HEALTH STATUS OF NOMADIC AND SEDENTARIZED FULANI CHILDREN IN DARAZO LOCAL GOVERNMENT AREA, BAUCHI STATE: A COMPARATIVE STUDY
A DISSERTATION SUBMITTED
BY
DR. SOLOMON M. A. THLIZA
DEPARTMENT OF COMMUNITY MEDICINE
JOS UNIVERSITY TEACHING HOSPITAL
JOS, PLATEAU STATE.
TO
THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PART
FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF THE FINAL
FELLOWSHIP OF THE MEDICAL COLLEGE IN PUBLIC HEALTH AND
COMMUNITY MEDICINE.
MAY 2018 DECLARATION
I hereby declare that this project titled ‘Health status of nomadic and sedentarized Fulani children in Darazo Local Government Area, Bauchi State: a comparative study’ is my original work, done under appropriate supervision and that it has not been presented in part or full for any other examination.
NAME: ______SIGNATURE: ______
INSTITUTION: ______
DATE: ______
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CERTIFICATION
We hereby certify that DR. SOLOMON M. A. THLIZA carried out this work titled “Health status of nomadic and sedentarized Fulani children in Darazo Local Government Area,
Bauchi State: a comparative study” under our supervision and it is the original work of the candidate.
______
PROFESSOR A. P. BASSI (MBBS; FMCPH)
SUPERVISOR,
DEPARTMENT OF COMMUNITY MEDICINE AND PRIMARY HEALTH CARE
BINGHAM UNIVERSITY TEACHING HOSPITAL, JOS
______
PROFESSOR M. C. ASUZU (MBBS; FMCPH)
SUPERVISOR,
DEPARTMENT OF COMMUNITY MEDICINE
UNIVERSITY COLLEGE HOSPITAL IBADAN
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ATTESTATION This is to attest that this dissertation, submitted by DR. SOLOMON M. A. THLIZA to the
National Postgraduate Medical College of Nigeria in partial fulfillment of the requirements for the award of Fellowship in the specialty of Public Health was presented to the Department of
Community Medicine, Jos University Teaching Hospital.
______
DR. M. P. CHINGLE
(MBBS; FMCPH; MPH)
HEAD OF DEPARTMENT,
DEPARTMENT OF COMMUNITY MEDICINE.
JOS UNIVERSITY TEACHING HOSPITAL, NIGERIA
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DEDICATION
This dissertation is dedicated to my nomadic brothers and sisters, and indeed to all challenged children in desperate situations across the globe, especially those due to detestation.
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ACKNOWLEDGEMENT
My utmost gratitude goes to my supervisors Professor MC Asuzu, Professor AP Bassi, Professor
A.I. Zoakah and Professor Chikaike Ogbonna for not only taking time to ensure this work comes to fruition but the pain to reorder my steps even when I faltered. I owe them a lot for such tremendous support, encouragement and their patience through the sojourn over the years.
To the head of Department Dr. M.P. Chingle and indeed my charming trainers Dr. (Mrs) O.O.
Chirdan, Dr. J. Daboer, Dr. T. Akosu, Dr (Mrs) M.E. Banwat, Dr (Mrs) E.A. Envuladu, Dr (Mrs)
C. Miner, Dr (Mrs) L. Lar, Dr (Mrs) H. Agbo, Dr T. Afolaranmi, Dr. D. Bello, Dr. (Mrs) Y.
Tagurum, Dr (Mrs) Z. Hassan, Dr. P. Bupwatda my gratitude is beyond expression.
To my tutors in Ibadan; Professor TO Lawoyin, Professor MO Onadeko, Dr. Olumide, Professor
F Omokhodion, Professor F Fawole, Professor E. Owoaje, Professor KO Osungbade, Dr. A
Fatiregun for their valuable grounding at UCH
To Alhaji Abubakar Muazu, who was my supervisor in field experience in public health services and follow up on this study and all the staff, especially PHC Department of Darazo Local
Government Area, Bauchi State who spent valuable time to track the nomads for this study in
Bauchi State, I am also very grateful indeed.
I am very grateful to Drs. Shaahu, Sangowawa, Uchendu, Adebiyi, Balogun, Adewale and
(Funmi Balogun- of blessed memory). I still appreciate your readiness and unique gesture at
Ibadan to help out even at a very short notice. My brothers; Dr. I Jalo, Dr. IS Mdurvwa, Dr. O
Sarki, Dr B Dabu and in no wise the least to my brother Dr. J. Bimba for his support in the data analysis for this study; and resident doctor colleagues and the entire staff of the Department of
Community Medicine, Jos University Teaching Hospital (JUTH) who have shown me undue esteem and unionism during my postings for this achievement
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TABLE OF CONTENTS
TITLE PAGE……………………………………………………………………………………..i
DECLARATION…………………………………………………………………………………ii
CERTIFICATION………………………………………………………………………………..iii
ATTESTATION………………………………………………………………………………….iv
DEDICATION…………………………………………………………………………………....v
ACKNOWLEDGEMENTS………………………………………………………………………vi
TABLE OF CONTENTS………………………………………………………………...……...vii
LIST OF TABLES………………………………………………………..………………………xi
LIST OF FIGURES...…………………………………………………….……………….……. xii
LIST OF APPENDICES...……………………………………………….……………….……. xii
LIST OF ACRONYMS…………………………………………………………………………xiv
DEFINITION OF TERMS.……………………………………………………………………xvii
ABSTRACT…………………………………………………………………………….………xix
CHAPTER ONE: INTRODUCTION
1.1 Background to the study ………………………………………………….………………… 1
1.2 Statement of the problem …………………………………………………………………… 5
1.3 Justification for the study …………………………………………………………………… 9
1.4 Scope of the study ……………………………………………………….…………………. 12
1.5 Contribution of the study to public health……………………………….…………………. 12
1.6 Objectives of the study …………………………………………………...………………… 13
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CHAPTER TWO: LITERATURE REVIEW
2.1: Ethno demography of Fulani as a people……………………………...…………………... 14
2.1.1 Origins and spread of the Fulani...…………………………………………...…………... 14
2.1.2 Culture and rise to political stardom...…………………………………………..…...…... 15
2.2: Health status of children...……………..…………………………………...……………... 17
2.2.1 Definition and dimensions of health...... …...17
2.2.2 Global overview of child health…………………..……………………….………………20
2.2.3 African overview…………………………………………..………………………………21
2.2.4 Nigerian overview…………………………………………………………...……….……23
2.3: Factors affecting health status of children………………………………...….……….…….26
2.3.1 Nutritional status……………………………………….…………………………….…….26
2.3.2 Immunization status of the child………………………………………………………..….33
2.3.3 Morbidity status of nomadic and sedentarized Fulani children…….……………...…...….39
2.4 Factors influencing the health status of nomadic and sedentarized Fulani children...….……41
2.4.1 Access to health care and social services………………………………...…………..…….41
2.4.2 Safe potable water and sanitary waste disposal………………………….…………..…….47
2.4.3 Educational and socio-economic status of families………………..…………………..…..48
2.4.4 Ecological factors-drought and desertification…………………….…………………..…..50
CHAPTER THREE: METHODOLOGY
3.1 Background of the Study area……………………………………………………..………...53
3.2 Study design………………………………………………………………..………..………54
3.3 Study population……………………………………………………………………………..54
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3.3.1 Inclusion criteria………………………………………………………....……….……….54
3.3.2 Exclusion Criteria………………………………………………………..……….……….54
3.4 Sample size determination………………………………………………....……….……….55
3.5 Selection and training of research assistants……………………………….……….………56
3.6 Sampling method…………………………………………………………………..…..……56
3.7 Study instruments and data collection……………………………………..………..………58
3.7.1 Questionnaire……………………………………………………………………..….……58
3.7.2 Instruments………………….…………………………………………..……..………..…59
3.7.3 Preparation for data collection…………………………………….……………..……..…59
3.7.4 Data collection…………………………………………………….……………..……..…61
3.8 Data management and analysis………………………………………………….……….….62
3.9 Ethical considerations………………………………………………..…………..…….…….63
3.10 Limitations of the study………………………………………………….………..…….….64
CHAPTER FOUR: RESULTS
4.1 Socio- demographic characteristics of the study population……………….………..………65
4.2 Assessment of nutritional status of the children……………………………………..………72
4.3 Assessment of the immunization status of the children…………………………….…….….83
4.4 Clinical status and morbidities of the children………...…………………..………..……….94
4.5 Factors influencing the health status of the children……………………….……..…………97
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CHAPTER FIVE: DISCUSSION
Socio- demographic characteristics………………………………………..……….……………99
Nutritional status of sedentarized and nomadic children…...…………………………………..105
Immunization status of sedentarized and nomadic children…..………….…………………….110
Morbidities of sedentarized and nomadic children…..………………………...……………….115
Factors influencing health status of the children…..….…………………....…………….…….119
CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS
6.1 Conclusion ……………………………………………………………………..…………. 122
6.2 Recommendations……………………………………………………………..……….…...123
REFERENCES...…………………………………………………………...………………….124
LIST OF APPENDICES...………………………………………………...………………….136
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LIST OF TABLES
Socio- demographic Data
Table 1: Age and sex distribution of sedentarized and nomadic Fulani children...………….….65
Table 2: Socio-demographic variables of mothers/caregivers in the study population.....………66
Table 3: Socio-demographic variables of fathers in the study population …………………...... 68
Table 4: Summary statistics and t- test for sedentarized and nomadic populations ..…….…….69
Table 5: Family type and number of children in the study population………………………...... 70
Table 6. Distribution of animal wealth and monetary income of families in the population……71
Assessment of nutritional status of nomadic and sedentarized Fulani children
Table 7: Types of common foods consumed by the children in the study population…...…...…72
Table 8: Nutritional status indicators for the children in the study population……………...... 73
Table 9: Nutritional status indicators by type and within gender in the study population……....74
Table10: Nutritional status indicators by type and between genders in the study population…...75
Table 11: Nutritional screening using Shakir’s strip [MUAC in children (6-59 months)] ...…....76
Table 12: Logistic regression of predictive factors for stunting in the study population…...…...80
Table 13: Log Logistic regression of predictive factors for underweight in study population...... 81
Table 14: Logistic regression of predictive factors for wasting in the study population…...…....82
Assessment of immunization status of nomadic and sedentarized children
Table 15: Routine Immunization coverage for children in the study population………...…...…83
Table 16: Attendance of Child Welfare Clinic services & Routine Immunization utilization….84
Table 17: Fully immunized status (Measles) by age of children in the study population…….…85
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Table 18: Fully immunized status (Measles) by age of mothers in the study population…….…86
Table 19: Maternal educational status and child access to immunization (BCG vaccination) ….87
Table 20: Maternal educational status & fully-immunized child (Measles vaccination)-FIC…...88
Table 21: Relationship between fully immunized status of child (Measles) and distance to health facility in the study populations……………………………………………...………………...... 89
Table 22: Status of access to immunization by occupation of father in the study population…...90
Table 23: Supplemental Immunization Activities (SIAs) status in the study population...……...91
Table 24: Logistic regression to determine factors influencing access to immunization…...…...92
Table 25: Logistic regression to determine factors influencing immunization status (DPT-3) utilization among the sedentarized and nomadic children………………...…………………...... 93
Clinical status and common morbidities of sedentarized and nomadic Fulani children
Table 26: Recent disease/illness presentation among the children in the study population….….94
Table 27: Types of place of treatment visited for recent illness in the study population…….….95
Table 28: Time taken to reach place of treatment for recent illness in the study population…....96
Factors that influence the health status of nomadic and sedentarized Fulani children
Table 29: Factors influencing health status of children in the study population………………..97
Table 30: Environmental factors and social amenities in the study population…………………98
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LIST OF FIGURES
Figure 1: Nutritional status of Sedentarized and Nomadic children compared to WHO standard
(Weight for Height Deficit-Wasted) ………………………………………………...……...... 77
Figure 2: Nutritional status of Sedentarized and Nomadic children compared to WHO standard
(Weight for Age Deficit-Underweight) …………………………………………...…………….78
Figure 3: Nutritional status of Sedentarized and Nomadic children compared to WHO standard
(Height for Age Deficit-Stunted) …………………………………………………….…...…….79
LIST OF APPENDICES
Appendix 1: Questionnaire for the assessment of the health status of Fulani children………...136
Appendix 11: Consent form…………………………………………………………………….144
Appendix 111: State Ministry of Health approval letter...……………………………………...145
Appendix 1V: Ethical clearance certificate…...………………….…………………………….146
Appendix V: Map of Darazo LGA, Bauchi State...…………………………………...……...... 147
Appendix VI: IMCI Training Manual ………………………………………………...……...... 148
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LIST OF ACRONYMS
ARTI Acute Respiratory Tract Infection
BCG Bacille Calmette-Guérin
CDD Control of Diarrheal Diseases Programme
CHO Community Health Officer
CHQ-PF Child Health Questionnaire-Parent Form
CHW Community Health Worker
CHEWs Community Health Extension Workers
CHO Community Health Officer
CWC Child Welfare Clinic
DPT Diphtheria Pertussis Tetanus
EPI Expanded Programme of Immunization
FIC Fully Immunized Child
GIS Geographic Information System
GMP Growth Monitoring and Promotion
HAZ Height for Age-z score
Hep B Hepatitis B vaccine
HFCAM Health Facility Catchment Area Map
HIV Human Immunodeficiency Virus
IMCI Integrated Management of Childhood Illnesses
IMR Infant Mortality Rate
IPV Inactivated Polio Vaccine
ITNs Insecticide Treated Nets
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JUTH Jos University Teaching Hospital
LGA Local Government Area
MICS Multiple Indicator Cluster Survey
MNCH Maternal Neonatal Child Health
MNTE Maternal and Neonatal Tetanus Elimination
NDHS Nigeria Demographic and Health Survey
NICS National Immunization Coverage Survey
NERICC National Emergency Routine Immunization Coordination Center
NPHCDA National Primary Health Care Development Agency
NPI National Programme on Immunization
OPV Oral Polio Vaccine
OR Odds Ratio
PCV Pneumococcal Conjugate Vaccine
PHC Primary Health Care
PRRINN Partnership for Reviving Routine Immunization in Northern Nigeria
Penta Pentavalent Vaccine (DPT+ Haemophilus influenza and Hep B)
PCV Pneumococcal Conjugate Vaccine
REW Reaching Every Ward
RI Routine Immunization
SDGs Sustainable Development Goals
SPSS Statistical Package for Social Sciences
UCH University College Hospital
UN United Nations
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UNICEF United Nations Children’s Fund
VPDs Vaccine Preventable Diseases
WASH Water Sanitation and Hygiene
WAZ Weight for Age-z score
WHZ Weight for Height-z score
WFPs Ward Focal Persons
WHO World Health Organization
YF Yellow Fever
xvi
DEFINITION OF TERMS
Ardo -The local village head usually overseeing Fulani camp that is the authority figure who
takes decision on the communities’ behalf.
Fulani -They are the migratory people referred to as (Peul in Wolof, Fula in Bambara, Felaata in
Kanuri and Mbororo in Marghi language and called different names in other languages in different regions) who are culturally diverse and the most widely dispersed people in Africa on the Sahel and Savannah parts of West and Eastern Africa, largely in Senegal, Niger, Nigeria,
Chad and Cameroon
Fulfulde -The language spoken by those with common ancestry generally referred to as Fulani or Peul
Fully Immunized Child -A child that has received the full complement of 9 vaccines in the
Nigerian immunization schedule in infancy.
Nomadic (Rural) Fulani -Fulanis in the rural areas that are migratory and without permanent
abode usually camping adjacent to the rural communities.
Sedentarized (Urban) Fulani -These are Fulanis in the township or areas that have settled and are non-migratory with permanent abode usually permanent housing structures like other tribes in the communities
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Data analysis -Statistical Package for Social Sciences (SPSS) version 23.0 was used for data entry and analysis to determine frequencies, means ± standard deviations, graphical representations and statistical associations of dependent and independent variables. The Chi- square test was used to determine any association between categorical variables and outcomes to test for association.
WHO Anthro Version 7.0 -The World Health Organization (WHO) Anthro for nutritional assessment was used to determine the standard deviations (z-scores) from the mean of the international reference population based on the WHO 2006 growth standards.
Stunted – The height-for age deficit considered for stunting was Z score level of < -2SD (HAZ- height for age) compared to the WHO international reference population.
Underweight – The weight for age deficit for underweight was z score of < -2SD (WAZ-weight for age) compared to the WHO international reference population.
Wasted - The weight for height deficit for wasted was z score of < -2SD (WHZ-weight for height) compared to the WHO international reference population
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ABSTRACT Background: Health status is a general term referring to all aspects of the health of individuals or populations and it specifies some tangible components; a feeling of well-being, freedom from the risk of disease and premature death which requires a safe environment, enhanced immunity, good nutrition and prudent health care. Research has demonstrated that rural populations are often at a disadvantage of receiving health services. These problems may be compounded when the population is nomadic, hence the objective of this study to assess and compare the health status of nomadic and sedentarized Fulani children in Darazo Local Government Area of Bauchi
State.
Method: This was a community based comparative cross-sectional study where 250 mother/caregiver-child pairs in each sedentarized and nomadic household were selected using multistage sampling technique.
A semi- structured, interviewer-administered questionnaire was used to collect information from the parents as well as assessment of the sampled children. Data generated were processed and analyzed using Statistical Package for Social Sciences (SPSS) version 23.0. Anthropometric measurements were analyzed using the WHO Anthro software version 7.0. Results were presented using percentages, means, charts, bivariate and logistics regression to identify the predictors of health status. A 95% confidence level with a p-value of ≤ 0.05 was considered statistically significant.
Result: Sedentarized mothers had better literacy level, whereas more nomadic women engage in trading (selling of cows’ milk). Carbohydrate was main diet, with nomadic children consuming less fish/meat compared to their sedentarized counterparts (62.2% v 36.2%). Nomadic children were 2-3 times more malnourished with stunting (12.0% v 34.0%), underweight (8.4% v 19.2%) and wasting (8.0% v 11.2%). Females were more affected than males in both populations. xix
Predictive factors for stunting was non-attendance at Child Welfare Clinic (CWC) for Growth
Monitoring and Promotion (P=0.001) and for underweight were children older than 2 years and if female (OR=1.831; 95% CI=1.041-3.220; P=0.036). Sedentarized children had better immunization coverage with good access to BCG (43.2% v 26.0%) and utilization rate of DPT-3 of (34.0% v 29.2%) (OR=2.178; 95% CI=1.199-3.957; P=0.011) with a high rate of up to 64.0% of nomadic children not completing immunization schedule at all. Predictive factors for full immunization rates after logistics regression were; attendance of CWC (OR=8.292; 95%
CI=4.236-16.233; p=0.001), hospital delivery and those residing close to HFs (P=0.001) as well as mothers with formal education than Qur’anic or nil literacy levels. Conjunctivitis was seen in
75.3%, followed by ARTI in 63.5% sedentarized. Majority, 81.4% of sedentarized Fulani lived within 30 minutes’ walk (5kms) to the nearest place of treatment with better utilization rates
(χ2=19.499; df=2; P=0.001). More nomadic Fulani patronized medicine vendors compared to the sedentarized Fulanis as treatment points for recent illness. However, there were 21.6% nomads compared to 13.2% sedentarized who did not seek care at all. Sedentarized had better sanitary conditions and potable water than nomadic populations.
Conclusion: This study showed sedentarized Fulani children had better nutritional and immunization compared to nomadic children. It has also demonstrated that maternal education, availability and proximity to health facilities, and social amenities influenced health status.
These can be improved by availing food groups with high protein content that will reduce stunting and wasting especially among nomadic children, health educating them to access PHC services for ailment, and better utilization for immunization services. Appropriate policies to strengthen the health system and its implementation will better the lives of the pastoralists.
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CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND OF THE STUDY
Health status is a general term referring to all aspects of the health of individuals or populations and as composed by specialists in preventive medicine it specifies some tangible components; a feeling of well-being, freedom from the risk of disease and untimely death. It is usually understood to include mortality risks, diseases, health states, impairments and disability.1 In order to maintain good health status, people require healthy children, enhanced immunity, safe environment, sensible behavior, good nutrition, and prudent health care system.1
Migrants and particularly pastoralists suffer deprivation of access to health and social services.
Hence poor health outcomes compared to neighboring populations as there are several reports that rural populations are often at a disadvantage of receiving health services, especially when the population is nomadic.2, 3 There is a wide distribution of nomads across the globe, however pastoralists are found in Europe, North America, Canada, Australia, Asia, Africa and Middle
East. The term “pastoralist” is defined as a mode of production where livestock make up to 50 percent or more of the economic portfolio of a smallholder.4, 5 A broad distinction between the developed and developing world is that extensive livestock production is practiced in both
Australia and North America under very different conditions from elsewhere in the world, using fenced ranges and unambiguous tenure with high technology animal husbandry for meat and milk production that is highly economical and is usually practiced in settled regulated farmlands with a good health care services for both human populations and their animals.5
1
In Africa however, pastoralists are found in the vast arid regions south of the Sahara Desert spreading from Mauritania in the west to Somalia in East Africa where these pastoralists are either nomadic or semi-nomadic unlike in the developed world.6 Nigeria’s pastoralists, the nomadic Fulani represent over half of the pastoral societies of Africa who are principally engaged in animal herding and selling of cows, sheep, and goats as well as milk and milk products for livelihood.
Nigeria is believed to be the most populous country in Africa, with a population of about 175 million and about sixty percent of this population residing in the rural areas, with nearly forty- four percent of the population made up of children and mothers.7 Nigeria has the second highest burden of child deaths in the world, and home to 60% of the world's estimated 50–100 million nomads and semi-nomads of Africa.8 Nomads include pastoralists, nomadic hunters, gatherers, and peri-pathetic communities who are known groups of people moving around settled populations offering craft or trade for their livelihood.9 Throughout Africa, people of different ethnic backgrounds share the same environment, live together in the same communities and districts like in the southwest; the Yoruba and the Fulani live together in one environment but in separate settlements known as ‘gaa’ for Fulanis whose patterns reflect their culture and tradition, such cultural differences may also manifest in different health-care seeking preferences and behaviors that have been exhibited by the different ethnic groups.3 The pastoralist societies can be further differentiated into the nomadic groups migrating regularly between two grazing areas along well-defined routes often referred to as trans humans, they also move into different areas of the local communities in their pathway each year. They are often referred to as semi-
2
pastoralists with semi-sedentary residence and mobility patterns determined by their immediate needs and pastures for their herds.9
The movements expose them to health risks and therefore the need to improve child survival is paramount among these challenged groups of people especially so in northern Nigeria where the health indices are poor with a huge morbidity and mortality burden. These Fulanis are known pastoralists; those that are found in the rural areas and moving from one location to the other looking for greener pastures for their herds are the nomadic Fulanis while the sedentarized
Fulanis are those in the urban and semi-urban areas, where they are fully settled and integrated into the communities where they live. The pastoralists of the developed societies are non- migratory, with good access to health and social services creating a level of investment in land and animals with better health status among adults and children. In the developing world however, the ‘traditional’ animal husbandry systems live nomads with low income generation, poor health outcomes and livelihood.5 In Nigeria, the Fulani is primarily known to be herders moving within and from the northern states to the southern part of the country and neighboring countries in west and central Africa searching for pasture and water to raise their animals even at the detriment of their welfare and the risks they encounter in such adventures.
The nomadic populations and pastoralists have health challenges that are unmet by the health services providers in their domain as provision of public health services to pastoral nomadic societies has been a difficult task for governments. Issues of availability, accessibility, and compatibility of these services to nomads have become important, especially in sub-Saharan
Africa region in the recent years.6 The Maasai people in Tanzania and Kenya are characterized as
3
conventional pastoralists whose livelihood is majorly based on primary subsistence or exclusivity in livestock herding in most communities. However, specialized pastoralism which traditionally was the core of Maasai cultural identity has declined throughout the twentieth century and today livelihoods are increasingly diversifying towards agro-pastoralism and off- farm activities for most Maasai people.11 This is also gradually seen among Fulani pastoralists of
Nigeria where animal herding has dwindled due to stock loss and the gradual change in economic portfolio of most herders as they sedentarize and take up other activities and trades.
In terms of diversity, and demographic transition, like the Maasai pastoralists of East Africa; the pastoral Fulani are an ethnic group of people spread over many sub-Saharan countries, but found predominantly in West Africa.14 They are known to form an absolute majority in Guinea and
Cameroon, while one third of Senegal’s population are Fulas. It is estimated that Nigeria alone has up to 20 million Fulani who have been influential in regional politics, economies and histories throughout West Africa for over a thousand years.14 As a result of their nomadic lifestyle; they keep somewhat separate from the local agricultural populations that they pass through settling in camps around the natives and as they traverse the large savannah plains through this nomadic lifestyle, they have established numerous trade routes in West Africa.15
Although Fulani primarily known to be pastoralists, also trade the cattle, goats and sheep that they herd across the vast dry hinterlands of their domain. Furthermore, Fulas in time past were also known to trade in people.14, 15
4
1.2 STATEMENT OF THE PROBLEM
The Millennium Development Goals (MDGs) laid great emphasis on health; in many ways the goals are about children to enjoy the right to their childhood, health, education, equality and protection. At current rates of progress, for example, some 8.7 million children under five will die in 2015. However, if the goal to reduce child mortality is met, an additional 3.8 million of those lives would be saved.25 In the year 2015, leaders from 193 countries of the world came together to face the future by commitments to usher in the ‘Sustainable Development Goals’
(SDGs) known as the 2030 agenda sponsored by the UNDP. The set of 17 goals that would imagine a world rid of poverty and hunger, and safe from the worst effects of climate change.
Goal 3: Good Health and Well-Being for People - ‘Ensure healthy lives and promote well-being for all at all ages’ lays commitment to further ensure equitable healthcare to all.26
Significant strides have been made in increasing life expectancy and reducing some of the common killers associated with child and maternal mortality. Between 2000 and 2016, the worldwide under-five mortality rate decreased by 47 percent (from 78 deaths per 1,000 live births to 41 deaths per 1,000 live births), but 5.6 million children under age five died in 2016 alone. SDG Goal 3 aims to reduce under-five mortality to at least as low as 25 per 1,000 live births. But if current trends continue, more than 60 countries will miss the SDG neonatal mortality target for 2030 and about half of these countries would not reach the target even by
2050.26 The goal will be achieved only if underserved and vulnerable societies are reached and provided with the basic health needs through an efficient Primary Health Care (PHC) system.
Undernutrition remains a significant public health threat. Malnourished children have weakened immunity and therefore susceptible to infections.10 The vulnerable migratory Fulani population contributes to the rather poor indices such as the routine immunization coverage of northern 5
Nigeria leading to the staggering gap when compared to their southern counterparts with a resultant poor national summative coverage for immunization in the country. The role played by individual and community-level characteristics in full immunization uptake and migrant adaptation as they move between social settings has important policy implications, both for health outcomes in Nigeria and other developing countries undergoing significant internal migration.29
Nomads have also been known to sedentarize and undergo processes of social modernization which has been a major challenge. The cultural orientation of sedentarized Israeli Bedouin and compatible health services provision in the modern health care system has only given partial answers to address their health issues in terms of availability, spatial distribution and accessibility.16 In a study in rural Tanzania, 45% of the children resident in rural areas were stunted and particularly pastoralist children were found to have a higher stunting rate of 59%.11
In another study among different ethnic groups; the overall distribution of acute malnutrition by sex of all children also showed a tendency of higher levels of malnutrition among mobile pastoralist children when compared to sedentary children,55 these findings underscore the plight of nomads in Africa. Similar reports in the Lake Chad basin populations revealed that acute malnutrition was seen in 15% of the Foulbe mobile pastoralist, 18% among the Arab mobile pastoralists and 13% among sedentary children.12 Indicating that all pastoral societies suffer the same health challenges which is inherent in nomadism across Africa.
In Kenya, delivery of health care among the pastoral population showed major deficiencies where in particular, access to services is limited, and minor ailments continue to cause morbidity
6
and mortality. Although reports of immunization coverage in parts of Kenya which are inhabited by pastoralists have probably improved, they still lag behind as compared to the rest of the country. Attempts have been made to increase the number of health care delivery points to service communities although these do not target pastoral people, but their sedentary counterparts’ only.17 In Nigeria, over one million children die annually from preventable diseases with only an estimated 25% of one-year old children who had received DPT-3 vaccine in 2005.29
Making the country one of the least successful of African countries in achieving improvements in child survival during the past four decades. The preliminary findings from the 2016-2017
NICS show that Nigeria Penta-3 national coverage was 33% with Bauchi state having state coverage of only 19% where 3 out of 4 children remain un-vaccinated in the north-east region of
Nigeria.39 Reports of immunization coverage among migrant Fulani in south-western Nigeria where distance to HF was associated with immunization showed that those living <5km had better coverage of 4.3% than children located in faraway gaa who had over 70% of their children never immunized.3
Health issues are of great importance for pastoral nomadic Fulanis; the Fulani of northern
Nigeria who are indigenous are nomads while some are semi-nomadic pastoralists who have integrated into the local communities,18, 19 where studies have shown that 60% of Fulani women live in rural communities and are at a greater risk of health problems. The children of these migrants tend to live under especially difficult circumstances, they lack or are remotely located from appropriate health care services.18 Changes from nomadic sedentarization are not fully known, particularly the effects on nutrition and development of their children.
7
Undernutrition is an underlying cause of 45 percent of child deaths globally, and the lives of nearly 7.4 percent of the world’s children are at immediate risk due to severe wasting (low weight for height). In less developed countries, 26 percent of children under 2 years old are stunted and will suffer permanent physical and cognitive effects.10 Poor nutrition among under- fives contributed directly or indirectly to more than 33% of nearly one million children deaths in
Nigeria,9 the proportion may even be higher among rural and mobile communities who lack access to healthcare, food and social services. The nomads of northern Nigeria are settling in towns and cities taking up menial jobs and offering services as traders and security guards ‘mai gadi’ in homes and public places and their women selling milk and local cheese, while others are gradually migrating and settling in the southern part of the country in search of greener vegetation for herding their animals and better living conditions.
In a study in southwest Nigeria among settled nomadic Fulani children 38.7% were found to be malnourished.21 Food supplements as well as nutritional and health education programme have been suggested for pastoral Fulani settlements to improve the nutritional status and growth of settled Fulani children21. Reports in a study among nomads in north-eastern Nigeria had reported fever as the most common childhood illness accounting for 87.6% with other ailments of concern as ringworms in 19.7% and diarrhea in 17.3% of children.33 There are evidences from many
African countries such as Nigeria, Burkina Faso, and Zambia that more than half of the children with common childhood illnesses did not seek any medical advice just as revealed from a study in northcentral Nigeria where the Patent Medicine Vendors (PMVs) are the first source of care for up to 55 % of under-five child illnesses such as malaria and diarrhea if they seek treatment at all.8, 13
8
Children in underserved migrant communities have also been known to face multiple and often shared barriers to accessing comprehensive, affordable as well as culturally competent healthcare services and basic education. Some of these barriers include poverty and lack of awareness or the availability of healthcare services for nomadic populations or migrants living away from their normal communities.22
Nomads also face the challenges of sanitation, waste disposal and potable water sources for domestic use. A study among mobile east African pastoralist had reported that surface water was the source for consumption and washing which was often turbid and contaminated with animal and human excreta.12
1.3 JUSTIFICATION FOR THE STUDY
Every child, rich or poor, migrant or non-migrant has the right to health and health care. There is a dearth of evidence based data on the health status of nomadic and semi-nomadic pastoralist children globally, the Fulani child in Africa and more so, locally in northern Nigeria.16 This study will provide baseline data for future health research on Fulani communities in northern
Nigeria. Such research is also crucial for designing appropriate health policies at the national and regional levels for nomadic and Fulanis that are sendentarizing.
This population is not only migrant but also lack access to social amenities and infrastructure.
The effect of the migratory nature of the parents and caregivers on the health status of children has not been investigated thoroughly and there is deficient data on child health indicators such as, infant mortality rates, immunization coverage and nutritional status especially among pastoralists’ children. Innovative and integrated health care services for nomads can be extended
9
as pastoralists have in common a similar way of life driven by the needs of their animals.16, 23
Therefore the reports of this study will help inform policy on how best to plan for nomads in
Nigeria and elsewhere in sub-Saharan Africa.
State operators also devote many resources to developing the livestock capital to the detriment of the human capital; the government spends more money to vaccinate the cattle than to immunize the children of the Fulani,24 thereby increasing the morbidity and mortality amongst nomadic populations. Therefore, a strong evidential database is the first step in the process to ensuring appropriate and feasible policies and interventions for this underserved population to ensure access and utilization of affordable, acceptable and culturally sensitive and efficient health care services.25 Those sedenterizing and taking up different roles in the communities, towns and cities also often find challenges in utilizing social and health services for their wives and children where the effect of sedentism has not been fully explored.
Thousands of Nigerians wholly or partly make a living from selling, milking, butchering, or transporting herds. Government also earns revenue from cattle trade (and in the past, from the cattle tax- Jangali).24 The plight of the nomadic Fulani therefore, should be looked into because they play an important role in the economy and nutrition of Nigerians. Many pastoral advocacy groups in Africa have also emerged in the last two to three decades to champion the needs of pastoralists, for example, the Miyetti Allah Association of northern Nigeria, advocating for the
Fulani and others like Association pour la Promotion de l’Elevage au Sahel et en Savane
(APESS), in Burkina Faso advocating for Fulani in the Volta region.26 These groups should also advocate for peaceful coexistence as Fulani herdsmen and indigenous host communities has
10
brought violent conflicts and hardship for people with loss of lives and disruption of economic activities in recent times as a result of grazing encroachments on farmlands.
The focus on children is because their physiology, growth and development are sensitive to both adequate food (food security) and nutrition as childhood malnutrition contributes to nearly
33.3% of under-five deaths in the world and up to 11 % of Disability Adjusted Life Years-
DALYS, with 80 % of the deaths occurring in low-income countries.28 A major challenge for pastoralists is in the control of infectious diseases and the delivery of essential health care to ensure equity in healthcare delivery. Health interventions should be accessible to all; irrespective of location, socio-economic status and organization, social class, lifestyle or gender. Nomadic populations however constitute a significant proportion of the population in many sub-Saharan
African countries that lack access to healthcare.9
Not much is known of how to best provide essential health care to mobile and remote populations with community involvement. The constant mobility of nomadic populations excludes them from health delivery services which is often situated near settled communities.
The provision of interventions seems to be ill-adapted to the nomadic lifestyle as efforts to provide health services for nomads has proven to be costly and ineffective largely due to the lack or limited availability of demographic and medical data of the nomads in various geographic areas they reside.9 The availability of health and demographic data will assist in the design of a more efficient heath care system for Fulani pastoralist whether sedentarized or nomadic.
11
1.4 SCOPE OF THE STUDY
Bauchi State is being focused as a deliberate planned study in the state on nomadic and sedentarized Fulanis as Darazo LGA has large nomadic population and peculiar to this geographical setting as a known cattle route. Many of the nomadic populations have over time settled in the villages and the township with Darazo township having substantial sedentarized
Fulani. The goal of this community based, cross-sectional comparative study, is to assess and compare the health status of Fulani children aged 0-59 months, between the sedentarized and the nomadic ones. The study will also determine the availability, access and utilization of health care services, education, and safe potable water in this peculiar group.
1.5 CONTRIBUTION OF THE STUDY TO PUBLIC HEALTH
This study will provide baseline data for future health research on Fulani communities in northern Nigeria where most Fulani populations are settling in townships and villages as well as the large migrant nomadic Fulani populations traversing in Nigeria and the West African sub- region. This sedentarization process may influence their lifestyle and health status and therefore the need to document these findings. Also the results of this study may inform policy which will improve services rendered to this migrant and underserved population by institutionalizing child survival strategies through PHC as childhood morbidities and infant mortality has been found to be higher among nomadic than neighboring settled populations.23
The contribution of geographical and socioeconomic factors to mortality differences in infancy and childhood was shown in a study to assess infant and child mortality differences in Cameroon by residence area, mother's education, ethnicity and the interplay of those factors on mortality differentials.30 The need to target these groups will further elucidate their plight and give a
12
baseline information that will be used to improve on healthcare provision for both nomads and sedentarized Fulanis. In the Cameroons, the most vulnerable groups of children in the country are rural residents and Fulbe-Fulani children. Such research is crucial for designing appropriate health policies at the national and regional levels. This study will provide such information and influence policy for Fulani populations in Nigeria, especially in the north where they are gradually sendentarizing and taking up work roles outside the traditional herding.
1.6 OBJECTIVES
1.6.1 GENERAL OBJECTIVES:
To determine and compare the health status of nomadic (Rural) and sedentarized (Urban) Fulani children in Darazo Local Government Area of Bauchi State.
1.6.2 SPECIFIC OBJECTIVES:
1. To determine and compare the nutritional status of nomadic and sedentarized Fulani children
in Darazo Local Government Area of Bauchi State.
2. To assess and compare the immunization status of nomadic and sedentarized Fulani children
in Darazo Local Government Area of Bauchi State.
3. To identify and compare the morbidities of nomadic and sedentarized Fulani children in
Darazo Local Government Area of Bauchi State.
4. To determine factors that influence the health status of nomadic and sedentarized Fulani
children in Darazo Local Government Area of Bauchi State.
13
CHAPTER TWO
LITERATURE REVIEW
2.1 ETHNODEMOGRAPHY OF FULANI AS A PEOPLE
2.1.1 Origins and spread of the Fula
The peoples of Africa are often described in terms of their ethnic background, place of or their languages. There are several thousand ethnic groups in Africa, ranging in physical stature from the short Pygmies of the Congo valley to the tall Maasai in Kenya,31 each with its own cultural traditions and a way of life that is distinct yet evolving over time. Fula or Fulani or Fulbe are an ethnic group of people spread over many sub-Saharan countries, although predominantly found in West Africa, but found also in Central Africa and Sudanese North Africa.14, 15 Fulanis move over vast areas and come across many cultures and are called Peul in Wolof, Fula in Bambara,
Felaata in Kanuri.24 and Mbororo in Marghi language with many ethnic nationality names in different countries.
The origins of the Fulani people have been speculated by several scholars as believed to be of
North African or Arabic origin, this has however been highly disputed. Current linguistic and genetic evidence suggests an indigenous West African origin as historical and archaeological records indicate that Peul-speakers have resided in western Africa since at least the 5th century
A.D. Interestingly, scholars specializing in Fulani culture believe that some of the archeological imagery depicts rituals that are still practiced by contemporary Fulani people in the recent past to the present era.13
14
2.1.2 Culture and rise to political stardom
The Fulani dynasties began as early as the 17th and 18th centuries, but mainly in the 19th century,
Fulas and others took control of various states in West Africa. Fula ethics are strictly governed by the notion of ‘pulaaku’ and they are primarily known to be pastoralists, but are also traders in some countries and areas where they reside. Most Fula are the only major migrating people of
West Africa. They spend long times alone on foot, moving their herds in the countryside although most Fula now live in towns or villages having fully settled.15 Many of them intermarrying with the indigenous population, like the Hausa creating the Hausa-Fulani dynasties and ruling class of northern Nigeria.
In Western Africa the nomadic Fulani people have settled and are fully sedentarized in countries like Mali, Guinea Conakry, Senegal, Gambia and Burkina Faso. They are traditionally nomadic pastoralist, trading people, herding cattle, goats and sheep across the vast dry hinterlands, where they live in sympatry with the local agricultural populations.32 Total number of Fulanis is not known but it ranges between 45-60 million. Nigeria alone has up to 20 million Fulas, they form absolute majority in Guinea and Cameroon while one third of Senegal’s population are Fulas.12
They are nomadic people who have been influential in regional politics, economics, and histories throughout western Africa for over a thousand years. They were also responsible for introducing and spreading Islam throughout much of western Africa. The height of the Fulani Empire was between the early 1800s and early 1900s. This power was consolidated under Usman dan Fodio and was centered in northern Nigeria. Usman dan Fodio was a devout Muslim who used religious fervor to ignite his troops to undertake series of holy wars to form an extensive and
15
powerful empire subduing the indigenous populations and enthroning their followers to rule the territories.15
A distinctive difference between the Fulani and other African peoples are that Fulani express the sense of difference between them and other groups through the manner in which they acknowledge, perceive and interpret illness. Being Fulani means perseverance, strength of character, discipline and providing leadership over others.33 Fulani have a huge respect for their culture and a strict caste system; the four major caste subdivisions in Fulani kinship are the nobility, merchants, blacksmiths, and descendants of slaves of wealthy Fulani. The wealthy
Fulani normally raise large amounts of cattle and have therefore settled in the large plain areas of
Mali, Niger, Burkina Faso and Guinea abandoning the nomadic lifestyle and have become sedentarized.14, 15 Fulani religion is largely, if not wholly Islamic. Notable Fulanis in west Africa include among others Souleymane Baal, founder of Futa-Toro Islamic state (circa 1750),
Katoucha Niane, former haute couture model and anti-female circumcision activist; Usman dan
Fodio, founder of Sokoto Caliphate, Thomas Sankara, former President of Burkina Faso and
Ahmadu Ahidjo, the first President of Cameroon.15
Like sedentary populations in most countries of Africa, nomads have definable communal hierarchy and structures with leaders and followers. Nomads are known to move their cattle in a definite pattern in search of grass and water and suffer from preventable health problems similar in pattern like the members of their host communities.9 In a study among Yoruba and Fulani populations living in same communities in southwestern Nigeria; despite having similar illness patterns as they present in health facilities, the two groups had somewhat different health-care
16
preferences. Even though private health services were costlier, their greater use by the Fulani may reflect sociocultural orientation and previous neglect by the government health sector.3
In Cameroon national minority groups recognized as indigenous people by the UN are Mbororo,
Pigmies and Kirdi communities. Both nomadic pastoral Fulani (Mbororo) and the settled Fulani
(Fulbe) share a common language which is the Fulfulde language with common ancestry and generally referred to as Fulani or Peul. The Peul are culturally diverse and the most widely dispersed people in Africa on the Sahel and Savannah parts of West and Eastern Africa, largely in Niger, Nigeria, Chad and Cameroon. Social disadvantage observed among Fulani is associated with poverty viewed by the Mbororo as lack of cattle and land, exclusion from community social life, and also being considered as less than equal or discriminated against results in worse health and higher risk of premature death.34 The typical Fulani household has a headman, his wife or wives, children and dependents. About 15 household units aggregate in an area to form a ‘wuro’
(camp) and many wuro constitute a ‘gure’ believed to be traditionally their town.33
2.2 HEALTH STATUS OF CHILDREN
2.2.1 Definition and dimensions of health
In the preamble to the constitution of the World Health Organization (WHO) health is described as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." It describes an ideal state rarely attained by most people, and it contains no ingredients that can be readily measured or counted; either at the individual or at the population level.35
17
Another definition, composed by specialists in preventive medicine, specifies some tangible components of health; calling it "a state characterized by anatomical, physiological, and psychological integrity; ability to perform personally valued family, work, and community roles; ability to deal with physical, biological, psychological, and social stress; a feeling of well-being and freedom from the risk of disease and untimely death." Which can be measured and counted at the individual and at the population level.1 Health status is a general term referring to all aspects of the health of individuals or populations and is usually understood to include mortality risks, disease presentations, health states, impairments and disability.1 In order to maintain a healthy state, the individuals and community must follow on the basic goals of health promotion and health maintenance, a safe environment, enhanced immunity, sensible behavior, good nutrition, well-born children, and prudent health care services utilization.
The United Nations provided eight Millennium Development Goals (MDGs), which serve as a framework for the entire international community to work together to reduce child morbidity and mortality. These goals were adopted by all world leaders in 2000 and was set to be achieved by
2015.36 When the goals are properly implemented, the poor health indices will turn for better as maternal and child survival will be assured. In Nigeria, an evaluation of the MDG between 2000 and 2007 showed that their achievement in reducing child mortality rate was unsatisfactory, while the maternal mortality rate was actually increasing; there remain wide gaps between targets and actual achievement particularly in the rural communities. It is a well-known fact that, attainment of many of these MDG’s requires good nutrition status for children and adolescent girls.7 The SDGs goal 2 aims at zero hunger - End hunger, achieve food security and improved
18
nutrition and promote sustainable agriculture. In the past 20 years, hunger has dropped by almost half, but nearly 1 out of every 9 people on earth go to bed hungry every night.26
In Nigeria, over one million children die annually from preventable diseases, making the country one of the least successful of African countries in achieving improvements in child survival during the past four decades.29 Even though the current MICS/NICS 2016-2017 survey report shows a 33.6% national Penta3 coverage with 40.0% who did not receive vaccinations from health facilities, millions of children remain un-immunized leading to the declaration of an emergency on RI, National Emergency on Routine Immunization Coordination Center
(NERICC) to ensure all states in the federation meet up with the 85% coverage target projected by the National Primary Health Care Development Agency.39 Poor nutrition increases the risk of illness. Evidence has shown that children who are malnourished and have deficiencies of micronutrient early in life have a lifelong impairment of cognitive and physical development as undernourished children are regularly prone to measles, pneumonia and other illnesses which increases morbidity and mortality burden in Nigeria before they reach the age of 5 years.9, 34
Most populations are ethnically heterogeneous containing dissimilar subgroups and incidence of diseases prevalence and complications vary from one ethnic group to another within the different
Fulani and indigenous ethnic nationalities. Ethnic variations in disease burden has been observed in the differential rates, individual responses to environmental conditions and risk factor profiles.34 Also nomadic Fulani dependence on herbal remedy and private medical outlets in health seeking behavior is well documented.33
19
2.2.2 Global overview of child health
A program in North Carolina to deliver primary health care services to migrant farm worker women and children from birth to 5 years showed that dietary assessments of protein intakes of most of them met or exceeded the U.S. Recommended Dietary Allowances among the children,
18 percent were obese while black American women had the highest proportion of low birth weight infants.38
Commonly reported health problems among migrant children include: lower height, weight, and other anthropometric attainments; respiratory disease such as tuberculosis, pneumonia, asthma, emphysema, and bronchitis; parasitic conditions, skin infections or continuous bouts of otitis media leading to hearing loss.3 Chronic diarrhea and vitamin A deficiency are common presentations among the children in the primary healthcare center. An untreated health problem among these migrant children is dental caries.40 The disparities in child nutrition outcomes in developing countries alongside urban-rural gradient and increasing incidence of child malnutrition in urban areas raises an important health policy question especially in a country like
Nigeria and more so among nomadic Fulani whose lifestyle leaves them at risk as they settle in settlements and move in the bush all their lifetime.
There are no fundamental differences in the characteristics that determine child nutrition outcomes in urban and rural areas. Differences in the levels of socio-economic characteristics such as maternal education, spouse's education and the wealth index (incorporating household asset ownership and access to drinking water and sanitation) contribute a major share of the disparities in the lowest quantiles of children’s health outcomes.40 Processes of increased
20
sedentarization lifestyle have fragmented the landscape making it difficult for herders to move their livestock freely, which is the pastoralists primary management strategy of their animals. As human populations have also grown, availability of livestock have decreased, spurring the need for livelihood diversification by the herders. Pastoralists’ settlements are increasingly springing up closer to villages as people seek better access to schools, health care, jobs and water for livelihood and survival.41 Fulani have been known to settle in towns and villages across Nigeria and in recent times spurring violent conflict and the incessant herders attack in quest for land tenure ship.
2.2.3 African overview
Most developing nations continue to struggle with persistently high rates of infant and child mortality and morbidity where malnutrition continues to be a major public health problem, particularly in southern Asia and sub-Saharan Africa having a disproportionately high child death rates globally.42 In a survey report, data shows that African countries have the highest
Under 5 and Under 1 mortality rates in the world, Nigeria ranked 13th and Cote D’Ivoire ranked
14th on the list in the recent country rankings of childhood mortality rates in the state of the world’s children.43
Using data from Demographic and Health Surveys from 17 countries to assess the impact of maternal rural-urban migration on the survival chances of children under age two in the late
1970s and 1980s. Brockerhoff et al showed that the existence of child mortality differentials in favour of settled urban dwellers suggests that migration from the rural to urban areas can improve children’s survival chances.44 Data on weight, height, skinfolds, and circumferences 21
collected from 534 individuals in a study to assess the nutritional status of Maasai pastoralists living in a period of great social, economic and ecological changes in Kajiado County, southern
Kenya, the data were used to describe mean differences in human nutrition between ages, sexes, and within and among three group ranches. Results indicate that nutritional status has remained poor despite numerous changes to the socio-ecological system. including livelihood diversification, sedentarization, human population growth and decreased access to vegetation heterogeneity for the pastoralists.41
In an attempt to summarize the fragmentary evidence on the health status of nomadic and semi- nomadic pastoralists populations in the arid regions south of the Sahara Desert, infant mortality has been found to be higher than childhood malnutrition among nomadic than the neighboring settled populations. Nomads often avoid exposure to infectious agents, helminth infections are relatively rare as people leave their waste behind when they move away from epidemics,23 however, the high prevalence of trachoma and tuberculosis is ascribed to the presence of cattle, crowded sleeping quarters and lack of access to health care services and treatment compliance which is generally poor also.6, 23 Guinea worm disease is common due to contaminated water sources for both human and animal use in the arid region as the migrant populations move from place to place and often settle around pools and dams.. Malaria is usually epidemic and seasonal leading to high mortality especially during intense malaria transmission in the rainy season.
Diseases such as Leishmaniasis and onchocerciasis are encountered and brucellosis occurs but most often goes undetected.6, 23
22
Reports of nutritional survey among rural populations living in northern Ghana showed that only
15.7% received appropriate complementary feeding, 58.2% met the minimum meal frequency,
34.8% received minimum dietary diversity (≥4 food groups) and with respect to nutritional status, 20.5%, 11.5 % and 21.1% were stunted, wasted and underweight respectively among the children aged 6–23 months studied. Children from households with high household wealth index were 51% protected against chronic malnutrition compared to children from households with low household wealth index.45
2.2.4 Nigerian overview
The 2006 Population and Housing Census reported Nigeria’s population to be 140,431,790, with a national growth rate estimated at 3.2 percent per annum. With this population, Nigeria is the most populous nation in Africa and the seventh most populous in the world. With the present population of about 175 million, it is often reported that nearly sixty-seventy percent of this population resides in the rural areas, with about forty-four percent of the population made up of children and mothers and a high national average infant mortality rate is 85 deaths per 1,000 live births.7
Nigeria, a country with the second highest burden of child deaths in the world has marked differentials in child mortality rates within it, with two to three-time higher rates in the northern states than in the south. In response to this need, the Partnership for Reviving Routine
Immunization in Northern Nigeria (PRRINN) was established in 2006 in four northern states of
Nigeria (Jigawa, Katsina, Yobe, and Zamfara) and expanded to include maternal, newborn, and
23
child health (PRRINN-MNCH) in 2008. The program is comprehensive, encompassing multiple aspects of the health system including human resources, governance, health information, strengthening of clinical services and community engagement in order to reduce maternal, newborn, and child mortality.8 However the 2013 NDHS still reports maternal deaths of up to
1,650 in the north-west and child mortality of 90 and under-five mortality rate of 160 per 1,000 live births in the north east. Bauchi state having child mortality rate that is second highest in the region.46
Nigeria has adopted the UNICEF/WHO program for the Integrated Management of Newborn,
Infant and Childhood Health (IMCI), but to date the implementation of IMCI has been limited to select, Local Government Areas, and has generally not included the community IMCI. The
PRRINN-MNCH program therefore developed a two-pronged approach to the implementation of community IMCI: Community volunteers, who translate the IMCI prevention messages into participatory dialogues, consistent with a pilot in southern Nigeria, and trained community health extension workers (CHW), delivering the diagnosis, treatment and referral elements of C-IMCI, modelled after the Ethiopian experience in order to treat common childhood illnesses and reduce mortality rates in the country.8
Several approaches including the introduction of the Expanded Programme of Immunization
(EPI), oral rehydration, timely administration of effective antibiotics for pneumonia and meningitis, improved management of malnutrition, including vitamin A prophylaxis, and better methods for prevention and treatment of malaria has led to decrease of childhood mortality.
Tragically, there is more evidence of stasis than improvement for many countries in recent years 24
in childhood diseases management,47 especially in northern Nigeria where childhood morbidity and mortality in the northern states is being threatened with malnutrition affecting a substantial number of under five children. Moreover, vaccines are still unavailable for a number of preventable diseases such as human immunodeficiency virus (HIV) and malaria which are leading concerns. However, despite these challenges, the global community is finding new and innovative ways to solve these issues through international collaborations, Public-Private
Partnerships, and sustainable, evidence-based, country-led initiatives which Nigeria must implement well to reduce the huge disease and death burden.38, 48
There are challenges in healthcare provision to nomadic as well as the sedentarized Fulanis as healthcare facilities are remotely placed away from the reach of the migrant population. In a longitudinal study of Hausa/Fulani women of northern Nigeria, 100% were found to be full-time house wives and were married at the mean age of 13 years, 60% of the women lived in remote rural communities which lacked appropriate health care services.18 In another cross-sectional study of growth of Fulani children, aged 1-16 years, living in the Jos Plateau, the children were found to be shorter and lighter than the international standards. It is however not known if the slow growth of the Fulani children had a genetic basis or was the result of nutritional shortcomings.25
In a similar survey to investigate and compare the nutritional and health status of three distinct groups of children in rural Nigerian village, the nutritional status of the children in the three study populations differed and seasonal changes affected the one to four-year-old children
25
among the Fulani more than the other 2 groups. An attempt was made to explain the results on the basis of environmental and socioeconomic differences among the groups.49
2.3 FACTORS AFFECTING HEALTH STATUS OF CHILDREN
2.3.1 NUTRITIONAL STATUS OF NOMADIC AND SEDENTARISED FULANI
CHILDREN
Nutrition is a fundamental right and basic requirement for survival of humans especially the growing child. Nutrition may be defined as the science of food and its relationship to health; it is primarily concerned by the part played by nutrients in body to be able to do daily tasks, boost immunity to fight infections and is required for growth, development and body structure maintenance. It is also defined as the science that interprets the relationship of food to the functioning of living organism.50, 51
Nutritional status is concerned with the social, economic, cultural and psychological factors relating to food production distribution and consumption in order to have balanced diet needed for body metabolism.51 The nutritional status of a mother is important, both as an indicator of her overall health and as a predictor of pregnancy outcome for both mother and child. A mother who was malnourished as a fetus, young girl child or adolescent is more likely to enter pregnancy stunted and malnourished. Her compromised nutritional status affects the health and nutrition of her un-born children subsequently.7
26
Malnutrition, with its two constituent deficiencies of protein–energy malnutrition and micronutrient continues to be a major health burden especially in the low and middle-income countries which is one of the global culprits that resists the optimal health achievement among children and has serious implications, including increased maternal and child morbidity and deaths.42, 52 It is globally the most important risk factor for illness and death, with hundreds of millions of pregnant women and young children affected particularly in poor low income countries,40 this is adjudged the greatest cause of ill-health in under five-years children, underscoring its importance in child survival in developing nations.
The World Health Organization estimates that about 60% of all deaths occurring among children aged less than five years in developing countries could be attributed to malnutrition.96 However, nutritional research in sub-Saharan Africa has primarily focused on under-nutrition, particularly among vulnerable population subgroups such as women and children. Data from several developing countries suggest that rising Sedentarization and improvements in developmental indicators lead to concurrent double edged under- and over-nutrition burden in the populations.54
Malnutrition causes measurable adverse effects on human body structure and function; resulting in specific physical and clinical outcomes that could result in a deficiency state of both macro and micronutrients leading to under-nutrition or their over consumption causing obesity which is prevalent in Africa.55 It is believed that over 2 billion people are affected by micronutrient deficiency, also referred to as hidden hunger. On the other hand, more than 805 million people do not consume enough calories. According to the 2014 Global Nutrition report, 2-3 billion people are malnourished, diagnosed as undernourished, overweight or obese, or deficient in
27
micronutrients which is the major cause of mortality in children under 5 years old worldwide, with approximately one-third of the nearly 8 million deaths attributed to it.56
Globally, more than 3.5 million mothers and children under five years of age majority of whom are in south-central Asia and sub-Saharan Africa die each year due to the underlying cause of under-nutrition, and millions more are permanently disabled by the physical and mental effects of poor nutrition.7 Chronic malnutrition still poses a serious threat to the dream of realizing the
MDG-4 for resource constrained and developing nations especially Nigeria with poor scorecard in MDGs implementation.
There has however been a global decline in malnutrition levels from the 1990s; however, the levels in sub-Saharan Africa have remained high and disturbing as a leading cause of child death.
Close to 90 % of stunted children in the world live in Africa and Asia, with the prevalence of stunting in Africa being 36% in 2011. For example, in Kenya, the prevalence of stunting was
26% in 2014 and in a study in 2010 in informal settlements in Nairobi, 60% of children below 5 years were stunted as compared to 17% for the whole of Nairobi. In poor, low and middle- income countries where few households can produce their own food, the prevalence of stunting are often higher.28
Malnutrition is an important public health problem with under-nutrition being the prevalent type in tropical developing countries. At greatest risk are children and women from poor socioeconomic background and the nutritional status of under-five children is one of the indicators of household well-being and one of the determinants of child survival.57, 58 The
28
contribution of malnutrition to high death rates from infection is well recognized, such as persistent diarrhea or AIDS.57 The introduction of affordable micronutrient interventions such as vitamin A and zinc have not only improved clinical outcomes but reduced the impact of child morbidity and mortality.59
Problems responsible for child under-nutrition are numerous. Some are basic problems like political instability, slow economic growth, and lack of education. The underlying causes such as food insecurity and lack of maternal and childcare services with the third group which includes the highly specific risk factors like frequent infections and inadequate dietary intake has put the children of the low and middle income countries in peril.55 It is a fundamental problem that must be addressed among children in the developing world and within all geographical settings and urban-rural gradients equitably.
In 2000, malnutrition was associated with 60% of all childhood deaths.58 Furthermore, it contributes to over 6 million child deaths each year, where 55 per cent of the nearly 12 million deaths among children under five in developing countries is attributed to it.61 In recent nutrition reports, prevalence of malnutrition worldwide differed from region to region and country to country as well as within countries with neglected communities contributing the highest numbers of the undernourished. Nevertheless, little is known about how malnutrition differs between multiple locations along the urban-rural continuum, and its severity has led to international organizations proposing its inclusion in the global development framework that succeeded the
Millennium Development Goals (post-2015 framework)-the Sustainable Development Goals
29
(SDGs). It’s been reported in sub-Saharan Africa that malnutrition is particularly severe, especially among women and children under 5 years wherever they lived.56
A considerable body of literature has documented the urban-rural health disparity in children and adults from developing countries where most of these studies were focused on discrepancies in child nutritional status and demonstrated that sedentarized/urban children are less likely to suffer stunting and underweight.62 A study in Filtu town Somali region of Ethiopia identified factors associated with nutritional status among infants and young children, the prevalence of stunting, wasting and underweight were 33.0%, 22.2% and 33.5% respectively for under five year old children. Wasting prevalence in the region was found to be the highest among the regions of the country. Infant and young child feeding practices in the region were reported to be poor as compared to the other regions of Ethiopia. Breast feeding of 16.7 months’ median duration was the lowest in the country while only 0.8% and 11.7% of the children met the guidelines for dietary diversity and minimum meal frequency respectively. However, there is a paucity of evidence regarding the factors associated with nutritional status of infants and young children in pastoralist areas in Ethiopia and in most of Africa as these migrant populations have suffered deprivation.63
It is estimated that a quarter of young children in South Asia and Africa will still be malnourished by 2020 as reports have shown that rates of under nutrition among young children are declining in all regions of the world except in sub-Saharan Africa.57 In a study in southwest
Nigeria for example, the prevalence of protein energy malnutrition among the children revealed to be 41.6% out of which 40.8% were stunted indicating chronicity of malnutrition.64 Optimal
30
infant feeding practice recommended by World Health Organization and United Nations
Children's Fund involves exclusive breastfeeding for the first 6 months of life, followed by adequate complementary feeding, and breastfeeding until the child is at least 2 years old,65 but infant feeding practices in developing countries are far from ideal where exclusive breast feeding is hardly adhered to.
It has been shown that breastfeeding remains a pivotal factor between life and death for the vast majority of children in developing countries such as Nigeria, but current data reveals that 55% of
Nigerian mothers are ignorant of the importance of exclusive breastfeeding. Also, the underlying factor of more than 50% of all childhood deaths in the country has been due to or associated to under-nutrition,65 and the importance of improving dietary micronutrients and antioxidant intake including carotenoids on morbidity is increasingly recognized and may contribute to infant mortality rate (IMR) reduction also.59 Current estimates have added iron, zinc, iodine and vitamin A deficiencies to the anthropometric approach as a measure for nutritional status assessments.61
There are universally accepted survival, growth, and health status indicators. The most commonly used indicators include, rate of low-birth weight babies (<2.5 Kg at birth), infant and child mortality rates, malnutrition, micronutrient levels, morbidity status and immunization rates.60 Anthropometric measurements such as height, weight and mid upper arm circumference are used for the assessment of the growth pattern by conversion into values for nutritional indices which are valuable indicators of the nutritional status and reflect patterns of growth and development of children.60 Anthropometric indices have been found to be highly reliable and
31
sensitive indicators of growth and body composition. They are the single most widely used measure of nutritional status because of their precision, replicative nature and the availability of accurate standards for comparison. Therefore, relatively simple measures of weight and height; with information on age and sex can yield reliable information on nutritional status.41
A study that documented the nutritional status of Maasai pastoralists within its changing social, economic and ecological context showed that, new settlement patterns and land fragmentation is an important and has a complex relationship between the environment, economic status, lifestyle and nutritional status. These changes often influence availability of labor and work tasks which improves income and is accompanied by a shift in diet and a reduction in physical activity, both of which affect people’s nutritional status.41
In northern Kenya, a nutritional and health survey in three communities utilizing interviews, anthropometric measurements, physical examinations and hemoglobin measurements of 105 mothers and their 174 children under six years of age was conducted. Results indicated that while the nomadic Rendille community of Lewogoso shared similar morbidity patterns with its sedentary counterparts with similar numbers of malnourished children during the wet year, the sedentary communities had significantly more malnutrition among children under six years old during the dry year.61 Despite numerous changes to the social-ecological system including livelihood diversification, sedentarization, human population growth and decreased access to vegetation heterogeneity, nutritional status remains poor despite transitioning to greater market integration of the populations studied.41
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2.3.2 IMMUNIZATION STATUS OF NOMADIC AND SEDENTARIZED FULANI
CHILDREN
The world has committed to the common vision of a decade of vaccines where global efforts are focused on extending the full benefits of immunization to all people, regardless of their birth status or where they live in all strata of the society globally.47 Immunization has been shown to be one of the most cost-effective health intervention that has greatly helped in prevention or eradication of diseases. Despite this, an estimated 2.7 million children die annually from
Vaccine-Preventable Diseases (VPDs), the implementation of immunization programs varies greatly across different communities, and approximately 34 million children do not have access to any immunization services worldwide.66, 67 In Nigeria, current national surveys put the number of un-immunized at 4.3 million in 2015 alone in a country with over 175 million eligible for immunization services. The challenge is more in the northern part and worst in rural and migrant populations that are hardly reached with the PHC services where only 1 in 4 children get to complete the immunization schedule.39
Nomadic populations face significant challenges regarding access to health services especially child immunization against polio and other VPDs.9 The optimum level with Nigeria achieving a universal childhood immunization coverage of 81.5% was recorded by the early 1990s. Since then the country has witnessed consistent reduction in immunization coverage. By 1996, the national data showed less than 30% coverage for all antigens, and this decreased to 12.9% by
2003.119 The recent National Immunization Coverage Survey puts the national average for Penta3 coverage of 33% with one out of three receiving penta-3 with poorer coverage in the rural areas.39
33
The drive to eliminate polio from Nigeria is of strategic importance to the global polio eradication initiative because most importations of polio into non-endemic regions from the last decade have been traced to Nigeria, leading to global spread of polio.66, 69 Recently, the global commitment to immunization programs has led to unparalleled successes in public health. In
2011, 83% of the world's children received all three doses of the Diphtheria-Pertussis-Tetanus vaccine primary series and routine immunizations now save the lives of approximately 2.5 million children per year. Polio is on track for eradication where during the past decade, annual measles-related mortality has been reduced by 71% and neonatal deaths from tetanus were reduced by >90%. VPDs however still account for one-quarter of deaths in children younger than
5 years of age. Vaccines against common causes of pneumonia and diarrheal diseases, the leading causes of death in children, are still not widely accessed by developing countries. Even though Nigeria has introduced the Pneumococcal Conjugate Vaccine (PCV), the coverage is still low and Rotavirus vaccine is yet to be introduced in the RI schedule to help curb diarrheal diseases caused by Rota virus. Children in the lowest wealth quintiles are still the least likely to receive immunizations. As countries continue to lack the capacity to collect quality data on the impact of immunization programs, or report and evaluate adverse events following immunizations, or detect outbreaks of public health importance the actual coverage and perceived protection of children against VPDs remains a great challenge.48
There are evidences that VPDs are responsible for severe rates of morbidity and mortality in
Africa. Despite the availability of appropriate vaccines, widespread disparities in the coverage of immunization programmes persist between and within rural and urban areas, regions and communities in Nigeria with the likelihood of full immunization being higher for children of
34
non-migrant mothers compared to children of Nomadic/migrant mothers.70 The involvement of
Ardos in mapping and planning has been the reason for the increasing number of nomadic children reached over time. However, coverage varied in these communities, perhaps because of seasonal migration in search of pasture for their animals during which community members relocated to other states that were not covered by the demand creation interventions to increase uptake, hence low coverage.3, 70
The Nigerian expanded programme on immunization EPI was initiated in 1979 where significant progress was made in the 1980’s with the universal child immunization-UCI when 80% coverage for all antigens was recorded. The current Routine Immunization schedule in Nigeria stipulates that infants should be vaccinated with the following vaccines: at birth or within two weeks-a dose of BCG, Hep B, OPV, at 6weeks-OPV1, DPT(Penta1), PCV1 & Rota1 at10weeks- OPV2,
DPT(Penta2), PCV2 & Rota2 and at 14 weeks- OPV3, DPT(Penta3), PCV3 & IPV, at 6months-
Vitamin A first dose, at9 months- Measles1 & Yellow Fever and at 12months- Vitamin A second dose & Measles2. A child was considered to have received full immunization status when they have received the full complement of eight vaccinations according to the EPI schedule.71
It is a fact that, immunization remains the primary strategy in the control and prevention of common childhood diseases. Each child should be immunized against the common communicable diseases for which vaccines are available. Choice of vaccine especially outside the national immunization schedule should be selected on the basis of local epidemiological situations.72 The grim picture for countries like Niger Republic where DPT3 vaccine uptake rate was only 34.7% by age 12 months among children aged 12–23 months in 2006 was attributed to
35
long distance to hospitals and other logistical challenges. These figures illustrate some of the health challenges in Niger which is akin to situations found in neighboring northern Nigeria.73
Children of Nomads and rural settlement dwellers face challenges of accessing immunizations, reports of vaccination coverage was found to be high for all ethnicities, with over 90% of all children reported to have had recommended vaccinations for BCG, Polio and DPT, however,
Maasai pastoralist children were less likely to have received measles vaccination compared to the Rangi and Meru ethnic groups in Tanzania also.11
Infant mortality rates reduced impressively in most countries, even in the poorest, between the
1960s and the 1980s,59 where VPDs are still a major cause of morbidity, disability and mortality among children and adults in the African region due to immunization programs. Immunization coverage rates have generally been stagnant or on a decline since 1995. The Expanded program on immunization (EPI) Plan of Action for 1995-2000 identified reasons for poor immunization performance where commonest reasons were civil unrest, lack of resources and poor program management. Specific objectives have been defined in four broad areas in the area of strengthening immunization systems, at least 80% coverage in DPT3 (now Penta3 coverage) in all districts; regarding the accelerated disease control, interruption of the circulation of wild poliovirus, elimination of maternal and neonatal tetanus-MNTE, and control of measles and other VPDs such as yellow fever and meningitis and introduction of new and under-used vaccines, e.g. Rota, PCV and IPV.74
In Nigeria, immunization activities commenced early in the 1960s with small pox eradication campaigns. The launching of EPI in the late 1970s widened the scope and intent of immunization 36
activities thereby providing immunization services to all children routinely against VPDs. With time, immunization coverage suffered setbacks and inadequacies, necessitating the re-launch of the EPI as a National Programme on Immunization (NPI) in July 1997,75 but to date vaccine coverage in northern Nigerian states are the worst in all the geopolitical regions of the country.
Rural populations are often at a disadvantage for receiving health services resulting in low immunization coverage. These problems may be compounded when the population is nomadic.
In a study among a minority group of nomadic Fulani cattle herders in southwestern Nigeria,
58.5% of children under 5 had received no immunization and only 2.6% of children below 24 months had been fully immunized. Culturally appropriate health education programs should be targeted at Fulani leaders in order to improve uptake other findings also indicate very low coverage of 2% among nomadic Fulani compared to other tribes in the same LGA with a general population coverage of 40%.3
Childhood immunization uptake remains critical in Nigeria despite sporadic success in the reduction of VPDs with widespread disparities in immunization coverage persisting between and within its regions to the disadvantage of children of parents in geographical, cultural, ethnic, and socio-economic diversity. The parents in the lowest socio-economic quintiles, and with no education, residing in rural areas, especially in the North do not avail their children PHC services where immunization uptake varies between and within geographical regions with variations leading to clusters of children that are under-vaccinated.29 As a result of this, there is increased vulnerability of the rest of the population to major outbreaks of Vaccine Preventable Diseases.
37
Migration is an important determinant of child immunization uptake as studies in individual and community contexts are strongly associated with the likelihood of receiving full immunization among migrant groups.70 In 2001, 550 million children were immunized with oral polio vaccine in Nigeria. Program data indicated that extraordinary efforts were needed to reach children in geographically remote areas as well as migrant children, newborns and infants, and children in nomadic groups among others.74 The likelihood of full immunization was higher for children of non-migrant compared to children of migrants. Findings provide support for the traditional migration perspectives, and show that individual-level characteristics, such as migrant disruption, selectivity (demographic and socio-economic characteristics), and adaptation as well as community-level characteristics such as region of residence, and proportion of mothers who had hospital delivery are important in explaining the differentials in full immunization among the children.70 This is an example of the greater risk the nomadic child faces of being exposed to infection as a result of being missed in immunization campaigns.70, 74
To address poor vaccination coverage in Chad among three nomadic groups; Fulbe, Arabs and
Gouranes, the use of mixed teams were able to vaccinate an important number of children and women. This showed a high potential in terms of organizational and logistic feasibility, acceptability as well as cost-effectiveness which can be replicated in different settings to improve vaccination services.77 the multiple approaches are used to reach special groups in high- risk populations and those dispersed in the rural communities such as nomads.
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2.3.3 MORBIDITY STATUS OF NOMADIC AND SEDENTARIZED FULANI CHILDREN
Morbidity and mortality from childhood illnesses has remained a major concern globally.
Malaria, respiratory tract infection and diarrheal diseases are the leading causes of childhood morbidity and mortality with a huge economic burden on developing nations,78 and according to a UNICEF report, five infectious diseases- pneumonia, diarrhea, malaria, measles, and AIDS account for more than one-half of all deaths in children aged <5 years, most of whom are undernourished. Malnutrition increases diarrhea incidence and duration, moreover malnutrition increases the risk of mortality from diarrheal forming a vicious cycle and acute lower respiratory tract infection in children less than two years of age. it is estimated that about 53% of under-five mortality is attributed to malnutrition as well as inadequate brain development in children.64
In 2000-2003, Malaria alongside pneumonia, meningitis and measles, caused high mortality in children under-five with neonatal causes accounting for 17% of the deaths among children under five years of age.73 Diarrhoea and related gastrointestinal illnesses continue to be among the most important causes of illness and death worldwide especially amongst vulnerable groups such as young rural children. Each year, diarrhoeal dehydration claims the lives of 2.2 million children under five in developing countries. Estimates for sub-Saharan Africa indicate that the prevalence is approximately 30%. Control of diarrheal diseases (CDD) programme has over the decades channeled their support to communities. Other important interventions include improvements in socioeconomic status, the promotion of breastfeeding, improved supplemental feeding, female education, immunization against measles, safe water supply, safe faeces disposal and the provision of vitamin A.79
39
In Nigeria, approximately one child in five dies before the fifth birthday. This represents about a million children that died in 2006.8 Besides malaria, the major causes of morbidity and mortality among Nigerian children are chickenpox (varicella), poliomyelitis, tuberculosis, measles, whooping cough (pertussis), diphtheria and tetanus accounting for about 22% of infant deaths amounting to over 200,000 deaths annually with northern Nigeria child mortality rates that are two to three times higher than in the southern states.76
A survey carried out in a 5-yr period in part of the city of Ilorin Nigeria to investigate the factors affecting the health status of the under-five children showed the common causes of child mortality and morbidity included diarrhea, acute respiratory infections, measles, and malaria.49 In yet another community based study on the prevalence of otitis media in a semi-urban settlement among children aged 0-12 years was found to be 14.7%.80 A similar study to assess urinary schistosomiasis in a rural community showed that 89.5% of the children had urinary schistosomiasis which was endemic in the area.81
There are very few medical reports on the nomadic peoples of the world. In Nigeria such reports are few or non-existent. It was found that infected herds of cattle revealed similarities in species of dermatophytes isolated from the herdsmen with ringworm infections among Nigerian nomadic
Fulanis.82 Skin infections including scabies have been reported among rural pastoralist and even sedentarized children. In a study in Mali, the ability to cope with multiclonal Plasmodium falciparum infections was assessed among the Fulani and the Dogon ethnic group which showed that the Fulani had lower parasite prevalence and densities, and more prominent spleen
40
enlargement in children aged 2-9 years with low clinical presentation compared to the Dogon population.77
In a study carried out in Chad Republic among different ethnic groups, the Chadian nomadic pastoralists accounted for approximately 6% of the total population with Tuberculosis suspected in 4.6% of nomadic Fulani adults and children less than five years of age. Malaria was frequent in Fulani who stay in the vicinity of Lake Chad and febrile diarrhea was more prevalent during the wet season when access to clean drinking water was more difficult.83 studies from Adamawa,
Nigeria reported that nomadic Fulani regarded pabboje (a type of "fever" that comes today, goes tomorrow, returns the next) as their commonest health problem.33 Similarly sero-prevalence of zoonotic diseases such as brucellosis and Q-fever were evaluated in humans and livestock in three Chadian Fulani and Arab nomadic communities where the human brucellosis sero- prevelance rate was found to be 2%. Males were significantly affected more often than females where fifteen human sera were positive for Q-fever.84
2.4 FACTORS INFLUENCING THE HEALTH STATUS OF NOMADIC AND
SEDENTARIZED FULANI CHILDREN
2.4.1 Access to health care and social services
Health for All by the Year 2000 was a goal embraced in 1978 by all countries, especially the developing countries even though remarkable advances have been made in both health status and the healthcare sector in general,85 majority of children in developing countries are still dying
41
because of preventable infectious disease. Pneumonia, diarrhea, and malaria remained the major killers of children under the age of five. These three diseases account for more than half of all the deaths in that age group because children are not getting access to appropriate treatment.86
However, countless children die needlessly due to childhood illnesses that can be prevented with effective interventions as a result of the failure of their guardians to seek care timely.
Access to health care is multi-dimensional comprising of several factors that include availability, acceptability, financial accessibility and geographic accessibility.73 In 2001, the World Health
Organization estimated that in as many as 35 of the poorest countries, 30-50 per cent of the population may have no access to health services at all. Geographical isolation, which limits access to modern health care facilities and availability of health workers and medicines to treat common ailments such as malaria, measles, dysentery, and diarrhea are prevalent among children that are environment-related.87
Ease of access to health care is of great importance in any country; particularly restricted access can put people at risk of mortality from diseases. Physical access of populations to health facilities within Niger with an emphasis on availability of adequate health services, provision of drugs and vaccinations has been key to ensure equity.73 It has been proven that disparities in health conditions and health care utilization are evident between local residents and migrants and this phenomenon exists between recent and long-term migrants, who are more marginalized and vulnerable until they have adapted to the social and cultural norms of a new place.66 Empirical research has shown that pastoral mobility is a highly efficient and sustainable strategy to cope with spatial and temporal variation in grazing resources that is typical in arid and semi-arid
42
ecosystems which influence pastoralists mode of settlement.88 when settled populations are availed with appropriate health care services, treatment of common ailments will reduce morbidity burden especially in children under five.
Previous studies have shown the existence of various health disparities between urban and rural areas in the United States, Canada, Australia, China, and other countries in health status, health access, and health utilization. Urban-rural health disparities have been shown to be pronounced in China, since the central as well as local governments still implement policies that are preferential towards urban areas and the health care systems in China have been entirely different for these populations for the past 60 years.89 When urban-rural communities are compared, rural communities are usually poorly served by the health system, the gap between nomads and settled communities is even wider even within the same geographical region. First, the formal health system appears ill adapted for extending services to constantly mobile communities of nomads where local authorities often disregard the existence or totally forget nomads with respect to health service delivery planning processes. For example, in Southwestern Nigeria, guinea worm case detection scouts "forgot" to include visits to nomad settlements in ivermectin distribution for the control of onchocerciasis. In often marginalized nomadic Fulani settlements, nomads are often ignored to the extent that less than 3% of children below 2 years benefit from full immunization service in some areas.33
In a study in Nomadic hamlets in Southwestern Nigeria, the Yoruba had a significantly higher attitude towards government clinics than the Fulani; perceptions of distrust and discrimination by minority populations are some of the reasons for the different health-care preferences by the
43
Fulani to utilize private healthcare services when the majority runs health services.10 Nomads will most likely continue to patronize the private health facility abandoning the public health facility to sedentary community populations as Fulanis in different regions of Nigeria have shown similar preference.33
The problem of pastoralism in Kenya’s northern district of Marsabit where over 80% of the population are pastoralists and nomads elsewhere today is that of its very survival. Pastoralists face dwindling resources, uncertainties and poor health-related issues to malnutrition. The current economic difficulties in the country where living in areas characterized by low population densities and extensive geographical dispersion with long distances between service delivery points and programs have not profited pastoralists.17
All nomads share characteristics that include an unstable life pattern, an interest in livestock, and strong cultural beliefs with a strong faith in their traditional medicine and distrust of outsiders.
Their independence, sense of community organization, and the predictability of their movements between water-points could give an insight into the design and the development of health services that specifically fit them in order to reduce morbidity and mortality common among these pastoralists.90 In order to meet the needs of the nomadic population, siting of healthcare services in communities near their route or water points will also improve access and utilization of services as the proximity will encourage service uptake.
When compared to the urban populations, rural communities and nomads that are found in hamlets and camps near the indigenous locals are greatly underserved everywhere, especially in
44
developing countries that still lag the furthest behind in every field of progress. They continue to be neglected and left out of the developmental mainstream, including access to health services and education. Infant and child mortality and accidental deaths tend to be high among these group compared to the general populations.77, 93
According to evidence from many African countries such as Nigeria, Burkina Faso, and Zambia more than half of the children with common childhood illnesses did not seek any medical advice where the median public health facility use for the treatment of common childhood illness in under-five children is below 50% in all settings. Acute child under-nutrition was relatively high with child under - nutrition, poverty and poor access to health services were important predictors of wasting in the study populations in all the countries.86, 56
Of recent, geographic information system, (GIS) geo-referencing of the pastoral environment has been used in the inner Lake Chad Basin to highlight the complexity of the temporo-spatial context associated with health care seeking behaviour by nomadic pastoralists. The nomadic groups, researchers, planners and administrators of health and veterinary services used, constructive group discussions, semi-structured interviews participatory mapping to improve communication among all actors for better outcomes. This holistic approach provided a tool to assist public health decision-makers in optimizing the use of health care facilities by nomadic communities.77, 92
Health care for pastoralist people has serious shortcomings and it must be delivered under difficult circumstances. Often, the most basic requirements cannot be met due to the limited
45
accessibility of health care provisions to pastoralists. The question then is how primary health care, which integrates a diversity of basic care provisions, such as pharmaceutical provision, child delivery assistance, mother and childcare and prevention activities, can be implemented,17 considering the fact that our PHC systems are far from adequate to settled populations let alone nomads. This adds major problems to the daily struggle for life, caused by bad climatic circumstances, illiteracy and poverty which has been increasing over time due to the general economic downturn and climate change affecting forage and consequent dwindling animal production.
Fulanis in northern Nigeria whether sedentarized or nomadic face difficulties in accessing formal health care systems. Ease of access to health care is of great importance in any country but particularly access by those walking long distances to facilities for care. In a study in Niger 39% of the population was within 1-hours walk to a health center in the dry season, with the percentage decreasing to 24% during the wet season due to bad terrain.73 Studies in Nigeria have shown that nomadic populations in outlying areas face significant challenges regarding access to health services when compared to settled local communities with facilities sited in or close to their areas.9
The most important issues in health service utilization among nomads are the belief that fever is a Fulani illness that needs no cure until a particular period, preference for private medicine vendors and the avoidance of health facilities. They often seek treatment in private health facilities against fevers that are persistent and defied their local herbs using orthodox antimalarial medicines as a last resort for care.33 Access barriers include financial constraints and cultural and
46
political differences including health workers’ preferences between nomadic and settled populations. These populations are also disproportionately vulnerable to infectious diseases such as Trachoma, Brucellosis, Polio, Malaria, Tuberculosis, Guinea Worm, Leishmaniasis,
Onchocercaisis, Intestinal Parasites and Helminths. The nomad populations also face significant challenges regarding access to health services like immunizations. The nomads are not often included at the planning stage. Although communication technology-driven empowerment combined with simple rapid diagnostic tools and creative packaging of medicines may increase access to fever management services, they are often left out of the mainstream of care.33
2.4.2 Safe potable water and sanitary waste disposal facilities
During this century, while the world’s population has tripled, water withdrawals have increased by over six times leading to the receding of water points like the lake Chad basin and perennial drying of streams, dams and rivers in the tropics has increased. The pollution and increasing scarcity of renewable fresh water supplies also threaten human health and welfare with mobile populations in the arid regions suffering the most.93 In 2000 WHO and UNICEF estimated that
1.1 billion people lacked access to an improved water source. Access to an improved water source may be as little as a protected well or spring within an hour’s walk of home, but around
80% of these ‘unserved’ populations like in rural and nomadic areas lack simple facilities for getting clean sources of water for daily needs.94 Access to safe water has contributed greatly to health - enabling and encouraging hygiene practices through key actions such as hand-washing, food hygiene, laundry and general household hygiene which is lacking in rural communities.
Contaminated water may transmit disease and lack of water may prevent minimum hygiene practices for cleanliness to protect health. The most important of ailments are diarrheal diseases;
47
other infectious diseases with similar patterns of transmission include hepatitis A and E, cholera, typhoid fever also associated with skin and eye infections including trachoma, and schistosomiasis which are common presentations in children.94
Globally, 2.4 billion people, most of them living in peri-urban or rural areas in developing countries do not have access to any type of improved sanitation facilities. The lowest levels of
31% and 48% of facility coverage are found in Asia and African rural populations respectively.
They do not have access to adequate sanitation facilities, where lack of sanitation is also associated with infection with diarrhea, dysentery and helminths.94 Faecal pollution of the household and community environment by adults including those of children with the absence of basic sanitation favor transmission of a number of major diseases leading to increased morbidity and mortality among the population especially in children less than five years of age.
The USAID’s Water and Development Strategy calls for increased integration of water, sanitation, and hygiene (WASH) and food security programs. Use of safe water, sanitation facilities, and good hygiene can positively affect nutritional outcomes by addressing both immediate and underlying causes of malnutrition. Lack of sanitation and fecal- contaminated environment is linked to chronic undernutrition and is strongly correlated with acute malnutrition and stunting (low height for age).10
2.4.3 Educational and socio-economic status of families
Education and economic empowerment and status are intricately related. Educated families tend to have jobs and economic wealth better than illiterate ones. Being able to financially provide and cater for the family translates into better health status among the members of the household.
48
Hence, child survival, health and development are influenced by families and communities’ ability to protect, care and provide for them adequately. Although several studies have investigated the effects of specific family level factors on child health and survival, there have been few attempts to systematically categorize and empirically assess the relative importance of various family variables on child health.95 Moreover, in Nigeria; it is likely that the links between these variables will vary in the pastoral communities when compared between nomads, sedentarized Fulanis and the rural-urban local populations.
In a study in 2000, in Accra Ghana, data from a representative survey of households with children less than 3 years of age was used to test a number of hypothesized constraints to childcare. These included maternal education, employment, marital status, age, ethnic group, migration status and household-level factors like income, calorie availability, quality of housing, household size and asset ownership as well as availability and use of preventive health services by families. Maternal schooling was the most consistent constraint associated with childcare and survival.59
The contribution of geographical and socioeconomic factors to mortality differences in infancy and childhood is important. In a study to assess infant and child mortality differences in
Cameroon by residence area, mother's education, ethnicity, marital status and union type, religion and the interplay of those factors on differential mortality, the most vulnerable groups of children in the country were the rural residents and Fulbe-Fulani children. Lack of maternal schooling alone explained all the excess childhood mortality of Fulbe-Fulani children.30 In a similar study among nomadic Gabbra families from northern Kenya, on the wealth and
49
reproductive success, findings indicated that size of the camel herd (a family wealth measure) was positively related to the reproductive success. It was posited that the beneficial effects of wealth on reproductive success is that fathers maximize their wealth by making certain that a small number of children are well catered for.96
In Somalia, a survey provided one of the few sources on nomadic settlement conditions, 48% of the population in the settlement areas were children 15 years old and below. Males tended to be more literate and/or in school than females and up to 47% of the households were headed by
Women who were satisfied with settled life and preferred their sons and daughters to be educated and become civil servants in the future.97
2.4.4 Ecological factors-drought and desertification
The impact of drought on pastoral people has aggravated their situation, because their capacity to anticipate, cope with, resist and recover from the impact of drought is diminishing. There is the increasing consensus that meteorological drought is likely to become more frequent and more severe in the decades to come, as a result of global climate change. This will adversely affect nomadic livelihood due to poor animal yield.98 Drought forces nomads to concentrate near water sources or even enter into relief camps and settlements, with often-disastrous consequences for their health. Existing health care systems are in the hands of settled populations and are geographically and socioeconomically hard to reach rarely give access to nomads with effective health interventions due to cultural, political and economic obstacles.6
Being located in geographically isolated areas often in small mobile communities with poor roads create barriers for nomads. Little is known of how to best provide essential health care to
50
mobile and remote populations with community involvement because the constant mobility of nomadic populations excludes them, or at the best places them at the edge of health delivery services.9
The impact on health of a key aspect of the semi-nomadic lifestyle, namely geographic mobility, suggests that seasonal migrations of pastoralists tend to increase the risk of a poor health. There is an inverse association between spatial mobility and health status among the herders of rural
Mongolia; two types of mobility are involved in this process, for households, seasonal migration and at the level of individuals, of travelling to meet personal needs. However, both of these levels have a significant influence and impact on health.99
Environmental factors are a major subset of the overall problems of the Fulani. These factors include the elements of weather, especially rainfall patterns where the weather dictates the patterns of migration, the presence or absence of water and herbage for livestock use rather than for human use governs the mobility of Fulani herders. Where farmers and grazers live in the same geographic space, violent clashes have occurred over trespassing or eating up of crops of farmers. The sedentary people also report that a migrating herd brings unwanted birds and biting flies that affect humans and often destroy food-crops.24 Pastoral grazing orbits extended beyond administrative boundaries caused conflicts between local crop farmers and agro-pastoralists where the land-cover has been altered considerably, leading to limited grazing space and the encroachment on farmlands of the local tenures. It was concluded that a form of intervention was needed that would guarantee sustainability of the land-use system,100 these factors impact on family food security and health and influence the nutrition of the family, particularly children
51
who are at the greatest risk of malnutrition and increased mortality in this underserved and mobile population.
Nomadic Fulani regarded fever as being inherent in all nomadic Fulani for which treatment is therefore unnecessary despite its interference with performance of duty such as herding. But insect bites especially mosquitoes transmitting seasonal malaria among herders is prevalent.
Traditional medicines are used to reduce the severity, and rituals carried out to make it permanently inactive or to divert its recurrence is a common practice among pastoralists.33 Being located in geographically isolated areas places them as hard to reach with effective health interventions where past efforts to provide health interventions for nomads have proved to be costly and sometimes ineffectual.9
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CHAPTER THREE
METHODOLOGY
3.1 BACKGROUND OF THE STUDY AREA
Bauchi State Nigeria was formed in 1976 when the former North-Eastern State was broken up. It originally included the area now Gombe State. Bauchi state has a total area of 49,119 Km2 and lies 100 30′N and 100 00′E with a population of 4,653,066 (2006 Census).20 It has 20 Local
Government Area councils with several indigenous tribes. Fulanis are a substantial part, though
Hausa is widely spoken. Majority are farmers, traders and herdsmen. The study was carried out in Darazo Local Government Area of Bauchi State in north-eastern Nigeria. Darazo LGA is selected for this study purposively as most of the nomadic Fulani cattle grazing reserve route
(Burtali) from north-western Nigeria into Gombe and Adamawa states in north-eastern Nigeria as well as those migrating to the southern part of the country are found in this LGA. Darazo
LGA is one of the 20 LGAs in Bauchi State; created in 1976, the LGA is bordered to its North by Dambam and Misau LGAs, Yobe and Gombe States to its East, Jigawa State to its West and
Ganjuwa LGA to its South.
The LGA has a land mass of 3,015 Km2 made up of 2 political districts and 17 wards. There are two urban wards Darazo East and Darazo West, the remaining fifteen wards are rural. These include Gabarin East, Gabarin West, Gabciyari, Konkiyal, Lago, Lanzai East, Lanzai West, Papa
North, Papa South, Sade East, Sade West, Tauya East, Tauya West, Wahu and Yautare.
According to 2006 census figures, the population of the LGA is 251,597 comprising of 129,182
Males and 122,415 Females.101 The major tribes of the area are Fulani, Karai-Karai and Hausa.
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Farming and cattle rearing are the main occupations in this area while Islam and Christianity are the dominant religions.
3.2 STUDY DESIGN
This was a community-based comparative cross-sectional study.
3.3 STUDY POPULATION
Fulani children (0-59 months) and their care-givers in urban and rural areas of Darazo LGA,
Bauchi State (Urban population represents the sedentarized Fulani while the rural are the nomadic group).
3.3.1 INCLUSION CRITERIA
Every selected Nomadic and Sedentarized Fulani household with children 0-59 months whose parents/caregivers had consented to participate in the study.
3.3.2 EXCLUSION CRITERIA
Parent /caregivers who have children 0-59 months but were not available during the period of study.
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3.4 SAMPLE SIZE DETERMINATION
The minimum sample size required was estimated using the formula for calculating sample size for the comparison of two independent proportions.102 Thus, the minimum sample size of each of the groups was arrived at, using the formula below:
2 N/ group = 2(Zα + Zβ) π (1- π) e2 Where
N = minimum sample size per group
Zα = standard normal deviate corresponding to the probability α, i.e. the probability of
making a type 1 error at 5% = 1.96
Zβ = standard normal deviate at 80% statistical power, corresponding to the probability
of making a type 2 error of test = 0.84
π = mean of two proportions P1 and P2 i.e. P1 + P2/2
P1 = the proportion of Sedentarized children with malnutrition
P2 = the proportion of Nomadic children with malnutrition e = the desired level of difference between the two groups
Ekpo, Omotayo and Dipeolu (2009) observed a level of malnutrition of 38.7% among settled nomadic Fulani children;21 therefore, a proportion of 38.7% will be the nutritional status of the
Sedentarized Fulani children and to detect a difference of 15% between the Nomadic-
Sedentarized Fulani children
Therefore, P1 = 38.7% P2 = 23.7% e = P1 - P2 = 0.387 – 0.237 = 0.15
π = 38.7 + 23.7/2
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= 31.2% = 0.31
1 – π = 1 – 0.31 = 0.69
2 N/ group = 2(Zα + Zβ) π (1- π)
e2
= 2(1.96 + 1.28)2 * 0.31 (0.69)/ (0.15)2
N/group = 199.5 ~ 200
Therefore, the minimum sample size for each group = 200
Anticipating a response rate of 90%, the correction for non-response will be:
102 ns = n/anticipated response. ns = n/0.9 = 200/0.9 = 222.222 per group to make room for non-response.
Therefore 250 children per each group was used for this study.
3.5: SELECTION AND TRAINING OF RESEARCH ASSISTANTS
Six PHC department staff and three HF staff from the study community/wards were part of the team. Criteria for their selection included being a health worker who has been working within the
LGA, being literate in English, Hausa or Fulani or being multilingual. They were trained using the IMCI module on children’s examination, assessment of weights, heights/lengths and classification of status, diseases patterns as well as treatment and referral guidelines during a two-day session organized in the LGA secretariat conference hall.
3.6: SAMPLING METHOD
Selection of subjects in each household in the sedentarized and among the nomads was done using multistage sampling technique in four stages.
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Stage I - Selection of LGA
From the list of the 20 LGAs in Bauchi state, Darazo LGA was purposively. selected being the
LGAs with the highest number of nomadic Fulani in the state.
Stage II -Selection of wards
There are 17 wards in the LGA. Two are urban (sedentarized) and 15 are rural (nomadic). The two urban wards were selected purposively. All the political wards were listed out to form the sampling frame; two rural wards were selected using simple random sampling technique by balloting out of the 15 rural (Nomadic) wards.
STAGE III -Selection of household
All the Fulani households in the study populations of the Sedentarized (urban) and the nomadic
(rural) communities were visited and all the mothers/caregivers with children 0-59 months of age who consented were recruited for the study. In Darazo Township cluster representing the
Sedentarized community, a systematic sample of the houses was used. In the sedentarized community the serial numbering of households as used by the PHC listing for Supplemental
Immunization Activities (SIAs) using the micro-plan template was obtained and followed. To get the sampling interval, the total number of households in a ward was divided by the sample size of 250 in the frame. The first household was then randomly selected using balloting within the first interval, and the next household for the subsequent interval was selected. This process continued until the required minimum sample size of 250 mother/child pairs were selected. There was no house numbering in nomadic settlements but with the aid of the community guides households were identified and listed from settlement to settlement.
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STAGE IV -Selection of participants
In the urban ward (sedentarized), all consenting Fulani households’ caregivers were interviewed and their children’s clinical assessment and anthropometric measurements were done by the research team. Respondents were recruited from households and not houses, as many families lived in one house or compound as is common in Nigeria. Only one eligible caregiver-child pair participant was selected from each household for the study.
For the rural ward (nomadic) only the nomadic households in their camps were recruited and the sedentarized Fulani in the neighborhood excluded. There was no house numbering in most of the ruga (camps) visited, the team with the help of the elder Fulani guide had to ascertain the house units in the ruga to now temporarily assign the numbering just for the team to serialize each cluster. Eligible mother/caregiver- child pair were assessed and the caregivers interviewed once the Ardo (local chief) consented. Often times the nomadic children were found herding and the
Fulani guide helped in the identification and the appropriate matching of caregiver for the team to be able to get back to the caregivers. The eligible children were then picked with their caregivers. Those found herding were retrospectively traced with the help of the guide.
3.7: STUDY INSTRUMENTS AND DATA COLLECTION
3.7.1: QUESTIONNAIRE
A semi-structured interviewer administered questionnaire consisting of four sections was used in data collection for the study. The instrument was adapted from the National Demographic and
Health Survey (NDHS) questionnaire,105 and the Child Health Questionnaire-Parent Form (CHQ-
PF28).106 The questionnaire in English language translated to Hausa and Fulfulde languages. The 58
Hausa and Fulfulde language questionnaires were back translated to English by a bilingual translator to ensure that the original meanings were retained.
The research questionnaire has four sections
Section A: Socio-demographic information of child
Section B: Child health status
Section C: Clinical findings
Section D: Parent/primary caregivers section
3.7.2: INSTRUMENTS
Weighing scales, stadiometer, measuring tapes, calculators and Health Facility Catchment Area
Map (HFCAM) and Reaching Every Ward (REW) micro-plan data set for all the selected wards.
3.7.3: PREPARATION FOR DATA COLLECTION.
There were three teams of research assistants; consisting of a village guide, two interviewers
(one Fulani one Hausa) or one multilingual interviewer, a Nurse/CHO/CHEW and a driver/bikers. Advocacy visits were made to the head of department PHC of Darazo LGA as well as the district head to intimate them on the purpose of the research and solicit for their support.
The team met with the Health Educator of the LGA who helped organize meeting with the Ward
Focal Persons (WFPs) in the Nomadic wards and subsequently arranged meeting with the Ardos and other Fulani leaders, religious leaders and the health care providers in the Nomadic communities and they were intimated on the research.
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During the first visit to the Ardo we were introduced by the local guide who initiated informal conversations about the health of their animals and their family and then our mission. With the assistance of the Ardo, settlements (rugas) were selected from each of the villages in the area we went. The Ardo facilitated entry to the settlements and introduced the team and the objective of the study to the Jauro and household heads as Fulanis respect their kinsmen at all times.
Members of the research team selected had previous experience as they worked with the Local
Government PHC department and health facilities in some of the wards. They have been into community research for a long time and some of them were fluent in Hausa and/or Fulfulde, the language of the Fulani. The research team/assistants received a 2-day training on how to use the questionnaire, practical sessions on the clinical assessments/instruments for the research and a little orientation on Fulani culture and local dialectical usage of the Fulfulde language.
Advocacy visit was made to the Chairman of Dambam LGA, we intimated him on the pretest in
Jalam Ward of his council through the PHC department Director who consented for the pre-test to be conducted in his LGA. The team visited the ward head and the Ardo who expressly gave us the go ahead and we were able to conduct the pretest for the study and made necessary amends before we went out on the field in Darazo LGA. The pre-test was done in a Nomadic and
Sedentarized ward. A total of thirty Mother/caregiver- child pair were interviewed and ambiguities on questionnaire corrected.
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3.7.4: DATA COLLECTION
The members of the research team gave detailed explanation as to the purpose of the study to all eligible respondents in the households and verbal informed consent was obtained from each household head/caregiver that were found in each household before the administration of the questionnaire and the clinical assessments. The respondents who could speak English were interviewed in English, while Hausa Language was generally used for the Hausa speaking
Sedentarized Fulani respondents and some Fulfulde speaking sedentarized Fulani were interviewed in Fulfulde. The nomadic population had the administration of the questionnaires in
Fulfulde as the ‘Nomadic research team’ was strategized in such a way that the Fulfulde speaking Community Health Extension Worker/Community Health Officer (CHEWs/CHO) were assigned in each group. The data collection was done over a period of five months March & June of 2011 and March to May of 2012 due to the 2011 post presidential election crisis that resulted in killings in Bauchi state, the research team had to withdraw from the field.
The nomads are constantly on the move; therefore, the “Ardo” was communicated as to when the research team will visit his settlement. He made all the necessary arrangement to get his people ready for the research once the information is passed across to him. The terrain was difficult, but the use of a local guide was useful in tracking the nomads.
The trained research assistants administered the questionnaires to the mothers/caregivers and conducted the clinical examination and weighing of the participants using the mature research assistants who are also their PHC ‘Doctors’ with good advocacy techniques. They interviewed all consenting caregivers as well as clinical examination of the children and anthropometric 61
assessments. General examination was carried out, searching for signs such as pallor, pedal oedema and other signs of malnutrition as well as any disability. The procedure for the physical examination of the child was weighing without shoes and with only minimal clothing to the nearest 0.5 kg, using the UNICEF digital weighing scale (UNISCALE). Two measurements were taken for each participant and an average reading was used. For children unable to stand on the scale, differential weighing was done with the aid of the assistant or caregiver. Height was measured without shoes and headgear, using a portable stadiometer calibrated to the nearest 0.1 cm. The height/ (supine length) of the child measured with the aid of a stadiometer and the mid- upper-arm circumference measurements using flexible tape measure (Shakir Strip).
3.8: DATA MANAGEMENT AND ANALYSIS
All data generated were collated, processed and analyzed using Statistical Package for Social
Sciences (SPSS) version 23.0 and WHO Anthro version 7.0. The nutritional status was analyzed and compared using the WHO z score of the standard reference population using the WHO anthro. Immunization and morbidity status was compared using mean scores and percentages using the SPSS.
Qualitative data like sex, mother’s occupation and educational status was presented as percentages, while continuous quantitative data like ages of children and caregivers/parents, weights, heights arm circumference were described using mean, median and standard deviation.
Descriptive statistics such as the mean, standard deviation, range, frequencies, percentages were used to describe the data which were presented as tables and charts while inferential statistics was used to determine associations between variables.
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The World Health Organization (WHO) Anthro for nutritional assessment was used to determine the standard deviations (z-scores) from the mean of the international reference population of the children’s weight for age (WAZ) indicating under-nutrition, weight for height (WHZ) indicating acute malnutrition and height for age (HAZ) indicating stunting or chronic malnutrition based on the WHO 2006 growth standards. SPSS version 23.0 was used to determine frequencies, means
± standard deviations, graphical representations and statistical associations of dependent and independent variables. and the Chi-square test was used to determine any association between categorical variables and outcomes to test for association. Tests were two-tailed with 95% confidence interval and (P0.05) was considered statistically significant.
Logistic regression analysis was used to assess the predictive factors for child’s health status.
The variables used for Logistic regression were those that had shown some level of statistically significant association on univariate or bivariate analysis (using chi-square test). A confidence interval of 95% was used in this study and a P-value of 0.05 was considered significant.
3.9: ETHICAL CONSIDERATIONS
Ethical clearance was obtained from the Ethical Committee, Bauchi State Specialist Hospital before the commencement of the study. A written permission was sought and obtained from the
Ministry of health, Bauchi before proceeding to the Chairman, Darazo Local Government Area who gave approval for the research team. The district head was informed of the study as well as the heads of the wards who in turn linked the study team to the mai-ungwa (ward head) of the urban and Ardos for the Nomadic Fulani communities where the aims and objectives of the study were explained to them.
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Verbal informed consent was obtained from each study subject’s household/caregiver before enrollment into the study. The essence of the study was also explained to them, they were assured of confidentiality of any information they gave, that there was no penalty or denial of benefit due them for refusal to participate as a punitive measure even after the research activities by the research assistants.
All assessments and interviews were confidential, and anonymity was maintained by using serial numbers only as no names were recorded on the proforma. The benefits to the participants are enormous as the study may inform policy and possible legislation to ensure nomads benefit in government programmes for the study population. Clinical condition requiring attention was treated or referred for subsequent care and follow-up.
3.10: LIMITATIONS OF THE STUDY
1. The post-election violence of April 2011 Presidential elections made the research team to
withdraw completely from the field as the killing of youth corps members in Bauchi state
was tragic and no activities could be done throughout that year
2. The terrain was difficult and reaching the Fulani settlements (rugas) was not easy, but
the use of a local guides ensured proper tracking and reduced the chances of missing out
some settlements which was inevitable.
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CHAPTER FOUR
RESULTS
The study population who participated in the research were caregiver’s/mother child pairs of 250 households each from the nomadic and sedentarized Fulani communities and their children assessed. The details of the data of the subjects is presented below.
SECTION A
4.1.0: SOCIO DEMOGRAPHIC CHARACTERISTICS OF THE STUDY POPULATION
Table 1: Age and sex distribution of sedentarized and nomadic Fulani children
Sedentarized Nomadic Total (n=250) (n=250) (n=500) Variable Freq. % Freq. % Freq. % χ 2 df p-value Age (months) 0 -11 46 18.4 67 26.8 113 22.6 7.595 4 0.108 12 -23 49 19.6 52 20.8 101 20.2 24 -35 41 16.4 30 12.0 71 14.2 36 -47 51 20.4 38 15.2 89 17.8 48 -59 63 25.2 63 25.2 126 25.2 Sex Male 139 53.9 119 46.1 258 53.9 3.034 1 0.082 Female 112 46.1 131 53.9 243 46.1
Mean ± SD (28.47±18.42)
Table 1: above shows the sex distribution between group shows that males were 258(53.9%) which was slightly higher than females 243(46.1%) though not statistically significant as there was not much difference between sexes. Overall, children in age group 48-59 months had the highest representation of 25.2% followed by infants with 22.6%.
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Table 2: Socio-demographic variables of mothers/caregivers in the study population
Sedentarized Nomadic Variable (n=250) (n=250) Total χ2 df p-value
Mothers age Freq. % Freq. % Freq. % (Years) 25.794* 5 0.001 <20 55 22.0 86 34.4 141 28.2 20 - 24 71 28.4 93 37.2 164 32.8 25 - 29 75 30.0 45 18.0 120 24.0 30 - 34 37 14.8 16 6.4 53 10.6 35 - 39 10 4.0 9 3.6 19 3.8 40 + 2 0.8 1 0.4 3 0.6
Level of No education 106 42.4 122 48.8 228 45.6 52.768* 4 0.001 Education Quranic 86 34.4 123 49.2 209 41.8 Primary 24 9.6 3 1.2 27 5.4 Secondary 19 7.6 2 0.8 21 4.2 Tertiary 15 6.0 0 0.0 15 3.0
Occupation Housewife 204 81.6 228 91.2 432 86.4 13.217* 3 0.004 Self employed 26 10.4 17 6.8 43 8.6 Skilled 15 6.0 5 2.0 20 4.0 Professional 5 2.0 0 0.0 5 1.0
Younger mothers aged <20 years in the nomadic population were 34.4% compared to 22.0% in their peers in the sedentarized population (P=0.001). Mothers in the age group 20-24 years accounted for a greater part (32.8%) of the respondents with nomads accounting for 37.2%.
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Most of the mothers had no formal education in both sedentarized and nomadic, 42.4% & 48.8% respectively. Sedentarized mothers had higher levels of primary, secondary and tertiary education levels with only two (0.8%) who had completed secondary education and none had tertiary education among the nomadic women.
Majority were housewives (86.4%) followed by self-employed in both areas. There was a statistically significant difference in the two populations in terms of mother’s occupation,
(P=0.004), where Sedentarized Fulani mothers were more skilled and 2% were professionals while none of the Nomadic Fulani mothers attained this occupational status.
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Table 3: Socio-demographic variables of fathers in the study population
Variables Sedentarized Nomadic Total χ2 df p-value
Fathers age (years) Freq. % F req. % Freq. % 20 – 29 47 19.3 71 28.5 118 23.9 8.889 5 0.114 30 – 39 98 40.2 102 41.0 200 40.6 40 – 49 49 27.2 34 13.7 83 16.8 50 – 59 34 13.9 29 11.6 63 12.8 60 – 69 13 5.3 9 3.6 22 4.5 70+ 3 1.2 4 1.6 7 1.4
Level of No education 41 16.9 77 32.6 118 45.6 52.726* 4 0.001 Education Quranic 99 40.9 118 50.0 217 41.8 Primary 36 14.9 26 11.0 62 13.0 Secondary 31 12.8 14 5.9 45 9.4 Tertiary 35 14.5 1 0.4 36 7.5
Occupation Unemployed 42 17.0 37 15.3 79 16.2 17.40* 3 0.001 Self 159 64.4 188 77.7 347 80.0 employed Skilled 30 12.1 14 5.8 44 9.0 Professional 16 6.5 3 1.2 19 3.8
The fathers ages in both sedentarized and nomadic population were comparable (P=0.114)
Educational level shows sedentarized having higher literacy level where 12.8% against 5.9% having secondary education, those in the Sedentarized had (14.5%) tertiary education compared to only one (0.4%) among the nomadic fathers. The Sedentarized fathers were more gainfully employed with statistically significant difference in the two populations (P=0.001), being skilled and professionals.
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Table 4. Summary statistics and t- test for sedentarized and nomadic populations
95% Confidence Interval of the
Difference Place of Std. Age Residence Mean Deviation t p-value Lower Upper Children Sedentarized 29.48 18.045 1.235 0.217 -1.201 5.269 (Months) Nomadic 27.45 18.769 Fathers Sedentarized 39.43 11.411 2.052 0.041 0.090 4.169 (Years) Nomadic 37.30 11.563 Mothers Sedentarized 25.85 5.895 4.672 0.001 1.408 3.451 (Years) Nomadic 23.42 5.658
The distribution of the studied population where the mean age of the children was 28.48 + 2.034 months for the sedentarized and 27.45±2.034 months in the nomadic group which were comparable (P=0.108).
The mean age of mothers/caregivers was 24.67±5.92 years with nomadic mean of 23.42±5.658 who were more in the age group of <20 years compared to the sedentarized (P=0.001)
The mean age of the nomadic and sedentarized fathers was 38.29±11.53 years. The age groupings were comparable with those 30-39 years accounting for 40.6% while 60+ years representing only 5.9% of the study population.
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Table 5: Family type and number of children in the study population
Sedentarized Nomadic Total Variables Freq. % Freq. % Freq. % χ2 df p-value Family Type n=241 n=237 n=478 Monogamous 154 63.9 165 69.6 319 66.7 1.761 1 0.184 Polygamous 87 36.1 72 30.4 159 33.3 Number of children n=250 n=250 n=500 1 – 4 119 47.6 147 58.8 266 53.2 3* 0.084 5 – 10 97 38.8 79 31.6 176 35.2 11 – 20 32 12.8 22 8.8 54 10.8 20 + 2 0.8 2 0.8 4 0.8 *Fishers exact test
The parents’ family orientation in both sedentarized and nomadic areas were predominantly monogamous (66.7%). Polygamy was practiced slightly higher in sedentarized than in the nomadic areas.
The number of living children in the households at the time of the study show that more than half of the study population (53.2%) had at least 1-4 children in each household, this was slightly higher among the nomadic population. Up to 38.8% of the sedentarized and 31.6% nomadic households had between 5-10 children.
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Table 6. Distribution of animal wealth and monetary income of families in the population Sedentarized Nomadic Total
(n=250) (n=250) (n=500) Wealth Quantity Freq. % Freq. % Freq. % χ2 df P-value Cow 0 186 74.4 20 8.0 206 41.2 235.376 2 0.001 1 – 49 60 24.0 170 68.0 230 46.0 50+ 4 1.6 60 24.0 54 12.8 Sheep 0 155 62.0 32 12.8 187 37.4 122.049 2 0.001 1 – 49 91 36.4 168 67.2 259 51.8 50+ 4 1.6 29 11.6 33 6.6 Goat 0 160 64.0 86 34.4 246 49.2 47.445 2 0.001 1 – 49 87 34.8 147 58.8 234 46.8 50+ 3 1.2 17 6.8 20 4.0 Family 500 - 18,000 128 51.2 163 65.2 291 58.2 28.080 6 0.001 income 19,000 - 36,000 27 10.8 14 5.6 41 8.2 (Naira) 37,000 - 54,000 22 8.8 2 0.8 24 4.8 55,000 - 72,000 9 3.6 3 1.2 12 2.4 73,000 - 90,000 4 1.6 3 1.2 7 1.4 90,000+ 2 0.8 2 0.8 4 0.8 NR 58 23.2 63 25.2 121 24.2 NR they did not disclose their animal wealth NR they claimed not to have earnings/didn’t have monthly income (1 US $ = 350 Naira exchange rate)
The wealth parameter presented above showed that the animal heard distribution in families with average herd of 1-49 cows were 60 (24.0%) in the sedentarized and ten times, 170 (68.0%) amongst the nomadic group. Those with (50+ cow herd- referred to as ‘garke’-an animal wealth measure) was found to be 1.6% in sedentarized and 24.0% in the nomadic households, nomads had significantly higher herds (P=0.001). Earnings from 500-18,000 Naira (US $ 1.43-51.42) constituted 58.2% of the bulk earnings with nomads earning higher 65.2% compared to 51.2% in the sedentarized group, but between 19,000-72,000 (US $ 5.43-205.71) sedentarized Fulani were better. With only 1.4% of the Fulani earning 73,000 - 90,000 (US $ 208.57-257.14) per month in the study population.
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SECTION B ASSESSMENT OF NUTRITIONAL STATUS OF NOMADIC AND SEDENTARIZED FULANI CHILDREN Table 7: Types of common foods consumed by the children in the study population Sedentarized Nomadic Types of common food consumed Freq. % Freq. %
Drinks cow milk/cheese daily 51 46.8 129 65.2
Eats meat/fish daily 34 30.6 22 15.1
Eats meat/fish 1-3 times a week 102 62.2 59 36.2
Does not have meat or fish to eat 7 8.2 15 13.2
Eat beans, akara or moin-moin* 174 93.1 151 87.3
Eats ‘danwake’** 157 92.9 156 88.1
Breast milk alone 37 37.8 38 31.4
Breastfeeding and supplementary feeds 86 61.9 63 39.6
Eats Talia (local spaghetti) 210 95.0 169 88.9
Eats ‘Dumamme’*** 214 96.0 156 88.1 *Beans cake, **Carbohydrate flour rolls in oil, ***Left over food that is reheated the next morning for breakfast The dietary intake was mainly carbohydrate (Dumame, danwake and talia) among sedentarized and nomadic. Carbohydrate consumption was 10-percentage point lower among nomads.
The meat/fish at least 1-3 times a week among the sedentarized was 62.2% and about half the nomadic 36.2%, with up to 13.2% of the nomadic children not having access to meat/fish
(P=0.001).
The children exclusively breast fed was 37.8% for sedentarized while 31.4% of the nomadic children had exclusive breastfeeding.
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Table 8. Nutritional status indicators for the children in the study population
Population Sedentarized Nomadic Total (n=250) (n=250) (n=500) Classification Freq. % Freq. % Freq. % χ2 df p-value
Not stunted 220 88.0 165 66.0 385 77.0 34.16 1 0.001 Stunted (HAZ) 30 12.0 85 34.0 115 23.0
Not underweight 229 91.6 202 80.8 431 86.2 12.26 1 0.001 Underweight (WAZ) 21 8.4 48 19.2 69 13.8
Not wasted 230 92.0 214 85.6 444 88.8 5.15 1 0.023 Wasted (WHZ) 20 8.0 36 14.4 56 11.2
Z score level of < -2SD (WHZ-weight for height, WAZ-weight for age, HAZ-height for age)
The table of nutritional status of the children shows that the height-for age deficit (stunting, < -
2SD) among the sedentarized was 12.0% while the nomads’ stunting was nearly three times
(34.0%) with an average stunting rate of 23.0% in both populations.
The underweight children in sedentarized community was 8.4% while twice as much (19.2%) nomadic children were found to be underweight.
Underweight and stunting showed statistically significant difference P=0.001 with more of the nomadic children affected, however there were fewer children with wasting (acute malnutrition)
11.2% in the study area considering the three categories of nutritional indices.
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Table 9. Nutritional status indicators by type and within gender in the study population
Nutritional Status
Children Stunted Not stunted Total χ2 df P-value Freq. % Freq. % Freq. % Male Sedentarized 18 12.9 121 87.1 139 53.9 15.71 1 0.001 Male Nomadic 40 33.6 79 66.4 119 46.1 Total 58 22.5 200 77.5 258 100.0 Female Sedentarized 12 10.8 99 89.2 111 45.9 18.49 1 0.001 Female Nomadic 45 34.4 86 65.6 131 54.1 Total 57 23.6 185 76.4 242 100.0 Underweight Not Underweight Male Sedentarized 15 10.8 124 89.2 139 53.9 7.49 1 0.007 Male Nomadic 28 23.5 91 76.5 119 46.1 Total 43 16.7 215 83.3 258 100.0 Female Sedentarized 6 5.4 105 94.6 111 45.9 6.09 1 0.020 Female Nomadic 20 15.3 111 84.7 131 54.1 Total 26 10.7 216 89.3 242 100.0 Wasted Not Wasted Male Sedentarized 11 7.9 128 92.1 139 53.9 6.43 1 0.015 Male Nomadic 22 18.5 97 81.5 119 46.1 Total 33 12.8 225 87.2 258 100.0 Female Sedentarized 9 8.1 102 91.9 111 45.9 0.47 1 0.519 Female Nomadic 14 10.7 117 89.3 131 54.1 Total 23 9.5 219 90.5 242 100.0 The nutritional status of the children by gender presented above shows that the stunting, underweight and wasting among the nomadic males was higher than the sedentarized males and was statistically significant (P=0.001) The nomadic females had higher rates for stunting, underweight and wasting of 34.4%, 15.3% & 10.7% respectively. However, the female nomadic and sedentarized wasting was similar (P=0.519) but higher among the nomadic but difference was not statistically significant at P=0.05.
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Table 10. Nutritional status indicators by type and between gender in the study population
Nutritional status Children Stunted Not stunted Total χ2 df P-value Gender Freq. % Freq. % Freq. % Male Sedentarized 18 12.9 121 87.1 139 55.6 0.267 1 0.697 Female Sedentarized 12 10.8 99 89.2 111 44.4 Total 30 12.0 220 88.0 250 100.0 Male Nomadic 40 33.6 79 66.4 119 47.6 0.015 1 1.000 Female Nomadic 45 34.4 86 65.6 131 52.4 Total 85 34.0 165 66.0 250 100.0 Underweight Not Underweight Male Sedentarized 15 10.8 124 89.2 139 55.6 2.33 1 0.169 Female Sedentarized 6 5.4 105 94.6 111 44.4 Total 21 8.4 229 91.6 250 100.0 Male Nomadic 28 23.5 91 76.5 119 47.6 2.74 1 0.109 Female Nomadic 20 15.3 111 84.7 131 52.4 Total 48 19.2 202 80.8 250 100.0 Wasted Not Wasted Male Sedentarized 11 7.9 128 92.1 139 55.6 0.00 1 1.000 Female Sedentarized 9 8.1 102 91.9 111 44.4 Total 20 8.0 230 92.0 250 100.0 Male Nomadic 22 18.5 97 81.5 119 47.6 3.08 1 0.104 Female Nomadic 14 10.7 117 89.3 131 52.4 Total 36 14.4 214 85.6 242 100.0
The nutritional status between gender shows that stunting in sedentarized males and females was
12.9% & 10.8% respectively while the nomadic had 33.6% & 34.4%, which was not statistically significant. The underweight and wasting between gender were also similar, which generally depicts no difference observed between gender in the sedentarized and nomadic children in the study population.
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Table 11: Nutritional screening using Shakir’s strip [MUAC in children (6-59 months)]
Location of children Sedentarized Nomadic Total Mid Upper Arm Circumference n=228 n=221 n=449 Color code Centimeters Freq. % Freq. % Freq. % Green ≥12.5 139 61.0 106 48.0 245 54.5 Yellow 11.5-12.5 79 34.6 94 42.5 173 38.5 Red ≤11.5 10 4.4 21 9.5 31 7.0
The table of nutritional status screening using the Shakir strip shows that over half of the children 54.5% were normal (green, ≥12.5 Cms), 38.5% were showing some level of malnutrition (yellow, 11.5-12.5 Cms) while 7.0% had overt malnutrition (red, ≤11.5 Cms).
There were twice as many nomadic in the red category 9.5% compared to 4.4% in sedentarized, where overall the nomadic population had higher level of malnutrition.
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Figure 1: Nutritional status of Sedentarized and Nomadic children compared to WHO standard (Weight for Height Deficit-Wasted)
The children in the study population in the red color were more wasted compared to the WHO reference standard for general population distribution (represented in green color) by nearly 15% with some children with severe malnutrition-3 SD as shown in the graph.
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Figure 2: Nutritional status of Sedentarized and Nomadic children compared to WHO standard (Weight for Age Deficit-Underweight)
The weight for age deficit representing the -underweight children shown in the graph above has a marked left shift which depicts an increased underweight status compared to the standard reference population in green color, indicating more of the children were underweight.
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Figure 3: Nutritional status of Sedentarized and Nomadic children compared to WHO standard (Height for Age Deficit-Stunted)
The height for age deficit-stunting in the graph above shows a marked left shift with depression of the curve and obvious severity <5 z-score in the population compared to the WHO general reference population curve.
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Table 12: Logistic regression of predictive factors for stunting in the study population
95% Confidence Int. Variables Odds Lower Upper P-value Child sex Male 0.990 0.626 1.566 0.967 Female 1 - - - Child age in months 6-23 1.232 0.760 1.998 0.397 24-59 1 - - - Mothers occupation House wife 0.854 0.355 2.053 0.724 Professional 3.572 0.463 27.547 0.222 Self-employed 1 - - Fathers occupation Professional 0.649 0.052 8.021 0.736 Self-employed 1.293 0.682 2.450 0.431 unemployed 1 - - Mother age ≤20 years 0.816 0.434 1.536 0.529 >20 years 1 - - Mothers Level of education Formal education 0.282 0.076 0.043 0.050 No Formal education 1 - - Fathers Level of education Formal 0.631 0.339 1.175 0.147 No formal 1 - - Attend CWC for GMP Attended 0.366 0.212 0.630 0.001 Not attended 1 - -
The logistic regression for predictive factors for stunting among the study population showed that a child is likely to have stunting when the mother does not attend CWC for growth monitoring (OR=0.366; 95%CI=0.212-0.630; P=0.001) and if mother has no formal education.
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Table 13: Logistic regression of predictive factors for underweight in study population
95% Confidence Int. Variables Odds Lower Upper P-value Child sex Male 1.831 1.041 3.220 0.036 Female 1 - - - Child age in months 6-23 3.247 1.777 5.934 0.001 24-59 1 - - - Mothers occupation House wife 3.090 0.689 13.854 0.140 Professional 3.630 0.221 59.574 0.367 Self-employed 1 - - Fathers occupation Professional 0.993 0.202 4.874 0.993 Self-employed 1.255 0.590 2.668 0.555 unemployed 1 - - Mother age ≤20 years 1.621 0.794 3.311 0.185 >20 years 1 - - Mothers Level of education Formal education 0.421 0.095 1.879 0.257 No Formal education 1 - - Fathers Level of education Formal 1.274 0.621 2.502 0.535 No formal 1 - - Attend CWC for GMP Attended 0.569 0.307 1.054 0.073 Not attended 1 - - Logistic regression showed that a child is more likely to be categorized as underweight if a female (OR=1.831; 95% CI=1.041-3.220; P=0.036) or aged between 24-59 months i.e. older children were more underweight than the younger ones in the study population (OR=3.247; 95%
CI=1.777-5.934; P=0.001).
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Table 14: Logistic regression of predictive factors for wasting in the study population
95% Confidence Int. Variables Odds Lower Upper P-value Child sex Male 1.427 0.773 2.634 0.255 Female 1 - - - Child age in months 6-23 2.909 1.502 5.636 0.002 24-59 1 - - - Mothers occupation House wife 2.079 0.456 9.487 0.345 Professional 2.639 0.160 43.558 0.498 Self-employed 1 - - Fathers occupation Professional 1.162 0.228 5.914 0.857 Self-employed 1.079 0.486 2.391 0.852 unemployed 1 - - Mother age ≤20 years 3.457 1.639 7.292 0.001 >20 years 1 - - Mothers Level of education Formal education 0.589 0.127 2.721 0.497 No Formal education 1 - - - Fathers Age ≤30 years 0.404 0.177 0.921 0.031 >30 years 1 - - - Fathers Level of education Formal 0.876 0.392 1.956 0.747 No formal 1 - - Attend CWC for GMP Attended 0.608 0.310 1.192 0.148 Not attended 1 - - Logistic regression showed that wasting was not influenced by mother’s education but by the age of the child (P=0.002), mothers age (OR=3.457; 95% CI=1.693-7.292; P=0.001) fathers age (P=0.031) but not by CWC attendance.
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SECTION C ASSESSMENT OF IMMUNIZATION STATUS OF NOMADIC AND SEDENTARIZED CHILDREN
Table 15: Routine Immunization coverage for children in the study population
Sedentarized Nomadic (n=250) (n=250) Vaccinated Not-Vaccinated Vaccinated Not-Vaccinated Vaccine Freq. % Freq. % Freq. % Freq. %
BCG 108 43.2 104 56.8 65 26.0 185 74.0
Polio-3 98 39.2 152 60.8 74 29.6 176 70.4
HBV-1 115 46.0 135 54.0 84 33.6 166 66.4
DPT*-3 85 34.0 165 66.0 73 29.2 177 70.8
Measles 95 38.0 155 62.0 73 29.2 177 70.8
Yellow Fever 69 27.6 181 72.4 66 26.4 184 73.6 DPT*(Now Pentavalent vaccine containing 5 antigens-Hep. B, Hib, Diphtheria, Pertussis, Tetanus)
The Routine Immunization coverage in the study population presented above shows that in terms of access BCG was 43.2% for the sedentarized was higher than the nomadic children with 26.0% coverage.
The DPT-3 (Penta) used as indicator for administrative coverage showed that sedentarized had
34.0% while the nomadic children had 29.2%.
The third dose of Polio (Polio-3) was 39.2% among the sedentarized children with 70.4% nomadic children not vaccinated with Polio-3.
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Table 16: Attendance of Child Welfare Clinic services & Routine Immunization utilization
Sedentarized Nomadic (n=250) (n=250) Clinic Appropriate Inappropriate Appropriate Inappropriate attendance Freq. %) Freq. % Freq. % Freq. %
Yes 80 50.0 80 50.0 65 43.0 86 57.0
No 5 5.6 85 94.4 8 8.1 91 91.9
χ2=50.70,df=1, P=0.001 χ2=35.36,df=1, P=0.001
The children whose mothers availed them at the CWC had up-to-date immunization for DPT-3
(Penta-3) with 50.0% coverage in those sedentarized and slightly less 43.0% among the nomadic population. The vaccination coverage with DPT-3 (Utilization) in the sedentarized and nomadic population showed that the child’s DPT-3 vaccination coverage was better with CWC attendance
(P=0.001).
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Table 17: Fully Immunized status (Measles) by age of children in the study population
Sedentarized Nomadic (n=250) (n=250) Age of child Appropriate Inappropriate Appropriate Inappropriate Freq. % Freq. % Freq. % Freq. %
< 23 months 24 25.3 71 74.7 27 22.7 92 73.0
>24 months 71 45.8 84 54.2 46 35.1 85 64.9
χ2=10.55,df=1, P=0.001 χ2=4.66,df=1, P=0.031
The vaccination coverage with measles vaccination after receiving all the routine vaccines up to
DPT-3 (fully immunized child-FIC) presented above showed that the sedentarized were more up- to-date and had appropriate vaccination than the nomadic by the age of 24 months with
45.8%being up-to-date whereas in the nomadic children 64.9% did not receive measles vaccinations χ2=4.66 df 1, P=0.031 by age 24 months.
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Table 18: Fully Immunized status (Measles) by age of mothers in the study population Sedentarized Nomadic (n=250) (n=250) Age of Mother Vaccinated Not vaccinated Vaccinated Not vaccinated Freq. % Freq. % Freq. % Freq. %
<20 Years 18 32.7 37 67.3 24 27.9 62 72.1
>20Years 77 39.5 118 60.5 49 29.7 116 70.3
χ2=0.832 df=1, P=0.362 χ2=0.088,df=1, P=0.767
The fully immunized children were more in the sedentarized group at 39.5% compared to 29.7% in the nomadic for mothers >20 years as well as mothers <20 years who had 32.7% of their children in the sedentarized group compared to 27.9% among the nomads. However, the vaccination coverage with a child being up-to-date and fully immunized among the sedentarized and nomadic children showed no statistically significant difference, (P=0.362) and (P=0.767) respectively in both study populations.
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Table 19: Maternal educational status and child access to immunization (BCG vaccination)
Sedentarized Nomadic (n=250) (n=250)
Educational status Vaccinated Not vaccinated Vaccinated Not vaccinated Freq. % Freq. % Freq. % Freq. %
Formal 35 60.3 23 39.7 1 20.0 4 80.0
No Formal 47 44.3 59 55.7 47 38.5 75 61.5
Quranic 26 30.2 60 69.8 17 13.8 106 86.2
χ2=12.90,df=2, P=0.002 χ2=19.52,df=2, P=0.001
The maternal education status and child’s vaccination status using BCG rates as first antigen for access to vaccination schedule for RI at birth in the population shows that sedentarized mothers with formal education had 60.3% coverage rate while mothers with no formal & Quranic education level had 44.3% & 30.2% respectively which was statistically significant χ2=12.90, df=2, P=0.002.
The nomadic population had 80.0% of their children who did not receive vaccines compared to their sedentarized counterparts with 39.7%, (P=0.001) which was statistically significant.
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Table 20: Maternal educational status & fully-immunized child (Measles vaccination)-FIC
Sedentarized Nomadic (n=250) (n=250)
Educational status Vaccinated Not vaccinated Vaccinated Not vaccinated Freq. % Freq. % Freq. % Freq. %
Formal 35 60.3 23 39.7 4 80.0 1 20.0
No Formal 34 32.1 72 67.9 43 35.2 79 64.8
Quranic 26 30.2 60 69.8 26 21.1 97 78.9
χ2=16.07,df=2, P=0.001 χ2=11.74,df=2, P=0.003* *Williams's criterion (Likelihood-ratio chi-sq.)
The fully immunized child by the age of one year for measles in relation to educational status of mothers with formal, non-formal and Qur’anic was 60.3%, 32.1%, 30.2% for sedentarized and the nomadic had 80.0%, 35.2%, 21.1% respectively, showing mothers with formal education had higher coverage in both populations.
They also had the lowest rates of un-immunized children of 39.7% & 20.0% respectively in both sedentarized and nomadic population when compared with those who had Quranic or no formal education with 67.9% & 64.8% respectively. Which was statistically significant (P=0.001 &
P=0.003) respectively.
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Table 21: Relationship between fully immunized status of child (Measles) and distance to health facility in the study populations Sedentarized Nomadic (n=250) (n=250)
Vaccinated Not vaccinated Vaccinated Not vaccinated Distance Freq. % Freq. % Freq. % Freq. %
>10 Km 1 16.7 5 83.3 1 6.2 15 93.8
5-10 Km 3 8.1 34 91.9 9 15.0 51 85.0
<5 Km 86 45.7 102 54.2 54 41.9 97 58.1
No response 19 7.6 45 18.0
χ2=23.39 df=2, P=0.001* χ2=13.24 df=2, P=0.001 *Williams's criterion (Likelihood-ratio chi-sq.)
There were 45.7% children leaving within 5km reach to the HF who had received vaccination, reducing to 8.1% at 10km with 16.7% for children whose parents reside >10 Km or more away from HF in the sedentarized Fulani group.
The closer the parents to HF the better the vaccination status of the child (P=0.001). This is also similar in the nomadic group where 41.9% of the children were up-to-date at 5km distance,
P=0.001. Eighteen percent of nomadic Fulani and 7.6% sedentarized parents could not attest the vaccination status of their children.
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Table 22: Status of access to immunization by occupation of father in the study population
Self Semi- Unemployed Trading Skilled Professional Others employed skilled BCG Freq. % Freq. % Freq. % Freq. % Freq. % Freq. % Freq. % Vaccination Vaccinated 13 31.0 42 50.6 28 36.8 1 16.7 9 75.0 12 75.0 3 25.0 Not Vaccinated 29 69.0 41 49.4 48 63.2 5 83.3 3 25.0 4 25.0 9 75.0 Sedentarized Fulani; χ2=20.46 df=6 P=0.002 Vaccinated 12 32.4 21 23.9 20 30.8 1 8.3 0 0.0 1 33.3 9 25.7 Not Vaccinated 25 67.6 67 76.1 45 69.2 11 91.7 2 10.0 2 66.7 26 74.3 Nomadic Fulani; χ2=5.41 df=6 P=0.493* Likelihood-ratio chi-sq.*
The table shows the relationship between child’s access (BCG) of the schedule of immunization services by fathers’ occupational status. The coverage with BCG in sedentarized Fulani showed skilled and professionals had the highest coverage with 75.0% each followed by traders with
50.6% while the unemployed had the least coverage of 31.0% in the group which was statistically significant χ2=45.73df=12 (P=0.002).
The pattern in the nomadic Fulani group was different, even though the professionals had the highest coverage of up-to-date of 33.3% there was no significant difference between the groups
(P=0.493)
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Table 23: Supplemental Immunization Activities (SIAs) status in the study population
Sedentarized Nomadic (n=240) (n=118) Vaccine/Pluses Freq. % Freq. % OPV 109 77.3 86 39.6 Injectable: BCG, DPT, Measles, YF 38 17.5 5 3.5 Vitamin A 22 10.1 6 4.3 De-worming tablets 25 11.5 10 7.1 ITN 23 10.6 4 2.8 Soap 23 10.7 7 5.0 Others 2 0.9 0 0.0
Supplemental Immunization Activities- SIAs (Polio campaigns) in the two study groups show that sedentarized children’s uptake is generally better than their nomadic counterparts. The OPV coverage was 77.3% for sedentarized and 39.6% for nomadic Fulani children. Sedentarized children compared to nomadic children (received more injectable vaccines 17.5% vs 3.5% and deworming 11.5% vs 7.1%) respectively.
Vitamin A supplementation was very low at 10.1% in sedentarized compared to 4.3% in the nomadic population.
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Table 24: Logistic regression to determine factors influencing access to immunization 95% Confidence Interval Odds Lower Bound Upper Bound BCG P-value Up-to-date Age of children < 1 Years 1.388 0.788 2.446 0.257 > 1 Years 1 - - - Age of Mother ≤20 Years 1.193 0.649 2.196 0.570 > 20 Years 1 - - - Mothers Education Formal 1.117 0.556 2.244 0.757 Non formal 1 - - - Fathers Education Formal 1.653 0.960 2.849 0.070 Non formal 1 - - - Place of birth Hospital birth 1.295 0.773 2.170 0.326 Home 1 - - - Attend CWC for Immunization Attended 8.292 4.236 16.233 0.001 Did not attend 1 - - - Distance to Health Facility >10 Km 0.105 0.013 0.860 0.036 5-10 Km 0.137 0.061 0.306 0.001 <5 Km 1 - - -
Predictors for access to immunization were when mothers attended CWC (OR=8.292; 95%
CI=4.236-16.233; p=0.001) and living close to and being delivered in the hospital (P=0.001).
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Table 25: logistic regression to determine factors influencing immunization status (DPT-3) utilization among the sedentarized and nomadic children 95% Confidence Interval Odds Lower Bound Upper Bound DPT 3a P-value Up-to-date Age of children < 1 Years 0.585 0.334 1.025 0.061 > 1 Years 1 - - - Age of Mother ≤20 Years 0.885 0.493 1.587 0.681 > 20 Years 1 - - - Mothers Education Formal 1.309 0.676 2.538 0.425 Non formal 1 - - - Fathers Education Formal 1.048 0.629 1.749 0.856 Non formal 1 - - - Place of birth Hospital birth 1.065 0.646 1.754 0.806 Home 1 - - - Attend CWC for Immunization Attended 8.523 4.384 16.570 0.001 Did not attend 1 - - - Distance to Health Facility >10 Km 0.316 0.065 1.541 0.001 5-10 Km 0.257 0.122 0.306 0.001 <5 Km 1 - - - DPT= (Now comes as Pentavalent containing Hep. B, Hib, Diphtheria, Pertussis and Tetanus)
The logistic regression showed the most predictive factor for being fully immunized (DPT-3) in this study was residing less than 5Kms trekking distance from the PHC for CWC as well as being able to get to the health facility by mothers for immunization services (P=0.001)
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SECTION D
CLINICAL STATUS AND MORBIDITIES OF SEDENTARIZED AND NOMADIC FULANI CHILDREN Table 26: Recent disease/illness presentation among the children in the study population Sedentarized Nomadic (n=250) (n=250)
Disease/illness Now/This week Previous Week Now/This week Previous Week Freq. % Freq. % Freq. % Freq. %
Abdominal pain 27 37.0 36 63.0 22 32.4 46 67.7
Diarrhea (Watery) 28 43.1 37 56.9 19 31.1 42 66.9
Diarrhea (With blood) 13 56.5 10 43.5 5 27.8 13 72.2 Vomiting 41 56.9 31 43.1 26 43.3 34 56.7
Fever 45 46.9 51 53.1 51 60.0 34 40.0
Measles 17 58.6 12 41.4 22 59.5 15 40.5
ARTI 33 63.5 19 36.6 11 61.1 7 38.9
Conjunctivitis 18 75.0 6 25.0 4 66.7 2 33.4
Otitis Media 7 50.0 7 50.0 3 60.0 2 40.0
At the time of assessment of the children, recent illnesses showed conjunctivitis in 75.0% of sedentarized and 66.7% in the nomadic respectively.
ARTI followed with 63.5%, and 61.1% among the nomadic group, this was followed by Measles cases which were near equal 58.6% & 59.5% respectively. Fever was a more common presentation among nomads 60.0% than sedentarized Fulani children.
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Table 27: Types of place of treatment visited for recent illness in the study population
Population Sedentarized Nomadic Total (n=250) (n=250) (n=500) Place of treatment Freq. % Freq. % Freq. % General hospital 38 15.2 9 3.6 47 11.4 Health care center 67 26.8 34 13.6 101 20.2 Community health worker/Home visit 38 15.2 53 21.2 91 18.2 Chemist shop 37 14.8 40 16.0 77 15.4 Drug vendor in markets/garage 13 5.2 34 13.6 47 9.4 Traditional/spiritual healer 24 9.6 26 10.4 50 10.0 Did not seek treatment 33 13.2 54 21.6 87 17.4
Health care centers accounted for the highest number of clients 101(20.2%) where treatment was sought for recent illness for both populations. General Hospital visited by nomadic Fulani was only 3.6% compared to 15.2% for the Sedentarized population. However nomadic dwellers patronized drug vendors in garages 13.6% compared to 5.2% by sedentarized Fulani.
The place of treatment for the recent ailment shows that overall 87(17.4%) of the studied population did not seek care from the treatment facility/points for the child’s recent ailment at all. However, there were more nomadic 54(21.6%) than sedentarized 33(13.2%) who did not seek care in this study.
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Table 28: Time taken to reach place of treatment for recent illness by the study population
Population Sedentarized Nomadic Total (n=231) (n=205) (n=436) χ2 df P-value Trekking time Approximate Freq. % Freq. % Freq. % (Minutes) distance (Km) 1-30 <5 Km 188 81.4 129 63.0 317 4.2 19.499 2 0.001
31-60 5-10 Km 37 16.0 60 29.2 97 22.2 >61 >10 Km 6 2.6 16 7.8 22 5.0 * REW guideline: Communities within 5km radius to health facilities have routine services; 5-10 km outreach services while 10km and above should have mobile services
The approximate time to reach the point of treatment among those that responded is presented above with the spatial distances according to the estimated time to reach point of treatment.
While 72.8% of the studied populations were within 30 minutes’ walk (5kms) to the nearest place of treatment, with more sedentarized 81.4% and 63.0% nomadic families having close points of care. Walk time of 31-60 Minutes (10kms) accounted for 22.2% where the nomadic had to move longer distance than sedentarized to access services (P=0.001).
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SECTION E FACTORS INFLUENCING HEALTH STATUS OF NOMADIC AND SEDENTARIZED FULANI CHILDREN
Table 29. Factors influencing health status of children in the study population
Population Sedentarized Nomadic Total Variable Freq. % Freq. % Freq. % χ2 df p-value Hospital birth Yes 123 49.4 66 26.6 189 38.0 27.37 1 0.001 No 126 50.6 182 73.4 308 62.0 n=249 n=248 n=497 ANC attendance Yes 166 67.2 133 56.6 299 62.0 5.76 1 0.019 No 81 32.8 102 43.3 183 38.0 n=247 n=235 n=482 Attend Clinic for Yes 109 44.1 99 40.4 208 42.3 0.698 1 0.403 Growth Monitoring No 138 55.9 146 59.6 284 57.7 and Promotion n=247 n=245 n=492
Attend Clinic for Yes 109 44.1 99 40.4 208 42.3 0.689 1 0.406 Immunization No 138 55.9 146 59.6 284 57.7 n=247 n=245 n=492
Table shows the factors that influence health status among the children as more mothers in the sedentarized attended and delivered in the hospital 123 (49.4%) compared to the nomadic 66
(26.6%). where a child being born in the hospital was statistically significant (P=0.001) as well as attendance at ANC by mother (P=0.019). Whereas attendance of growth monitoring and promotion clinic and attendance of clinic for vaccination did not show difference between the sedentarized and nomadic populations.
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Table 30: Environmental factors and social amenities in the study population
Sedentarized Nomadic (n=250) (n=250) Variable Freq. % Freq. % Toilet facilities Available 215 86.0 81 32.4 Not available 35 14.0 169 63.6
χ2=148.682 df=1, P=0.001 Waste Management Sanitary 127 50.8 73 29.2 Non-sanitary 123 49.2 177 70.8
χ2=24.300 df=1, P=0.001 Sources of water for use Potable 214 85.6 168 67.2 Non-potable 36 14.4 82 32.8
χ2=23.471 df=1, P=0.001 Toilet facilities: Available (Flush, Pit Latrine, VIP); Not Available (Open field defecation) Waste Management: Sanitary waste disposal (Bin); Non-sanitary (Burning, open dumping, street/stream dumping) Sources of water for use: Potable water (Piped, Sanitary well); Non-potable (River/stream, Water vendor- ‘Mai moya’ The environmental factors and amenities table shows the traditional pit latrine was more available and is the popular method in both settings with far greater use in sedentarized 86.0% than nomadic 32.4% (P=0.001).
Solid waste disposal in both study populations had open dumping as the highest mode of disposal. Sedentarized population had 50.8 practicing sanitary method of waste disposal compared to 29.2% in the nomadic population.
Potable water source availability showed that sedentarized households had 85.6% potable water source and 67.2% of nomadic Fulani families for daily usage.
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CHAPTER FIVE
DISCUSSION
The socio-demographic variables of the sampled children studied were from birth to five years of age. The mean age of the sedentarized and the nomadic group were comparable with age group
48-59 months having the highest proportion followed by infants 0-11 months old. The children’s ages in the two groups were found to be similar. Studies among nomadic populations in other parts of the country,3, 7, 29, 33 other developing countries had similar findings where for example, the mean age of rural and urban children sampled in Zambia was 29+ 2.034 months as well as other central and east African countries.11, 107, 108
The gender distribution shows 258(53.9%) were males, which was slightly higher than females
243(46.1%) with no difference between and within group sex distribution among the sedentarized and nomadic children studied (P=0.198). This is similar to the distribution in the study on the morbidity status of rural and urban under-five children in southeastern Nigeria where 57.2% were males and 42.8% females.78 Similar findings have been reported in other
African countries, and among pastoralists in Tanzania and Ethiopia,11, 64, 107 as well as in Asia region where researchers had similar reports.66, 109 This shows comparability of the nomadic and sedentarized children in Nigeria with those from other regions.
The mothers/caregivers mean age was 24.67±5.92 years. Mothers in the age group 20-24 years accounted for a greater part (32.8%) of the respondents with nomads accounting for 37.2%. This finding is corroborated by the National Demographic Health Survey of 2013 where most current marital status of female respondents were within the ages of 15-49 years and also showed that 99
47% of Nigerian women had given birth by the age of 20 years. Younger mothers aged ≤20 years in the nomadic population were 34.4% compared to 22.0% in their peers in the sedentarized population (P=0.001). A similar finding has been reported in China where 68.4% of the surveyed mothers were 20-30 years old and 73.8% were housewives.66 A report on the study of childhood fever in South East Nigeria showed mothers were also found to be within the age range of 26–30 years 118 and in reports from East African study corroborates this finding.11 However there is a dissimilar finding in a study from Enugu Nigeria where the mean age was higher (30.9±5.9 years) in the rural and (31.4±6.1 years) in the urban areas where majority of the respondents were within the age range of 26–30 years.9
Education is an important determinant of an individual’s attitude and various outcomes of life. In this study, the highest proportion of women in both groups had no formal education accounting for 45.6% of the mothers studied, this was however lower than the state’s average of 72.8% which corresponds to the finding of the NDHS which reported that over 64.4% of women had no formal education in the North East Zone of the country with rural women less likely to be educated than their urban peers.106 However reports from Ethiopia were higher than findings from this study where 71.4 % of mothers had no formal education.64 Other report from a study among Bissa, Mossi and Fulani of Mali reveal that 75.6% of these women have not been to school.110
Studies from southeastern Nigeria however reported lower level for the rural women where
27.4% had no formal education9 as well as a greater percentage of the respondents of up to
62.1% who had either primary or secondary education,117 showing a higher literacy level in the
100
area compared to the north and particularly in the findings of this study. The general female population of Bauchi state with primary education from the NDHS 2013 was 8.6% as compared to 5% of the Fulani mothers found in this study. The mothers with secondary education was found to be only 4.2% and none of the mothers had tertiary education among the nomadic population in this study whereas the report in NDHS 2013 of 18.6% is more than quadruple the findings in this study.110 Reports from south America however showed urban dwellers had higher educational levels.62
The caregivers in this study had Qur’anic education in up to 42.0% of the respondents, this literacy level is fairly above the 38% for women reported in NDHS 2013 which is typical of and depicts the religious literacy level in the north. In a study among mothers in Burkina Faso, only
4% of the women had modern primary education while as many as 25% had been to Koranic school.120 In contrast to these findings however, studies from southeastern Nigeria shows that majority of mothers had primary education of 32.1% and secondary education of between
48.0%-62.1%,9, 36 this is buttressed by the reports of NDHS 2013 where literacy level in the southern states where reports showed a good percentage of up to 58.3% of urban women and
48.3% of rural mothers had secondary school education and only 4.3% did not have any formal education.110, 112 A similar study in rural china showed that up to 50.2% of the mothers received primary school education,66 which was higher compared to results of this study.
With regards to occupation, majority of sedentarized Fulani mothers were more skilled and 2% were professionals while none of the nomadic Fulani mothers attained this occupational status.
There was statistically significant difference in the two populations in terms of mothers’
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occupation (P=0.006). Reports are seen from Southeastern Nigeria where few mothers were professionals from (0.6% - 0.8%) only.9, 36,117
Majority, 85.6% were full time house wives, this is corroborated by similar reports where almost all of the mothers in a similar study were married (98.1%)64 and from Asia where 73.8% were housewives.66 Only 12.6% of the caregivers were employed in sharp contrast to the general female population of Bauchi state and northeastern zone of Nigeria where 51.1% & 45.8% respectively were gainfully employed,111 and also in reports from Lagos where 21.7% of rural and 32.0% of the urban women were unemployed.112 Of the mothers who were trading, 8.6% of the nomadic mothers sold cows’ milk and 3.6% sedentarized Fulani mothers as compared to other studies where the urban mothers were mainly traders (33.7%) and on the other hand 43.5% of rural mothers were traders with a quarter of the women engaged in farming.9 A report from
Ethiopia however showed that 78.6 % of the women were not engaged in work outside of the home.64
The mean age of the fathers was 38.29±11.53 years with most of the nomadic and sedentarized fathers in age group 30-39 years accounting for 40.6%, while 60+ years representing only 5.9% of the study population which is corroborated by other reports where around 68% of fathers were
<35 years of age.3 Reports from Tanzania showed, Maasai pastoralist households contained the highest proportion of 40% of the household heads in a polygynous marriage.11
The 2013 NDHS shows that literacy level for the general male population of Bauchi state was
33.4% compared to the results of this study which shows nomadic and sedentarized fathers had literacy level of only 12.8% & 5.9% respectively. In the sedentarized population, 14.5% of the
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fathers had tertiary education compared to only one (0.4%) among the nomadic fathers and were more gainfully employed with statistically significant difference in the two populations
(P=0.001). Majority of sedentarized Fulani fathers were traders, had skilled work while others were professionals. There are previous studies that had reported 29% and 42.4 % of the fathers who were illiterate,63, 110 and as high as 68% of Maasai male household heads had no formal education whatsoever.11, 64 The findings in this study contrasts with other studies where majority of the head of the households were unskilled workers. In other studies, agriculture and manual labor were their main occupations,65 while in other studies in Sugali tribe India and Maasai pastoralists of Tanzania up to 15.2 % of the household heads were unemployed.11, 109
The parents’ family orientation in both the sedentarized and nomadic areas were predominantly monogamous, this is similar to other nomadic population reports among pastoralists in northern
Kenya where 98% of the household were monogamous.64 In this study 66.7% polygamy rate was slightly higher among the sedentarized population and also among Maasai pastoralists that had
40% of household heads in a polygynous marriage.11
Documented evidence has shown that couples with more education do have smaller families than their less educated counterpart.113 However the number of children per household in the study population show that more than half 266 (53.2%) had at least 1-4 children in each household at the time of the study. This was slightly higher among the nomadic population with 58.8% than sedentarized with 47.6% and more than 30% of the households had between 5-10 children. This distribution is similar to NDHS 2013 and corroborated by a study in southern Nigeria where the mean number of children for the rural population was 3.1±1.5 and 2.6±1.1 for the urban.112 unlike in China where 56.7% of the households interviewed in a similar study had only one
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child.66 There are reports where age, religion, caste, and birth-order of the child are significant predictors of child’s health (nutritional) status.52
The wealth parameter showed that the animal herd distribution as expected was in favor of the nomadic population where over seventy percent of the sedentarized families are without cows at the time of this study, with sedentarization there is herd depletion. The average herd of 1-49 cows were recorded in 24.0% in the sedentarized and 68.0% amongst the nomadic population.
Those with (50+-cow herd- referred to as ‘garke’-an animal wealth measure) was found to be
1.6% in sedentarized and 8.0% in nomadic while only the nomads had 100+ cows accounting for
3.2%. The wealth of pastoralists is in the herds they keep where animal quantity counts though hardly ever sold at will except where there is dire need. The family monetary income showed that earnings from 500-18,000 Naira (US $ 1.43-51.42) constituted 58.2% of the bulk earnings with nomads earning higher 65.2% compared to 51.2% in the sedentarized group but overall is a peasantry earning with families earning as little as $ 1.43 only, between 19,000-72,000 (US $
5.43-205.71) sedentarized Fulani were better. The families earning 55,000-72,000 was only 2.4% of the study population, while 0.4% earned ≥180,000 = US $ 514.29+ per month in the study population. In a study to examine the effect of household food security status and its interaction with household wealth status on stunting among children aged between 6 and 23 months in resource-poor urban setting in Kenya as well as reports from India, showed the average monthly household income was INR 6277±4161 (US $ 98.47±65.28).28, 110 While in China, majority were unskilled workers and only 6.9% of them earned more than CNY 4,500 (US$ 725) per month,66 which were still better than the earnings of families in this study.
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The general staple diet of the northern states constitutes mainly cereal and legume prepared in several varieties with animal protein in the form of mutton-beef/goat meat, sheep or fish. The feeding pattern of the children as well as food habits in the sedentarized and nomadic children were similar in that the diets were comparable. Findings from this study also indicate that the nutritional/food groups consumed by the nomadic and sedentarized Fulani children were; carbohydrate based foods like ‘dumame’, danwake and talia eaten by nearly 96.0% by the sedentarized and 88.1% nomadic children respectively. In central Ugandan communities the main dietary staples were banana (matoki) and maize.114 whereas consumption of carbohydrate- rich staple foods, such as ugali, was found to be lower among the pastoralists compared to all other ethnic groups in Tanzania as compared to the findings of this study.11 Food insecurity is a proven cause of poor child health in low-income settings which is a strong determinant of nutritional differences among populations.
The protein meals as fish/meat eaten at least 1-3 times per week by sedentarized children was
62.2% compared to 36.2% in nomadic children while 8.2% and 13.2% respectively didn’t have access to fish/meat in the studied population. The daily milk/cheese and fish/meat consumption showed statistically significant difference between sedentarized and nomads in this study. This pattern has been shown in NDHS reports of protein rich foods like meat/fish and poultry of up to
23%, cheese 15% and other milk products of about 10% consumed by communities.111
Similar reports of meat consumption occurred at low frequency for Maasai, Rangi and Meru children with pastoralists children also the least likely to have eaten beans, legumes or peanuts, and leafy green vegetables compared to other ethnic groups.
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Reports of diets of pastoralists studied in east Africa showed fish consumption was also low for most ethnic groups, but particularly low for Maasai children where 2% ate fish on the previous day. Cow's milk was the only food category consumed more often with around 90% of the children among the nomads consuming more.11 The reports found in this study shows cheese consumption among the nomadic children of 65.2% was higher than their sedentarized counterparts. In China, nutrition intake has also been found to be one of the most important factors for all the health disparities between urban and rural Children, with a substantially lower fat intake than their urban Sedentarized counterparts also.89
In this study, the practice of exclusively breast feeding the child was high and in fact higher for nomadic mothers 68.6% compared to 37.8% for the sedentarized. The findings are in contrast to the NDHS 2013 where national average exclusive breastfeeding was 17% which is nearly half of results of this study. Studies in Kano and southern Nigeria revealed that the proportion of mothers who exclusively breastfed their babies were 22.0% and 21.2 respectively.65
There were more sedentarized children (61.9%) who had complementary feeding compared to
39.6% nomadic Fulani children. A study in northern Nigeria reported 58.2% infants in the township had been appropriately started on complementary feeding from 6 months of age,65 which is in keeping with the results of this study. The NDHS however reports 85% of breastfed children aged 6-23 months received solid or semisolid complementary foods in addition to breast milk which is higher than both findings.111
The most common form of malnutrition among children aged under five is stunting followed by underweight then wasting in this study. The nutritional status of the children studied in both
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sedentarized and nomadic children shows that the height-for-age deficit (stunting) among the sedentarized was lower compared to the nomadic children with an average stunting rate of 23.0% indicating the level of chronic malnutrition in this population. There were twice as many (19.2%) nomadic than the 8.4% sedentarized children that were underweight with and an average of
13.8% underweight rate in the studied population. Wasting and stunting showed statistically significant difference (P=0.001). Reports elsewhere were generally higher than the results obtained from this study as the prevalence of underweight, wasting, and stunting among under- five children in an Indian study was 32.7% 18.3% and 38.3% respectively.109
A considerable body of literature has documented rural-urban health status disparity in children from developing countries where sedentarized children are less likely to suffer stunting and underweight. An analysis of nutritional status indicated that Sedentarized-Nomadic population differences in underweight of 6.9%, stunting of 0.4% and wasting of 12.1% between boys and girls was observed in Argentina.62 The stunting rate in this study compared with a similar study in southern Nigeria was much lower where it reported 33.3% as underweight, 26.4% wasting and
24.6%, stunting,36 just as reports in a study among under five children in three ethnic groups in
Iran observed that underweight, stunting and wasting were low.116 These findings of this study has also been corroborated by a study amongst nomads in northeastern Nigeria where the nomadic population were more malnourished than the settled population with fewer children with wasting (acute malnutrition) which was 10.4% but higher in nomadic population. Similar studies in East Africa documented similar report where the sedentarized communities had less malnutrition compared to the nomadic populations.63
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In this study both sedentarized and nomadic children by gender shows that the stunting among the nomadic males was higher (33.6%) compared to the 12.9% in the sedentarized group which was significant (P=0.001), which is similar amongst sedentarized females having 10.8% and nomadic with 34.4% and an overall stunting rate of 23.6%. This finding is much lower compared to reports from Tanzania where 45% of the children resident in rural areas were stunted and particularly pastoralist children were found to have a higher stunting rate of 59%.11 In another study among different ethnic groups the overall distribution of acute malnutrition by sex of all children showed a tendency of higher levels of malnutrition among mobile pastoralist children when compared to sedentary children.55
The underweight rate among males in this study was 16.7% with twice as many, 23.5% observed in the nomadic population and much less among females. Wasting of 7.9% was found among the sedentarized males with a higher thinness rate among the nomadic children of 18.5%. Females were found to be more wasted, more stunted than males but were less underweight in the study population. These findings corroborate the results of earlier studies in a similar population where acute malnutrition was seen in 15% among the Foulbe mobile pastoralist, 18% among the Arab mobile pastoralists and 13% among sedentary children in the lake Chad basin.108
Even though no difference was observed between gender in the sedentarized and nomadic children in the study population, stunting between gender shows male and female nomadic having 33.6% & 34.4% about twice the sedentarized population of 12.9% & 10.8% respectively.
A similar study among under-fives reported similar findings among boys and girls.109 However studies in a rural area in the northern Iran showed under underweight, stunting and wasting was observed in 6.6%, 18.5% and 3.3%, respectively in boys more than girls.114 Similar findings was 108
reported in a study where nutritional indices among children indicates that girls are more deprived compared to boys.52
The nutritional screening using the Shakir strip showed over half of the children 54.5% were normal (green), 38.5% were showing some level of malnutrition (yellow) while 7.0% had overt malnutrition (red). There were twice as many nomadic children in the red category with 9.5% compared to 4.4% among the sedentarized, but overall there were 34.6% sedentarized and 42.5% nomadic in the yellow category. The low MUAC<12.5Cms was reported among 42.5% of nomadic children emphasizing the age-independent nature of the MUAC index. Researchers, working in southwestern Uganda and in the savanna belt of Nigeria have also shown that low
MUAC was the most sensitive predictor of mortality among the children.113
The predictive factors for stunting among the study population showed that a child is likely to have stunting when the mother does not attend CWC for growth monitoring (OR=0.366;
95%CI=0.212-0.630; P=0.001) and if mother has no formal education. In a study in Ghana the independent predictors of reduced odds for stunting was children's age, ANC attendance, and dietary diversity score ≥4 among the children.45
Logistic regression showed that a child is more likely to be categorized as underweight if female
(P=0.036 or aged between 24-59 months i.e. older children were more underweight than the younger ones in the study population (P=0.001). This finding is corroborated by a study on undernutrition risk among pastoral populations in central Africa where undernutrition was not uniformly distributed within the child population, even though same study reported undernutrition did not show a statistically significant sex difference within any age group.123
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The size of the family, or maternal and paternal socio-demographic variables did not influence underweight status in this study but other findings elsewhere showed breastfeeding was associated with reduced odds of underweight while diarrheal disease in the past 15 days was associated with increased odds of underweight,45 and acute child under-nutrition which was reported to be more prevalent in the dry season.56
Acute malnutrition presenting as wasting in this study was not influenced by mother’s education
& attendance of Child Welfare Clinic for Growth Monitoring and Promotion or the sex of the child (P=0.242) but a multivariable logistic regression model in a Ghanian study showed that breastfeeding was independently associated with reduced odds of wasting.45 Also in a study in
East Africa, wasting was more common among children of households without cooperative bank saving accounts, poverty and poor access to health services were shown to be important predictors of wasting.56
The current Routine Immunization schedule in Nigeria stipulates that infants should receive a full complement of eight vaccinations according to the EPI schedule before a child is considered fully immunized –FIC.70
The RI coverage in terms of access, (those up-to-date for BCG) was 43.2% among sedentarized and 26.0% in the nomadic children, indicating more access for the sedentarized children leaving the nomadic child at risk of VPDs.
The DPT-3 (now given as part of the Pentavalent vaccine) used as indicator for administrative coverage showed that DPT3 for sedentarized was 34.0% while the nomadic children had 29.2% which was statistically significant (P=0.001) in favor of the sedentarized children being up-to- 110
date for the pentavalent vaccine. There is generally poor coverage among the nomadic children who had the highest none-received figures of up to 53.2% who had not received BCG at all at the time of the study, but findings from this study contrasts reports from Uganda where 93.1% of the children had been immunized against tuberculosis, polio, diphtheria, and measles and showed better general health than children who were not immunized.115 Reports in a similar population of under-five nomadic children in southwestern Nigeria corroborates this finding where 58.5% of the children under five years had received no immunization, 39.1% had some immunization which was in favor of males.3 In a recent study in northcentral Nigeria, 57.3% of rural and 71.0% of urban respondents completed their child immunization according to the
Nigerian schedule with un-immunized rate of 24.6% among rural and 14.8% of the urban children.119 A study among migrant children in Asia also reports only 32.6% were given BCG at birth and DPT-3 coverage of 57.6%.66
The children whose mothers availed them at the CWC had appropriate immunization for DPT-3 with 50.0% coverage in those sedentarized and slightly less, 43.0% among the nomadic population, while 8.1% of the nomadic did not receive appropriate vaccination and about half of the sedentarized, showing increase in utilization with CWC attendance (P=0.001). It has been reported that nomadic populations in outlying areas of the settlement clinics face significant challenges regarding access to health services like immunizations.9 In a study in Niger Republic,
DPT-3 vaccine uptake rate was only 34.7% by age 12 months,72 this finding was in consonance with the results of sedentarized Fulani children with 34.0% but much lower result was found among nomads with 29.2% coverage.
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Measles vaccination coverage (Fully Immunized Child-FIC) showed that the sedentarized appropriate vaccination with 64.0% than their nomadic counterpart with 43.1% by the age of one year and a general low measles coverage of 38.0% recorded in this study. Reports have also shown that Maasai pastoral children were less likely to have received measles vaccination compared to their Rangi and Meru counterparts when disparities along ethnic lines are considered,11 these figures illustrate some of the health challenges in vaccination coverage in mobile nomadic populations across the globe.
Maternal education and her ability to take her child to initiate vaccination process in the sedentarized population shows that mothers with formal education had higher coverage rate for
DPT-3 of 60.3% than those without education and also 80% measles coverage for the children of mothers with formal education. Maternal education and socioeconomic status of the household were some of the factors related to the utilization of different types of health facilities as vaccination rates have been strongly correlated.86 The likelihood of full immunization was found to be higher for children of non-migrant mothers compared to children of migrant mothers in yet another study.70 This findings underscores education of caregivers as a key factor in health services utilization with better health outcomes for the children and the family.
In this study, there were 45.7% children leaving within 5km reach to the HF who had received vaccination, reducing to 8.1% at 10km with 16.7% for children whose parents reside >10 Km or more away from HF in the sedentarized Fulani group. Caregivers that reside close to HF had better vaccination status of the child (P=0.001). This observation is also similar in the nomadic group where 41.9% of the children were up-to-date at 5km distance, P=0.001 which was
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statistically significant. In a study in Niger Republic, children living in clusters within 1-hour of a health center had 1.88 times higher odds of completing vaccination by age 1-year compared to children living in clusters further from a health center,73 ease of access to health care have been strongly correlated with distance to HFs and vaccination rates in other studies.84 Results from this study is further corroborated by reports of immunization coverage among migrant Fulani in south-western Nigeria where distance to HF was associated with immunization as those living
<5km had better coverage of 4.3% than children located in faraway gaa who had over 70% of their children never immunized.3
In northern Nigeria, fathers have the final say in all matters that concerns the family, especially social and health services. Their consent determines where their wives deliver and indeed whether they can go to hospitals for whatever ailment or services for them or their children. The status of access to immunization by occupation of father in the study population shows the skilled and professional fathers had the highest immunization coverage for children’s access to
BCG with 75.0% each followed by traders with 50.6%. The unemployed had the least coverage of 31.0%, as well as having the highest number of children not receiving vaccination at all
(P=0.002). This was however not the case with the nomadic Fulani group who had a different pattern, even though the professionals had the highest coverage of 33.3% There was no improvement in child being up-to-date for BCG vaccination based on the occupation of the father.
Supplemental Immunization Activities- SIAs (Popularly called Polio campaigns) is a strategy for eradication of poliomyelitis globally. In Nigeria, the year 2013 marked a turning point for Polio
Eradication Initiative (PEI) where reports show that at least a 58% reduction in the number of
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WPV 1 cases compared to 2012 was recorded with a massive decrease of up to 88% in the number of cases as at May 2014.67 Findings in the two study groups show that sedentarized uptake is generally better than their nomadic counterparts with OPV coverage was 77.3% and
39.6% respectively. Sedentarized children had more injectable vaccines, pluses and deworming during this exercise. sedentarized children had nearly four times (10.6%) those that were given
ITNs as against 2.8% of nomadic children. Rural dwellers are often neglected during pluses distribution as is the case in a survey among Fulani communities where at baseline, none of the settlements had ITNs, and antimalarial usage was only 2.7% in intervention settlements as compared to 5.8% in the sedentarized communities.122
The soap pluses were received by 9.7% of the sedentarized, while 5.0% nomadic children had soap pluses during campaigns. This is common practice in the polio endemic high-risk states where caregivers who presented their children for immunization got some pluses such as soap, detergent or sugar to motivate them to bring more unvaccinated children in the neighborhood.70
A strategy to increase demand for the population to request for OPV included the provision of attractive benefits (pluses) during immunization activities to the nomadic Ardo and establishment of health camps in the past. Also, sensitization of the Qur'anic teachers and equipping them with polio and immunization materials, key messages, and fact sheets improved the accessibility of information.70 It has been seen that involvement of Community leaders in mapping and planning could have been the reason for the increasing number of nomadic children reached over time.70
Vitamin A supplementation was 10.1% in Sedentarized compared to only 4.3% in the nomadic population. In a study in east Africa, other tribes had better levels of Vitamin A supplementation
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of up to 60% - 89% than among pastoralists 11 which has been demonstrated in this study where vitamin A supplementation was poor.
Logistic regression showed that a child is more likely to have access to immunization when mothers attended CWC (p=0.001) and living close to and being delivered in the hospital
(P=0.001) and walking distance from the PHC especially if caregiver is within 5Kms (P=0.001).
The predictive factor for being fully immunized (DPT-3) in this study was residing less than
5Kms trekking distance from the PHC for CWC as well as being brought to the health facility by mothers for immunization services (P=0.001). Similar studies have shown that immunization was higher for children whose mothers had hospital delivery and residing close to where health facilities were sited.3, 29
At the time of assessment of the children, recent illnesses showed Diarrhoea and related gastrointestinal illnesses continue to be among the most important causes of illness and death worldwide especially amongst vulnerable groups such as young children. At the time of assessment of the children, recent illnesses showed conjunctivitis in 75.0% of sedentarized and
66.7% in the nomadic respectively with fever being a more common presentation among nomads with 60.0% cases compared to sedentarized Fulani children. ARTI followed with 63.5% among sedentarized and 61.1% among the nomadic group. This was followed by Measles cases which were near equal 58.6% & 59.5% respectively. This finding was higher than reports in a study among under-five year old children studied in Mali where malaria morbidity was 33·8%, followed by upper and lower acute respiratory infections (ARTI) of 17·7%, Fulani ethnicity had 115
significantly lower odds of a presumptive malaria diagnosis when compared to children of other ethnic groups.116
The cases who reported abdominal pain were 37.0% amongst sedentarized and 32.4% in nomadic children studied with overall watery diarrhea reported in 33.6% of them; while diarrhea with blood (dysentery) accounted for 8.9% in the presentations 2 weeks prior to the study which was similar to a study where the children were reported to have had an episode of diarrhoea in the last 2 weeks of 39.1%.36 Other studies have also reported infectious diarrhea of 14·0% 116 and diarrhea of 21.4% which was commoner in sedentarized children as was the case in this study.109
In a study in southeast Nigeria, common indications for admission were malaria 30.3%, diarrheal diseases 20.4% and respiratory tract infections with 19.0% which were the commonest presenting symptoms.78 Reports in a study among nomads in northeastern Nigeria had reported fever as the most common health problem accounting for 87.6% with other ailments of concern as ringworms in 19.7% and diarrhea in17.3% of children.33 Some studies have also reported high prevalence of infection in the week preceding the survey interview which included diarrhea, malaria or cough,3, 114 as well as at least one episode of ARTI (51.6%) during the previous one month in both boys and girls.109
Fulani populations seldom visit public health care facilities for treatment. In this study, over
17.4% of the studied population did not seek care from the treatment facility/points for the child’s recent ailment at all. However, there were more nomadic 54(21.6%) than sedentarized
33(13.2%) who did not seek care in this study. Health care centers accounted for the highest
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number of clients 101(20.2%) where treatment was sought for recent illness for both populations.
General Hospital visited by nomadic Fulani was only 3.6% compared to 15.2% for the
Sedentarized population. However nomadic dwellers patronized drug vendors in garages 13.6% compared to 5.2% by sedentarized Fulani. In a similar study among nomadic Fulani in recent times, they still patronize private health facilities but hardly public ones for care.31 Factors such as maternal education, socioeconomic status, number of children under five years of age in the household, and area of residence were some of the factors related to the utilization of different types of health facilities among pastoralists in eastern Africa.86 Reports from another study showed majority, 60.5% of Fulani use chemist shops and local herbs where 63.2% of the respondents were more likely to seek medical care at a chemist/ medicine vendor shops than at a government health facility.3
Community health workers visited for treatment accounted for 22.0%, which is next highest point of treatment in this study. The sedentarized Fulani visited PHCs and General Hospital by
17.5% compared to nomadic Fulani of 4.6% with nomads patronizing chemist shop and drug vendors in garages than sedentarized Fulani. Studies have adduced the reasons for preference of private care facilities were similar irrespective of clans or camp as payment condition, distance from camp and the politeness of the health care providers were the most important considerations by Fulani when accessing a health facility.33
The place of treatment for the recent ailment shows that overall 87(17.4%) of the studied population did not seek care from the treatment facility/points for the child’s recent ailment at all. However, there were more nomadic 54(21.6%) than sedentarized 33(13.2%) who did not seek care in this study. Just as reported in a previous study in Burkina Faso where more than
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three-fourths of the deliveries had taken place at home over the previous five years of the study where 21.6% of nomads and 13.2% sedentarized Fulani were least likely to seek care in any facility.120 According to evidence from many African countries such as Nigeria, Burkina Faso, and Zambia more than half of the children with common childhood illnesses did not seek any medical intervention. Evidence from northcentral Nigeria shows that PMVs are the first source of care for up to 55 % of under-five child illnesses, such as malaria and diarrhea.8, 13
Generally, wealthier households are more likely to seek treatment than the poorest as poor households tend to seek care from cheaper public facilities, while wealthier households seek care from private facilities.33, 86 A study in central Africa corroborates our findings as 64 % of the sedentarized population had their treatment at health facility and 18 % from community health workers.12 Also approximately three fourths of the children with illness sought some sort of treatment either in modern or in traditional medicine and about half (50.2%) of the children had received home remedies.109
It is posited, and there are documented evidences that nomads prefer private medicine vendors than government health facilities they will most likely continue to use the private health facility abandoning the public health facility to sedentary communities.33
There were 45(18.0%) caregivers in the nomadic communities and about half 19(7.6%) of the sedentarized parents who were unable to estimate the trekking time to the nearest facility to get treatment. Half of the families lived less than 30 minutes from the place of treatment where
61.6% sedentarized lived closer to where they can get care/treatment compared to 40.8% nomadic dwellers. Nearly twice the nomadic dwellers 24.0% compared to 14.8% of the nomads
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had to trek for an hour to reach treatment points in their wards with only 4.0% of the total population studied trekked for more than an hour to get treatment. An earlier study of nomads of east Africa revealed that 75% of Maasai sedentarized farmer households lived in a village with a health clinic or dispensary compared to just over half of Maasai pastoralist households.11
Majority, 81.4% of sedentarized Fulani lived within 30 minutes’ walk (5kms) to the nearest place of treatment compared to 63.0% of nomadic families. Only 5% had a walk time of >60 minutes
(>10kms), with 2.6% sedentarized and 7.8% nomadic Fulanis that had to travel this far or more to the nearest treatment point which was statistically significant (P=0.001). In a study in a rural district in Kenya, the average distance to the nearest health facility was found to be 60 km where the mainly pastoralist divisions of the district having the longest distances to health care facilities.17
Generally, wealthier households tend to patronize and utilize health facilities especially those living in urban areas compared to rural communities. It has been documented that nomads in the sedentarized area are more likely to seek treatment than the poor nomadic households.84 Mothers in the sedentarized area attended and delivered in the hospital in nearly fifty percent of the study population compared to the nomadic mothers where a quarter of them (26.6%) attended healthcare facility for care, which was in favor of sedentarized Fulani population (P=0.019). The attendance of growth monitoring and promotion clinic between the two populations was however not different. This finding is in sharp contrast to reports among other migrant populations where
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around 90% of the children were delivered in hospital even when only 46.2% of the mothers had received ANC among socio-economically disadvantaged migrants in East China.66
The environmental factors and amenities table shows the traditional pit latrine was more available and is the popular method in both settings with far greater use in sedentarized 86.0% than nomadic 32.4% (P=0.001).
Solid waste disposal in both study populations had open dumping as the highest mode of disposal. Sedentarized population had 50.8% practicing sanitary method of waste disposal compared to 29.2% in the nomadic population.
The waste management among the Fulani households studied shows that the traditional pit latrine is the popular method of fecal matter disposal in both settings with none of the nomadic communities uses flush system which is the ideal method. It was however observed that open field defecation is a common practice among the nomads. While 86.0% sedentarized Fulani had toilet facilities available, 63.6% of the nomads had none. Commonest solid waste disposal in both study population was the unsanitary open dumping which was also the highest mode of disposal (40.0%) among the nomadic population.
Potable water source available for 63.8% of study population was well water as most common source of water for household use and by extension for their herds. Sedentarized households had
85.6% potable water source and 67.2% of nomadic Fulani families for daily usage. The stream/river was the second most common source of water for household use and by extension for nomadic Fulani families for domestic use and watering their herds. A study among mobile 120
east African pastoralist had reported that surface water was the source for consumption and washing which was often turbid and contaminated with animal and human excreta.12
In a study to assess environmental factors influencing nutritional status of children in Uganda, rural living and the use of unprotected water supplies which were common practice was shown to be risk factors for marasmus and underweight.114
121
CHAPTER SIX
CONCLUSION AND RECOMMENDATIONS
6.1 CONCLUSION
This study ventured to highlight and compare the health status; the nutritional, immunization and common morbidities of nomadic and sedentarized Fulani children in Darazo LGA, Bauchi State of Nigeria.
Parents of the sedentarized had better literacy level than their nomadic counterparts which influenced the health status of their children. Sedentarized children had lower stunting, underweight and wasting rates than their nomadic counterparts, females in both sedentarized and nomadic populations were more malnourished. than males. The predictive factors for stunting was found to be non-attendance of CWC for GMP while risk for underweight was seen in children older than 2 years and if female.
Sedentarized children had better immunization coverage with good access and utilization rate of immunization with those born at and resident near health facilities as well as attended CWC. In addition, mothers with higher literacy level had their children having better immunization status.
Common childhood morbidities such as Diarrhea, ARTI, fever and measles were higher in nomadic population compared to the sedentarized children with nomads patronizing drug vendors more for treatment. Nomads also had poor sanitary disposal and lacked potable water for use compared to the sedentarized Fulani.
Parental education, especially maternal education, attendance of CWC for treatment and immunization including proximity of service points will improve the health status of Fulani children especially the nomads.
122
6.2 RECOMMENDATIONS
The three tiers of government from national, state down to LGAs should develop policies and implement same for pastoralists in order to have better health status as this group are disadvantaged
1. Health facilities be provided in settlements along nomadic routes to offer PHC services as
close as possible to the nomads and if resources are properly earmarked provision of mobile
health services will go a long way to improve access to nomads.
2. Parental education be improved through schooling of young Fulani children in the population
especially the mothers and encourage hospital/PHC attendance for ANC, delivery, RI,
nutrition and treatment service to improve family and children’s health.
3. Qualitative research methods should be employed among Fulani populations to form the
background for the planning of health and social services to inform policy formulation and
effective implementation to improve health outcomes to this disadvantaged population.
123
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APPENDICES
APPENDIX I: QUESTIONNAIRE
HEALTH STATUS OF NOMADIC AND SEDENTARIZED FULANI CHILDREN IN DARAZO LOCAL GOVERNMENT AREA, BAUCHI STATE: A COMPARATIVE STUDY Serial number______
SECTION A: CHILD DEMOGRAPHIC INFORMATION
1. Age of child in months/years______
2. Sex 1. Male 2. Female.
3. Is there a school available in your ward/village? 1. Yes 2. No
4. Does child attend school? 1. Yes (if yes go to question 6) 2. No
5. If No, why? Reason for not attending school Yes No 1. under aged 2. Hawking items in the neighborhood 3. Rearing cattle 4. Attends Tsangaya Quranic 5. Islamiyyah school only 5. Parents cannot afford 6. Parents don’t want western education 7. Selling goods in parent’s shop 8. Child runs away from school 9. Teachers not available in school 10. Due to beating/corporal punishment 11. Others (specify) 6. What level of schooling/education is the child presently? 1. Nursery 2. Primary 3. Others (specify) ______
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SECTION B: CHILD HEALTH STATUS 7. Immunization status (routine immunization) as seen on child health card/verbal history of vaccination at the HF
Immunization Polio Hepatitis B DPT CSM
status
BCG
Fever
Yellow Yellow P0 P1 P2 P3 HBV1 HBV2 HBV3 DPT1 DPT2 DPT3 Measles Up to date Not up to date None received
8. History of immunization (SIAs): received during the recent Immunization Plus Days (IPDs) 1. OPV 2. Injections: (I) BCG---- (II) DPT---- (III) Measles--- (IV) Yellow Fever 3. Vitamin A 4. De-worming tablets 5. ITN 6. Soap 7. Others (specify) ______
9. Dietary history: Dietary items Yes No 1. Drinks cow milk/cheese daily 2. Drinks cow milk/cheese weekly 3. Eats meat/fish daily 4. Eats meat/fish 1-3 times a week 5. Eats meat/fish once a month or longer 6. Does not eat meat or fish 7. Eat beans, akara (beans cake) or moin-moin 8. Eats danwake (local flour preparation) 9. Breast milk alone 10. Breastfeeding and supplementary feeds 11. Others (specify)
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10. History of recent disease/illness: Disease episode Now/This Last week Last two week weeks 1. GE (Diarrhoea/vomiting) 2. Malaria fever 3. Measles 4. Acute respiratory tract infection (ARI) 5. Conjunctivitis (red or discharging eyes) 6. Otits media (pus/water coming out of ear) 7. Others (specify) 11. Where did the child get treatment for the last episode of illness?
1. General hospital 2. Health care center 3. Community health worker 4. Chemist shop 5. Drug vendor in markets/garage 6. Traditional/spiritual healer 7. Others (specify) ______12. If 1-3 above how long does it take to reach the facility? ______Minutes
SECTION C: CLINICAL FINDINGS 13. Physical examination SIGN Present Absent 1. Light, fluffy hair 2. Rashes/spots 3. Pedal odaema 4. Eyes Pallor Red/watery eyes Discolored sclera 5. Oral Hygiene Angular stomatitis Swollen gums Dental plaque/discoloration Dental caries Missing tooth Filled tooth 6. Parotid enlargement 7. Skin infections Tinea capitis – head Tinea corporis-neck/trunk Scabies 8. Others (specify)
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14. Observed disabilities: Disability status Yes No 1. Nil 2. Hemiplegia 3. Deafness 4. Corneal scar 5. Blindness 6. Amputated limb 7. Others (specify)
15. Anthropometry 1. Weight in (kg) ______2. Height/length in (meters) ______3. Mid-upper arm circumference (cm) ______
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SECTION D: PARENT/PRIMARY CAREGIVERS SECTION
1. Location of parents/caretaker presently: 1. Urban 3. Nomadic
2. Religion 1. Islam 2. Christianity 3. Others (specify) ______
3. Age of mother in years ______
4. Level of education of mother 1. Nil/no formal education 2. Quranic school education 3. Primary school education 4. Secondary school education 5. Tertiary school education 6. Others (specify) ______
5. Occupation of mother 1. Full time house wife 2. Unemployed 3. Self employed ______4. Semi-skilled 5. Skilled 6. Professional 7. Others (specify) ______
6. Is the child’s father alive? 1. Yes 2. No If Yes, answer questions 7-13 otherwise go to question 14
7. Is the mother living with the child’s father presently? 1. Yes 2. No
8. If No why? 1. Separated 2. Divorced 3. Widowed 4. Others (specify) ______140
9. Age of father in years ______
10. Level of education of father 1. Nil/no formal education 2. Quranic school education 3. Primary school education 4. Secondary school education 5. Tertiary school education 6. Others (specify) ______
11. Occupation of father 1. Unemployed 3. Trading 4. Semi-skilled 5. Skilled 6. Professional 7. Others (specify) ______
12. Type of family: 1. Monogamous 2. Polygamous
13. If polygamous, how many wives? _____
14. Number of children in your family: Male _____ Female _____ Total ______
15. What is the birth order of index child? _
16. Was this child born in the hospital? 1. Yes 2. No
17. If No, where was the child born? ______
18. Did you attend Antenatal care clinic services (ANC) for the last baby you had? 1. Yes 2. No
19. If No, did you see anyone for care e.g. TBA? ______
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20. If No, why? 1. There is no Health facility in my ward 2. There is HF, but no Midwife to provide services 3. The staff are not friendly that’s why I don’t go for ANC 4. My husband does not allow me attend ANC 5. Due to religious belief 6. No reason 7. Others (specify) ______
21. Did you attend child welfare clinic (Growth Monitoring and Promotion Program) for your child? 1. Yes 2. No
22. If No, why? 1. I don’t know about GMP 2. There is no Health facility in my ward 3. There is HF, but no Nurse/Midwife to provide services 4. My husband does not allow me to go to hospital 5. Due to religious belief 6. No reason 7. Others (specify) ______
23. Did you attend child welfare clinic to immunize your child? 1. Yes 2. No
24. If No, why?
1. I don’t know about Routine Immunization for children 2. There is no Health facility in my ward/village to provide services 3. There is HF, but no (staff) Nurse/Midwife to provide services 4. The staff are rude that’s why I don’t go to clinic 5. My husband does not allow me to go to hospital 6. Due to religious belief 7. No reason 8. Others (specify) ______
25. Main source of potable water for the family: 1. Piped water in the compound 2. Public tap 3. Sanitary well in the compound 4. Public well 5. River/stream 6. Pond 7. Vendor (Mai moya) 142
8. Rain water 9. Others (specify) ______
26. Family solid waste disposal method: 1. Not available 2. Open dumping 3. Refuse bin in the compound 5. Public refuses collection point 4. Incineration 6. Others (specify) ______
27. Type of sanitary facility available 1. Flush toilet (W.C) 2. Ventilated Improved pit (VIP) latrine 3. Traditional pit toilet 4. Bush/open field 5. River 6. Others (specify) ______
28. Average family income in Naira 1. Daily ______2. Weekly ______3. Monthly ______
29. Average family herd/animals 1. Cows ______2. Sheep ______3. Goats ______4. Others (specify) ______
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APPENDIX II: CONSENT FORM
VERBAL CONSENT FORM
I am ______, the leader of this research team who works in Darazo
LGA Primary Health Care Department of Bauchi State.
We are carrying out a research on ‘HEALTH STATUS OF NOMADIC AND
SEDENTARIZED FULANI CHILDREN IN DARAZO LOCAL GOVERNMENT AREA,
BAUCHI STATE’ as we want to know what affects your children in this
LGA/Ward/community/ruga in order to help address them in the future. I will appreciate your full participation and cooperation in this research by kindly allowing us to ask you some questions and also take weights, heights and assess your children.
It is voluntary and no name is needed so please answer the questions as honestly as possible. You will not be punished if you opt out of the research at any point if you decide not to participate.
If you agree to participate, please kindly let us go ahead.
Thank you
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APPENDIX III: APPROVAL LETTER FROM SMOH
Error! Objects cannot be created from editing field codes. APPENDIX IV: ETHICAL CLEARANCE CERTIFICATE
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APPENDIX V: MAP OF DARAZO LGA, BAUCHI STATE
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APPENDIX VI: IMCI TRAINING MANUAL
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