to flrnally seal the deal, this was mainly due to my desire to produce a good report. I also wish to thank Dr. Kofi Ahmed, the Director of the National Ochocerciasis Secretariat for not only showing me the study site but also for providing me with useful background information. Within the Secretariat, I wish to thank Mr. Richard Odoi for transmitting my many messages to Ouagodougou and personally bringing to me their responses.
I wish to thank my 'foot soldiers' Ms. Harriet Takyi and Mr. Kodjovi Akpabli-Honu (both of the Department of Sociology, University of Ghana) for their readiness to forgo their other equally important commitments in order to be part of this study. Their sense of commitment shown from the beginning to the end of this study is highly remarkable. Without his sense of humour and punctuality and his good knowledge of the study site work would have been very difficult. This is why my team express its gratitude to Mr. Abudulai Adam Mogli, our pilot.
Finally, my thanks go to Dr. Asemanyi Mensah (District Director of Health Services, Atebubu), Mr. Zakaryya Abubakar and Mr. Gabriel Addah both Senior Technical Officers of MOH, Atebubu, and to all the community distributors and inhabitants of the Pru Basin who accorded us so much hospitality and to Ms. Ophelia Abedi who provided the needed secretarial support.
K.A.S 5
ACRONYMS
CD Community Distributors ( of ivernectine)
DDHS. District Director of Health Services
DHMT- District Health Management Team
DOC District Oncho Coordinator
FAO Food and Agriculture Organization
FGD Focus Group Discussion
GWEP- Guinea Worm Eradication Programme
MOH Ministry of Health
NOS National Onchocerciasis Secretariat
OCP Onchocerciasis Control Programme
RDHS- Regional Director of Health Services
RMS Regional Medical Stores
UNDP - United Nations Development Programme
VRA Volta River Authority wHo - World Health Organisation 6
EXEC UTIVE SUM RY
After several years combined of vector control and ivermectin treatment of the populations in the pru Basin against onchocerciasis, the Onchocerciasis Control Programme has recorded unsatisfactory entomo-epidemiological lObf; profile of the disease, especially in the Subene area. As part of the measures to enhance its understanding of the current state of affairs and to institute appropriate intervention measures before the end of the Programme, OCP commissioned this study.
In more specific terms, the study sought to do the following:
o Investigate the spatial distribution of and accessibility to the villages and hamlets in the pru Basin;
Study th^e^ movement ' (migratory) patterns of the people and the impact of such movements on the effectiveness of oncho control activities; o Examine the mode of organisation of community directed treatment with ivermectine; and o Investigate the knowledge, attitudes, beliefs and practices of health workers and members of the community with respect to oncho control activities.
and qualitative Quantitative data were collected from Ministry of Health,s programme officers, inhabitants and opinion leaders of the various communities in the basin, and some community distributors of ivermectin. The entire study was carried out in 24 days fr;; 1^tt 1ri;;.;;;;; 5/, December 2001. -
Main Findings.
o It has been found that villages along the banks of the river are essentially settler communities inhabited by various ethnic groups. These are close to each other but vary in terms of distance from the river' Subene is the closest to the river. These villages are surrounded by an unknown number of hamlets which are not easily accessible.
The villagers o do not migrate but movement is fairly rapid especially during the off-farming season' Visits are made to home villages while others engage in commercial activities. On the other hand, during the farming season there is an inflow of riigrant labourers o It has been found that such movements cause absenteeism and high default rate while the inclusion of migrant labourers often cause shortages of ivermectine driring distribution. r The mode of procurement and distribution of the drug is quite cumbersome and involve long bureacratic procedures' Thus, in times of shortage, immediaie re-stocking is almost impossible. o In the communities, ivermectine is distributed at central locations often for about a week. Thereafter people collect their medicines in the homes of CDs or the latter follow them to their homes. Some medicines are reserved for absentees and the very sick. Distribution period is often between August and November. o There were instances when non-eligibles were treated with the drug. o The communities are very satisfied with these arrangements. 1 t The CDs do others things apart from oncho activities. However, they are constrained by lack of means of transportation. i Ivermectine is loved by the people but there are a few misconceptions about it: people are not clear about how many times in a year the drug must be taken and how the drug works. t There are a number of health concerns in the village which need urgent attention. Perhaps the most urgent ones are the opthalmic problems and frequent epileptic seizures.
Recommendations
Against the background of these findings the following recorrunendations are made
0 There is the need for the DHMT rvith assistance from the district assembly, local leaders and members of the community to undertake a reliable mapping of all villages and hamlets in the basin. This rvill provide a reliable census figure rvith rvhich to plan future ivermectine distribution in the basin. i Because population movement is heavy during the off-farming season, the distribution of ivermectine must be done before this period to ensure higher coverage of the population.
The DHMT and the Regional Health Directorate must work out a plan to reduce the long process involved in the procurement of the drug. For instance, the medicine can be kept at the district medical store to enable a quicker access to it in case shortages occur during distribution.
Given the low educational background of CDs, it is necessary to organise refresher courses for them periodically. Subjects to be treated must include good record-keeping, treatment procures and community education.
0 The mode of delivery of ivermectine to the communities must be reviewed. In this regard it is suggested that the communities be put under two zones - Abease and Prang health centres. Communities near to these health centres will be made to collect their portion of ivermectine from here. a The DHMT must use the World Day Against Blindness to conscientize inhabitants of the basin on onchocerciasis and eye care. This should be in addition to frequent community education which must be carried on. i Given the large number of opthtalmic cases in the basin, there is the need for the DHMT to run eye clinic in Prang and Abease health centres on monthly basis. This will relieve people of the trouble in travelling to Atebubu or Agogo Hospital for eye care. a Although CDs are community volunteers, and indeed love their job, it is nonetheless suggested that their job be made lighter through motivating them rvith gifts such as T- shirts, bicycles and free health care. 8
The record books require additional information to enhance their usefulness (eg. number dead, absent, refuse, eligible etc. Also the names must be recorded according to households to enable ease ofreference and addition.
Thc DOC nrust usc tltc rccord books not ouly to conrpilc statistics on covcragc ratcs but also as a basis for interacting with CDs to learn of their dilliculties and how to overcome these. 9
CHAPTER ONE
INTRODUCTION
1.0 The Study Background
Onchocerciasis or river blindness is a parasitic disease of the tropics and it particularly affects much of the West African region. It has been known in this country long before the institution of colonial rule. In endemic areas of the country, it is known either by the blackfly (simulium damnosum) or its dermatological effects. Thus, in the Akan - speaking areas, it is referred to as nkontia yare- (the blackfly sickness). However, in the Pru Basin it is known as manpele (rough skin). In several areas there arejocular references to onchocerciasis also.
Although onchocerciasis constituted a public health problem, the Ministry of Health had no specific programme targeted at its control or elimination. However, there was passive treatment of individuals at various health centres in the country. In Ghana, perhaps, the first body to have started oncho control activities - albeit on a smaller scale- wai the Volta River Authority (VRA). Following the construction of the Akosombo and the Kpong hydroelectric dams in the late 1960s, VRA undertook larviciding with chemicals in the Akosombo area and in the waters downstream to the dam.
However, following the manifest consequences of oncho in the West African sub-region, in 1974, wHO together with UNDP, FAO and the World Bank launched the Onchocerciasis Control Programme (OCP) in Accra, Ghana. OCP then started the control of the disease in Ghana and in six other West African countries name, Burkina Faso, Togo, Niger, Benin, La C6te d'Ivoire and Mali In Ghana, the oncho control activities led to the establishment of the National Onchocerciasis Secretariat as a division within the Ministry of Finance. Its main task was to coordinate oncho control activities in the country. Since 1996, however, this division has been relocated as a directorate with the Ministry of Health (MoH)
In Ghana the control programme was limited to the northern areas of the country _ the Northern, Upper East and Upper West regions and some parts of the Brong Ahafo if.gion. Through epidemiological studies, OCP was able to map out ihe areas most af6cted in the river basins in the savannah areas of the country. These areas were the basins of the Black Volta, White Volta, Red Volta and their major tributaries. Consequently, the Black Volta, Mole, Kulpawn, Sissili, White Volta, Daka, Pru, Mo and Dayi basins became the areas of operation. In the earlier control activities, the main strategy for eliminating the blackly was the application of bio-degradable larvicides to breeding sites in rivers using helicopters and fixed- wing aircrafts. l.l ProgrammeAchievements
In the past, oncho devastated communities close to waterways where blackflies bred. Thus unable to tolerate the nuisance of the bite of the flies and its ophthalmic and dermatological consequences, many villagers fled from arable lands to eke out a living in less fertile but oncho-free areas- Thus abandoned communities gradually lost their vitalitt and fell into ruins. Today OCP's constant monitoring shows that the disease transmission irus been effectively l0
interrupted with negligible impact on aquatic environment .Abandoned areas such as Fumbisi Valley in Ghana are being repopulated.
Re-invasion of the oncho- freed areas by infective blackflies from the forest areas south of the OCP operational areas necessitatcd extending thc programme arca in 1986 to thc north and south east with to include Guinea, Guinea-Bissau, Senegal and Sierra Leone. Resistance to larvicides was also successfully ovcrcomc as ncw products because available and by the rotational use of existing compounds.
Since 1987, a new drug, a potent onchocercal microfilaricide known as mectizan (ivermectine) has been introduced into the programme. This drug has minimal side effects and is given once or twice a year. Currently, its distribution in the communities is directed by communities themselves.
1.2 The Problem Statement
Although the oncho control activities have achieved a lot through the joint effort of OCP and NOS, some outstanding problems remain. In some areas, the blackfly has returned following the cessation of the spraying and larviciding activities. Although these flies are generally non- infective, their very painful bites remain a nuisance to members of the community. There are also a number of 'black spots' where despite several years of regular larviciding, there still are the presence of infective blackflies which are transmitting the disease in the communities. Also in areas where ivermectine is distributed, all manner of problems have constrained a wide coverage of the population. Therefore, according to OCP, the ontomo-epidemiological profile of the disease especially, in the Subene area, is not satisfactory. Hence this study.
1.3 Objectives of the Study
. Major Objectives
The major objective of this study in to enhance OCP's understanding of the reasons for the relatively poor ontomo-epidemiological profile of the endemic communities in the Pru Basin. a Specific Objectives
In pursuance of the major objective of this study, the following issues were investigated
The spatial distribution of and accessibility to the villages and hamlets in the Pru Basin The movement (migratory) patterns of the people and the impact of such movement on the effectiveness of oncho control activities. The mode of organisation of community directed treatment with ivermectine The knowledge, attitudes, beliefs and practices of health workers and members of the community with respect to oncho control activities.
1.4 Method of Data Collection
The objectives of the study required the collection of both qualitative and quantitative data. They also required that each village must be visited given the fact that to a large extent each ll
village was different from the others, at least culturally. Consequently, in order to gain on time, focus group discussion were organised for men and women separately in relatively small and homogenous communities while in large communities, survey (using questionnaire) was conducted. Questionnaires were administered to community distributors also. However for heads of communities and other opinion leaders in-depth interviews were held. The table below shows the types of data collected, the various techniques employed and the number of people involved.
Table 1. Data Collection Techniques and Respective Respondents
TYPE OF DATA TOOL APPLIED POPULATION TOTAL NO Quantitative Questionnaire a Men lll Women 75 a CDs l0 Qualitative FGD o Men 20 . Women 25 In-depth Interview o Heads 5 . Opinion Leaders l0
1.5 Field Problems
Given the short duration earmarked for the entire study (24 days) time management became a big problem because so much was required in so short a time. The problem was compounded by the fact that almost each day coincided with the market day of a village and therefore there was heavy human and vehicular traffic. In order to meet the villagers in their homes, therefore, fieldwork often began as early as six o'clock in the morning.
Another difficulty related to female respondents. Often these were reluctant to be interviewed on one- on-one basis; however, they were more open during FGDs. This attitude was shown even to my female assistant. Also during the market days, many females were not at home. The end result is that for the survey there were more males than females, a situation which did not represent the true demographic structure of the communities, more so since we were dealing with one of their greatest concerns - onchocerciasis. t2
CHAPTER TWO
SOCIAL STRUCTURE OF PRU BASIN COMMUNITIES
2.0 Introduction
In this chaptcr we describc the social structure of the communities in the Pru Basin as a necessary background to the appreciation of the world-view of the people therein. It is a sociological/anthropological truism that only when a people's life -situation is understood can we make sense of why they do things or perceive situation in a particular way. In this chapter, therefore, we provide a brief description of the geographical features of the basin, the people and aspects of their social life and the social infrastructural facilities available to them.
2.1 Location
The Pru Basin is located to the north of the Atebubu District in the Brong-Ahafo Region of Ghana. Atebubu is the district capital for all the communities in the district. It is about 35 km from the first community in the Pru Basin. The entire district is described as 'deprived' because of the poor provisioning of infrastructural facilities. In the words of one district health official, "It is one district where all diseases - ordinary and strange - can be found."
The Pru Basin, the study area, consist of eleven (11) villages stretching over 24 kilometres along the Prang - Kintampo laterite road. The villages are: Adjaraja, Beposo, Subene, Senyase, Baya, Mantaukwa, Fawoman, Ohiampe, Daman Nkwanta, Buipe and Abease. These villages are located along the banks of the Pru Rivcr. The nearcst to the bank is Subene while the fartherest from the bank (6km) is Abease.
2.2. GeographicalFeatures
The geo-physical features of the basin are characteristic of the northern parts of Brong Ahafo which may be described ecologically as a transitional zone characterised by wide expanse of flat and of semi-deciduous forest, savannah shrubs and tall grases. However, it shares much of the relief of southern Ghana: the rainy season begins in April /May and ends in September to be followed by a spell of dry season which ends in April the following year. The Pru River provides the main drainage for smaller water bodies all of which ultimately drain into the River Volta.
2.3 The Population
According to official records, the I I villages have a total population of 12, 467. As to be expected, the villages vary in size and ethnic composition. The village with the largest population is Abease (2,981 people) and that with the least is Mantukwa (135 people). It is suspected that the small sizes of the villages have been fostered by the high incidence of onchocerciasis at least in the past. As characteristic of rural communities, the population structure of the basin is made up predominantly of children, women and the aged. There appears to be heavy out - migration of young adult males. l3
Historical accounts of the origins of the villages show that with the exception of the autochthonous Bono most of the villages were originally founded by people of northern Ghana origin who came to look for fertile land or to escape from the 1996 ethnic conflict in the north. There were other migrants from Tongu area in the Volta Region who came to fish in the pru River. The basin may therefore be described as culturally heterogeneous and linguistically polyglotic. Thus, there are the Gonja, the Dagarti, the Wala, the Chokosi, the Gruma, thl Konkomba, the Bono and the Ewe. Characteristically, each village is made up either of one ethnic group or pockets of two or three minor ethnic groups. For instance Subenl is made up of Gonja and Dagarti- speaking people and Mantukwa has Ewe, Wala and Konkomba - rp.uking people. Each village is under a village head who in turn is answerable to a higher .tii.f, tn. landlord.
2.4 Economic Activities
As characteristic of rural people, the major economic activities here are farming and fishing which are undertaken at the subsistence level. With regard to farming, mixed-cropping is the norrn. The major produce are yam, paddy rice, maizq millet, beans and groundnuts. Other economic activities include pito and akpeteshie brewing and charcoal production. Keeping livestock such as cows, goats, sheep, pigs and fowls is an economic activity to some extent. This is because cows are generally not sold; they are social wealth. On the other hand goats, sheep, pigs and fowls are sold or consumed. Women, especially, engage in long-diJance trading activities. They transport yams and cereals for sale in Kumasi, e.i.u and other urban centres in southern Ghana.
2.5 Social Infrastructure
As observed earlier, in terms of Social infrastructure, the settlements are very deprived. Except for Abease, none of the villages has electricity supply. Thus in most areas-peopte depend on the wireless set and in a few instances, television sets for news. Such tilevision iets are operated with a l2-volt car battery. Also only a few villages have bore-holes or hand-dug wells. Consequently, many of the villages depend on the Pru River for their source of water supply. The health implications of drinking polluted water manifest in high incidence of guinea worrn and other water-related parasitic diseases.
To serve the health needs of the people there are two health centres separated by 24 kilometres of laterite road. One of the centres is at Prang and the other is at Abease. These are sub-district health centres which provide primary and maternal / child care.
Given the distance between these centres, drugs vendors fulfil some of the needs of the villagers. These vendors retail both over-the-counter (Class C drugs) and ethical drugs (Class B). These include anti-malarial, cough mixtures, analgesics and capsules. As one of the district health officials explained, although the activities of the vendors violate the law, they nonetheless perform life-saving functions in the villages. Indeed, it is said that in the absencl of these vendors, the two health centres would be unable to cope to the volume of work.
The only motorable road linking the villages is a third class road. In the rainy season, this road is impassable as it is bifurcated by poodles and running waters. In the dry ieason, the road is not only bumpy but also dusty. It takes about 2l12 hoirs to do the 24 kmstretch by car. Thus, 14
for the villagers, bicycles and motorcycles are the quickest means of transport. Besides this road, all other routes to the hamlets, especially, are foot paths which cannot be used during the wet season.
Most of the villages have no decent school building. In many places, the school buildings have fallen into a state of disrepair. In other places such as Adjaraja, classes for pupils are organized within the villages woodlot. There were two pupil-tcachers handling four classes. In some areas such as Beposo, three teachers were found handling six classes. In Subene, we were informed that the school was temporarily closed down at the peak of the oncho infection. However, even long after the oncho control activities have considerably reduced the rate of infection, the school has been unable to regain its original vitality. Indeed, the schools in the basin are not only heavily understaffed but also heavily underenroled. During Prang market days, schools close earlier to enable both teachers and pupils patronize the market. During market days also, pupils are seen transporting on their Ui.y.t.s, large tubers of yam to thi markets for sale.
2.6 Conclusion
The Pru Basin is certainly a deprived area by any stretch of the imagination. Its inhabitants are clustered in eleven villages along the bank of the Pru River, exposing them to onchocerciasis. Many of the settlers are either indigenes of the area or are economic migrants or refugees from the northem ethnic conflict. In response to the harsh life in the basin, the people have developed various mechanisms which enable them to survive on daily basis. l5
CHAPTER THREE
FINDINGS
3.0 Introduction
In this chapter we present and discuss the findings which emerge from both the qualitative and quantitative data obtained from the field. The findings are presented in a way to address the concerns of the specific objectives in the manner they appear in chapter one. In other words, this chapter addresses the following issues:
. The pattern of settlement in the basin . The pattern of movement of the people. . The organisation of ivemectin distribution and . Other related matters relevant to the oncho control activities.
However, before the analysis begins, it is important to present the socio-demographic characteristics of the respondents for the survey.
3.1 Socio-demographicCharacteristicsofRespondents
An insight into the social background of respondents is crucial not only to foster an appreciation of the world-view of the people in the basin but also and perhaps more importantly to enable health policy makers to tailor-design policies and programmes which harmonize with the peoples' background.
In this regard, the focus of analysis are respondents' sex, age, educational background, economic activities, religion, and duration of residence in the communities.
3.1.0 Sex
Of the 186 respondents, the majority (59.7%) were males and the rest(40.3o/o) were females. However this gender representation does not appear to correspond with reality. Indeed, in all the 11 villages visited, there were more females than males, due perhaps, to the out-migration of young adults. Another explanation as stated earlier, is because many women shied away from the one-on-one interview while they were willing to participate in the FGDs. Perhaps, another important reason for the skweness in the gender representation is the fact that the fieldwork concided with many market days in the basin and women were often more involved in market activities than the men.
3.1.1 Age
The minimum age for respondents was pegged at 15 years in order to enable a fair representation of a cross-section of the people. As the data show the age distribution of respondents and therefore, of the population in the basin, reflects that of a young population. From the data analysis, the cohorts between ages 15 and 39 years constitute over 69 percent of the population. The table below shows the details. r6
Table 2. Age Distribution of Respondents
AGE NO PERCENTAGE 15 l9 27 t4.5 20-24 24 12.9 25 29 36 19.9 30 -34 6 3.2 35- 39 30 16. I 40- 44 30 16.1 45+ JJ 17.8 TOTAL 186 100.0
3.1.2 Educational Background
One's educational background is critical for the way one's world-view is shaped. Generally, the higher one's educational background, the higher one's level of consciousness. Thus, with regard to oncho, the expectation is that one's level of education must influence how one experiences and therefore relates to the disease. This is why the study sought for the educational background of respondents.
As the data show, as many as 53 percent of the respondents have had no formal education while only 16 percent have had primary school education only. This means that in fact, about 69 percent of the population is start illiterate. The significant proportion of respondents (24.2%) who have been to school completed the middle or the Junior secondary school only. The table below shows the details of the educational background of respondents.
Table 3. Educational Background of Respondents
Educational No. Percentage Level Nil 99 s3.3 Primary 30 16.1 Middle/JSS 45 24.2 SSS/SEC/VOC/TTC t8 4.8 Tertiary (University etc.) a Non -Formal J 0.6 TOTAL 186 100.0
Clearly, the basin's population is largely illiterate. And as described earlier, it does not look like the situatibn will improve in the future given the fact that the schools in the area are not only structurally deficient but also are understaffed and under-enrolled. t7
3.1.3 EconomicActivities
From the data the majority of the respondents(73%) were engaged in farming and or fishing activities. This is clearly in harmony with the existence of abundant land and water bodies in the area. A fairly significant proportion of respondents (l I .3Yo) are engaged in'business' such charcoal buming, production of alcoholic beverages and minor skilled labour such as sewing and operating lotto kiosks. There were a few students and unemployed (9.6%)
3.1.4 Religion
Although the basin has a high concentration of settlers from northern Ghana, the population is predominantly Christian (71%) and not Muslims. This is because the Konkomba who are generally Christians are in the majority in the settler communities. However, even though the majority claimed to be Christians, many said they were not church-goers. This is because there are very few churches in the area.
3.1.5 Duration of Residence
The length of respondent's residence in the communities was ascertained in order to determine the extent to which they had knowledge on oncho control activities. From the data many respondents (37.1%) claimed to have been born in the communities. Also a good proportion of them (35.5%) claimed to have lived in the communities for about 11 years while 17.7 percent of them claimed to have lived in their villages for periods ranging between one and five years. Against this background, it may be said that respondents are generally knowledgeable on oncho control activities perhaps not only on their respective communities but also in the entire basin.
At this juncture we now focus on the concerns of the study
3.2 SettlementPatterns
As indicated earlier, the Pru Basin has eleven communities along the bank of the River Pru. This villages are located along the 24 kilometre stretch of laterite road from Prang to Abease. On the average, the villages are not more than two kilometres apart from each other. And as indicated earlier each villages is inhabited mainly by one ethnic group. The linguistic and cultural differences appear to create a situation where villages minimally interact among themselves. Generally the interaction appears to be more intense between villages of similar linguistic and cultural background.
Structurally, the villages look alike - virtually all of them are built of mud and thatched with dry grass. Those roofed with atuminum sheets are few. The size of each village is determined principally by the size of its population. Clearly, then the bigger the population, the larger the village. Thus Subene, for instance, which has a population of not more than 150 people has only 19 physical dwellings. Several abandoned dwellings attest to the fact that the village used to be larger than it is now.
Although all the villages are located along the bank of the river, they differ in their propinquity or nearness to the river. Perhaps, the nearest to the river is Subene while the l8
fartherest from it is Abease (approximately 6 km). Given this situation, it is to be expected that although all the villages are within the flighrrange of the simulium damnosum, their infection rates will vary according to their distance from the river. Consequently Subene appears to have suffered most from onchocerciases. Indeed in this village, we counted no less than l2 totally blind persons. There were several others with ophthalmic problems and or with visible nodules and leopard skins (depigmentation).
The main settlements along the road are surrounded by an unknown number of smaller settlements orhamlets. Indeed, as the DistrictDirectorof Health Services remarked, " We keep discovering new settlements every now and then".
The difficulty in locating these settlements /hamlets lies in the fact that they are highly inaccessible - they.can be reached only by foot paths.
To the extent that some of these settlements are not covered by oncho control activities, they are possible sources of re-infection of other villages.It is therefore suggested that the District Health Management Team (DHMT) in cooperation rvith local leaders undertake a thorough mapping of all settlements/hamlets in the basin as a first crucial step toward sustained oncho control activities.
3.3 Patterns of population movement
The Pru Basin may be described as settlers' abode. As described earlier, in most cases, the settlements were founded by people who were hungry for farming and fishing opportunities which are abundant in the basin. Others also came to settle here in order to escape from the northern ethnic conflict which occurred in the mid-1990s. Thus, over time the original settlers were joined by a number of relatives to establish the village communities. Many people were also born here, creating a situation where relatives of different generations live together.
In an attempt to find out where people in the basin came from, a number of people including some who were born in the basin mentioned a number of places across Ghana. Places mentioned included Walensi, Saboba, Salaga and Tatale, all in the Northern Region; Kpandai, Kojokrom-Krachi and Battor in the Volta Region; Wa and Tumu in the Upper West Region; and a few other places in the Ashanti and Brong Ahafo regions. Interestingly also some people claimed to have migrated from villages within the basin, notably, Subene. Such local migrations appear to have been induced either by the oncho menace or by conflicts.
To the extent that most inhabitants of these communities see themselves as settlers, the tendency to return home some day is ever present. Consequently, to keep such hopes alive, frequent home visitation becomes the norm. During the fieldwork, it was realized that although people moved about a great deal, they do not migrate in the sense of changing residence or abode for relatively long periods.
In several FGDs, many people said: "As for us we travel to our homes all the time". Thus, during the survey when the question was asked: "Have you ever left this village for some time?" 66 percent of the respondents answered in the affirmative and 21 percent in the negative. In the case of the former, the majority of them (73o/o) went to their hometowns or villages. The rest went elsewhere to trade, seek medical assistance or look for a job. The l9
duration of such out-trips may range between one week and five months. When respondents were asked when in the year do such trips take place 51 percent mentioned the dry or lean season while to 29 percent of the respondents, there is no such fixed time. However, the evidence suggests that the off-farming season (November to March) which coincides with the dry season and the Christmas festivities (at least for the Christian Konkomba) are the periods such movements are likely to occur. Many community distributors complained about absenteeism during ivemectine distribution.
Another aspect of the population movement has to do with migrant labourers. Survey respondents, opinion leaders, community distributors and FGD discussants have all noted that during the farming season (April to October) as a result of labour-deficit through migration of young male adults, migrants labourers from the northern regions, especially, flock to the basin to look for paid farm work.
This pattern of migration has serious implications for oncho control activities. Essentially, some village residents who are not available during the distribution of ivemectine often miss their chances. Some CDs claim to reserve some tablets for such people. However, this appears possible when there are surplus tablets. However, in cases of shortages - which often occur - absentees are glossed over. Another difficulty is that since migrant labourers often partake of the drugs even when not catered for, this causes shortage most often.
Against this background, it is suggested that distribution of ivemectine must be done during the farming season when the resident population is fairly stable. This will, however, mean adding migrant workers to the villages' population. However, on balance, this is acceptable because it involves no extra cost to anybody. Indeed, it is better that such migrant workers are also taken care of more so when they live in the communities for a long time and thereby expose themselves to the blackflies. Since their numbers per farming season cannot be pre-determined, CDs must make allowance for extra number of tablets for which they must account at the end a distribution period. Also as far as practicable some tablets must be reserved for absentees who will return later.
3.4 Organisation of Treatment
In order to gain insight into the mode of treatment, we examined the processes of procurement of ivemectine, of delivery and of distribution in the various communities. To procure the medicine, the District Oncho Coordinator (DOC) first collects the returns (record books) from the various CDs in order to reconcile the figures on drugs supplied on drugs dispensed. He then arrives at a rough figure for each village. His requisition is often based on these figures.
The DOC's requisitions to his Regional Director of Health Services (RDHS) must first be endorsed by the District Director of Health Services (DDHS). The RDHS then sends the requisition to the Regional Medical stores (RMS) in Kintampo. The head of the RMS then advises the DOC when the tablets are ready for collection.
When the DOC finally collects the tablets, he deposits them at Abease Health Centre to be distributed by the Sub-district Oncho Coordinator (Sub-DOC) to the various CDs. We were informed however that this year, the Sub-DOC took it upon himself to distribute the tablets to the CDs. 20
When the CDs have received the tablets, they announce to their constituents when and where the distribution would take place. From the community survey, and from responses from the CDs, it came to light that the most common mode for distributing the tablets is the central location approach. Each person is expected to come to this location with a cup of water to take the medicine on the spot. This system continues for about a week after which late comers may go to the CDs house for the drug or the CD would follow the absentees to their homes or keep the medicines for them. The CDs and members of the communities find this arrangement very convenient. In order to simplify the web of the distribution process, rve present its diagramatic representation below.
FIG. I THE DISTRIBUTION PROCESS
DOC DDHS RDHS
SUB-DOC RMS
CD CD CD
THE PEOPLE
DOC: District Oncho Coordinator (Atebubu)
DDHS: District Director of Health Services (Atebubu)
RDHS:Regional Director of Health Services (Sunyani)
RMS: Regional Medical Stores (Kintampo)
SUB-DOC: Sub-district Oncho Coordinator (Abease)
CDs: Community Distributors. 2l
The procurement and distribution arrangement as shown in Fig. I might have worked well. However, it is deficient in two ways: first, it cannot easily respond to emergency situation such as when there is a shortage in the course of distribution. Secondly, the practice whereby the entire basin's supply is deposited with the Sub-DOC at Abease, for onward distribution to the various CDs is not satisfactory. This is because for a number of CDs who do not own their means of transport, (this applies to almost all of them) Abease is almost inaccessible.
In order to ease the burden of CDs the following are suggested
(i) There is the need to decentralize the storage of the drug so that the district directorate may be responsible for its storage and distribution. This may cut down on the long bureaucratic procedures in order to make system responsive to any emergency.
(ii) The basin communities should be put under two zones for the purposes of distributing the drugs. The trvo zones will operate around Abease and Prang health centres. The proximity of villages to these centres should be the guiding principles for putting them under the zones. This arrangement will considerably ease the burden of most CDs.
3.4.0 Coverage
During the study, records relating to treatment in the last two years (2000-2001) were obtained. According the figures, coverage rates for 2000 and 2001 were 76.1 percent and 64 percent respectively. This year's coverage was, l2 percent less than the previous years inspite of the fact that this years population to be covered was l l percent higher than the previous years. The CDs and DOC attributed this situation to shortage of ivemectine at the points of distribution. At this juncture it appears that the population sizes for the respective communities are not being calculated properly. Indeed, while one should not expect 100 percent coverage because of ineligibles it is still legitimate to expect higher coverage rates if the drugs had been available in the desired quantities.
Another point of interest here is the rise or fall in the population of the village over the two yearperiod. In some cases the magnitude of the increase or decrease is too big to ascribe it to the natural phenomena of birth or death. Perhaps, they may be due to migration or the discovery of 'new' settlements. See tables 5,6 and 7 for the details.
The difficulty with the statistics calls for a more efficient way of compiling the figures. For efficient register, it is important to include information such as the number of ineligibles, the number dead and the number absent per distribution period. Another way to compile the register is to arrange the names according to households. Thus, names can be added or deleted as the case may be. 22 z#F .-. 2*E< oo n c1 9 n q r- ,r) rr) q I + $ ca ca @ .f, A ce \o tg"- @ \o tr- @ \o oo @ tr) \o F- tr- EU a lrF^ @ rr) @ O rr) \o \f, oo \o tr) $ N (\ o\ (\ o\ o\ $ tr- l/-) $ v F-- o\ o\ c.n ca ca N N $ ol z F<'-
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H B F o) D rI] E] FA a o a ca ca z EA o trr B GI Fr 25 ooOr OO NN DW S v)-\)t $.o+t ,9 N\"s\ o$' N \Y -st rvs\\ o N .o$t od --* o ,;4, xh o N t fo*.dno o -\,\' TL N\s$ U) U' tlj IIJ o F zE d ..e" l F 9v Ah = z iF- o= I,IJ o N\-^, =F \$' €d ult rh F oh' ol U -o tr slu k 2-"""" o o o o o o o o o o O) @ N tr) s (f) c{ tx o t tu ()o s 26 Or oo NN it ++ll t I ,o, oo, t"% L-nL, vb^ 'Qp o 0, o ?o- c.l -L/9. 06 n/ o o ')o, c.{ oe, d o o IU LL l E U) ,0r- z LU l F -Zrr. E E d ,4r, o o Fz tU '%% 2 F b t.ul F 4o, f0 c, ,& tr o% t), 9r. -o^ O o o oooo o O o o O) @ r- (o tr, g (f) N SCVUS^OC % 27 3.4.1. The Community Distributors Every community is expected to have two official distributors. During the study we met ten of these. However, we found that in addition to these official distributors, the latter themselves have chosen additional young distributors to help them carry out the task especially in hamlets a which are inaccessible. Basically, all the distributors are fairly young, literate and energetic persons. They are highly enthusiastic about the work they do in spite of the fact that they earn no monetary rewards. It was found out that in addition to oncho control activities, these volunteers are engaged in community-based surveillance for the following: maternal mortality, poliomyelitis, tetanus, infant mortality, guinea worrn, leprosy, meningitis, measles, birth and other deaths, among others. In spite of all these, the CDs remain true volunteers. It was learned, however, that a few of them were given bicycles some time ago by the Guinea Worm Eradication Programme (GWEP). While this was in the right direction, it nonetheless inadvertently verticalized all the activities they were engaged. For instance, when asked what help they would require from MOH/OCP the common response is as follows: "Guinea worrn people have been giving bicycles to volunteers and so if oncho people too will do the same that will be fine" Often times, they look amazed when reminded that GWEP and oncho are all MOH activities This notwithstanding, it is absolutely necessary to reward the CDs for the work they are doing. Given the fact that mobility is their biggest headache, donating bicycles to each of them will not only motivate them but also enhance their performance. Another important suggestion is that they need some refresher courses. Their record books contain cases where one-year-old children were given the tablets. The refresher course should also include topics such as updating record books, taking of measurements and community education, among others. Finally, in relatively bigger communities, more volunteers must be recruited. Perhaps, as far as practicable, there should be one volunteer per hundred (100) people. 3.5 Other Issues In order to contextualize oncho and its control activities and also to bring out other related matters of relevance to the study, we chose to examine the health problems of the people as perceived by them, their knowledge, attitudes, beliefs and practices with respect to the disease and ivermectine. 28 Asked to mention some of the health problems confronting men, women and children in the village, a host of problems were mentioned with oncho, as to be expected, topping the list. The table below carries the details of the responses. Table 7 Perceived Health Problems of the Communities (N:459) Health Problem No. Percent Oncho / Blindess 168 36.6 Guinea Worm 84 18.3 Epilepsy 54 l 1.8 Malaria / Fever 45 9.8 Hernia 24 5.2 Cholera / Diarrhoea 24 5.2 Stunted Growth 24 5.2 Cough t2 2.6 Headache 9 2.0 Piles 9 2.0 Waist Pains 6 1.3 TOTAL 4s9 r00.0 It was no surprise that oncho was identified as the number one problem given the impact of the disease and the control activities going on. Indeed in the villages, everybody including children call the disease 'oncho'. However, another health condition which is currently a cause of worry to the DHMT is the sudden spate of epileptic fits which have been reported from the basin. Some villagers related how they or their children had suddenly become epileptics. It is suggested that the DHMT takes immediate action on this matter. 3.4.0 Causes and Treatment of Oncho In order to find out whether the extent of knowledge of oncho corresponded with its known causes, the question was asked: 'What causes oncho?' Surprisingly almost 42 percent claimed they did not know the cause; 6.5 percent claimed it was caused by supernatural forces while another 6.5 percent claimed it was caused by both natural and supernatural forces. However, of the 45 percent of respondents who claimed the disease was natural in origin, the causes were assigned to the following: t black river insects (possibly the black fly); a poor drinking water; 0 river worms; a bad blood; o mosquitoes and tsetsefly; and o a plant that hatches the eggs of an insect. As regards its treatment, the majority (80.6%) claimed it can be treated; 11 percent said it could not be treated completely. As some observed, this is "Because the oncho tablets only 29 reduces the effect of the disease but does not cure it completely. Some people have been taking the drug for years and yet they still have the disease in them." Although several years of control activities have taken place, it does not appear that the education aspect has been well handled. It is therefore suggested that community education must be intensified. Indeed, the World Day Against Blindness be used to promote this course. This is the task of the DHMT. 3.5.I Ivermectine Ivermectine distribution started in the basin in 1997. As to be expected therefore,9T percent of respondents claimed to know it. However, although knowledge of the drug is high, many do not know how often the drug must be taken. While 48 percent said once ayear,3l percent said twice a year. For others (4.8%) it is thrice ayear. Almost l6 percent said they did not know. During the study it was rumoured that some chemical sellers in Prang and Atebubu had stock of ivermectine and the drugs are sold to those who require more dosages or who did not receive their share during the normal distribution period. This rumour is worth investigating so that remedial action can be taken immediately. In the basin, itinerant drug peddlers abound and should ivermectine find its way into their hands, that would be a recipe for disaster. About 95 percent of respondents claimed to have taken the drug at least once. Only 3 people claimed not to have ever taken it. Their reasons are as follows: . "l am always out of town during the distribution" . "I have not written my name because I don't have oncho." o "I fear getting a new disease after taking the drug. I have no oncho". Although such persons are in the minority, their reasons are important ingredients for community education. 3.5.2. General Concerns At the end of each interview or FGD discussions, respondents are asked to air their views on the oncho control programme. Some of the strong views expressed are as follows: a There is the need for eye clinics to be run at least once a month at Abease and Prang health centres. This is in view of the numerous ophthalmic cases in the basin. Currently patients who want good eye services go to Atebubu or Agogo Hospital. The DHMT should solicit the assistance of charitable organizations in this regard. a There appears to be undue focus on Subene. According to the villagers all oncho officials and activities are directed to Subene. Members of other villages claim they are often excluded from skin-snipping and eye examination exercises. This feeling of exclusion may mar the control programme in the other villages. a Many villages express the view that the CDs be paid some allowance to motivate them to work hard. 30 CHAPTER FOUR CONCLUSION AND RECOMMENDATION I The focus of the study has been to strengthen the oncho control activities in the Pru Basin. And this study is critical because of OCP's devolution programme. The study sought to study the spatial distribution of and accessibility to the villages and hamlets in the basin; the movement (migratory) patterns of the people and the impact of these on the effectiveness of oncho control activities; the mode of organisation of community-directed treatment and the attitudes and beliefs of the people with respect to the whole control exercise. 2.0 Findings It has been found that villages along the banks of the river are essentially settler communities inhabited by various ethnic groups. These are close to each other but vary in terms of distance from the river. Subene is the closest to the river. These villages are surrounded by an unknown number of hamlets which are not easily accessible. 4.0.1, The villagers do not migrate but movement is fairly rapid, especially during the off-farming season. Visits are made to home villages while others engage in commercial activities. On the other hand during the farming season there is an inflow of migrant labourers while the local population is fairly stable. 4.0.2 It has been found that such movements cause absenteeism and high default rate while the inclusion of migrant labourers often cause shortages of ivermectine during distribution. 4.0.3 The mode of procurement and distribution of the drug is quite cumbersome and involve long bureaucratic procedures. Thus in times of shortage immediate re-stocking is almost impossible. 4.0.4 In the communities, ivermectine is distributed at central locations often for about a week. Thereafter people collect their medicines in the homes of CDs or the latter follow them to their homes. Some medicines are reserved for absentees and the very sick. Distribution period is often between August and November. 4.0.5 There were instances when non-eligibles (children under 5 years) were treated with the drug. 4.0.6 The CDs do others things apart from oncho activities. However, they are constrained by lack of means of transportation. 4.0.7 Ivermectine is loved by the people but there are a few misconceptions about it: people are not clear about how many times in a year the drug must be taken and how the drug works. 4.0.8 There are a number of health concerns in the village which need urgent attention. Perhaps the most urgent ones are the ophthalmic problems and frequent epileptic seizures. 31 4.1 Recommendations Against the background of these findings the following recommendations are made 4.1.0 There is the need for the DHMT with assistance from the district assembly, local leaders and members of the community to undertake a reliable mapping of all villages and hamlets in the basin. This will provide a reliable census figure with which to plan future ivermectine distribution in the basin. 4.1.1 Because population movement is heavy during the off-farming season, the distribution of ivermectine must be done before this period to ensure higher coverage of the population. 4.1.2 The DHMT and the Regional Health Directorate must work out a plan to reduce the long process involved in the procurement of the drug. For instance the medicine can be kept at the district medical store to enable a quicker access to it in case shortages occur during distribution. 4.r.3 Given the low educational background of CDs, it is necessary to organise refresher courses for them periodically. Subjects to be treated must include good record-keeping, treatment procures and community education. 4.t.4 The mode of delivery of ivermectine to the communities must be reviewed. In this regard it is suggested that the communities be part under trvo zones - Abease and Prang health centres. Communities near to these health centres rvill be made to collect their portion of ivermectine from here. 4.1.5 The DHMT must use the World Day Against Blindness to conscientize inhabitants of the basin on onchocerciasis and eye care. This should be in addition to frequent community education which must be carried out. 4.1.6 Given the large number of ophthalmic cases in the basin, there is the need for the DHMT to run eye clinic in Prang and Abease health centres on monthly basis. This will relieve people of the trouble in travelling to Atebubu or Agogo hospitals for eye care. 4.1.7 Although CDs are community volunteers, and indeed love their job, it is nonetheless suggested that their job be made lighter through motivating them with gifts such as T- shirts, bicycles and free health care. 4.1.8 The record books require additional information to enhance their usefulness (eg. number dead, absentees, refusals, eligible etc.) Also, names must be recorded according to households to enable ease of reference and addition. 4.1.9 The DOC must use the record books not only to compile statistics on coverage rates but also as a basis for interacting with CDs to learn of their difficulties and how to overcome these. a We make these recommendations in the hope that when they are implemented all of us would have contributed to improving the quality of life in the Pru Basin.