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COMMUNITY INVOLVEMENT IN HEALTH CARE PROGRAMMES IN UMUNZE ORUMBA SOUTH LOCAL GOVERNMENT AREA ANAMBRA STATE
PROJECT REPORT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF A MASTER OF EDUCATION DEGREE IN PUBLIC HEALTH EDUCATION OF THE UNIVERSITY OF NIGERIA, NSUKKA
BY
OKEREKE CHINYERE IJEOMA PG/MED/SD/04/35227
JULY, 2011
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Title Page
Community Involvement in Health Care Programmes in Umunze Orumba South Local Government Area Anambra State
A Project Report Submitted to the Department of Health and Physical Education, University of Nigeria, Nsukka in Partial Fulfillment of the Requirements for the Award of A Master of Education Degree in Public Health Education
By
Okereke Chinyere Ijeoma Pg/Med/Sd/04/35227
July, 2011
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Certification
Okereke, Chinyere Ijeoma, a post graduate student in the Department of Health and Physical Education, with Registration Number PG/MED/SD/04/35227, has completed the requirements for course and research work for the degree of M.Ed in Health Education.
...... ………………… Okereke, Chinyere Ijeoma Prof. Chuks Ezedum Candidate Supervisor
…………………. …. ……………………… Date Date
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Dedication
I dedicate this project to our Almighty God, my darling husband Mr. Daniel Okeke, my beloved father Mr. Abel Okereke, my late Mother Mrs. Eunice Okereke, My Son Nwachukwu Fidelis Okeke and my loving brother Basil Okereke Onyebuchi
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Acknowledgements
I wish to acknowledge with deep sense of appreciation and gratitude to all the people who in one way or the other contributed to the success of this project. Firstly, my profound gratitude goes to Prof Chuks Ezedum my project supervisor, for his patience, counsel, constructive, criticisms, advice, corrections and suggestions which made this work a reality. Also, I would like to thank the entire members of Umunze communities for their contributions towards completion of this study. I would like to particularly acknowledge the assistance of three people Prof Umeakuka, Tr. Prof. E.S. Samuel, and Mr Alex Okoli who encouraged me and provided useful pieces of advice all through. I also wish to thank members of my family especially my son Nwachukwu Fidelis Okeke for his love and concern, and also to my brother in-law Ernest Okeke and his family, my brother Basil Okereke and my sisters Udoka Okoye and her family, phoebe Nnabude and her family, Nikky Okereke and my relations who through their encouragement enable me to produce this piece of work. My thanks also go to my follewing friends Ogonna and Cecilia, for their moral support and encouragement. I also express my thanks to the whole HPE lecturers, staff and students. This will be incomplete if I do not acknowledge effort of my beloved husband Mr. Daniel Okeke S. who played an active part in my admission, management of the home, and finance. I appreciate all his support and that of my son Nwagod and the other members of my family Mmesoma, Temple and Gideon. Finally, I would like to express my utmost thanks to the Almighty God for His infinite mercy health, grace and love to complete this project. I am grateful. Thanks you all.
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Table of Contents Title Page ii Approval Page iii Certification iv Dedication v Acknowledgements vi Table of Contents vii List of Tables ix Abstract x CHAPTER ONE: Introduction 1 Background to the study 1 Statement of the Problem 6 Purpose of the Study 7 Research Questions 7 Research Hypotheses 8 Significance of the Study 8 Scope of the Study 9 CHAPTER TWO: Review of Related Literature 10 Conceptual Framework 10 Primary health care (PHC) 11 Community participation 12 Community involvement in health (CIH) development 13 Mechanisms of promoting community involvement in health care services 17 Socio-cultural factors affecting community involvement in health 19 Demographic factors associated with CIH programmes provision and utilization 20 Theoretical Framework 21 The top down model 21 Alternative development model 21 Urban development model 22 Integrated rural development mode 23 Empirical Studies on Community Involvement in Health care Programme 23 Summary of Literature Review 27 CHAPTER THREE: Methods 29 Research Design 29 Area of Study 29 Population for the Study 29 Sample and Sampling Techniques 29 Instrument for Data Collection 30 Validity of the instrument 30 Reliability of the instrument 31 Method of Data Collection 31 Method of Data Analysis 31
CHAPTER FOUR: Results and Discussions 33 Results 33 Summary of Major Findings 52 Discussion 54 Extent of community involvement in preventive, promotive and viii curative health programmes in Umunze 54 Reasons behind the extent of community involvement in health 56 Agencies behind community involvement in health programmes in Umunze 56 Age/Gender differentials in community involvement in health programmes in Umunze community. 57 Relative involvement of the various Umunze Village in health programmes 57 CHAPTER FIVE: Summary, Conclusions and Recommendations 58 Summary, 58 Conclusions 59 Recommendations 60 Suggestions for Further Studies 60 Limitations of the Study 60 References 61 Appendix I: The Questionnaire 66 Appendix II: Key Informants Interview (KII) Schedule 71
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List of Tables
Tables
1. Mean Ratings of Umunze Community on Extent of Involvement in Preventive Health Programmes in Umunze 2. Mean Rating of Umunze Community on Extent of Involvement In Promotive Health Programmes in Umunze 3. Means Ratings of Umunze Community on Extent of Involvement in Curative Health Programmes in Umunze 4. Percentage Distribution of Respondents on Community Involvement on Reasons Behind Community Involvement in Health Programme in Umunze 5. Percentage Distribution of Responses on Agencies / Agents Behind Community Involvement in Health Programme in Umunze 6. Gender Differentials in Preventive Health Programmes in Umunze 7. Gender Differentials in Promotive Health Programmes in Umunze 8. Gender Differentials in Curative Health Programmes in Umunze 9. Age Differentials in Community Involvement in Preventive Health Programmes in Umunze 10. Age Differentials in Community Involvement in Promotive Health Programmes in Umunze 11. Age Differentials in Community Involvement in Curative Health Programmes in Umunze 12. Relative Involvement of Umunze Villages in Preventive Health Programmes 13. Relative Involvement of Umunze Villages in Promotive Health Programmes 14. Relative Involvement of Umunze Villages in Curative Health Programmes 15. T-test of difference between male and female community involvement in health programmes 16. F-ratio of difference in community involvement in health according to Age. 17. F- ratio Relative Involvement of Umunze Villages in Community Health Programmes
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Abstract
This work investigated Community Involvement in Health Care (CIH) programmes in Umunze, Orumba South Local Government Area of Anambra State. The study specifically verified the extent of involvement of the community in preventive, promotive and curative components of health programme; reasons behind the extent of community involvement in health programmes, community agencies behind community involvement in health programmes; gender and age differences in community involvement in health programmes; community agencies behind community involvement in health programmes; and relative involvement of the various villages in Umunze in health programmes. The population for study comprised twenty-two health workers and 37409 adult members of the population in Umunze. A cross-sectional survey design was employed in the study. A sample of 300 adults (comprising 150 males and 150 females) was used in the study. Data were collected using structured questionnaire and key informants interview. The mean (x), standard deviation, t-test and analysis of variance (ANOVA) were used for data analysis. Results showed that the community involvement in the various components of health programmes varied: The community was involved in preventive health to a great extend; promotive health to a little extent; and curative health programme to a very great extent. The results also revealed, among others, that several reasons were behind community involvement in health programmes such as availability of qualified health personnel, awareness of health needs, presence of female caregiver. The hypotheses tested at.05 level of significance showed that there was significant difference in the extent of community involvement in health programmes according to gender, age and villages. Females were more involved than males in preventive and curative health programmes. The age brackets 18 – 25 and 46 – 55 were more involved than others in curative health. Among the villages, Ugwuano and Amuda villages led in the various health programmes. The need for the use of local and modern media to promote greater community involvement in promotive health; and greater empowerment of women and certain age groups for greater participation in matters concerning health programmes, were recommended.
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CHAPTER ONE Introduction
Background to the Study Good health is basic to human welfare and a fundamental objective of social and economic development (Ukwu, 1993). It is not by accident therefore that three of the eight Millennium Development Goals (MDGs) adopted by world leaders in September 2000 are on health. These are to reduce child mortality (MDG-4); improve maternal health (MDG-5) and combat HIV/AIDS, malaria and other diseases (MDG- 6). Nigeria is signatory to this pledge targeted for achievement before 2015. While government and donor agencies are stepping up efforts to strengthen health systems in order to meet the target, community involvement appears to be the only way to reach the grassroots. (Abiodun & Kolade, 2006). In most parts of Africa, the concept of community development and local involvement is a cultural phenomenon. Self-help efforts through which several social amenities were provided by local communities are not new in this part of the world. Since no local, state or even federal government can meet all the health demands of its people, especially in the light of contemporary complex health issues, local involvement in health care programmes has become indispensable and is intensified in recent years in Nigeria. Annett (2006) defined community involvement in health as a deliberate strategy which systematically promotes community participation and supports and strengthens it in order to provide better health care for the majority of people. It involves both a commitment to promote better health with people and not merely for them, and a strategy radically different from the more conventional approaches to health development. Community involvement in health is conceptually one of partnership between government and local communities in the three key areas of planning, implementation and utilization of health programmes. Health projects like the building of clinics, maternities, dispensaries, cottage hospitals, National Programme on Immunization (NPI) and so on, have tended to become focal points across the nooks and crannies of the Nigerian society since the 1980s (Ewhrudijapor & Ojie, 2005) . Indigenous participation as an approach in most developing economies has been able to penetrate the health sector as it is seen as a method of accelerating the reduction of ill health in the society. This is against the xii backdrop of contemporary public health issues like reproductive health, HIV/AIDS, tuberculosis, female genital mutilation and other harmful traditional practices. Aregbeyen (2006) observed that there was a deliberate attempt to draw a comprehensive national health policy dealing with such health issues as manpower development and the provision of comprehensive health care service based on the health services scheme, disease control, and efficient utilization of health resources, medical research, health planning and management. However, the mentioned factors below seem to account for the seemingly futile efforts of governments in Nigeria over the years to improve health care delivery under several health projects (NHPS, 1988): The coverage were inadequate, no more than 35% of the Nigerian population had access to health care services; rural communities and urban poor were not well served the orientations of the services were inappropriate with a disproportionately high investment on curative services to the detriment of preventive ones. The involvement of the communities were often negligible at critical points in the decision making process; and the management of the funds often showed major weaknesses resulting in defective basic infrastructures and logistic supports. It is therefore apparent that government alone neither can shoulder the responsibilities of communities health problems nor can the effort of government mean much in the absence of community involvement. Population is a question of people, healthy people, not of numbers. It is the indigenous participatory efforts in health issues that determine the extent of success of government health programmes. Udoye (1989) stated that community involvement in development programmes and strategies have become a handy framework for the provision of the basic needs of rural Nigeria communities. In Anambra State cooperative effort is a way of life, a philosophy embraced by the government and the people alike. What is perhaps new is that for the first time a direct and conscious effort is being made to harness this abundant resource (Adeyeye, 1987). There are two principles emerging from the idea of community participation. These are the principle of individual and corporate survival and the principle of societal felt need. According to Udoye (1992) these two have been the propelling force behind organizing and mobilizing the people in the pursuit of self- development. Apart from initiating certain programmes of self-help like building of health centres, the community must be involved in the context of embracing the health xiii programmes of government especially in the light of the prevailing health problems. Erinosho and Oke (1994) stated that chronic diseases and disability cannot be understood or treated solely as medical phenomena; but should be in the context of the total environment. According to them, there is general agreement among health providers that macro environmental variables of the people are as necessary and sufficient as physical conditions. The communities need to know the implications of some health hazards and certain behaviours on their well being. There is therefore symbiotic relationship between the government and the communities in the achievement of the health programmes. Hence, the idea of primary health care (PHC) emerged in the 1960s, in recognitions of the shortcomings of the health systems inherited by developing countries, like Nigeria after independence (1d 21, insights 2008). The Alma Ata conference of 1978 placed emphasis on preventive, rural peripheral and appropriate services, integration and local communities. According to Okoye (1989) the success of this programme requires the promotion of maximum community and individual self-reliance and participation in the planning, organization and control of primary health care, making fullest use of local, national and other available resources. Health programme is a deliberately planned activity by government aimed at eradicating or controlling specific identified diseases (Mbah, 2000). Health progrmmes are aimed at achieving public or community health and by so doing promote socio – economic activities and well-being of the society. There are three components of any health programme – preventive, promotive and curative health programmes. The preventive health programme seeks to prevent the occurrence of diseases. The programme tries to identify the habits of man that encourage the occurrence of diseases with a view to educating the masses on ways to avoid the habit or eliminating it. The promotive component of health programme is closely related to preventive health programmes since the main purpose of promotive health programme is to encourage people to lead healthy life style. However, promotive health programme could also be used to provide basic health education to communities, as well as provide information to communities on certain health concerns. Curative component of heath programme on the other hand aims at curing some specific diseases in order to curtail its prevalence for a health society. Against this background, Moronkola and Okanlawon (2003) concluded that the community is the common target of all the health programmes or activities xiv whether, it is called public, community or primary health care. The main goal is the attainment of a level of health that will permit all the citizens of a particular community to live a socially and economically productive life. Hence health pregrammes are usually all inclusive bringing in all the three components in order to achieve wider success. Community involvement in health was first used explicitly as the term to describe a basic principle of health care and promotion in community in 1985 at an inter-regional meeting on the subject of community involvement in health (WHO 1985). Community involvement in health (CIH) programme is a deliberate strategy which systematically promotes community participation and supports in order to provide better health care for the majority of people (Kahssay & Oakley, 2006 ) CIH is not a health programme in itself, but an essential principle of health development. CIH is essentially a process whereby people, both individually and in groups, exercise their right to play an active and direct role in the development of appropriate health services, in ensuring the conditions for sustained better health and in supporting the empowerment of communities for health development. CIH actively promotes people’s involvement and encourages them to take an interest in and to contribute to and to take some responsibility for the provision of services to promote health. Rifkin (1990) identified three components of community involvement in health care programmes – planning, implementation and utilization. CIH actively promotes people’s involvement in the critical areas of planning for, implementing and utilization of health programmes . It implies a partnership among individuals, groups, organizations and health professionals, in which all sides examine the basic of health issues and agree upon approaches to tackle them. At each stage of planning, implementation and utilization, all actors come together to discuss issues and feasible solutions and to agree upon a course of action. Planning is the process of determining the major objective of a programme and the strategy that will govern the acquisition, use and disposal of services to achieve those objectives (Ransome – Kuti; 1990). In the context of health, Jones (1992) described planning as: …. defining the extent and characteristics of community health problems and identifying unmet needs; assessing available and potential resources establishing priority goals by matching need and resources and considering alternative action to xv active programme goals and their consequences; formulating the necessary administrative action to achieve programme goals ; relating results to goals by continuing evaluative studies (p. 74).
The Successful implementation of a health programme is hinged on community involvement and support, the notion is that people are likely to support programme which they are a party in planning. The Pan American Health Organization (PAHO) reported on an experiment to promote community involvement in health (PAHO, 1994). The experiments have five main elements: identification and discussion of the key health problems within a particular community, agreement upon a proposal of action; ongoing negotiation when decisions are needed; implementation of agreed plan of action; and evaluation of the action with the involvement of all concerned. In the present study, all the three dimensions of health programme i.e. planning, implementation and utilization of health programmes will be considered at the three levels of prevention, promotion and cure. This will provide a comprehensive study of the nature and pattern of health involvement in the locality. CIH is not a new concept in Nigeria. Since the Alma – Ata adoption of primary Health care in 1978, community has remained the focal point of health service delivery (Mbah, 2000). In fact all the components of PHC are targeted at the community, for the achievement of the goal of health for all. Moronkola and Okanlawon (2003) argued that the focus of community health work is the promotion and maintenance of health of the host communities. According to them, it is essential that community health workers take note that the success of any health care initiative depends on community participation. The following should be noted: involve community to effectively assess community needs and resources, be able to assess the health of the community, identify the characteristic, resource and needs of the community; Work with community members on those issues that arise, addressing individual and environmental variables related to health issues; and facilitate meaningful participation of community members at all stages in the assessment, planning, delivery and evaluation of health services. Ewhrudjakpor and Ojie (2005) observed that community utilization of health programme facilities can be influenced by quite a number of variables such as location, namely distance of facilities, cost at which health care is provided to the xvi public, socio-economic factors in addition to the way in which illness is perceived or evaluated. Abiodun and Kolade (2006) observed that females utilize health facilities more than males on account of their care and their children’s care. It therefore follows that community involvement in health programme is skewed in favour of women. This is however understandable as Joint Learning Initiative (2004) stated, in a health crisis, by culture or tradition, it is women who ease pain and suffering, offer physical care and nurturing and provide comfort and support. The observations in the foregoing may not be different from what is obtained in Umunze which is the focus of this study. Umunze is one of the 16 autonomous communities in Orumba South and also the Headquarters of Orumba – South Local Government Area, Anambra state. Umunze has projected population figure of 37,490 people as at 2006 (LEEDS Document, Orumba – South L.G.A (2006). The Umunze community has one functional comprehensive health centre, three health posts, one cottage hospital (now elevated to general hospital), two mission hospitals and seven private hospitals. Umunze community is therefore a fertile ground for this kind of study. The Primary Health Care (PHC) programme is a visible health programme in Umunze community. Although it has been recognized that community involvement is a prerequisite for the success of the PHC programme, it is doubtful whether the community is actively involved in the three components of planning, implementation and utilization of health care programmes in the area. Indeed, one of the pillars of Primary Health Care is community participation, the active involvement of people and the mobilization of societal forces for health development (Dhillon & Philip, 1994). Following from this, the present study seeks to find out the extent of community involvement in the health care programmes in Umunze (a local community). Statement of the problem A collective approach to the fight against diseases has been observed by many authors and researchers (Okoye, 1989; Dhillion & Philip, 1994). Since the Alma Ata Declaration in 1978, the issue of community involvement in health care programmes has been given greater impetus. It has been shown that the success or failure of any health programme depends to a very large extent on community involvement. Community Involvement in Health (CIH) is a strategy that seeks to promote community participation alongside the government and other relevant bodies to xvii provide better health care for the majority of the people. CIH is a three-dimensional strategy that addresses the key areas of planning, implementation and utilization of health programmes. Every health programme has three components namely, preventive, promotive and curative health programmes. Ideally, communities are expected to be fully involved in the quest to achieving optimum well being based on these three dimensions of health programmes However, it is doubtful whether the Umunze community in Amambra State, Nigeria is wholly involved in these three components of health programmes, and if so, whether the degree of involvement is significant enough. Health programmes are seen as government business while the community is seen as mere recipient of this programmes. Following from the above, the problem of the study is to what extent is Umunze Community involved in health care programmes? Purpose of the study The purpose of the study is to find the extent of community involvement in health care programmes in Umunze community in Anambra state. Specifically, the study sought to ascertain the: 1. extent of community involvement in preventive health programmes in Umunze; 2. extent of community involvement in promotive health programmes in Umunze; 3. extent of community involvement in curative health programmes in Umunze; 4. reasons behind the extent of community involvement in health programmes in Umunze; 5. community agencies behind community involvement in health programmes in Umunze; 6. gender differentials in community involvement in health programmes in Umunze; 7. age differentials in community involvement in health programmes in Umunze; 8. relative involvement of the various Umunze villages in health programmes. Research Questions The following research questions guided the study. 1. What is the extent of community involvement in preventive health programmes in Umunze? xviii
2. What is the extent of community involvement in promotive health programmes in Umunze? 3. What is the extent of community involvement in curative health programmes in Umunze? 4. What are reasons behind the extent of community involvement in health programmes in Umunze? 5. Which community agencies are behind community involvement in health programmes in Umunze? 6. What gender differentials exist in community involvement in health programmes in Umunze? 7. What age differentials exist in community involvement in health programmes in Umunze? 8. What are the relative involvements of the various Umunze villages in health programmes? Significance of the study This study will benefit the various stake holders in the health sector especially the local communities. Preventive health is the most vital component of health programmes as encapsulated in the popular saying that prevention is better than cure. The study will enable the people understand the need for preventive health as well as areas to which they can be involved in promoting preventive health in their various communities. This has impact on their attitude to the environment, as well as life styles. The study will also have impact on promotive health component of health programmes. The communities will be able to gain insight on what it entails to engage in promotive health programmes. This knowledge will positively affect their involvement in various promotive health programmes of government and their local communities. In many communities, diseases have continued to pose challenges to the social and economic well being of their people. The study will also address the curative health programmes and how the people can get involved for the overall well being of the community.
The study addresses the reasons behind community involvement in health programmes. Knowing the reason will help the various stakeholders who include the community, health workers, health agencies and government to understand the xix communities’ health needs and so be able to engage in activities likely to promote community health. The study will also find out agencies behind community involvement in health programmes. This will benefit policy makers who need empirical data such as this in policy making processes. It will also benefit these local agencies as government can now involve them in the process of health promotion. Furthermore, government and other policy makers require various patterns of community involvement such as gender in planning health programmes. This study will therefore provide data on gender differential in community involvement in health programmes for use by government and health planners. Likewise, the study will provide data on age differential for use in health planning. Age is a correlate of health. The insight which this study will provide will therefore be of immense benefit to society. Finally, the study will benefit the various villages in Umunze. Results of the study will provide insight into their relative involvement in health programmes and so enable them to improve where level of involvement is poor. Research Hypotheses The following null hypotheses were postulated and tested at. 05 level of significance. HO 1: There is no significant difference in the extent of Community involvement in health programmes according to gender. HO 2: There is no significant difference in the extent of Community involvement in health programmes according to age. HO 3: There is no significant difference among the Umunze villages in the extent of their relative involvement in health care programmes . Scope of the study The study focused on community involvement in health programmes in the seven villages that make up Umunze community, namely, Ugwunano, Lomu, Ubaha, Nsogwu, Amuda, Ururo/Umucheke and Ozara villages. The study is also delimited to three components of health programmes which are preventive, promotive and curative as well as agencies behind community involvement in health programmes in Umunze community. The study also address gender and age differentials in community involvement in health programmes and the relative involvement of the various Umunze villages in health programmes
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CHAPTER TWO Review of Related Literature Community Involvement in Health (CIH) is being accepted as one clear strategy to improve the standard of health in rural communities. However, while health literature the world over is awash with the concept of CIH, only few works have been done by indigenous writers and researchers in this area. This chapter reviews some works done in the area of CIH under the following heading: 1. Conceptual Framework - Primary Health Care (PHC) - Community Participation - Community Involvement - Reasons Behind Community Involvement in Health (CIH) - Demographic Factors Associated With CIH Programmes Provision and Utilization. 2. Theoretical Framework - Top – Down Model - Alternative Development Model - Urban Development Model - Integrated Rural Development Model 3. Empirical Studies in Community Involvement in Health Care Programmes. 4.Summary of literature review Conceptual Framework Good health has implications for individual and national economic activities. The health of the people, not only contributes to better quality of life, but is also essential for the sustained economic and social development of a country as a whole (FMH,1998). Health related issues therefore are of strategic concern to all (government, professionals and consumers). Government and stake-holders in the health sector are concerned and focused on the provision and maintenance of such levels in health care that will make it possible for individuals to live socially and economically productive life. Health programme as a concept is any planned activity aimed at promoting health. According to Moronkola & Okanlawon,(2003), health is a status in which an xxi individual of a given sex and at a given state of growth and development is capable of meeting the minimum physical, physiological and social requirements for appropriate functioning in the given sex category and at the given growth and development level. In other words, health is a state of being well and free from diseases. A health programme is therefore any planned activity targeted at individual and Community with the aim of providing a state of wellness and eradicating diseases. The main goal of health programme is the attainment of a level of health that will permit all the citizens of a particular Community to live a socially and economically productive life. The focus of health programmes is therefore the community. Primary Health Care (PHC). The pursuit of the objective of health for all and Community based programme of health, has led many governments to the adoption of World Health Organization’s (WHO) strategic option: Primary Health Care (PHC). Abiodun & Kolade (2006) stated that primary health care represents essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the Community through their full involvement. This approach to health emphasizes the cooperative and involvement of the Community as contributors and customers in the health care system. The Alma Ata Declaration in 1978 defined PHC as basic health care built on technically sound and socially adequate approaches, universally accessible and affordable to all individuals (1d 21 insights, 2008:1) by the time of the Alma Ata Conference in 1978, a consensus had emerged placing fresh emphasis on preventive rural peripheral and appropriate services integration and inter-sectoral collaboration, collaboration, and participation of local communities. According to Mba (2000) reasons for adopting PHC are people will be made to take responsibility for their own health; health care will be community based; emphasis would be on preventive rather than active medicine; health care would be accessible to all at affordable prices. Different aspects of health were regarded as important and were incorporated in the efforts to achieve health for all. These different aspects were collectively termed ‘components of PHC’. According to Mbah (2000) these components are: education concerning prevailing health conditions and methods of preventing and controlling them; promotion of adequate food supply and proper nutrition; adequate supply of safe water and basic sanitation; material and child health plus family planning; prevention and control of locally endemic diseases; xxii appropriate treatment for common diseases and injuries; provision of essential drugs, and immunization against infectious diseases. Under the health care delivery system in Nigeria, the PHC is coordinated at the local government level with support from state and federal governments (FMH, 1988). Community health centres are a core institution in the PHC programme. In fact, in many communities in Nigeria, it is not only the first point of contact but the only available health practice in the rural areas (Lambo, 1989). Community Participation. According to Rahssay and Okakley (2001), the concept of people’s participation in development has come to have a major influence upon development thinking and practice. The concept however defies any single attempt at definitions or interpretation. In many ways, participating has become an umbrella term for a new and more people –centred approach to development intervention. They stated that researches have revealed a number of different interpretations of the concept of participation. Inevitably, interpretations reflect both the ideological position of those initiating the participation process and its content. They identified two broad and distinct interpretation of participation in development: Participation is seen as a process that ensures local people’ s cooperation or collaboration with externally introduced development programmes or projects. Participation thus facilitates the effective implementation of such initiative. People’s participation is sponsored by external agencies as technique to support project progress. The term participatory development is more commonly used to describe this approach and implies externally designed development projects implemented in a participatory manner. This approach seems quite widespread and essentially promotes participation as a means of ensuring the successful outcome of projects undertaken. Participation is seen as a goal in itself that can be expressed as the empowerment of people in terms of their acquisition of skills, knowledge, and experience to take greater responsibility for their development. Poverty is often explained in terms of the exclusion of people and their lack of access to and control of the resources they need to sustain and improve their lives. Participation is an instrument of change and it can help to reverse the exclusive and to provide poor people with the basis for their more direct involvement in development initiatives. xxiii
However, aside these two broad interpretations of participation of people in development, Agudelo (2003) identified distinct interpretations of people’s participation in development: In this interpretation, people in less developed countries voluntarily, or as a result of some persuasion or incentive, agree to collaborate with an externally determined development project, often by contributing their labour and other resources in return for some expected benefits. People’s participation is sponsored by an external agency, either the government or some other form of development agency. In nationwide health, for instance, people’s collaboration will be sought as a mean of ensuring the success of the programme, they have less direct involvement in the programme design, control or money concept. It could be argued that participation as collaboration is the interpretation which dominates much or the practice of current development programmes and projects. Participation as collaboration has also given rise to the concept of ‘stakeholder’ which in practice involves the identification and inclusion in the project process, of these individual, or groups who could affect, or be affected by the outcomes of the project activities (Montgomery, 1995). One aim of people’s participation is to include previously excluded groups such as small farmers or urban poor in development activities by targetting benefit directly at them. Paul (1987) summarizes this interpretation when he defines community participation as ‘’ active process whereby beneficiaries influence the direction and execution of development projects rather than merely receiving a share of the project benefits’’ (P. 43). While many development projects seek to put Paul’s interpretation into practice, the extent to which beneficiaries effectively influence the direction and execution of development projects varies considerably and may, in some cases, be negligible. Participation as an exercise in empowering people has gained widespread public support. A major study undertaken by the United Nations Research Institute for Development during the 1980s took as its working definition of participation as ‘’ the empowerment of excluded groups in order to increase their access to and control over development resources’’ and in 1990, a conference on popular participation in Africa organized by the Economic Commission for Africa (ECA) adopted the Africa Charter for Popular Participation , stressing empowerment and advocating the liberalization of political processes to accommodate freedom of opinion and rural people and their organizations (Friedmann, 1992: 99) xxiv
Community Involvement in health development. The concept of community involvement in health (CIH) is not new. kahssay and Oakley (2003) observed that indigenous health practices, traditional methods community support in time of poor health and positive community action to tackle existing health problems and needs (e.g.) mobilizing community efforts for a vaccination campaign or community labour to build a health post) are all manifestations of community participation. Also there has been a strong relationship between community participation and programmes aimed at disease control. However, community involvement in health is not just a mechanism to lend support to external led health development programme. It is a deliberate strategy which promotes community participation and supports in order to provide better health care for the majority of people. Community involvement in health involves both a commitment to promote better health with people and not merely for them. World Health Organization publications in the early 1980s examined the concept of community involvement in health as part of various health programmes which help to spread awareness of the concept (Fonaroff, 1983; PAHO, 1984). The publications however, lacked a coherent view of people’s participation; they did not challenge or question the basis of health care delivery but sought to involve people in this practice, and hardly modified or changed established approaches. Thus, people participation became an additional ingredient in the health care delivery instead of the means to increasing the effectiveness and accessibility of health care. The WHO (1985:202) reviewed the concept of community involvement at a conference in Brioni. Yogoslavia and summarized it as follows: • Community involvement in health is a basic right of all people. Involvement in decisions and actions that affect people health build self- esteem and encourages a sense of responsibility. As principle community involvement in health of intrinsic value in general community development and should be promoted as the basic
approach to health development. • Many health services, especially in developing countries depend on limited resources. Community involvement in health can therefore help make the available health resources more responsive to the basic needs of the people. Local knowledge and resources can be used to complement those provided by the formal health services. Furthermore, Community involvement in health can help to extend the coverage of health services. xxv
• Community involvement in health increases the possibility that health programmes and projects will be appropriate and successful in meeting the health needs defined by local people, as opposed to those defined by the health service. Health programmes will have better chance of success when health services are consistent with local perceptions of health needs and managed with the support of local people. • Community involvement in health breaks the bond of dependence that characterizes much health development work and generally creates awareness among local people of their potential involvement in development (WHO),1985 :205) Furthermore, with revelations overtime, coupled with more awareness of the concept of community involvement in health, Rifkin (1996:121) summarized the benefits which community participation was expected to bring to Primary, Health Care (PHC). • People would make better use of existing health services and would ensure the sustainability of new services being involved in decisions about their development. • People would be able to contribute resources of money, labour and materials to support the scarce resource allocated to health care. People would change their poor health behavior if they had been involved in exploring its consequences. • People would gain experience and information which would help them to gain control of their own lives and thus challenge the existing social, political and economic system which had deprived them of this control. Although there has been a lot of interpretations of the concept of Community Involvement in Health, some authorities have attempted definition of Community Involvement in Health . One definition which has been presented in the context of primary health care states as follows: Community Involvement in Health development is a process by which partnership is established between the government and local communities in the planning, implementation and utilization of health activities in order to benefit from increased local self-reliance and social control over the infrastructure and technology of primary health care (Tatar, 1996:76). The definition indicates that Community Involvement in Health is one of partnership in the area of planning, implementation and utilization. The definition is further strengthened by WHO (2004). At its meeting in Geneva in December, 2003, a World Health Organization study group on Community Involvement in Health reviewed a range of interpretations xxvi and agreed that CommunityIinvolvement in Health is essentially a process where people both individual and in group exercise their right to play an active and direct role in the development of appropriate health services, in insuring the conditions for sustained better health and in supporting the empowerment of communities for health development. Community Involvement in Health actively promotes people’s involvement and encourages them to take interest in, to contribute to and to take some responsibility for the provision of services to promote health. Furthermore, Community Involvement in Health implies a partnership among individuals, groups, organization and health professionals in which all sides examine the basic of health issue and agree upon approaches to tackle them. Over all, the community involvement in health can help to bring about: a better understanding among communities and health workers on health care and development; better health care for people; and shared management of resources with the objective of achieving efficiency, equity and people’s empowerment in health development. Having observed that Community Involvement in Health has three critical elements of planning, implementation and utilization, it is pertinent at this juncture to expose the various aspects of community involvement in health care. Mordi & Metiboba (1994) describe planning as defining the extent and characteristics of community health problems and identifying aimed needs; assessing available and potential resource and considering alternative action to achieve programme goals and their consequences, formulating the necessary administrative action to achieve programme goals; relating results to goals by continuing evaluative studies. Implementation involves programme of action based on planned objectives. This stage is critical in the entire process. Rifkin (1996) identified two approaches to implementation of community involvement: One which is target-orientated and the other which seeks empowerment. Rifkin canvassed for the marriage of the two to achieve better result. The synergy will bring about a process whereby communities are strengthened in their capacity to control their own lives and make decisions without the direction of professionals and authorities. Finally, utilization provides answer to the success or failure of the entire process. It tends to ask questions such as what use the people make of available health facilities or the availability of health facilities or programme to address identifiable health problems. Mechanisms of Promoting Community Involvement in Health Care Services: xxvii
There is a need for local structures or organizations to serve as facilitating mechanisms to help people to get involved in health service. The World Health Organization (1996) identified some of these mechanisms to include village health committees, community health workers, health campaigns, local meetings, drama, dance. Village health committees or similar bodies can form the organizational base for community involvement in health. These communities perform such roles as identifying local health needs, mobilizing resources for health development and implementing and evaluating health projects. Moreover, Community health workers or other individuals can help to link the health service with local people and indigenous knowledge and practices. These workers are members of the community and they help to allay people’s suspicion of external projects. They can mount health campaigns in which health issues are promoted in the communities. Teams are deployed throughout a region in a mass information operation and seek to involve people in the proposed health action. Again, people can play an active part in the analysis of health problems in their particular area. These meetings are a chance to listen to people’s opinions, their perceptions and understanding of health problems, and their ideas about possible solutions. According to Akinbode (1986) It should not be “a one – way delivery in information”. Such discussions can lead to new insights into health problems, combining aspects of popular knowledge with scientific and technical knowledge. As World Health Organization (1994:225) stated. “Opportunities for open and equal discussion are a fundamental prerequisite of any process of community health involvement (CHI)”. In a similar vein, Moronkola & Okanlawon (2003) stated that drama, dance and songs are innovative techniques for encouraging participation, which are now being recognized in the health sector. People may be more receptive to narrative, dramatic, and musical forms of communication than to purely didactic lectures and talks. These less conventional media are also excellent for building awareness, mobilizing people for action and encourage them to think about particular issues. As people become involved, these types of communication help them express their own ideas and feelings about a situation. Indigenous forms of communication can have a unifying effect, helping to develop solidarity among a group of people over a matter of common concern. xxviii
The Pan American Health Organization (PAHO) reported on its experiments with what it called “the SILO concept” aimed at promoting community involvement in health (PAOH), 1994). The core of the methodology is the notion of co- management which denotes the explicit division of responsibilities and authority between health service staff and community representative in the management of health care. According to the report, co-management has five main elements: • Identification and discussion of the key health problems within a particular community • Agreement upon a proposal for action • Ongoing negotiation when decisions are needed • Implementation of agreed plan of action • Evaluation of the action with the involvement of all concerned Furthermore, reviewing the Implementation of community involvement in health over the past decades, Rifkin (2006) suggested the need for a fundamental paradigm shift with regard to the implementation. She argued that there are two diametrically opposed approaches to community participation; one which is essentially “target- orientated” and the other which seeks “empowerment”. The target -orientated framework sees community participation as: 1. A way of mobilizing community resources to supplement health service 2. A means to an end 3. Passive, responding to professional direction 4. A product of primary health care programme 5. Best evaluated by quantitative methods. The empowerment framework sees community participation as : 1. A means of given people power over their health choices 2. A means in itself 3. Active and based on communities are strengthened in their capacity to control their own lives and make decisions without the direction of professionals and authorities 4. Best evaluated by qualitative methods (Rifkin, 2006) Rifkin further argues however, that the above framework share a common paradigm, which is that community participation is seen as an intervention to achieve a particular objective; health improvement or a change in political relationships at the xxix community level. According to her, community participation should be characteristic of the entire health system, a continuous learning process of interpreting existing events and relations. The new paradigm, according to her will avoid the dichotomy between the existing two frameworks and allow both to be used for promoting community involvement in health. Socio-Cultural factors affecting Community Involvement in Health. The health of a person is closely tied to his social life and culture (Mbah, 2000) Social factors have tremendous influence on his attitude to health issues. The social habits, activities, occupation gender and gender roles, the family structure and functioning, the roles of social organizations, beliefs, taboos and superstitions, the literacy role and social interaction between individuals and groups all affect the way they respond to health . Even social class structures do make a lot of impact on people’ state of health. The culture of a people often determines what status women should be given. In cultures where women (whose status of health is closely tied to that of their children) are rated second class, where they have no say and cannot take decision without their husbands the general state of health in such societies are often poor (Jelkife, 1992). The (WHO (1991) admitted that one major issue concerning community involvement is culture, and how the notion of community participation is perceived in different cultural contexts. Different communities react differently to efforts to promote their participation in a health development project. (Woelk (1992) examined culture in relation to participation in health programmes in Zimbabwe and concluded that, given factors such as marginalization, community stratification and local political influence, community participation would not be easy to generate or sustain. Furthermore, stone’s (1992) review of cultural influences on community participation in health progrmmes have overemphasized structural factors in health care systems rather than cultural factors within local communities which have often caused health service staff to overestimate the community’s likely response. Culture is not an obstacle to community participation, but it must be understood before participation is externally promoted (Stone, 1992). Many communities have different attitudes to health and illness and use a very different range of traditional cures and healers (Helman, 1994). The relevance of culture to the understanding of health and illness behavior cannot be over-estimated as xxx the influence of the belief system on the conception of illness and disease, therapeutic choice and utilization of health facilities (Adepoji, 2005) This position has earlier been noted by Boston (1971) who stated that the community is the base of the socio-cultural context programme of the people. This is because the socio-cultural practices of a people are not easily overcome and their response or participation is often influenced by these factors. According to Aina & Salam (1992) the poor status of women and its relationship to tradition, customs and various cultural practices affect their health in many ways. They further stated that some ethnic groups superstitiously believe that if a baby’s head touches the mother’s clitoris during child birth, still birth may occur. This kind of belief affects people’s reaction to orthodox health care programmes and their involvement. Demographic Factors Associated With CIH Programmes Provision And Utilization. Most health institutions in developing countries are concentrated in urban areas where only 20 % of the nation’s population resides. In the rural settings, the few health institutions that exist are meant to serve a large population, living in small and scattered villages. Majority of the population finds it difficult to gain access to the health facility (Lucas & Gilles, 1993; Mbah, 2000). In Orumba south local government of Anambra state, there are twenty health facilities (8 primary health centres and 12 health posts). There are only seven (7) qualified nurses/ midwives, three of which are not working at the primary health centres. Majority of staff working at the PHCs are community health Extension Workers (CHEWs) and health assistants. (LEEDS, 2006). Yet, according to the document, the maternal mortality rate is high in the local government ranging between 1500 -2000 per 100,000 live births; the infant mortality rate is equally high at between 80-150 per 1000 live births. There is high prevalence of endemic diseases such as malaria, helminthiasis, pneumonia, onchocenciasis, and diarrhea. About 95% to 98 % of infant and under five mortality is caused by malaria. Diarrhea disease is still poorly managed in the local Government because of the low literacy level of the parents especially mothers as well as lack of manpower. These coupled with inadequate environmental health services and low standard of xxxi individual and public hygiene contribute to a generally low health status of the population. However immunization coverage is high between 85% and 95% (LEEDS, 2006) and surveillance officer mounts surveillance on noticeable disease in Nigeria and report outbreak of diseases to the L.G.A health office first. However, intensive surveillance is often marred by lack of logistics. Generally, most health institutions in developing countries including Nigeria are concentrated in urban areas where about 30 per cent of the nation’s population reside (WHO 2007). In the rural settings, the few health institutions that exist are meant to serve a large population, living in small and scattered villages. These villages have poor population network. The result is that majority of the population finds it difficult to gain access to health facility. Theoretical Framework In order to locate the concept of Community Involvement in Health care, there is the need to explore some theoretical underpinnings of development. Lackey (1996) outlined two models of development: • The top- Down Development Model • The alternative Development model The Top- Down Model Abbot (1996) states that prior to 1970, the Top- Down Model of development appeared to be best for recording improvement in peoples’ lives. The top- Down Model stresses external delivery, physical or tangible improvements and employment of professionals to design and direct development programmes and projects. In that vein, development only comes from forces outside the immediate environment (long, 1978). However, critics of top-down model argued that though that model of development may have helped to improve the living conditions of some people it did little to develop the talents, skill and abilities of the mass of urban and rural poor; nor did it provide any role for the poor in the development process (Oakley & kahssay,1997). They argued further that the Top-Down Model of development is an antithesis of the very concept of development. The present study will seek to find out attitude of people to externally directed health programmes especially against the back drop of the fact that most health policies and implementation are externally motivated rather than people driven. Alternative Development Model xxxii
The concept and practice of development are subject to constant changes as researchers and practitioners introduce new forms of analysis and enquiry and learn more about causes and problems of under -development and poverty. These changes influence health development. Thus, proponents of Alternative Model, “ people – centred development’’, “counter- development’’ or “participatory development’’ as it is variously called suggest that development should be more people-centred, with less emphases on purely physical improvements, and that it should more directly promote people’s participation . (Brown, 1992: Bossert, 2006). Essentially, the theory argued two things. The first premise was that poverty is structural and has its roots in the economic and political conditions that influence people’s livelihoods. Therefore in order to tackle poverty, it is important to develop people’s ability to change these conditions. The second premise was that development programmes and projects have largely bypassed the vast majority of people; there is a need, therefore to rethink development intervention in order to give the excluded majority a chance to benefit from development initiatives. Perhaps, this approach to development informed the definition of development by Dissanayake (1985) who sees development as: The process of social change which has its goals, the improvement of the quality of life of all or the majority of the people without doing violence to the natural and cultural environment in which they exist and which seeks to involve the generality of people as clearly possible in this enterprise (p.21) The Alternative Model of development therefore assures: a) Respect for the culture and environment of the people by the change agent. b). Participation of all majority of the people c). The change must affect a majority of the people. d). Improving the living conditions of the people. The Alternative model appears to support CIH. programmes since the concept of CIH entails collaborative effort of the people and external agents in health issues . It is therefore the aim of the study to find out the extent to which the alternative model applies to community involvement in health programmes in Umunze. Akinbode (1986) identified two development models of rural development which have been adopted by many countries to achieve effective rural development. These models become pertinent in view of the peculiar nature of rural health conditions. They are as follows: xxxiii
Urban Development Model This model favours the concentration of development projects in a few selected urban centres with the assumption that development will “trickle down” to the rural areas from the urban centre (Lele, 1995). One of the proponents of this model argued that tricked down benefits from the urban centres will stimulate development in rural centres. However, the concentration of development incentives such as health facilities in a few selected urban centres has not had the expected impact on the rural centres. Rather, it has witnessed unpalatable congregation of patients from the rural centres in the few existing “specialist” hospitals located in urban centers. Some experts have noted with concern the effect of Urban development model on rural community such as Umunze. Given the thrust of this model, communities are expected to wait for development that would come down from the urban centres rather than get actively involved in charting the cause of development. Whether this is the prevailing notion in Umunze community is one of the key issues this study wishes to address. Integrated Rural Development Model: This model advocates equitable distribution of national wealth. In other words, all sectors of the rural economy are developed and effectively linked with the urban sectors. Integrated rural development sprouts from the belief that all sectors of the economy are interlinked to health. However, many developing countries have not succeeded in implementing the integrated rural development concept (Akinbode, 1986). Many communities do not prioritize health and some have lackadaisical attitude towards health issues. A study to find out extent of CIH programmes such as this will reveal how serious or otherwise communities take health issue. Empirical Studies on Community Involvement in Health Care Programmes Many studies have been carried out on community involvement in health care programmes as well as the influence of certain variables like poverty and socio- cultural factors on community accessibility to health care services. Ewhrudiakpor & Ojie (2005) carried out a study on indigenous participation in health care services in Ethiope east local Government Area of Delta State. The local government comprises two distinct clans; Agbon clan with 9 communities and Abraka clan with 13 communities. Two Hundred and fifty two persons were involved in the study. They were purposively sampled to include local government staff, opinion leaders, community leaders, youth leaders, women leaders and government health workers xxxiv because they were directly involved or concerned in community participation and development in their communities. A structured questionnaire schedule containing 2 sections was used to elicit information from respondents. Section A contains 10 questions related to knowledge of health issues and physical development health projects implemented. Section B contains Attitude questions related to community participation in Health related matters. One hypothesis was stated thus: knowledge of health affects the attitude of the indigenes’ participation in health care services. The Pearson product moment correlation was used in analysis of data. The study revealed a dismal basic knowledge of health matters and significant negative attitude towards participation in health care services by indigenes of Ethiope East Local Government Area. The study recommended that the state government should encourage partnering with non-government organizations in raising health awareness in the local government area through handbills, bill-boards, and so on. In another study by Abiodun & kolade (2006) to find out the rural people’s perception of health care service quality in the rural health centres, three villages in a local government in South Western part of Nigeria were used. 200 respondents were selected using a purposeful sampling which excludes teenagers 17 years and under. Questionnaire was the main instrument employed for gathering data for this study. It was made up of 8 questions. A total of 183 questionnaires were duly completed and returned. Using correlation coefficient as instrument of analysis, the study found among others that there are more female partners of health centres that male. This is probably because of female utilizing facilities because of theirs and their children care. Omotoso (2006) investigated the relationship between health and rural poverty in Ekiti State. The study was carried out in the rural areas of Ekiti State, and data were collected from the sampled areas for both quantities and qualitative analysis. Data for the study were collected from both primary and secondary sources. A total 1500 copies of questionnaire were distributed while 1257 copies were retrieved and these analyzed. The result of the study indicated that the majority of the health patrons were low income earners, and most of them cannot meet their health needs in established medical centres, consequently they resort to self medication. It also showed that majority of rural inhabitants were engaged in peasant and subsistence activities, all these are indirectly affecting their health status. The study also found that most of rural dwellers meet their health need through self medication. xxxv
Adepoju (2005) carried out a comprehensive study to find out the attitudes and perceptions of urban and rural dwellers to traditional medical practice. The study was in three phases. The first phase was an in-depth interview. This was followed by the focus group discussion (FGD) and finally the structured questionnaire. The preliminary result of in-depth interview provided information for preparing the FGD instrument, while the results of both in-depth interview and focus group discussion were used to prepare for the structured questionnaire. The population of the study consisted of people of lbarapa local government area of Oyo State. The area was used to compare the urban centre. An eligible household has an adult member over 18 years who must be resident in the household selected. The data revealed that the majority of the respondents (75%) in the urban area were educated (Formally) while about 25% were illiterate. In rural area the respondents had formal education while about 44% were illiterate. The respondents in both areas indicated that the types of traditional medical practice include bone- setters, herbalists, and traditional birth attendants. About 44% of the respondents in the urban centre showed preference towards TMP while about 56% were against it. In the rural area about 61% preferred traditional medicine leaving only about 36% who preferred orthodox medical practice. The chi-square analysis showed that a significance difference exist in the perception and attitudes of rural and urban dwellers to traditional medical practice in Nigeria. The study concluded that since the cultural belief system of the people especially in rural areas still plays a major role in their health behavior and/or therapeutic choice, adequate and effective public health education programme must be embarked upon to effectively neutralize the effect of cultural beliefs on therapeutic choice. The study equally observed other practices such as user changes which tend to discourage people in the rural areas in using health care facilities; women status especially in many communities where house-wives remain subservient to their husbands. Cornish and Ghosh (2007) carried out a study on contradictions of community – led health promotions in HIV prevention in an Indian Red Light District. The Study observed the Songachi project’s participation activities and conducted 39 interviews with a range of people including sex worker employees and their clients (The Songachi project is led by sex workers); health and development professionals; and brothel managers. The researchers looked at the unequal social relations that exist in the local community and how the project engaged with them . xxxvi
The researchers found that relationships with non – sex worker interest groups have a strong influence on the project. Other findings of the study include: Health and development professionals play leading rules, mediating between sex workers and funding agencies, settling up systems for documenting work and ensuring accountability; sex workers took on supervisory and leadership roles as they acquired the necessary skills. The study suggested that funding agencies high expectations of community participation may not be realistic and may also discourage community projects from acknowledging certain dilemmas they face. The study therefore recommended that much time and effort are needed to build the skills of marginalized groups so that they can take initiatives. Moreover, practitioners, project evaluators and policy makers should take into account unequal power relations existing in the communities, rather than denying that they exist. It is only by addressing the problem of such inequalities that the ordinary people will be encouraged to participate actively in issues that affect them. In another study in Nepal by Pokhrel (2005) of the University of Heidelberg, Germany, to find out the extent to which gender influences child health care. It considers four stages of a health seeking action including reporting of illness; choosing external care; choosing a health care provider; and spending money on treatment for the ill child. Gender was found to be a factor in all four stages. While a boy only marginally affected the reporting of illness, it played a stronger role in choosing external care as well as public provider and money spent with private health providers. Further, findings included: a boy was 15 percent more likely to be reported ill than a girl irrespective of the family’s income; for a boy, the likelihood of external care being sought was 42 percent higher than for a girl, boys were 43 percent more likely to be taken to the public health care provider than girls; and householders spent more money with private health providers for a male child. Hurst and Nader (2006) carried out a study to gain preliminary Knowledge about issues identified by native health investigators who would encourage greater communities’ involvement in indigenous health programmes and research in Canada, Pacific Rim, and the United States. Thirty-six health professionals from rural and urban health centres participated which resulted in 10 groups and four individual interviews. Subjects included programme managers, clinical physicians, and health researches. Approximately 58% of the subjects self – identified as indigenous. They xxxvii study found that (i) integration of cultural values of family and community into health provision; (ii) emphasis on health education and prevention programmes for indigenous youths; and (iii) indigenous recognition and self – determination in health delivery and research. The study concluded by stating that to improve and promote community involvement in primary health programmes and services for indigenous people involves a long-term social and political commitment to health protection on a national and international level, as well as the understanding that research methodologies and health interventions must explicitly involve actually appropriate values and behavious that are implemented by indigenous people. , Metiboba (2010) investigated the impacts of community participation efforts on the various health goals in O-kun Yoruba of Kogi state, Nigeria. Data for the study were generated mainly through multi-stage sampling technique, by the use of questionnaire administrated to 250 respondents randomly selected from 7 communities in O-kun land of Kogi state, Nigeria. Techniques of data analysis were mainly by the use of non-parametric statistics which included simple frequency distributions, sample means and percentage values from opinion information derived on the Likert 5- point scale. The findings of the study mainly show that community participation in the study area had greatest impact in the area of immunization as the areas of health goals identified in the communities studied. The study also revealed the predominance of infective and parasitic diseases which especially plague the younger population in the study area must have accounted for the people’s maximum participation in immunization. The study therefore recommended that government and all stakeholders in health should take cognizance of the fact that people who live in the rural areas are rational beings who must be treated as such. The World Health Organization (WHO) in collaboration with UNICEF (1990) carried out a study on community financing of health services for the improvement of primary health care in Asante province of Ghana. The study employed a longitudinal design that spanned over ten years. The population consisted of community leaders, health workers, and segment of the population proportionally selected from the various districts in Asante. The study found that communities participate in the funding of health services especially in the area of building of hospitals and clearing of environment. Government and donor agencies take the bulk of responsibility in the xxxviii financing of community health. The study also found that conflict often arose over the issue of revenue which communities claim are never reported to them. Summary of Literature Review Literature was reviewed on conceptual framework. Concepts such as primary health care, community participation and community involvement were explored. The PHC was adopted to enable people take responsibilities tor their own health since health care will be community based. Community participation is a concept that promotes a more people- centered approach to development intervention while community involvement is a process by which partnership is established between the government and local communities in planning implementation and utilization of health activities. The key components of CIH programme are planning, implementation and utilization. Under the conceptual framework also reasons behind CHI and demographic factors associated with CIH programmes provision and utilization were explored. The theoretical framework considered some models of community development. The models include The Top Down Model, which dominated developmental thinking prior to 1970; the Alternative Development Model which proposed people –centered approach to development and encourages people participation; The Urban Development Model; and Integrated Rural Development Model. The Alternative Development model appears to favour the concept of CIH programmes The third aspect of the review dwelt on empirical study on community involvement in health programmes. Works reviewed included Ewhrudjakpor &Ojie (2005), Abiodun & Kolade (2006), Omotoso (2006), Adepoju (2005), Cornish & Ghosh (2007), Pokhrel (2005), Hurst & Nader (2006), Metiboba (2010), and WHO & UNICEF (1990). From the studies reviewed, the researcher discovered that community involvement in health programmes is very important in achieving the Millennium Development Goals on health. It will also contribute to economic growth as health is a correlate of economic development From the literature review, the researcher discovered that related works have been done in the area of CIH such as indigenous participation in health care service in Ethiopia East local Government Area, Delta state, community involvement in health and Rural poverty in Ekiti state Nigeria; and health care service quality in the rural health centres and its impact on Nigerian citizens, a case study of Ibarapa Local xxxix
Government Area of Oyo State. Strikingly nothing has been done on community participation or involvement in health care programmes for communities in Anambra State. Based on this, the researcher picked interest to carry out this study in order to bridge the yawning gaps which include: extent of involvement in planning, implementing and utilization of preventive, promotive and curative health care programmes in Umunze, Anambra State. In order to do justice to this, the study will be anchored on the following theories: the Alternative Model and the Integrated Development Model of development. The choice is premised on the ever changing view on development which at the moment de-emphasizes the top-down paradigm. CHAPTER THREE
Methods This chapter presents the general methods and procedure the researcher used in carrying out the study. It discusses the research design, population of the study, sample and sampling techniques, instrument for data collection, validity of the instrument, reliability of the instrument, methods of data collection and data analysis. Research Design The type of research design used in the study was a cross-sectional survey design. According to Anaekwe (2007) it is one in which a group of people or items is studied by collecting and analyzing data from only a few people or items categorized and considered to be representative of the entire group. The study involves collection of data at one short for the purpose of describing them. This design was used because there is the need to establish the extent of involvement of Umunze community in the three component areas of health programmes, i.e. planning, implementation and utilization. Similar study by Metiboba (2010) adopted a cross sectional survey design to investigate community participation on the various health goals in O-kun Yoruba in Kogi State, Nigeria Area of Study The area of study was Umunze, Orumba South Local Government area, Anambra State. Umunze comprises seven villages namely Nsogwu, Ugwunano, Lomu, Ubaha, Amuda, Ururo/Umucheke and Ozara. Umunze is situated at the centre of Orumba North, Umunnochi, Ideato Okigwe. Umunze is the headquater of Orumba South Local Government Area. Population for the Study xl
The population for the study comprised four qualified nurses/midwives and twenty-two Community Health Extension Workers (CHEWs) working in the various health centres and health posts in Umunze as well as 37,409 adult population in Umunze (Orumba South LEEDS Document, 2006) . Sample and Sampling Techniques. The sample consisted of the 26 health partitioned (four qualified nurse/midwives and 22 (CHEWs) and 300 adult members of Umunze Community selected across the seven villages using proportionate stratified random sampling. In Ugwunano, with population of 10,009, 40 males and 40 females were sampled. From Lomu village with population size of 6218, 25 males and 25 females were selected. In Ubaha village, 28 male and female adults were selected from a population of 7118. Nsogwu had population size of 4212 and 17 male and female adults apiece were selected. Amuda with population of 4115 contribute 16 male and 17 female to the sample. Ururo / Umucheke village with a population of 1618 had 7 male and 8 female adults in the sample; while Ozara village with population of 4200 had 17 male and 16 female adults drawn from it thus, from a total population of 37,470 across the villages in Umunze 150 male and 150 female adults, making up 300 respondents, were sampled. Instrument for Data Collection The instruments used for data collection were a structured questionnaire and interview schedule. The questionnaire consisted of two parts (A and B). The part A sought information about respondents’ sex, village and age bracket. The part B comprised five ( 5 clusters), each addressing a particular research objective. For each item in the cluster, there were five options as follows: Very great Extent (VGE), Great Extent (GE), Moderate Extent (ME), Little Extent (LE), No Extent (NE ) The point for the options ranged between 3 and 0 in that order. The cluster one sought information on extent of involvement of Umunze community in preventive health programmes, the second cluster was on promotive health programmes, while the third was on curative health programmes. The reasons behind community involvement and agencies behind community health programmer were the aspects of the fourth and fifth clusters. A key informant’s interview (kill) schedule was also developed to obtains information from community health workers, community leaders and relevant xli agencies. Questions were developed to address involvement in preventive, primitive and creative health programmes as well as reasons for involvement. Validation of the instrument. The draft questionnaire and the interview schedule were taken to experts in Health Education and Measurements and Evaluation for validation. Two experts in Health Education and one in Measurement and Evaluation all from the University of Nigeria Nsukka. They were requested to study the items and assess the suitability of the language, adequacy and relevance of the items in addressing the research questions bearing in mind the purpose of the study. Their corrections and comments be used to modify the questionnaire. Based on their corrections the final version of the instrument be structured to ensure face validity Reliability of the instrument. In order to determine the reliability of the instrument, trial study was carried out using seven health workers and thirty members of Ezira Community in Orumba South local Government Area, Anambra State. Crombach Alpha was used to find out the internal consistency of the items, Crombach Alpha was used to find out the internal consistency of the items. This yielded index of .82 which the researcher considered high enough for the study. Anaekwe (2007) stated that Crombach Alpha formula is used in determining the reliability of an instrument when the items are not dichotomously scored. He further stated that the nearer a correlation is to 1.00, the higher the reliability of the result and the better the instrument. Method of Data Collection The researcher employed the services of five research assistants who helped her administer questionnaire on the respondents. The research assistants were trained on how to convince the potential respondents to respond to the questionnaire as objectively as possible as well as how to collate the completed questionnaire with regard to the various variables of interest such as, village of respondents, gender, age, and so on. Method of Data Analysis The data generated from the field study on research questions 1 to 3 were analyzed using the mean (x) on a 5 point scale as follows: 2.5 – 3.00 Very great Extent (VGE) 2.00 – 2.49 Great Extent (GE) 1.50 – 1.99 Moderate xlii
1.00 – 1.49 Little Extent (LE) 000 – 99 No Extent (NE) The mean of a 5 – points scale is obtained thus: Sum of the points = 3+2.5+2+1.5+1 = 10 = 2.00 No of points 5 5
It follows therefore that any item with mean score of 2.00 and above was acceptable extent while any item with mean score below 2.00 was rejected unacceptable extent. Research questions 4 and 5 were analyzed by the use of simple percentage obtained by dividing the frequency of each category by the total number of the frequencies and then multiplying the quotient by 100. The questions 6,7, and 8 were analyzed using the mean ( ) and standard deviation (SD). The hypothesis one was tested using t-test, while hypotheses two and three were tested with Analysis of variance (ANOVA).
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CHAPTER FOUR Results and Discussions This chapter presents the results of the study. The data were presented on the eight research questions and three null hypotheses which guided the study. Means and standard deviation were used in analyzing research questions 1 to three while percentage was used for questions 4, 5 and 8. The hypothesis one was tested using t-test, while hypothesis two and three were tested with Analysis of variance (ANOVA). Research Question One What is the extent of community involvement in preventive health programmes in Umunze? Data used in answering their research questions are contained in table 1. Table 1 Mean Ratings of Umunze Community on Extent of Involvement in Preventive Health Programmes in Umunze. (n = 313) S/N0 ITEMS X 1 Involvement in health committees meetings where issues for 1.65 preventive health are planned 2 Work closely with community health workers (CHEWs) to 1.73 plan safer sanitation and environmental health. 3 Use local medium like the town criers to announce dates for 2.90 health programmes such as immunization. 4 Hold meetings to inform villagers on ways to implement 2.10 health programmes such as sanitation 5 Immunize children and pregnant women against diseases. 2.97 6 Utilize the primary health care advice on prevention of 1.90 diseases.
7 Use safety nets and other measures to prevent malaria 2.04 Cluster Mean 2.18
Table 1 shows that items 3 and 5 had mean scores of 2.90 and 2.97 respectively, indicating that Umunze community were involved in this item to a very great extent. The table further shows the mean scores of 2.10 and 2.04 for items 4 and 7 respectively indicating that the community was involved in these items activities to a great extent. The table also shows that mean scores of 1:65, 1.73 and 1.90 for items 1,2 and 6 implying that the community were involved in these activities to moderate extent. Overall, the table shows a xliv
mean value of 2.18 which means that Umunze community was involved in preventive health programmes to a great extent. Research Question Two What is the extent of community involvement in promotive health programmes in Umunze ? Data used in answering their research questions are contained in table 2.
Table 2 Mean Ratings of Umunze Community on Extent of Involvement in Promotive Health Programmes in Umunze (n = 313)
S/N ITEMS X 8 Plan for community health through awareness 1.00 campaign 9 Proving measures to promote healthy living among 1.08 citizens 10 Set aside time to promote campaign for healthy living 1.03 11 Provide community resources for promotion of health 1.97 programmes 12 Utilize the various promotive health progrmmes for 1.49 the good of the community e.g. promotion of environmental sanitation 13 Use knowledge gathered from health programmes to 1.74 promote healthy lifestyle . 1.23 ClusterMean
Table 2 shows mean values scores of 1.74 and 1.97 for items 13 and 11 respectively. This implies that Umunze Community was involved in these items to a moderate extent. The table further shows the mean values of 1.44 for items 12, indicating that the community was involved in this promotive activity, to a little extent. Data in the table also shows mean value of 1.00,1.03, and 1.08 for items 1, 2 and 3 respectively, indicating that the community was involved in these promotive health programmes to a little extent. The table also shows an overall mean score of 1.23 indicating that Umunze Community participated in promotive health programmes to a little extent.
Research Question Three xlv
What is the extent of community involvement in curative health programmes in Umunze? Data used in answering their research questions are contained in table 3. Table 3
Mean Ratings of Umunze Community on Extent of Involvement in Curative Health Programmes in Umunze (n = 313)
S/N0 ITEMS X 14 Organization for the provision of health facilities in the locality 2.57 15 Applying for deployment of health personnel in the health centres 2.63 16 Administer first aid on patients 2.94 17 Provide alternative care for certain ailments, e.g. bone setting, 2.54 burns healing. 18 Make use of health facilities for the cure of diseases 2.51 Cluster Mean 2.69
Table 3 shows that the mean values of the items 14 to 19 are between 2.50 and 3.00 which implies that Umunze Community, 15 involved in curative health programmes to a very great extent. Items 16 and 19 had mean scores of 2.94 and 2.92 respectively. Item 15 was rated 2.63; which items 14 and 18 received mean scores of 2.57 and 2.51. The overall mean rating of 2.69 indicated that the community is involved to a very great extent in curative health programmes in Umunze.
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Research Question Four What are reasons behind the extent of Community Involvement in health programmes in Umunze? Data used in answering their research questions are contained in table 4. Table 4 Percentage Distribution of Respondents on Reasons Behind Community Involvement in Health Programmes in Umunze (n = 313) REASON f % a. Awareness of health needs 205 65.50 b. High level illiteracy 102 32.59 c. Over- dependency on cultural practices 32 10.22 d. Inadequate health facilities 199 63.58 e. Uncooperative attitude of health workers 61 19.49 f. Lack of confidence in health workers 4 1.28 G Female care giver in the family 202 64.54 h. Availability of qualified personnel 292 93.29 i. Absence of spirit of self help 0 0 j Any other (specify) 0 0
Table 4 shows that majority of the respondents perceived that availability of qualified personnel (93.2%), awareness of health needs (65.5%), female care giver in the family (64.54%) and adequacy health facilities (63.58%) are the majority reasons behind community involvement in health programmes. Other reasons included high illiteracy live (32.59%), uncooperative attitude of health workers (19.49%) and over dependency on cultural practices (10.22).
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Research question five What are agencies/ agents behind community involvement in health programmes in Umunze? Data used in answering their questions are contained in table 5.
Table 5: Percentage Distribution of Responses on Agencies/ Agents Behind community involvement in health programmes in Umunze (n = 313)
Reasons f %
a. Town Union 299 95.53 b. Village heads 301 96.17 c. Women Organization 199 63.58 d. Village health committees 37 11.82 E Age grades 0 0 f. The church 167 53.35 G Social clubs / NGOs 122 38.98 h. Public spirited individuals 188 60.06 i. Citizen Association in diaspora 279 89.14 J Kindred/wards 292 93.29 K Any other (specify ) 0 0
Table 5 shows that majority of the respondents believe that village heads (96.17%), town Union (95.53%), kindred/wards (93.29%), citizen associations in Diaspora (89.14%), women organizations ( 63.58%), public spirited individuals (60.06%) and the church (53.35%) are the agencies/agents behind community involvement in health programmes in Umunze. Other reasons were social clubs/NGOs (38.98%) a Village health communities (11.82%). Age grades (0%) are not behind community involvement in health care programmes.
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Research Question 6 What are gender differentials in community involvement in health programmes in Umunze community? Data answering the above question are contained in Tables 6,7 and 8.
Table 6 : Gender Differentials in community involvement in preventive Health Programmes in Umunze ( N= male -150; Female : 163 )
S/N Items Male Female ( N=150 ) (n= 163) X X Involvement in health committees meeting where Issues for preventive health are planned 1.55 0.88
Work closely with community health workers (CHEWs) to plan safer sanitation and Environmental health. 1.70 1.82
Use local medium like the town criers to Announce dates for health programmes such As immunization. 2.55 2.40
Hold meetings to inform villagers on ways to mplement health programmes such as Sanitation. 2.10 2.13
Immunize children and pregnant women Against diseases . 2.92 2.94
Utilize the primary health care advice on Prevention of diseases. 2.82 2.15
Use safety nets and other measures to prevent Malaria. 2.04 2.80
Cluster mean: 2.24 2.27 xlix
Table 6 shows that the male mean value for item 5, 6, and 3 were 2.92, 2.82 and 2.55 respectively which indicate that they participate in those items to a very great extent. Item 4 and 7 were rated 2.10 and 2.04 respectively which shows they participate in those items to a great extent. They also participate in items 3 (2.55) and 1 (1.55) to moderate extent. The female mean ratings for items 5 and 7 were 2.94 and 2.80 respectively which indicates participation to a very great extent. Items 3, 6 and 4 received mean scores of 2.40, 2.15 and 2.13 which show they participate in those items to a great extent. Items 2 and 1 were rated 1.82 and 1.65 which indicate participation to a moderate extent. The overall mean scores for male and female were 2.24 and 2.27 respectively which shows that they both participate in preventive health programmes to a great extent.
Table 7 Gender Differentials in promotive Health Programmes in Umunz S/N Items Male Female (n=150) (n=163) X l
Plan for community health through Awareness campaign . 0.90 1.00
Proving measures to promote health Living among citizens. 1.05 1.25
Set aside time to promote campaign For healthy living. 1.02 1.05
Provide community resources for Promotion of health programmes. 1.92 1.97
Utilize the various promotive health Programmes for the good of the Community e.g. promotion of Environmental sanitation. 1.49 1.55
Use knowledge gathered from health Programmes to promote healthy Lifestyle .74 .83 Total 1.19 1.28
Table 7 shows that the male had mean scores of 1.92 for item 11 which shows they participate in that item to a moderate extent. They also had mean scores of 1.49, 1.05 and 1.02 for items 12, 9, and 10 which indicate participation to a little extent. Items 8 and 13 had mean scores of 0.90 and 0.74 respectively which indicate participation to no extent. The mean scores for the female in items 11 and 12 were 1.97 and 1.55, which show participation to a moderate extent. Items 9, 10, and 8 had mean scores of 1.25, 1.05, and 1.00 respectively which indicate participation to a little extent. Item 13 had mean score of 0.83, which show participation to no extent. The overall mean scores for male and female were 1.19 and 1.28 respectively which implies participation in promotive health programmes to a little extent. Table 8 Gender Differentials in Curative Health Programmes in Umunze.
S/N Items Gender Male Female li
(n=150) (n=163)
14 Organization for the provision of Health facilities in the locality 2.57 2.84
15 Applying for deployment of health Personnel in the health centers. 2.61 2.68
16 Administer first aid on patients. 2.94 2.97
17 Provide alternative care for certain Ailment e.g. bones setting, burns healing. 2.52 2.54
18 Make use of health facilities for the cure of diseases. 2.51 2.6
19 Make use of health facilities for antenatal and maternal care. 2.80 2.92 Total 2.66 2.76 Table 8 shows that both male and female gender participated in all the items to a very great extent . Item 14 had mean scores of 2.57 and 2.84 for male and female respectively, while item 15 recorded mean scores of 2.61 and 2.68 in that order. Items 16 and 17 had scores of 2.94, 2.97, 2.52 and 2.54 respectively. For items 18 and 19, 2.51 and 2.80 were mean scores for male while 2.6 and 2.92 were recorded for female. The overall mean scores of 2.66 for male and 2.76 for female imply participation in curative health programmes t a very great extent.
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Research Question 7 What are age differentials in community involvement in health programmes in Umunze. Data answering the above research question are contained in tables 9, 10 and 11. Table 9 Age Differentials in Community Involvement in Preventive Health Programmes in Umunze. S/N Items Ag differential s 18-25 26-35 36-45 46-55 56-65 66+ (n=51) (n=40) (n=85) (n=92) (n=25) (n=20) X X X X X X
Involvement in health committees Meetings where issues for preventive Health are planned. 1.56 1.70 2.10 1.82 1.80 2.00
Work closely with community Health workers. (CHEWs) to Plan safer sanitation and environ- mental health. 1.70 1.85 0.95 1.85 1.81 1.45
Use local medium like the town Crier To announce dates for health Programmes such as immunization. 1.55 1.62 1.82 1.99 1.91 1.39
Hold meeting to inform villagers On ways to implement health Programmes such as sanitation. 2.00 1.80 1.99 1.94 2.00 1.41
Immunize children and pregnant Women against diseases. 2.01 1.55 1.93 1.95 2.1 1.55
Utilize the primary care advice on Prevent of diseases. 1.70 1.50 1.80 1.80 2.11 1.50 use safety nets and other Measures to prevent malaria. 1.85 1.60 1.56 1.69 2.19 1.49
Cluster mean 1.77 1.66 1.88 1.86 1.99 1.54
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Table 9 shows that the overall mean scores of the various age brackets (18-25, 26-35, 36 – 45, 46 -55, 56 – 65 and 66+) were 1.77, 1.66, 1.88, 1.86, 1.99 and 1.54 respectively. These implies that they participate in preventive health programmes in Umunze to a moderate extent.
Table 10 Age Differentials in Community Involvement in Promotive Health Programmes in Umunze.
S/N Items Ag differential s 18-25 26-35 36-45 46-55 56-65 66+ (n=51) (n=40) (n=85) (n=92) (n=25) (n=20) X X X X X X
8 Plan for community through awareness Campaign. 1.61 1.42 1.85 1.73 2.11 1.35
Providing measures to promote healthy among citizens. 1.63 1.05 0.90 1.80 1.99 1.82
10 Set side time to promote campaign Healthy living. 1.70 1.61 1.91 1.99 2.00 1.84
11 Provide community resources for Promotion Health programmes . 1.71 1.71 1.93 2.00 2.05 1.60
12 Utilize the various promotive health Health programmes for the good Of the community e.g. promotion of Environmental sanitation. 1.82 1.82 1.99 2.00 2.11 1.41
13 Use knowledge gathered from Health programmes to promote Healthy lifestyle 1.61 2.00 1.68 2.10 2.10 1.51
Cluster mean 1.68 1.60 1.88 1.94 2.06 1.59
Table 10 shows that the overall mean scores of the various age brackets ( 18 – 25, 26 – 35, 36 – 45, 46 – 55 and 61+) were 1.68, 1.60,1.88, 1.94 and 1.59 respectively, which indicate they participate in promotive health programmes in Umunze to a moderate extent. The age bracket (56 – 65) had overall mean score of 2.06 which implies participation to a great extent.
Table 11 liv
Age Differentials in Community Involvement in curative Health Programmes in Umunze. S/N Items Ag differential s 18-25 26-35 36-45 46-55 56-65 66+ (n=51) (n=40) (n=85) (n=92) (n=25) (n=20) X X X X X X 14 Organization for the provision of Health facilities in the locality. 2.00 2.10 1.41 2.45 2.11 1.50
15 Applying for deployment of health personnel in the health centers. 2.05 1.92 1.83 2.03 1.98 1.48
16 Administer first aid on patients 2.60 1.99 1.82 2.15 1.99 1.90
17 Provide alternative care for certain aliments e.g. bone setting, burns healing . 2.08 1.85 1.85 2.11 1.61 1.91
18 Make use of health facilities for the cure of diseases. 1.76 1.75 1.90 2.05 1.73 2.00
19 Make use of health facilitates for antenatal and material care 1.90 1.80 1.66 1.99 1.40 1.99
Cluster mean 2.07 1.98 1.75 2.13 1.80 1.80
Table 11 indicates the overall mean scores of the age brackets (46 – 55 and 18 – 25) were 2.13 and 2.07 which imply participation in curative health programmes to a great extent. The age brackets (26-35, 36 – 45, 56 – 65 and 66+) had mean scores of 1.98, 1.75, 1.80 and 1.80 respectively which indicate participation to a moderate extent. Research Question 8
What are relative involvements of the various Umunze Villages in health programmes? Data answering the above research questions are contained in tables 12, 13 and 14. lv
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Table 12 shows that the overall mean values for Ugwunano and Amuda were 2.03 and 2.05 respectively. This indicates that the two villages were involved in preventive health programmes to a great extent. Other villages (Lomu, Ubaha, Nsogwu and Ururo/Umucheke) had mean scores of 1.81, 1.94, 1.87, and 1.85 respectively which show involvement to a moderate extent. Ozara village had overall mean score 1.47 which implies involvement in preventive health programmes to a little extent. lvii
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Table 13 indicates that Ugwunano, Ubaha, Amuda and Ururo/Umucheke villages had the following overall mean scores: 2.10, 2.07, 2.02, and 2.10 respectively. These show that they were involved in promotive health programmes to a great extent . Lomu, Nsogwu and Ozara had overall mean scores of 1.49, 1.79 and 1.46 respectively. These show that the three villages were involved in promotive health programmes to a moderate extent. lix
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Table 14 above show that Ugwnano and Amuda had overall mean scores of 2.03 and 2.06 respectively which imply that they were involved in curative health programmes to a great extent. Other villages (Lomu, Ubaha, Nsogwu , Ururo/Umucheke and Ozara) had overall mean scores of 1.82, 1.97, 1.74, 1.86 and 1.61 which indicate that they were involved in curative health programmes to a moderate extent.
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Hypothesis One There is no significant difference in the extent of community involvement in health programmes according to gender. Data verifying the above hypothesis are presented in Table 15 Table 15 T-test of difference between male and female community merit on involvement in health programmes. Gender X S.D N DF t- cal t.crit Male 2.03 0.81 150 311 0.10 1.960 Female 2.10 0.89 163
Table 15 shows that the calculated t-value was 0.10 and the table value 1.960 at .05 level of significance with 311 degrees of freedom (df = 317, 0.10 { 1.960,(P .05). This shows that there was no significant difference in extent of community involvement in health programmes according to gender. Therefore the null hypothesis was accepted. The result shows that all although difference exists between gender in involvement in health programmes, this difference is not significant.
Hypothesis Two There is no significant difference in the extent of community involvement in health programmes according to age. Data testing the above hypothesis are presented in Table 16. Table 16 t-ratio of difference in community involvement in health according to age. Sources of Sum of Degrees of Variation Variation Squares Freedom Estimate F- crit F crit Between 374.64 5 74.93 21.97 3.02
Within 368.16 108 3.41 38.50 2.09
l 742.80 113
Table 16 above shows that the calculated f- value (21.97) is greater than the table value of 3.02 at 5 and 108 degrees of freedom at .05. Alpha level. The null hypothesis is therefore rejected. This implies that a significant difference exist in the extent of community involvement in health programmes according to age. lxii
Hypothesis Three There is no significant difference among the Umunze villages in the extent of their relative involvement in health programmes Data testing the above hypothesis are presented in table 17.
Table 17: F- ration of Relative involvement of Umunze villages in community Health Programmes. Sources of Sum of Degrees Variation F cal F crit Variation Squares Freedom Estimate
Between 4.64 6 0.77
Within 2.34 127 0.02 38.50 2.09
Total 6.98 133
Table 17 shows that the calculated f- value (38.50) is great than critical (table) value (2.09) for 6 and 127 degrees of freedom (df) and .05 level of significance. The null hypothesis therefore rejected. This results showed that there is significance difference among Umunze village in their relative involvement in health programmes.
Summary of the Major Findings
The major findings of the study are summarized as follows: 1. Umunze Community was involved in preventive health programmes to a great extent (x = 2.18). 2. Umunze Community participated in promotive health programmes to a little extent (x = 1.23). 3. Umunze Community was involved in curative health programmes to a very great extent (x=2.69). 4. Availability of qualified health personnel, awareness of health needs, presences, presence of female caregiver and inadequate health facilities are mostly reasons behind community involvement in health programmes in Umunze. 5. Agencies/agents behind community involvement in health programmes in Umunze were mainly town union, village heads kindred/wards, citizen associations in diasporas, women organizations and public spirited individuals. lxiii
6. Females are more involved (2.27) than male (2.24) in preventive health programmes in Umunze. Both are however are involved to a great extent. 7. Males were involved in promotive health programmes to a little extent (1.19) while females were involved to No extent (.84) 8. Males (2.66) and females (2.76) are involved in curative health programme in Umunze to a very great extent. 9. All the various age groups were involved in preventive health programmes in Umunze to a moderate extent. 10. All but age group 56 - 65 were involved in promotive health programmes to a moderate extent. The age group 56-65 was involved to a great extent. 11. Age groups: 18-25, and 46-55 were involved in curative health programmes to a great extent.while other age groups:25 – 35, 36 – 45, 56-65 and 66+ were involved in curative health programmes to a moderate extent. 12. Ugwuano and Amuda were involved in preventive health programmes to a great extent. Lomu, Ubaha, Nsogwu, and Ururo/ Umucheke were involved to a moderate extent while Ozara Village was involved to a little extent. 13. Ugwuano Ubaha, Amuda and Ururo/ Umucheke Villages were involved in promotive health programmes to a great extent while Lomu, Nsogwu and Ozara villages were involved to a moderate extent. 14. Ugwuano and Amuda villages were involved in curative health programmes to a great extent while other villages were involved to a moderate extent. 15. There was significance difference in the extent of community involvement in health programmes in Umunze according to gender. 16. There was significance difference in the extent of community involvement in health programmes in Umunze according to age. 17. There was significance difference among Umunze villages in the extent of their relative involvement in health programmes.
Discussion The findings of the study are discussed under the following sub-heading: lxiv
1. Extent of community involvement in preventive, promotive, and curative health programmes in Umunze 2. Reasons behind community involvement in health programmes 3. Agencies behind community involvement in health programmes in Umunze 4. Age/Gender differentials in community involvement in health programmes in Umunze 5. Relative involvement of Umunze villages in health programmes Extent of Community Involvement in Preventive , Promotive and Curative Programmes in Umunze The research question one sought to find out the extent of question involvement in preventive health programme in Umunze. The result of research question one showed that Umunze community involved in preventive health programmes to a great extent. Those areas of preventive health programmes include: Involvement in health committees, working closely with community health, using the town cries to announce dates for health programmes such as immunization. Others are holding village meetings to health issues, immunizing children and pregnant mothers, utilizing the primary health care (PHC) advice on disease prevention and using safety nets and other measure to prevent malaria. The mean score of 2.97 (item 5) is the highest in the table, an indication that immunization of children and pregnant mothers stood out as the highest area of involvement in preventive health programmes. It is also important to note that item 1 had the lowest mean rating of 1.65 on the table. This suggests that although the community is involved in preventive health programmes generally to a great extent, it is involved in health communities ratherly poorly. Based on the analysis in table 1, the cluster mean is 2.18 which far exceeds the 1.50 which is the criterion mean. The conclusion drawn is that Umunze Community is involved in preventive health programmes to a great extent. This finding is in line with the earlier finding by Metiboba (2010) in kogi state. Metiboba (2010) found that community participation in health had the greatest impact on the area of immunization as predominance of disease often lead people to seek ways to prevent them.
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Extent of community involvement in promotive health programmes in Umunze The research Question two sought to find out the extent of community involvement in promotive health programmes in Umunze. The responses to this question were summarized in table 2 in chapter four. The result showed that the only way the community was involved in promotive health was through the provision of community resources for promotive of health programmes. The community did not plan for community health through awareness campaign, providing measures to promote health living among citizens, and did not set aside time to promote campaign for health lifestyle. It also did not utilize the various promotive health programmes for the good of the community or use knowledge gathered from health programmes to promote healthy lifestyle. All but item 11 had mean ratings below the criterion mean of 1.50 required for acceptance. The cluster mean of 1.22 was below the criterion mean of 1.50 required for acceptance. The cluster mean of 1.22 was below the criterion mean and suggests that Umunze community was involved in promotive health programmes to a little extent . The finding of the present study is in line with the earlier finding by Ewhrudiakpor & Ojie (2005). The study found that the indigenes of Ethiope East Local Government Area, Delta state have negative attitude towards participation in health matters. Extent of community involvement in curative health programmes in Umunze The research Question Three dwelt on extent of community involvement in curative health programmes in Umunze. The result were analyze in table 3 in chapter four. The result of this research question showed that Umunze community was involved to a very great extent in curative health programmes. All items attracted very high mean ratings ranging between 2.51 and 2.94. The highest mean rating of 2.94 showed that Umunze community administer first aid on patients. Other activities include organizing for the provision of health facilities in the locality, applying for deployment of health personnel in the health centres, provision of alternative care for certain ailments, e.g bone setting, burns healing, making use of health facilities for the cure of disease and making use of health facilities for antenatal and maternal care. The cluster mean for table 3 was 2.69 and this is far above the criterion mean of 1.50. The findings support the alternative development model which encourages people participation and people- centred approach to health issues.
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Reasons behind Community Involvement In health programmes in Umunze The research Question four focused on reasons behind extent of community involvement in health programmes in Umunze. The result were as analyzed in table 4 in chapter four. The percentage distribution of responses showed that reasons behind community involvement in Umunze included awareness of health needs inadequate health facilities, female care giver in the family and availability of qualified personnel. The finding that awareness of health needs influence community involvement has earlier been Observed in Adepoju (2005). The study found that in the rural communities, public health education programmes is critical in addressing the need gap. Again, adequate health facilities means people resort to alternative measure for their health needs. This findings has been corroborated by Omotoso (2006) while investigating relationship between health and rural poverty. The availability of female care giver in the family encourages greater involvement in health matters. This is because women are closer to the children than men and often area involved directly in children and family health matters. This argument has been sustained in table 5 (item B) and in Table 6 on gender differentials in community involvement in health programmes. Agencies behind community involvement in health programmes in Umunze The research Question five identified agencies/agents behind community involvement in health programmes in Umunze . The results were as analyzed in table 5 in chapter four of this report. Agencies/agents identified by respondents included town union women organizations, village heads, the church public- supirited individuals, citizen association in diasprora and kindred/wards. The highest percentage of 96.17 percent went to women organizations – this suggest that women organizations are most important agency behind community involvement in health care programmes in Umunze. This is followed closely by town union (95.53 percent) and kindred wards (95.53 percent). The finding that women organization play vital role as agency behind community involvement in health programmes has earlier been reported in Abiodum & Kolade (2006). They found that there are more Equally, Metiboba (2010) found that a successful health programmes in the rural area should respect the role of the rural epole in health programmes. Age/Gender differentials in community involvement in health programmes in Umunze community The research Question six sought to find gender differential in community involvement in health programmes in Umunze. The results were reported in table are more males (75.36 percent) than females (24.64 percent) in the planning component of the three aspects of health programmes in the community. Also, In implementation componement, there are more males (66.67 percent) that females (33.33 percent ) in the three aspects of lxvii
preventive promotive and curative health programmes . The female however, dominate the utilization component of health programmes with 75.61 percent leaving the male with 24.39 percent. Findings that male members of the community dominate the programmes in Umunze reflect the cultural context in which male dominates the decision making process whether in the family, community or the larger society. The finding support the earlier work of Adepoju (2005). According to Adepoju (2005) women status especially in many rural communities where house wives remain subservient to their husbands affect women participation in health matters. Age differentials in community involvement in health programme in Umunze The research Question Seven is on age differentials in community involvement in health programmes in Umunze. The result were analyzed in table 1 in chapter four. The results showed that the age group 36-45 years constituted 28.10 percent of total population who was involved. The age group 26-36 years followed with 18-10 percent. Those in age bracket 66 and above had lowest representation at 11.95 percent. The findings suggest that age is an important factor in community involvement in health programmes . Relative involvement of the various Umunze Village in health programmes The research Question eight sought answer to relative involvement of Umunze Village in health programmes. The results were analyzed in table 8 in chapter four. The result showed that involvement in health programmes varies by villages in Umuzne. The highest percentage (32.36) was from Ugwunano village. The lowest, Ozara village was represented by 6.19 perenct. There is clear evidence therefore that involvement in health programmes in Umunze varies according to village.
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CHAPTER FIVE Summary, Conclusions and Recommendations
The study was carried out to investigate the extent of involvement of Umunze Community in community health programmes. Eight (8) research questions and three (3) hypotheses guided the study. Literature relevant to the study was reviewed. A cross-sectional survey design was used and a structured questionnaire and they informants interview were used to obtain data from a total of 326 respondents. Data were analysized using the mean (x), frequency and percentage. The hypotheses were tested using the t-test and Analysis of variance (ANOVA) statistics at .05 level of significance. The following results were obtained: 1. Community involvement in preventive health programmes in Umunze was to a great extent (x – 2.18). 2. Community participation in promotive health programmes in Umunze was to a Little extent (x=1.23). 3. Community involvement in curative health programmes in Umunze was to a very great extent (x = 2.69). 4. Reasons behind CIH programmes in Umunze were availability of qualified personnel (93.2%) awareness of health needs (65.5%), female caregiver in the family (64.54%), in adequate health facilities 63.56% high illiteracy rate (32.59%), and uncooperative attitude of health workers (19.49%) and over dependency on cultural practices (10.22%). 5. Agencies/agents behind CIH programmes were village heads (96.17%), town union (95.53%) citizen associations in diaspora (89.14%), kindred wards (93.29%), women organizations (63.58%), public spirited individuals (60.06%) the church (53.35%), social clubs/NGOs (38.98%) and village health committees(11.82%). 6. Females (2.27) and males (2.24) were both involved in preventive health programmes to a great extent. 7. Males were involved in promotive health programmes to a little extent (1.19). Females were involved to no extent (.84). 8. Males (2.66) and females (2.76) were involved in curative health programmes to a very great extent. 9. Age groups were involved in preventive health programmes to a moderate extent. 10. Age groups except 56-65 were involved in promotive health programmes to a moderate extent. The age group 56-65 was involved to a great extent (2.06) 11. The age groups 18 – 25 and 46-55 were involved in curative health programmes to a great extent (2.07 and (2.13) other were involved to a moderate extent. lxix
12. Ugwuano and Amuda were involved in preventive health programmes to great extent (2.03) and (2.05). Lomu, Ubaha, Nsogwu and Ururo/ Umucheke villages were involved to a moderate extent; while Ozara village was involved to a little extent. 13. Four villages (Ugwuano, Ubaha, Amuda and Ururo/ Umucheke were involved in promotive health programmes to a great extent while three (Lomu, Nsogwu and Ozara) Villages were involved to a moderate extent. 14. In curative health programmes, Ugwuano and Amuda villages were involved to a great extent while the rest were involved to a moderate extent. 15. Significant differences existed in all hypotheses tested. Gender, age and villages were significant factors in community involvement in health programmes in Umunze. Conclusions On the basis of the major findings and discussions, the following conclusions were drawn: 1. The extent of involvement of Umunze Community in preventive health programmes was great. This answers research question one. 2. The extent of involvement of Umunze Community in promotive health programmes was little. This answers research question two. 3. The extent of involvement of Umunze community in curative health programmes was very great. This answers question three. 4. Main reasons behind extent of community involvement in community health programmes were availability of qualified personnel awareness of health needs, female caregiver in the family and inadequate health facilitates. This answers research question four 5. Main community agencies/agents behind community involvement in health programme were village heads, town union, kindred/ ward, citizen associations in diaspora women organizations and public spirited individuals. This answers research question five. 6. There was gender difference in community involvement in health programmes. More females than males were involved in preventive and curative health programmes. More males than females were involved in promotive health programmes. This answers research question six and hypothesis one. 7. Community involvement in health programmes in Umunze differ according to age. The age group 56-65 was most involved in preventive health, 18-25 and 46-55, mostly involved in curative health programmes. This answers research question seven and test hypothesis two. 8. Villages in Umunze differ in their relative involvement in health programmes. Ugwuano and Amuda were mostly involved in preventive and curative health lxx
programmes. They along side Ubaha and Ururo/Umucheke villages were also more involved in promotive health programmes to a great extent. This answers research question eight and test hypothesis three. Recommendations In line with the findings of the present study the discussion and conclusions there-of, the following recommendations were made: 1. The little extent of involvement of the community in promotive health could be influenced by efforts made at preventive and curative components of health programmes. It is hereby recommended that efforts be made through community health education via local and modern media to communicate the need for promotive health programmes to achieve balance in community health. 2. Since agencies/agents involved in community health programmes were part and parcel of the community, there is the need for government to empower these agencies/groups through financial assistance and training to enable them serve as effective middle men in health awareness and dispensation. 3. Gender and age were found to be associated with community health programmes. It is not a surprise that women were more concerned with the issue of health especially as it concerns their children and family. Efforts should be intensified to involve more men in the issues of health. Again, the involvement of elderly age group in preventive health could be out of experience on the need for prevention rather than cure. The younger active age groups who are more predisposed to diseases should be enlightened through seminars and workshops, organized through community agencies/agents on the needs for preventive health programmes. Suggestions for further study The following further studies are suggested: 1. A replication of the study using another community or area. 2. Extent of community involvement in health implementation using traditional methods. Limitations of the Study The study was constrained by a number of problems, outstanding among which are: § The study was restricted to Umunze community Orumba South Local Government Area Anambra State. It may not be ideal to generalize the findings. § The researcher made extra effort to convince respondents to answer the questionnaire. It is not likely therefore that response might be as objective as expected.
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Appendix I Questionnaire
University of Nigeria Nsukka Nigeria
Dear Respondents, lxxvi
EXTENT OF COMMUNITY INVOLVEMENT IN HEALTH CARE PROGRAMMES IN UMUNZE, ANAMBRA STATE I am a postgraduate student of Department of Health Education, University of Nigeria Nsukka. I am carrying out a research study on the above stated topic. This is part of the requirements for the award of Masters Degree in Health Education. You are requested to supply answers to the attached questions to help me carry out the study. You are assured that all responses will be treated with utmost confidentiality. Thanking you for your anticipated cooperation.
Yours sincerely
Okereke, Chinyere
QUESTIONNAIRE
PART A: Please tick as appropriate 1 Sex: Male
Female
2 Village: Ugwunano Lomu Ubaha Nsogwu
Amuda Ururo/Umucheke Ozara lxxvii
3 Age
18 - 25 26 - 35 36 - 45 46 - 55 57 - 65 66 +
PART B Key to options: Very Great Extent (VGE) 3 points Great Extent (VE) 2.5 points Moderate Extent (ME) 2.00 point Little Extent (LE) 1.5 point No Extent (NE) 1 point lxxviii
Please tick (_/) in the appropriate space corresponding to the items of your choice. 4 What is Umunze community extent of involvement in the following preventive health programmes? VGE GE ME LE NE 1 Involvement in health committee meetings where issues for preventive health are planned 2 Work closely with community health workers (CHWs) to plan safer sanitation and environmental health. 3 Use local medium like the town cries to announce dates for health programme such as immunization. 4 Hold meetings to inform villagers on ways to implement health programmes such as sanitation 5 Immunize children and pregnant women against diseases 6 Utilize the primary health care advice on prevention of diseases 7 Use safety nets and other measures to prevent malaria.
What is the extent Umunze community involvement in the following curative health programmes : VGE GE ME LE NE 8 Plan for community health through awareness campaign. 9 Provide measures to promote healthy living among citizens 10 Set aside time to promote campaign for healthy living 11 Provide community recourses for promotion of health programmes. 12 Utilize the various promotion health programmes for the good of the community. Eg 13 Use knowledge garnered from health programme to promote healthy lifestyle `
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What is the extent of Umunze community involvement in the following preventive programme? VGE GE ME LE NE 14 Plan for the provision of health facilities in the locality 15 Plan for the deployment of health personnel in the health centres 16 Administer first aid on patients 17 Provide alternative care for certain ailments eg. 18 Make use of health facilities for the cure of disease 19 Make use of health facilities for antenatal and maternal care.
What is the reason behind the extent of community involvement in health programmes in Umunze.
NB: Tick as may reason (s): as they apply to you.
5. Awareness of health needs
6. High level of illiteracy
7. Over dependency on cultural practices
8. Inadequate health facilities
9. Uncooperative attitude of health workers
10. Lack of confidence in health workers
11. Any other (specify): ……………………………….
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What are the community agencies behind community involvement in health programmes in Umunze Community? Tick as many agencies as they apply to you.
1.) Town Union
2.) Women organization
3.) Village heads
4.) Village health committees
5.) Age grades
6.) The church
7.) Social clubs /NGOs
8.) Public – spirited individuals
9.) Citizen Associations in disposers
10.) Kindred/Wards
Any other (Specify): …………………………………..
Appendix II Key Informants Interview (KII) Schedule. (Community health workers community leaders and community agencies) 1. Involvement in preventive health programmes a. Who plans preventive health programmes in Umunze Community b. Are you always consulted in course of planning health programmes? lxxxi
c. Who implements preentive health programme d. What problems do you experience/ encounter in the process of implementing preventive health progemmes? e. Who usually utilize preventive health programmes in the community? f. How do they utilize it? 2 Involvement in promotive health programmes a. Whose responsibility is it to plan promotive health in the community? b. How successful are these plans? c. What problems do you encounter at the implementage stage ? d. Do the people utilize the benefit of promotive health 3 Involvement in curative health programmes a. Who normaly plans for curative health programmes in your community? b. How do you implement this programme? c. What problems do you normally encounter in the implementation of curative health programmes ? d. How and where do people utilize this programme? 4. Reasons for involvement a. Do you think that the community’s involvement in health programs is encouraging? b. What problems do you think hamper their fill involvement? c. How should the community be motivated for greater involvement? d. What rules do you think the traditional healers play in promoting health programmes in the community?
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Table 12 Relative Involvement of Umunze Villages in Preventive Health Programmes
S/N QUESTIONNAIRE ITEMS VILLAGES IN UMUNZE ITEMS Ugwunano Lomu Ubaha Nsogwu Amuda Ururo/Umucheke Ozara (n=1o1) (n=42) (n=52) (n=36) (n=32) (n=31) (n=19) X X X X X X X 1 Involvement in health committee Meetings where issues for Preventive health are planned. 2.10 2.11 1.85 2.00 1.97 2.10 1.91
2 Work closely with Community Health workers (CHEWs) to plan Safer sanitation and environmental Health. 2.15 1.85 1.94 1.99 2.02 2.1
3 Use local medium like the town criers To announce dates for health program- Mes such as immunization. 2.17 1.86 1.92 1.46 2.15 1.90 1.40
4 Hold meetings to inform villagers On ways to implement health Programmes such as sanitation. 1.99 1.87 1.85 1.72 2.10 1.94 1.31
5 Immunize children and pregnant women against diseases. 2.15 1.67 1.94 1.88 2.14 1.93 1.29
6 Utilize the primary health care advice On prevention of diseases. 1.86 1.55 1.99 1.97 1.99 1.41 1.45
7 Use safety nets and other measures to prevent malaria. 1.79 1.73 2.10 2.10 1.98 1.52 1.49
Cluster Mean: 2.03 1.81 1.94 1.87 2.05 1.85 1.47
78 Table 13: Relative Involvement of Umunze Villages in Promotive Health Programmes
S/N QUESTIONNAIRE ITEMS VILLAGES IN UMUNZE ITEMS Ugwunano Lomu Ubaha Nsogwu Amuda Ururo/Umucheke Ozara (n=1o1) (n=42) (n=52) (n=36) (n=32) (n=31) (n=19) X X X X X X X lxxxiii
8 Plan for community health Awareness campaign . 1.97 1.65 2.10 1.99 2.10 2.18 1.71
9 Proving measures to promote healthy Living among citizens 1.98 1.50 2.11 1.57 1.99 1.88 1.14
10 Set aside time to promote campaing For healthy living 2.00 1.51 1.98 1.65 1.87 2.01 1.28
11 Provide community resources for Health programmes. 2.15 1.61 1.99 1.88 1.99 2.20 1.49
12 Utilize the various promotive health For the good of the community e.g. Promotion of environmental sanitation. 2.18 1.49 2.12 1.9 2.05 2.11 1.51
13 Use knowledge gathered from health Programmes to promote healthy Lifestyle. 2.19 1.19 2.14 1.72 2.11 2.09 1.62
Cluster Mean: 2.10 1.49 2.07 1.79 2.02 2.10 1.46
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Table 14: Relative Involvement of Umunze Villages in Curative Health Programmes
S/ N QUESTIONNAIRE ITEMS VILLAGES IN UMUNZE ITEMS Ugwunano Lomu Ubaha Nsogwu Amuda Ururo/Umucheke Ozara (n=1o1) (n=42) (n=52) (n=36) (n=32) (n=31) (n=19) X X X X X X X lxxxiv
14 Organization for the provision Of health facilities in the locality 2.00 1.88 1.88 1.82 2.11 2.00 1.55
15 Applying for deployment of health personnel in the health centre. 1.99 1.65 2.10 1.70 2.15 1.88 1.60
16 Administer first aid on patients 1.87 1.79 2.20 1.65 1.98 1.95 1.58
17 Provide alternative care for certain Ailments, e.g. bone setting, burns Healing. 2.08 1.80 2.17 1.67 2.00 1.88 1.59
18 Make use of health facilities for the Cure of diseases. 2.10 1.85 1.98 1.77 2.05 1.62 1.63
19 Make use of health facilities for antenatal and maternal care. 2.11 1.92 1.49 1.82 2.06 1.81 1.70
Cluster Mean: 2.03 1.82 1.97 1.74 2.06 1.86 1.61