Background of the Study
It has been estimated that more than ten million children in developing countries die of preventable and curable conditions before their fifth birthday (WHO, 2000). This high mortality among children is a global public health problem and a threat to child survival which takes a higher toll on developing countries, including Nigeria. Child survival in Nigeria is threatened by nutritional deficiencies and other curable and preventable illnesses particularly malaria, diarrhoeal diseases, acute respiratory infections and vaccine preventable diseases which account for the majority of morbidity and mortality in childhood (Policy Project/Nigeria, 2002). Traditionally, most of the control measures to reduce incidence of these diseases had been multiple diseases-specific control programmes found to have administrative, political and technical difficulties in the delivery of health services (Steinwand, 2001).
In response to these identified difficulties, the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) led the development of an alternative approach known as Integrated Management of Childhood Illness (IMCI). This initiative is a strategy that emerged in response to continuing high child morbidity and mortality. WHO (2000) described IMCI as an integrated approach to child health that focuses on the well-being of the whole child. WHO added that IMCI strategy aimed at reducing death, illness, and disability due to five major causes (i.e., malaria, acute respiratory infections, diarrhoea, measles and malnutrition). Its target was to address childhood death as well as promote improved growth and development among children under 5 years of age. IMCI, according to WHO (2000), includes both preventive and curative elements that are implemented by health facilities as well as by families and communities.
Hill, Kirkwood and Edmond (2004) identified the three main components of the IMCI strategy as follows:
- improvement in the case management skills of health staff through the provision of locally adapted guidelines on IMCI and activities to promote their use;
- improvement in the health system required for effective management of childhood illness, and
- improvement in family and community practices. This third component is the focus of this study. These three components encompass curative, disease preventive and health promotive activities.
The first component of IMCI focused on improving the health worker’s skill. The improvement involves training and reinforcement of correct performance for detection and treatment of major causes of childhood illnesses (i.e., acute respiratory infections, diarrhoea, measles, malaria and malnutrition).
The training would be based on the use of adapted guideline known as algorithm to assess signs and symptoms, classify illness on the basis of treatment needs and provide appropriate treatment including education of the child’s mother or caretaker. The guideline relies on detection of cases or sickness based on simple clinical signs without tests, and offer empirical treatment.
The second component of IMCI focused on improving the essential elements of the health system. The improved health system involved ensuring the availability of essential drugs and other supplies; improving organization of work at health facility level; improving supervision and monitoring; improving health information data; and health sector reforms.
Despite all these improvements made in the above two components of IMCI, UNICEF (1997) observed that significant reduction in child morbidity and mortality was not achieved. In other words, the purposes of the two components were not satisfactorily achieved and hence, the need for an alternative approach was suggested by yet the same WHO and UNICEF.
Family and Community Practices (FCPs) was developed in 1997, in response to the inability of improved care at health facility level to reduce significantly childhood morbidity and mortality. This was sequel to the observation that most mothers and caretakers did not seek care at health facilities (UNICEF, 1997). UNICEF (1999) noted that 40-80% of all child deaths occur in the home without the child receiving appropriate care from a trained health worker or attending a health facility. They incidentally observed that 72% of these threatening deaths were preventable or curable, but people did not seem to use existing low-cost technologies that improve the quality of care for sick children. Hill, Kirkwood and Edmond (2004) noted that families have the major responsibility for caring for their children. They suggested that success in child survival programmes require partnership between health workers and families with support from their communities.
Family as a unit within the community is defined by Ingalis and Salerno (1991) as a special grouping, usually of biologically related persons bound by strong ties of intimacy and caring. The family has the responsibility to provide attention, love, affection, support and services, to meet the physical, mental and social needs of the child and also teach the child the ethical and spiritual concept of the community. The type and quality of care provided by the family is of immense importance to the child’s health and well-being (Ingalis & Salerno, 1991). MacQueen, et al. (2001) defined community as a group of people with diverse characteristics who are linked by social ties, share common perspectives and engage in joint action in geographical locations or settings. This definition applies to the study because Enugu State is seen as a community of diverse but closely knitted social ties and share common perspectives and engages in joint actions in geographical locations.
Practices refer to the actions and behaviours of mothers and caretakers to provide food, healthcare, stimulation and emotional support necessary for child SGD (Engle, 1999). This definition elaborates that the actions and behaviours emanating from the family and community should lead to child’s optimal well-being. Engle further explained that it was not only the practices that were critical to child survival, growth and development but also the way these practices were performed with affection and responsiveness to the child.
UNESCO (2000) conceptualized child survival as a process of seeking a healthy state at birth and in the early months and years of life. Aina, Etta and Zeitlin (1992) viewed child survival as the application of all available resources and knowledge to curb infant and child mortality. A close look at the two definitions of child survival could show that they are similar because they perceived child survival as application of child survival programmes or strategies. The implication of the above could be that child survival involves programmes or strategies that will help to improve the health of children. It could be observed that when these programmes or strategies are implemented properly at the family level, they could now result to optimal growth and development.
Child growth refers to a child attaining a certain growth norm or process of steadily increasing in size (UNESCO, 2000). Child growth in the present context is a process of a child attaining steady increase in size. However, growth and survival can be influenced by how well a child is developing both socially and psychologically.
Davis (1999) understood child development to mean the gradual changes in a child’s physical, mental and emotional state viewed together as a whole. Child development is a process of change in which the child learns to handle even more complex levels of moving, thinking, feeling and relating to others. Child development occurs continuously following recognized patterns, although having some variations according to cultural influences. The child’s family and community provide the child with early care that helps the child to survive, grow and develop. A summary of the above conceptions could show that child development implies a process of change whereby the child learns more complex things such as moving, thinking, feeling and relating to others. This summarization of the concept of development was adopted by the researcher in the present study in order to study mothers’ adoption of FCPs in Enugu State.
Studies conducted by Evans and Myers (1994) and Mosley and Waters (in-press) have shown that there are practices which promote child survival, growth and development. On the other hand, there are also practices which are detrimental to child growth and development which need to be discouraged. Evans and Myers further observed that there are individual variations in practice from family to family depending on the psychological make-up of the parents, their personality, the experiences they had as children and the condition under which they are living. Despite these variations in practice, Hill et al. (2004) advised that families need to know how to feed their children, how to prevent and respond to illnesses (including knowing when to follow treatment advice given by health worker).
Consequently, FCPs as a combination of three concepts of family, community and practices, UNICEF (1999) defined FCPs as an integrated childcare approach that aims at improving key household practices that are likely to have the greatest impact on child survival, growth and development. Such child care practices in the home, according to Waldman, Bartlett, Campbell and Stekettee (1996) can prevent severe morbidity and complications, improve the health and nutritional status of the child during illness and directly prevent mortality. FCPs focus on prevention, timely and appropriate action at the peripheral or grass root level of health care. FCPs, in the present study, mean those child care practices provided by mothers or caretakers to improve survival and enhance healthy growth and development of children under five years of age thus reducing mortality.
WHO and UNICEF (1998) identified twelve FCPs considered to be of key importance in order to ensure survival, reduce morbidity and promote healthy growth and development among young children. Eleven of these practices relate to the provision of good home care for the child while the twelfth practice ensures that the mother receives adequate antenatal care to enable a newborn child get the best start in life. The WHO and UNICEF outlined FCPs as follows: take children as scheduled to complete a full course of immunizations (BCG, DPT, OPV and measles vaccines) before their first birthday; breastfeed infants exclusively for six months; start at six months of age to feed children with freshly prepared energy and nutrient rich complementary foods, while continuing to breastfeed up to two years or longer; ensure that children received adequate amount of micronutrients (vitamin A, iron and zinc in particular) either in their diet or through supplementation; dispose faeces safely and wash hands after defecation before preparing meals and before feeding children, and protect children in malaria endemic areas, by ensuring that they sleep under insecticide treated bed nets.
Other FCPs are the need to continue feeding and offering more fluids including breast milk to children when they are sick; give sick children appropriate home treatment for infections; recognize when sick children need treatment outside the home and seek care from appropriate providers; follow the health worker’s advice about treatment, follow-up and referral; promote mental and social development by responding to a child’s needs for care, and through talking, playing and providing a stimulating environment, and ensuring that every pregnant woman has antenatal care.
Furthermore, UNICEF (2001) reported that additional four groups of practices were adopted by UNICEF/ESARO, WHO/AFRO and the NGOs after a meeting in Durban South Africa in 2000. These practices include: Preventing child abuse and neglect, and taking appropriate actions when it has occurred; adopt and sustaining appropriate behaviours regarding HIV/AIDS prevention and care for the sick and orphans; ensure that men actively participate in the provision of child care and are involved in reproductive health initiatives; and preventing and providing appropriate treatment for child injuries. The third practice is excluded from the study because it involves men and men are outside the scope of the study.
The fifteen practices were therefore, adopted in this study because these practices were globally identified and agreed upon by major partners such as UNICEF, WHO, World Bank, USAID, DFID, BASIC, PVOs /NGOs, UNICEF/ESARO, and WHO/AFRO (Steinwand, 2001; Hill et al., 2004;UNICEF, 2001). These recognized practices of mothers, families and community, according to Waldman et al. (1996) are critical to preventing infant and child morbidity and mortality. A close examination of the fifteen listed practices revealed a number of simple and low-cost strategies which if implemented in the home can lead to improvement in child survival, growth and development in any setting. This is significant because the first level of child care is the home. Consequently, it can be reasoned that what happens in the household and community are the proximate determinants of favourable healthy outcome (World Bank, 2000).
Mosley and Waters (in press) identified the family as the primary locus of health care with the mother as the primary producer of health. They added that her time, energy, knowledge, skills and her own health along with the resources on her command are critical for the survival and healthy development of each child during the first few years of life. Childcare practices were conceptualized by Momoh (1988) as a primary responsibility of mothers. The practices mothers adopt affect the style and quality of care given to the children.
In recognition of this truth, mothers should be well oriented to know what necessary care to provide the child for health promotion. Consequently, FCPs of IMCI provide the mothers the opportunity for providing good home care for the children particularly for prevention and treatment of the five conditions ( i.e., Acute respiratory infections, Diarrhoea, Malaria, Measles and Malnutrition) which are the major contributors to child death. Provision of the above care by the mothers will invariably promote survival, growth and development of the child. This situation can be facilitated by initiating effective adoption of the key childcare practices in the families and communities in Enugu State where the present study was conducted.
FCPs for child survival, growth and development may be influenced by such socio-demographic variables as level of education, occupation, age, parity, religious affiliation and location of residence. The interaction between these independent and dependent variables may influence specific behavioural outcome of mothers (Mosley & Chen 1984; Bolaria, 1994; Akman, 2001).Taking into consideration that no previous literature on the influence of these variables on FCPs exist, as a result, the interplay between mothers behavioural outcome and morbidity and mortality of children was used to supplement the influence of the above demographic variables and FCPs.
Studies such as Caldwell (1979, 1994), Ware (1984), Desai and Alva (1998) and Zahid (2004) have investigated the influence of maternal level of education on child morbidity and mortality in developing countries. Generally, their results showed that level of education of the mothers strongly affected infant and child mortality. These studies identified that maternal education influences child mortality through various pathways: enhanced socio-economic status, better health choices for their children, including interaction with medical personnel, cleanliness, and emphasis on child quality in terms of having fewer children and greater food and capital investments. How much this is true among Nigerian mothers still needs to be investigated.
The age of the mother seems an important determinant of infant and child mortality. Zahid (2004) pointed out that the relationship between child mortality and maternal age has been found to be non-linear and U-shaped that is to say that the risk is highest at both the younger and older ages. Howlader and Bhuijan (1999), Gyimah (2003) and Zahid (2004) observed that child mortality has been higher in children whose mothers are under 20 years than those whose mothers are 20-35 years. Zahid (2004) pointed out that children born to very young mothers are associated with high mortality risk because of the physiological immaturity combined with the social and psychological stress that comes with it. Zahid further explained that the high mortality risk at older ages are due to maternal depletion associated with pregnancy complications and repeated childbirth. It seems necessary situating FCPs-age relationship in Enugu State.
Maternal occupation has also been seen as an important determinant in child SGD. Basu (1992) referred to status of women as the ability of the women to understand and deal with the world outside the home and their control over decisions on a range of household matters. She represented status of women using two main components: education and employment.
Widayatun (1991) noted that maternal employment has both negative and positive effects on infant and child mortality. He explained that the negative effects may be as a result of reduced time available for child nurturing, although place of work, family size and the extended family may ameliorate the effects. Similarly, Basu (1992) found that maternal employment has negative effect on child survival. He reasoned that employed women may not look after their children or arrange adequate substitute for childcare. On the other hand, Widayatun (1991) noted that the positive effect of maternal employment on child survival may result from increases in household income and improvements in mother’s knowledge of childcare, and also through the greater contact working mothers make with modern ideas. It seems worthwhile situating FCPs-maternal occupation relationship in Enugu State.
Another variable of importance is parity. Aguirre (1995) noted that parity follows an expected pattern: low parity (3-4 children or less) reduces mortality than high parities (5 children or more). Rajna, Mishra and Krishnamoorthy (1998) were of the view that children of low parity faced lower risk of dying when compared with those of higher parity. It can be reasoned that children of higher parity may face competition for resources such as food and medical care by virtue of being born in large families. Gyimah (2003) pointed out that children of higher parity could be expected to be more vulnerable to infection because the quality of care and attention reduces as the number of children a woman has increases. He also noted that the higher the number of children in the household the higher the risk of being exposed to diarrhoea pathogen.
Location of residence is another important factor associated with infant and child survival in developing countries (Martin, Trussell, Salvail & Shan, 1983; Alam & Cleland, 1984). Rural and urban residency are known for their varying characteristics and a corresponding impact on living conditions of people and their child caring practices.
Zahid (2004) and Kabir and Chowdhury (1993) stated that child survival status is usually higher in urban areas than in rural areas. They explained that the differentials in child survival by location of residence may be attributed to differences in health care services including higher immunization coverage, safe delivery of births and access to health care and standard of living in urban area.